L'état de stress post-traumatique-complexe : un concept novateur à explorer

Les mauvais traitements représentent un facteur de risque pouvant entraver le développement normal des enfants qui en sont victimes. L’objectif général de cette thèse est de mieux comprendre le concept d’état de stress post-traumatique-complexe (ÉSPT-C) et ce, en permettant l’évaluation rigoureuse de ses symptômes et en documentant sa relation avec d’autres variables. La présente thèse est composée de deux articles empiriques. L’objectif du premier article est d’obtenir une mesure de l’ÉSPT-C pour une population francophone. Pour ce faire, les qualités psychométriques de la traduction francophone du Structured Interview of Disorders of Extreme Stress-Self-Report (SIDES-SR) ont été testées par le biais d’analyses préliminaires auprès de 438 adultes canadiens-français provenant de la population générale et de l’Université de Montréal. Les résultats démontrent que l’instrument possède une structure factorielle de 5 facteurs comparable à celle obtenue pour l’instrument en anglais dans sa version originale. Les facteurs obtenus sont : 1) les croyances pessimistes par rapport aux autres et au futur, 2) la gestion des affects, 3) l’évitement des contacts physiques et sexuels, 4) la somatisation et 5) la prise de risques. La cohérence interne de 4 facteurs sur 5 varie d’acceptable à très satisfaisante alors que leur stabilité temporelle et leur validité convergente, divergente et concurrente ressortent comme étant assez satisfaisantes. Le but du deuxième article de cette thèse est d’examiner l’apport des symptômes d’ÉSPT-C retrouvés chez les mères et de leurs pratiques parentales (supervision et utilisation abusive de la punition) pour expliquer les symptômes d’ordre psychologique chez leurs enfants victimes d’agression sexuelle (AS). Les symptômes d’ÉSPT-C des mères et leurs pratiques éducatives ont été évalués auprès de 96 mères à l’aide de mesures auto-rapportées alors que les symptômes de leur enfant ont été mesurés à partir d’un instrument qui leur était destiné. Les résultats suggèrent qu’en contrôlant les variables sociodémographiques et les caractéristiques de l’AS de l’enfant, les symptômes d’ÉSPT-C des mères sont liés à plusieurs symptômes retrouvés chez les enfants après le dévoilement de l’AS qu’ils ont subie. Le rôle modérateur de la supervision maternelle dans la relation entre l’ÉSPT-C des mères et les symptômes de dépression et d’opposition des enfants a également été démontré. Les implications théoriques et cliniques concernant les résultats obtenus dans le cadre de ce projet doctoral sont finalement abordées.

L’impact d’une interaction sociale centrée sur le trauma sur la réactivité physiologique d’individus avec un état de stress post-traumatique, en fonction de leurs symptômes et de leur soutien social.

Introduction: Les personnes ayant développé un état de stress post-traumatique (ÉSPT) évitent systématiquement d’aborder avec leurs proches le sujet du trauma ainsi que tout élément y étant associé. Cette forme d’évitement peut entraver le processus naturel de rétablissement. Les hypothèses suivantes peuvent être énoncées à cet égard. Tout d’abord, une discussion avec une personne proche et centrée sur le trauma peut être vécue comme étant anxiogène et, par conséquent, provoquer une augmentation de la fréquence du rythme cardiaque, d’ailleurs communément connue sous le nom de réactivité du rythme cardiaque. La réactivité provoquée par une telle situation peut positivement varier en fonction de l’intensité des symptômes d’ÉSPT. Cette association entre les symptômes et la réactivité peut, à son tour, varier en fonction des perceptions de la personne anxieuse du soutien social de la part de son proche et/ou de son entourage. Il en va de même pour les individus ayant développé un trouble anxieux comparable, soit le trouble panique (TP). Toutefois, toutes ces hypothèses n’ayant pas été jusqu’à maintenant vérifiées empiriquement, la présente thèse a eu pour objectif de les tester. Méthodologie: Un total de 46 personnes avec un ÉSPT et de 22 personnes avec un TP ont complété des entrevues diagnostiques et des questionnaires auto-rapportés concernant leurs symptômes ainsi que leurs perceptions des interactions sociales soutenantes et non soutenantes ou négatives avec leur proche significatif et leur entourage. Elles ont également participé à une interaction sociale avec une personne proche et centrée sur leur trouble anxieux, situation qui incluait également des mesures continues du rythme cardiaque. Résultats: Les résultats ont démontré qu’une interaction sociale centrée sur le trauma avec une personne proche provoquait une augmentation significative de la fréquence du rythme cardiaque des participants en comparaison à une interaction sociale non conflictuelle et non anxiogène avec cette même personne. Cette réactivité du rythme cardiaque corrélait de façon significative et positive avec l’intensité de leurs symptômes d’ÉSPT. Les résultats ont également permis de constater que l’hypothèse de modération concernant les perceptions d’interactions sociales positives était partiellement confirmée, soit pour les symptômes d’évitement; les perceptions d’interactions sociales négatives étant quant à elles associées de façon significative et positive à cette réactivité (c.à.d. suivant un effet principal). Quant aux personnes avec un TP, une atténuation significative dans la fréquence de leur rythme cardiaque fut observée dans le contexte analogue, atténuation qui était positivement liée à la sévérité de leurs attaques de panique. Certaines dimensions de leurs perceptions de soutien social étaient significativement et négativement liées à cette atténuation (c.à.d. suivant un effet principal). Discussion: La présente thèse a notamment démontré qu’il existait des liens entre les symptômes d’ÉSPT et la réactivité du rythme cardiaque dans le contexte d’une interaction sociale avec un proche et centrée sur le trauma. Elle a également permis de constater que les symptômes d’ÉSPT et les perceptions d’interaction sociales positives et négatives peuvent prédire cette réactivité. Dans l’avenir, des devis longitudinaux pourront informer davantage à propos de la direction des liens ici explorés.

Specificity of cognitive and behavioral complaints in post-traumatic stress disorder and mild traumatic brain injury.

Characterization of cognitive and behavioral complaints is explored in Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (MTBI) samples according to the severity of PTSD, depression and general anxiety conditions. Self-reported questionnaires on cognitive and behavioral changes are administered to PTSD, MTBI, MTBI/PTSD and control groups. Confounding variables are controlled. All groups report more complaints since the traumatic event. PTSD and MTBI/PTSD groups report more anxiety symptoms, depression and complaints compared to the MTBI group. Relatives of the PTSD group confirm most of the behavioral changes reported. Results suggest the utility of self-reported questionnaires to personalize cognitive and behavioral interventions in PTSD and MTBI to cope with the impacts of the traumatic event.

Objective neuropsychological deficits in post-traumatic stress disorder and mild traumatic brain injury: what remains beyond symptom similarity?

This exploratory study intends to characterize the neuropsychological profile in persons with post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) using objective measures of cognitive performance. A neuropsychological battery of tests for attention, memory and executive functions was administered to four groups: PTSD (n = 25), mTBI (n = 19), subjects with two formal diagnoses: Post-traumatic Stress Disorder and Mild Traumatic Brain Injury (mTBI/PTSD) (n = 6) and controls (n = 25). Confounding variables, such as medical, developmental or neurological antecedents, were controlled and measures of co-morbid conditions, such as depression and anxiety, were considered. The PTSD and mTBI/PTSD groups reported more anxiety and depressive symptoms. They also presented more cognitive deficits than the mTBI group. Since the two PTSD groups differ in severity of PTSD symptoms but not in severity of depression and anxiety symptoms, the PTSD condition could not be considered as the unique factor affecting the results. The findings underline the importance of controlling for confounding medical and psychological co-morbidities in the evaluation and treatment of PTSD populations, especially when a concomitant mTBI is also suspected.

Effects of trauma exposure on the cortisol response to dexamethasone administration in PTSD and major depressive disorder

Objective: To evaluate cortisol suppression following 0.5 mg of dexamethasone (DEX) in trauma survivors (N = 52),with posttraumatic stress disorder (PTSD), major depressive disorder (MDD), both, or neither disorder, and in subjects never exposed to trauma (N = 10), in order to examine interactions between diagnosis and trauma history on cortisol negative feedback inhibition. Method: Lifetime trauma exposure and psychiatric diagnoses were assessed and blood samples were obtained at 8:00 a.m. for the determination of baseline cortisol. Participants ingested 0.5 mg of DEX at 11:00 p.m. and blood samples for determination of cortisol and DEX were obtained at 8:00 a.m. the following day. Results: PTSD was associated with enhanced cortisol suppression in response to DEX Among trauma survivors, the presence of a traumatic event prior to the "focal" trauma had a substantial impact on cortisol suppression in subjects with MDD. Such subjects were more likely to show cortisol alterations similar to those associated with PTSD, whereas subjects with MDD with no prior trauma were more likely to show alterations in the opposite direction, i.e. relative non-suppression. Conclusions: Cortisol hypersuppression in PTSD appears not to be dependent on the presence of traumatic events prior to the focal trauma. However, prior trauma exposure may affect cortisol suppression in MDD. This finding may have implications for understanding why only some depressed patients show non-suppression on the DST. Published by Elsevier Ltd.

Virtual reality Post Traumatic Stress Disorder (PTSD) exposure therapy results with active duty Iraq war combatants

Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been used with reports of positive outcomes. The aim of the current paper is to present the rationale and brief description of a Virtual Iraq PTSD VR therapy application and present initial findings from its use with PTSD patients. Thus far, Virtual Iraq consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Results from an open clinical trial at San Diego Naval Medical Center of the first 18 treatment completers indicate that 14 no longer meet PTSD diagnostic criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up. Clinical tests are also currently underway at Ft. Lewis, Emory University, Weill Cornell Medical College, Walter Reed Army Medical Center and 10 other sites. Other sites are preparing to use the application for a variety of PTSD and VR research purposes.

Examining vulnerability to involuntary memories in schizophrenia comorbid with post-traumatic stress disorder

The current study explored whether individuals diagnosed with schizophrenia and a high level of PTSD symptoms experience more frequent neutral intrusive memories than individuals diagnosed with schizophrenia with low level PTSD symptoms. Results supported a vulnerability to neutral intrusive memories within the comorbid group, which did not seem to be related to psychotic symptom severity. It is possible that a subgroup of psychotic individuals’ process information in a manner that make them susceptible to frequent intrusive memories, characteristic of a PTSD presentation. A longitudinal study is required to specify the development of this vulnerability so as to inform future interventions.

Suicidality in Obsessive-Compulsive Disorder: Prevalence and Relation to Symptom Dimensions and Comorbid Conditions

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Sex differences in the phenotypic expression of obsessive-compulsive disorder: an exploratory study from Brazil

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Role of stressful and traumatic life events in obsessive-compulsive disorder

Whilst genetic factors are thought to contribute to the development of obsessive-compulsive disorder (OCD), the role of environmental factors in OCD is only beginning to be understood. In this article, we review the influence of stress-related factors in OCD. Overall, studies indicate that: patients with OCD frequently report stressful and traumatic life events before illness onset, although these rates do not seem to be significantly different from those described in other disorders; the association between OCD and post-traumatic stress disorder (PTSD) might result from symptom overlap, although cases of patients developing OCD after PTSD and showing obsessive-compulsive symptoms that were unrelated to trauma have been described fairly consistently; it is unclear whether patients with OCD and a history of stress-related factors (including stressful life events, traumatic life events or comorbid PTSD) may respond better or worse to the available treatments; and comorbid PTSD may modify the clinical expression of OCD-although controlled studies comparing pre-versus post-traumatic OCD patients are still unavailable. In conclusion, there is a growing evidence to suggest a role for stress-related factors in OCD. Although the available literature does not confirm the existence of a post-traumatic subtype of OCD, it does call for further systematic research into this topic. © 2011 Future Medicine Ltd.

Towards a post-traumatic subtype of obsessive-compulsive disorder

We evaluated whether traumatic events are associated with a distinctive pattern of socio-demographic and clinical features of obsessive-compulsive disorder (OCD). We compared socio-demographic and clinical features of 106 patients developing OCD after post-traumatic stress disorder (PTSD; termed post-traumatic OCD), 41 patients developing OCD before PTSD (pre-traumatic OCD), and 810 OCD patients without any history of PTSD (non-traumatic OCD) using multinomial logistic regression analysis. A later age at onset of OCD, self-mutilation disorder, history of suicide plans, panic disorder with agoraphobia, and compulsive buying disorder were independently related to post-traumatic OCD. In contrast, earlier age at OCD onset, alcohol-related disorders, contamination-washing symptoms, and self-mutilation disorder were all independently associated with pre-traumatic OCD. In addition, patients with post-traumatic OCD without a previous history of obsessive-compulsive symptoms (OCS) showed lower educational levels, greater rates of contamination-washing symptoms, and more severe miscellaneous symptoms as compared to post-traumatic OCD patients with a history of OCS. © 2011 Elsevier Ltd.

Symptom dimensions, clinical course and comorbidity in men and women with obsessive-compulsive disorder

The study aimed to compare male and female patients with obsessive-compulsive disorder (OCD) across symptom dimensions, clinical course and comorbidity. A cross-sectional study was undertaken with 858 adult OCD patients (DSM-IV) from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders. Patients were evaluated using structured interviews, including the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) and the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I). The sample was composed of 504 women (58.7%) and 354 men (41.3%) with a mean age of 35.4 years-old (range: 18-77). Men were younger, more frequently single and presented more tics, social phobia and alcohol use disorders. Among men, symptom interference occurred earlier and symptoms of the sexual/religious dimension were more common and more severe. Conversely, women were more likely to present symptoms of the aggressive, contamination/cleaning and hoarding dimension and comorbidity with specific phobias, anorexia nervosa, bulimia, trichotillomania, skin picking and compulsive buying. In the logistic regression, female gender remained independently associated with the aggressive and contamination/cleaning dimensions. In both genders the aggressive dimension remained associated with comorbid post-traumatic stress disorder, the sexual/religious dimension with major depression and the hoarding dimension with tic disorders. Gender seems to be relevant in the determination of OCD clinical presentation and course and should be considered an important aspect when defining more homogeneous OCD subgroups. © 2012 Elsevier B.V.

Clinical features of pure obsessive-compulsive disorder

Objective Psychiatric comorbidity is the rule in obsessive-compulsive disorder (OCD); however, very few studies have evaluated the clinical characteristics of patients with no co-occurring disorders (non-comorbid or pure OCD). The aim of this study was to estimate the prevalence of pure cases in a large multicenter sample of OCD patients and compare the sociodemographic and clinical characteristics of individuals with and without any lifetime axis I comorbidity. Method A cross-sectional study with 955 adult patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (C-TOC). Assessment instruments included the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, The USP-Sensory Phenomena Scale and the Brown Assessment of Beliefs Scale. Comorbidities were evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders. Bivariate analyses were followed by logistic regression. Results Only 74 patients (7.7%) presented pure OCD. Compared with those presenting at least one lifetime comorbidity (881, 92.3%), non-comorbid patients were more likely to be female and to be working, reported less traumatic experiences and presented lower scores in the Y-BOCS obsession subscale and in total DY-BOCS scores. All symptom dimensions except contamination-cleaning and hoarding were less severe in non-comorbid patients. They also presented less severe depression and anxiety, lower suicidality and less previous treatments. In the logistic regression, the following variables predicted pure OCD: sex, severity of depressive and anxious symptoms, previous suicidal thoughts and psychotherapy. Conclusions Pure OCD patients were the minority in this large sample and were characterized by female sex, less severe depressive and anxious symptoms, less suicidal thoughts and less use of psychotherapy as a treatment modality. The implications of these findings for clinical practice are discussed. © 2013 Elsevier Inc. All rights reserved.