Myocardial infarction and post-traumatic stress disorder: frequency, outcome, and atherosclerotic mechanisms

BACKGROUND: Post-traumatic stress disorder (PTSD) may develop in the aftermath of an acute myocardial infarction (MI). Whether PTSD is a risk factor for cardiovascular disease (CVD) is elusive. The biological mechanisms linking PTSD with atherosclerosis are unclear. DESIGN: A critical review of 31 studies in the English language pursuing three aims: (i) to estimate the prevalence of PTSD in post-MI patients; (ii) to investigate the association of PTSD with cardiovascular endpoints; and (iii) to search for low-grade systemic inflammatory changes in PTSD pertinent to atherosclerosis. METHODS: We located studies by PubMed electronic library search and through checking the bibliographies of these sources. RESULTS: The weighted prevalence of PTSD after MI was 14.7% (range 0-25%; a total of 13 studies and 827 post-MI patients). Two studies reported a prospective association between PTSD and an increased risk of cardiovascular readmission in post-MI patients and of cardiovascular mortality in combat veterans, respectively. In a total of 11 studies, patients with PTSD had increased rates of physician-rated and self-reported cardiovascular diseases. Various cytokines and C-reactive protein were investigated in a total of seven studies suggesting that PTSD confers a pro-inflammatory state. CONCLUSIONS: Increasing evidence suggests that PTSD specifically related to MI develops considerably frequently in post-MI patients. More research is needed in larger cohorts applying a population design to substantiate findings suggesting PTSD is an atherogenic risk factor and to understand better the suspected behavioural and biological mechanisms involved.

Integrating fragmented evidence by network meta-analysis: relative effectiveness of psychological interventions for adults with post-traumatic stress disorder

BACKGROUND To summarize the available evidence on the effectiveness of psychological interventions for patients with post-traumatic stress disorder (PTSD). METHOD We searched bibliographic databases and reference lists of relevant systematic reviews and meta-analyses for randomized controlled trials that compared specific psychological interventions for adults with PTSD symptoms either head-to-head or against control interventions using non-specific intervention components, or against wait-list control. Two investigators independently extracted the data and assessed trial characteristics. RESULTS The analyses included 4190 patients in 66 trials. An initial network meta-analysis showed large effect sizes (ESs) for all specific psychological interventions (ESs between -1.10 and -1.37) and moderate effects of psychological interventions that were used to control for non-specific intervention effects (ESs -0.58 and -0.62). ES differences between various types of specific psychological interventions were absent to small (ES differences between 0.00 and 0.27). Considerable between-trial heterogeneity occurred (τ 2 = 0.30). Stratified analyses revealed that trials that adhered to DSM-III/IV criteria for PTSD were associated with larger ESs. However, considerable heterogeneity remained. Heterogeneity was reduced in trials with adequate concealment of allocation and in large-sized trials. We found evidence for small-study bias. CONCLUSIONS Our findings show that patients with a formal diagnosis of PTSD and those with subclinical PTSD symptoms benefit from different psychological interventions. We did not identify any intervention that was consistently superior to other specific psychological interventions. However, the robustness of evidence varies considerably between different psychological interventions for PTSD, with most robust evidence for cognitive behavioral and exposure therapies.

Limbic brain responses in mothers with post-traumatic stress disorder and comorbid dissociation to video clips of their children.

Maternal dissociative symptoms which can be comorbid with interpersonal violence-related post-traumatic stress disorder (IPV-PTSD) have been linked to decreased sensitivity and responsiveness to children's emotional communication. This study examined the influence of dissociation on neural activation independently of IPV-PTSD symptom severity when mothers watch video-stimuli of their children during stressful and non-stressful mother-child interactions. Based on previous observations in related fields, we hypothesized that more severe comorbid dissociation in IPV-PTSD would be associated with lower limbic system activation and greater neural activity in regions of the emotion regulation circuit such as the medial prefrontal cortex and dorsolateral prefrontal cortex (dlPFC). Twenty mothers (of children aged 12-42 months), with and without IPV-PTSD watched epochs showing their child during separation and play while undergoing functional magnetic resonance imaging (fMRI). Multiple regression indicated that when mothers diagnosed with IPV-PTSD watched their children during separation compared to play, dissociative symptom severity was indeed linked to lowered activation within the limbic system, while greater IPV-PTSD symptom severity was associated with heightened limbic activity. Concerning emotion regulation areas, there was activation associated to dissociation in the right dlPFC. Our results are likely a neural correlate of affected mothers' reduced capacity for sensitive responsiveness to their young child following exposure to interpersonal stress, situations that are common in day-to-day parenting.

Selected bibliography : post-traumatic stress disorder with special attention to Vietnam veterans /

Item 983-A

Blunted growth hormone response to clonidine in post-traumatic stress disorder

Hyperactivity of the sympathetic and noradrenergic systems is thought to be a feature of post-traumatic stress disorder (PTSD). Assessment of noradrenergic receptor function can be undertaken by measuring the growth hormone (GH) response to the alpha(2)-agonist clonidine. The aim of this study was to examine whether subjects with combat-related PTSD (with or without co-morbid depression) have a blunted growth hormone response to clonidine, compared to a combat-exposed control group. Twenty-three Vietnam veterans suffering from PTSD alone, 27 suffering from PTSD and co-morbid depression, and 32 veteran controls with no psychiatric illness were administered 1.5 mug/kg clonidine i.v. Plasma growth hormone was measured every 20 min for 120 min. The growth hormone response to clonidine was significantly blunted in the non-depressed PTSD group compared to both the depressed PTSD group and the control group as measured by peak growth hormone, delta growth hormone and AUC growth hormone. Subjects with PTSD and no co-morbid depressive illness show a blunted growth hormone response to clonidine. This suggests that post-synaptic alpha(2)-receptors are subsensitive. This finding is consistent with other studies showing increased noradrenergic activity in PTSD. (C) 2003 Elsevier Ltd. All rights reserved.

Glucocorticoid receptor polymorphisms and post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is reported in some studies to be associated with increased glucocorticoid (GC) sensitivity. Two common glucocorticoid receptor (GR) potymorphisms (N363S and 8cll) appear to contribute to the population variance in GC sensitivity. There is some evidence that there may be a genetic predisposition to PTSD. Hence we studied 118 Vietnam war veterans with PTSD for (i) GR polymorphisms, particularly the N363S and the Bcll polymorphisms which are thought to be GC sensitising, and (ii) two measures of GC sensitivity, the tow-dose 0.25 mg dexamethasone suppression test (LD-DST) and the dermal vasoconstrictor assay (DVVA). The DST and GR polymorphisms were also performed in 42 combat exposed Vietnam war veterans without PTSD. Basal plasma cortisol levels were not significantly different in PTSD (399.5 +/- 19.2 nmol/L, N=75) and controls (348.6 +/- 23.0 nmol/L, N = 33) and the LD-DST resulted in similar cortisol suppression in both groups (45.6 +/- 3.2 vs. 40.8 +/- 4.1%). The cortisol suppression in PTSD patients does not correlate with Clinician Administered PTSD Scores (CAPS), however there was a significant association between the Bcll GG genotype and low basal cortisol levels in PTSD (P=0.048). The response to the DVVA was similar to controls (945 +/- 122, N = 106 vs. 730 +/- 236, N = 28, P = 0.42). PTSD patients with the GG genotype, however, tended to be more responsive to DVVA and in this group the DVVA correlated with higher CAPS scores. The only exon 2 GR polymorphisms detected were the R23K and N363S. Heterozygosity for the N363S variant in PTSD, at 5.1% was not more prevalent than in other population studies of the N363S polymorphism in Caucasians (6.0-14.8%). The GG genotype of the Bcll polymorphism found to be associated with increased GC sensitivity in many studies showed a tendency towards increased response with DVVA and correlated with higher CAPS scores. In conclusion, the N363S and Bcll GR polymorphisms were not more frequent in PTSD patients than controls and reported population frequencies. Our PTSD group did not display GC hypersensitivity, as measured by the LD-DST and DVVA. In a subset of PTSD patients with the Bcll GG genotype, CAPS scores and basal cortisol Levels were negatively correlated. (C) 2004 Elsevier Ltd. All rights reserved.

Förekomst av sekundär traumatisk stress hos sjuksköterskor och dess påverkan på personcentrerad vård : - En litteraturstudie

Bakgrund: Sjuksköterskan har stor del i den nära patientvården och förväntas vara en god lyssnare genom sitt personcentrerade vårdgivande. Händelser som är traumatiska drabbar förutom den direkt berörda patienten även sjuksköterskan genom sekundär exponering. Syfte: Syftet med studien var att belysa förekomst av STS hos sjuksköterskor samt beskriva hur det påverkar vårdkvalitet och personcentrerad vård. Metod: Litteraturstudie med en översikt av relevanta artiklar i databaserna PubMed och CINAHL. Resultatet baseras på 14 artiklar som uppfyllde inklusionsoch kvalitetskrav. Resultat: Sjuksköterskan påverkas av STS på flera plan, både professionellt och personligt. Vårdkvaliteten blir lidande om STS påvisas. Den personcentrerade vården utgör grunden i sjuksköterskans yrkesutövande men om medvetenhet saknas för STS finns risken att sjuksköterskan påverkas så till den grad att hen väljer att sjukskriva sig och/eller byta arbetsplats. Slutsats: STS är ett relativt okänt begrepp och det kan vara svårt att se tecken på begynnande symtom. Sjuksköterskan kan utsättas för STS oberoende arbetsplats. Detta kan sänka effekten i yrkesutövandet genom personliga symtom som; irritabilitet, trötthet, minskad empati, depression, återupplevelser av tidigare upplevda traumatiska händelser med flera. Arbetsplatsens ledarskap inverkar på identifieringen av sjuksköterskans utveckling/hanterande av STS.

Vivências de Esposas de Ex-combatentes Diagnosticados com Stress Pós-traumático: uma abordagem fenomenológica

A Guerra Colonial assombrou a sociedade Portuguesa, durante mais de 10 anos. Durante esse tempo, milhares de jovens soldados foram obrigados fazer parte dessa Luta. Grande parte deles desenvolvera a Perturbação de Stress Pós-Traumático, com a qual ainda hoje vivem. A presente Investigação pretendeu descrever e compreender as Vivências das Esposas de Ex-Combatentes diagnosticados com a Perturbação de Stress Pós-Traumático, utilizando uma abordagem Qualitativa de Orientação Fenomenológica. Através deste Método, pretendeu-se conhecer a globalidade do Fenómeno, de uma forma compreensiva. Foram entrevistadas quatro Esposas que vivem de perto com este problema, as quais revelaram informações importantes para a Investigação. Desta maneira, foram recolhidos dados acerca da Infância e Adolescência, Casamento, Doença do Marido e Perspectivas de Futuro, destas Mulheres. Entre outras conclusões, destacamos a emergência de significações existenciais para estas Mulheres e o facto de esta doença ter influência a nível social, pessoal, familiar e económico. Além disso, as inúmeras estratégias de coping relatadas, demonstraram ser uma mais-valia na forma como estas esposas lidam com a doença dos Maridos. Desta maneira compreendeu-se o fenómeno de uma forma holística, o que forneceu dados importantes para entender o que estas Mulheres vivenciam diariamente, tal como uma melhor compreensão do estado Psicológico destas Esposas e dos Maridos. / The Colonial War haunted the Portuguese society, for over 10 years. During that time, thousands of young soldiers were forced to be part of that fight. Most of them developed Post-Traumatic Stress Disorder, which they still live with. This research aims to describe and understand the Experiences of War Veterans’ Wives, whose husbands were diagnosed with the Post-Traumatic Stress Disorder, using the qualitative method and phenomenological orientation. Through this method, we meant to understand the whole phenomenon in a comprehensive manner. We interviewed four Wives who live closely with this problem, which revealed important information for the investigation. Therefore, we collected data on Childhood and Adolescence, Marriage, Husband’s Disease and Future Prospects, of those Women’s. Among other findings, we highlight the emergence of existential meaning for these Women’s and the fact that this disease influences their lives on social, personal, familial and financial issues. Moreover, the many coping strategies reported, have proven an asset in the way this Wives deal with their husbands illness. Thus it was understood the phenomenon in a holistic way, which provided important information to understand what these Women’s live daily as a better understanding of the psychological state of Husbands and Wives.

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.