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

Item 983-A

Parental post-traumatic reactions after premature birth: implications for sleeping and eating problems in the infant.

BACKGROUND: Progress in perinatal medicine has made it possible to increase the survival of very or extremely low birthweight infants. Developmental outcomes of surviving preterm infants have been analysed at the paediatric, neurological, cognitive, and behavioural levels, and a series of perinatal and environmental risk factors have been identified. The threat to the child's survival and invasive medical procedures can be very traumatic for the parents. Few empirical reports have considered post-traumatic stress reactions of the parents as a possible variable affecting a child's outcome. Some studies have described sleeping and eating problems as related to prematurity; these problems are especially critical for the parents. OBJECTIVE: To examine the effects of post-traumatic reactions of the parents on sleeping and eating problems of the children. DESIGN: Fifty families with a premature infant (25-33 gestation weeks) and a control group of 25 families with a full term infant participated in the study. Perinatal risks were evaluated during the hospital stay. Mothers and fathers were interviewed when their children were 18 months old about the child's problems and filled in a perinatal post-traumatic stress disorder questionnaire (PPQ). RESULTS: The severity of the perinatal risks only partly predicts a child's problems. Independently of the perinatal risks, the intensity of the post-traumatic reactions of the parents is an important predictor of these problems. CONCLUSIONS: These findings suggest that the parental response to premature birth mediates the risks of later adverse outcomes. Preventive intervention should be promoted.

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.

Posttraumatic stress avoidance symptoms as mediators in the development of alcohol use disorders after exposure to childhood sexual abuse in a Swiss community sample.

This study examined the role of posttraumatic stress disorder (PTSD) symptoms of re-experience, avoidance, and hyperarousal in the relationship between different types of trauma and alcohol use disorders (AUD). We used data from 731 trauma-exposed individuals who participated in the first wave of the PsyCoLaus-study. Trauma characteristics were assessed relatively to the occurrence of lifetime PTSD symptoms and AUD. The results suggest that lifetime and childhood sexual abuse as well as overall childhood trauma were directly linked to AUD and PTSD symptoms, in particular to avoidance symptoms. From single symptom clusters PTSD avoidance was found to specifically mediate the trauma-AUD pathway. Both childhood and sexual trauma strongly contribute to the comorbidity of PTSD and AUD and avoidance-type symptoms appear to play a central role in maintaining this association. Hence, the alleviation of avoidance symptoms might be an important target for therapeutic intervention among victims of sexual abuse before specific addiction treatment is initiated.

Le stress post-traumatique chez l'agresseur – intérêt pour le clinicien

Introduction : Cet article présente un cas de psychothérapie de stress post-traumatique chez l’agresseur. Ce syndrome clinique est bien décrit dans la littérature, mais notre recherche ne nous a permis de trouver que 2 rapports de cas témoignant de son traitement en psychothérapie. Le traitement de cette population présente plusieurs défis. Un effort a dû être déployé pour réviser une littérature complexe. D’autres contraintes à notre démarche touchaient l’identification d’un sujet éligible, l’adaptation du protocole de psychothérapie à ce sujet et à au contexte de la pratique clinique, ainsi que l’administration du protocole en tenant compte de contraintes organisationnelles spécifiques. Méthode : Toutes les étapes du projet ont été dirigées par le premier auteur. Une revue de la littérature sur l’état de stress post-traumatique chez l’agresseur a été réalisée sous la supervision du deuxième auteur. Elle a été présentée au congrès annuel de l’Association des Médecins Psychiatres du Québec (AMPQ) de 2011. Cette expérience a permis une sensibilisation aux manifestations de ce syndrome clinique dans la pratique psychiatrique. Grâce à cela, un sujet hospitalisé a été identifié comme présentant des symptômes suggestifs d’état de stress post-traumatique chez l’agresseur. Une psychothérapie a été planifiée et administrée, à partir des connaissances acquises lors de la revue de la littérature, sous la supervision du troisième auteur. Le sujet a été sélectionné par échantillon de convenance. Les données colligées concernant l’évolution clinique du sujet sont de nature qualitative. La méthode d’intervention est une thérapie cognitivo-comportementale intensive, chez un patient hospitalisé. Une attention particulière a été portée au vécu subjectif de l’agresseur, tel que suggéré par la littérature. Un suivi a eu lieu en clinique externe par la suite, permettant de colliger des données supplémentaires. Résultats : L’évolution du sujet a été positive, se concluant par le désir de devenir un membre productif de la société. Conclusion : Un protocole de thérapie cognitivo-comportementale visant l’état de stress post-traumatique en général peut être adapté à la situation de l’agresseur. L’exercice d’être attentif à l’expérience subjective de l’agresseur permet de dépasser certains défis que présente son traitement. La psychothérapie peut être adaptée à la situation du patient hospitalisé en psychiatrie. L’ensemble de la démarche illustrée dans cet article représente un exemple concret d’application de principes scientifiques au traitement d’un sujet dont la présentation clinique ne correspond pas à un diagnostic pour lequel il existe un traitement bien établi. Nous invitons le lecteur clinicien à aborder les défis présentés par un cas clinique en formulant une question de recherche pertinente, qui pourra être mise à l’épreuve pendant la phase de traitement du patient. De plus, nous croyons que la rédaction d’une histoire de cas, organisée en fonction de ce principe, constitue un outil didactique précieux dans la formation en psychiatrie.

Oxytocin response to an experimental psychosocial challenge in adults exposed to traumatic experiences during childhood or adolescence.

Long-term implications of the exposure to traumatizing experiences during childhood or adolescence, such as sexual abuse, or cancer, have been documented, namely the subjects' response to an acute stress in adulthood. Several indicators of the stress response have been considered (e.g. cortisol, heart rate). Oxytocin (OT) response to an acute stress of individuals exposed to trauma has not been documented. Eighty subjects (n=26 women who had experienced episodes of child abuse, n=25 men and women healthy survivors of cancer in childhood or adolescence, and 29 controls) have been submitted to a laboratory session involving an experimental stress challenge, the Trier social stress test. Overall, there was a clear OT response to the psychosocial challenge. Subjects having experienced a childhood/adolescence life-threatening illness had higher mean levels of OT than both abused and control subjects. There was a moderate negative relationship between OT and salivary cortisol. It is suggested that an acute stress stimulates OT secretion, and that the exposure to enduring life-threatening experiences in childhood/adolescence has long-lasting consequences regarding the stress system and connected functions, namely the activation of OT secretion. Better knowledge of such long-term implications is important so that to prevent dysregulations of the stress responses, which have been shown to be associated to the individual's mental health.

Female genital mutilation and its prevention: a challenge for paediatricians.

Female genital mutilation (FGM) is defined as an injury of the external female genitalia for cultural or non-therapeutic reasons. FGM is mainly performed in sub-Saharan and Eastern Africa. The western health care systems are confronted with migrants from this cultural background. The aim is to offer information on how to approach this subject. The degree of FGM can vary from excision of the prepuce and clitoris to infibulation. Infections, urinary retention, pain, lesions of neighbouring organs, bleeding, psychological trauma and even death are possible acute complications. The different long-term complications include the risk of reduced fertility and difficulties during labour, which are key arguments against FGM in the migrant community. Paediatricians often have questions on how to approach the subject. With an open, neutral approach and basic knowledge, discussions with parents are constructive. Talking about the newborn, delivery or traditions may be a good starting point. Once they feel accepted, they speak surprisingly openly. FGM is performed out of love for their daughters. We have to be aware of their arguments and fears, but we should also stress the parents' responsibility in taking a health risk for their daughters. It is important to know the family's opinion on FGM. Some may need support, especially against community pressure. As FGM is often performed on newborns or at 4-9 years of age, paediatricians should have an active role in the prevention of FGM, especially as they have repeated close contact with those concerned and medical consequences are the main arguments against FGM.

Délire religieux treize ans après traumatisme crânien [Religious delusion 13 years after brain injury].

We report here with a case of religious delusion in a 39 years old woman. She had suffered a head injury with right temporal concussion 13 years before but had no earlier history of psychiatric disorder. In view of the fact that this acute psychiatric state lasted for a short duration of time and that personality and affects were preserved, this incident is compared to the schizophreniform disorder of the type DSM-III-R. The hypothesis of an acquired predisposition due to head injury has been put forward as an explanation.

Migrations sans frontières mais...barrières des représentations [Migration without borders, but...barriers of meaning].

Immigration, a political, economic, demographic, social and ethic, as well as a medical issue, continues. Among migrants, asylum seekers, refugees and undocumented immigrants are characterised by their vulnerability, particularly related to their health status. Western physicians are more and more frequently confronted to "colorful" and often vulnerable patients. They face diseases related to international migrations; and at the same time have to integrate the differences in representations and meanings given to illness by patients of diverse origins. A bio-psychosocial and spiritual approach coupled with an evaluation of pre-migration, migration and post-migration trajectories is therefore useful for the clinician; these complementary approaches have all been integrated in the learning of cultural competencies.

Les fentes labio-palatines: suivi psychologique et investissement de l'enfant dans sa famille [The cleft lip and palate: psychological following child and family investment].

Congrès de la Société Française de Pédiatrie et de l'Association des Pédiatres de Langue Française (APLF)

Altered processing of contextual information during fear extinction in PTSD: an fMRI study.

Medial prefrontal cortical areas have been hypothesized to underlie altered contextual processing in posttraumatic stress disorder (PTSD). We investigated brain signaling of contextual information in this disorder. Eighteen PTSD subjects and 16 healthy trauma-exposed subjects underwent a two-day fear conditioning and extinction paradigm. On day 1, within visual context A, a conditioned stimulus (CS) was followed 60% of the time by an electric shock (conditioning). The conditioned response was then extinguished (extinction learning) in context B. On day 2, recall of the extinction memory was tested in context B. Skin conductance response (SCR) and functional magnetic resonance imaging (fMRI) data were collected during context presentations. There were no SCR group differences in any context presentation. Concerning fMRI data, during late conditioning, when context A signaled danger, PTSD subjects showed dorsal anterior cingulate cortical (dACC) hyperactivation. During early extinction, when context B had not yet fully acquired signal value for safety, PTSD subjects still showed dACC hyperactivation. During late extinction, when context B had come to signal safety, they showed ventromedial prefrontal cortex (vmPFC) hypoactivation. During early extinction recall, when context B signaled safety, they showed both vmPFC hypoactivation and dACC hyperactivation. These findings suggest that PTSD subjects show alterations in the processing of contextual information related to danger and safety. This impairment is manifest even prior to a physiologically-measured, cue-elicited fear response, and characterized by hypoactivation in vmPFC and hyperactivation in dACC.

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.