1. Unique Identifier 20222317
Author Ballenger JC, Davidson JR, Lecrubier Y, Nutt DJ, Foa EB, Kessler RC, McFarlane AC, Shalev AY
Title Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. [Review] [15 refs]
Source Journal of Clinical Psychiatry 2000 61 Suppl 5p60-66
Abstract

OBJECTIVE: To provide primary care clinicians with a better understanding of management issues in posttraumatic stress disorder (PTSD) and guide clinical practice with recommendations on the appropriate management strategy.
PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Other faculty invited by the chair were Edna B. Foa, Ronald C. Kessler, Alexander C. McFarlane, and Arieh Y. Shalev.
EVIDENCE: The consensus statement is based on the 6 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles.
CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees.
CONCLUSION: PTSD is often a chronic and recurring condition associated with an increased risk of developing secondary comorbid disorders, such as depression. Selective serotonin reuptake inhibitors are generally the most appropriate choice of first-line medication for PTSD, and effective therapy should be continued for 12 months or longer. The most appropriate psychotherapy is exposure therapy, and it should be continued for 6 months, with follow-up therapy as needed. [References: 15]

2. Unique Identifier 91144326
Author Breslau N, Davis GC, Andreski P, Peterson E
Title Traumatic events and posttraumatic stress disorder in an urban population of young adults
Source Archives of General Psychiatry Mar. 1991 48(3) p216-222
Abstract

To ascertain the prevalence of posttraumatic stress disorder (PTSD) and risk factors associated with it, we studied a random sample of 1007 young adults from a large health maintenance organization in the Detroit, Mich, area. The lifetime prevalence of exposure to traumatic events was 39.1%. The rate of PTSD in those who were exposed was 23.6%, yielding a lifetime prevalence in the sample of 9.2%. Persons with PTSD were at increased risk for other psychiatric disorders; PTSD had stronger associations with anxiety and affective disorders than with substance abuse or dependence. Risk factors for exposure to traumatic events included low education, male sex, early conduct problems, extraversion, and family history of psychiatric disorder or substance problems. Risk factors for PTSD following exposure included early separation from parents, neuroticism, preexisting anxiety or depression, and family history of anxiety. Life-style differences associated with differential exposure to situations that have a high risk for traumatic events and personal predispositions to the PTSD effects of traumatic events might be responsible for a substantial part of PTSD in this population

3.Unique Identifier 93036082
Author Mellman TA, Randolph CA, Brawman-Mintzer O, Flores LP, Milanes FJ
Title Phenomenology and course of psychiatric disorders associated with combat-related posttraumatic stress disorder
Source American Journal of Psychiatry Nov. 1992 149(11) p1568-1574
Abstract

OBJECTIVE: Studies indicate that chronic combat-related posttraumatic stress disorder (PTSD) is frequently associated with other psychiatric disorders. Questions regarding the nature and interrelationships of these conditions require clarification. The purpose of this study was to address primary and secondary illness relationships by focusing on the specific phenomenology and course of illness onset of PTSD comorbidity.
METHOD: In order to minimize confounding factors, only outpatients without recent substance use disorders were included. Sixty subjects who had been exposed to severe combat stress including veterans of Vietnam and veterans of World War II or Korea, 15 of whom were former prisoners of war, received structured assessments over serial evaluations.
RESULTS: PTSD was the most prevalent lifetime disorder followed by major depression, panic disorder, generalized anxiety disorder, and phobic disorder or symptoms. Endogenous-appearing features overlapping other clinical populations were common; however, some specific symptom patterns also were suggestive of traumatic influence. Unlike generalized anxiety disorder and past substance use, the mean onset of phobias, major depression, and panic disorder, respectively, occurred later than PTSD.
CONCLUSIONS: These observations suggest that persistent conditions related to PTSD progress toward symptoms that are increasingly autonomous in their pattern of occurrence

4. Unique Identifier 90183347
Author Davidson JR, Kudler HS, Saunders WB, Smith RD
Title Symptom and comorbidity patterns in World War II and Vietnam veterans with posttraumatic stress disorder
Source Comprehensive Psychiatry Mar. 1990 31(2) p162-170
Abstract

Forty-four veterans with posttraumatic stress disorder (PTSD) from World War II and Vietnam were compared. The groups were comparable on many socioeconomic and combat measures and age at onset of PTSD. Vietnam veterans exhibited more severe PTSD symptoms, higher Hamilton depression scores, and higher scores on the hostility, psychoticism, and "additional symptom" Symptom Checklist-90 (SCL-90) scales. They also had more survivor guilt, impairment of work and interests, avoidance of reminders of trauma, detachment/estrangement from others, startle response, derealization, and suicidal tendencies. Differences were noted between the groups as to the nature of upsetting experiences. Vietnam veterans had a greater lifetime frequency of panic disorder and an earlier age of onset for alcoholism. In other respects, the two groups were diagnostically similar, with PTSD being related to the sequential emergence of psychiatric diagnoses in similar manner for World War II and Vietnam patients

5. Unique Identifier 92364649
AuthorMcFarlane AC and Papay P
Title Multiple diagnoses in posttraumatic stress disorder in the victims of a natural disaster
Source Journal of Nervous & Mental Disease Aug. 1992 180(8) p498-504
Abstract

A population of the fire fighters who had been exposed to a natural disaster were screened using the General Health Questionnaire 4, 11, and 29 months after a natural disaster. On the basis of these data, a high-risk group of subjects who had scored as cases and probable cases and a symptom-free comparison group were interviewed using the Diagnostic Interview Schedule 42 months after the disaster. The prevalence of posttraumatic stress disorder (PTSD), affective disorders, and anxiety disorders was examined. Only 23% of the 70 subjects who had developed a PTSD did not attract a further diagnosis, with major depression being the most common concurrent disorder. Comorbidity appeared to be an important predictor of chronic PTSD, especially with panic disorder and phobic disorders. The subjects who had only a PTSD appeared to have had the highest exposure to the disaster. Adversity experienced both before and after the disaster influenced the onset of both anxiety and affective disorders

6. Unique Identifier 20254623
Author Brady KT, Killeen TK, Brewerton T, Lucerini S
Title Comorbidity of psychiatric disorders and posttraumatic stress disorder.
Source Journal of Clinical Psychiatry 2000 61 Suppl 7p22-32
Abstract

Posttraumatic stress disorder (PTSD) commonly co-occurs with other psychiatric disorders. Data from epidemiologic surveys indicate that the vast majority of individuals with PTSD meet criteria for at least one other psychiatric disorder, and a substantial percentage have 3 or more other psychiatric diagnoses. A number of different hypothetical constructs have been posited to explain this high comorbidity; for example, the self-medication hypothesis has often been applied to understand the relationship between PTSD and substance use disorders. There is a substantial amount of symptom overlap between PTSD and a number of other psychiatric diagnoses, particularly major depressive disorder. It has been suggested that high rates of comorbidity may be simply an epiphenomenon of the diagnostic criteria used. In any case, this high degree of symptom overlap can contribute to diagnostic confusion and, in particular, to the underdiagnosis of PTSD when trauma histories are not specifically obtained. The most common comorbid diagnoses are depressive disorders, substance use disorders, and other anxiety disorders. The comorbidity of PTSD and depressive disorders is of particular interest. Across a number of studies, these are the disorders most likely to co-occur with PTSD. It is also clear that depressive disorder can be a common and independent sequela of exposure to trauma and having a previous depressive disorder is a risk factor for the development of PTSD once exposure to a trauma occurs. The comorbidity of PTSD with substance use disorders is complex because while a substance use disorder may often develop as an attempt to self-medicate the painful symptoms of PTSD, withdrawal states exaggerate these symptoms. Appropriate treatment of PTSD in substance abusers is a controversial issue because of the belief that addressing issues related to the trauma in early recovery can precipitate relapse. In conclusion, comorbidity in PTSD is the rule rather than the exception. This area warrants much further study since comorbid conditions may provide a rationale for the subtyping of individuals with PTSD to optimize treatment outcomes. [References: 77]

7. Unique Identifier 99348897
Author Alarcon RD, Glover SG, Deering CG
Title The cascade model: an alternative to comorbidity in the pathogenesis of posttraumatic stress disorder. [Review] [70 refs]
Source Psychiatry 1999 62(2) p114-124
Abstract

Comorbidity has been used extensively to explain the numerous co-occurring psychiatric syndromes accompanying chronic posttraumatic stress disorder (PTSD). A cascade model is proposed as an alternative to comorbidity for the pathogenesis and clinical course of the condition. This model allows for a dynamic, integrated conceptualization of disease progression in PTSD. Findings in the clinical, epidemiological, neurobiological, and psychosocial literature which might support this model are described. Conceptual and heuristic difficulties and/or potential objections to the model are also examined. Finally, diagnostic and treatment implications as well as potential research applications of the model are discussed. [References: 70]

8. Unique Identifier 96180602
Author Bremner JD, Southwick SM, Darnell A, Charney DS
Title Chronic PTSD in Vietnam combat veterans: course of illness and substance abuse
Source American Journal of Psychiatry Mar. 1996 153(3) p369-375
Abstract

OBJECTIVE: The purpose of this study was to measure the longitudinal course of specific symptoms of posttraumatic stress disorder (PTSD) and related symptoms of alcohol and substance abuse and the effects of alcohol and substances on the symptoms of PTSD.
METHOD: A structured interview for the assessment of PTSD and alcohol and substance abuse, as well as other factors such as life stressors and treatment, was administered to 61 Vietnam combat veterans with PTSD.
RESULTS: Onset of symptoms typically occurred at the time of exposure to combat trauma in Vietnam and increased rapidly during the first few years after the war. Symptoms plateaued within a few years after the war, following which the disorder became chronic and unremitting. Hyperarousal symptoms such as feeling on guard and feeling easily startled developed first, followed by avoidant symptoms and finally by symptoms from the intrusive cluster. The onset of alcohol and substance abuse typically was associated with the onset of symptoms of PTSD, and the increase in use paralleled the increase of symptoms. Patients reported a tendency for alcohol, marijuana, heroin, and benzodiazepines to make PTSD symptoms better, while cocaine made symptoms in the hyperarousal category worse. There was no relationship between treatment interventions and the natural course of PTSD.
CONCLUSIONS: These findings suggest that symptoms of PTSD begin soon after exposure to trauma, that hyperarousal symptoms are the first symptoms to occur, that the natural course of alcohol and substance abuse parallels that of PTSD, and that specific substances have specific effects on PTSD symptoms

9. Unique Identifier 92052846
Author Davidson JR, Hughes D, Blazer DG, George LK
Title Post-traumatic stress disorder in the community: an epidemiological study
Source Psychological Medicine Aug. 1991 21(3) p713-721
Abstract

Post-traumatic stress disorder (PTSD) was studied in the Piedmont region of North Carolina. Among 2985 subjects, the lifetime and six month prevalence figures for PTSD were 1.30 and 0.44% respectively. In comparison to non-PTSD subjects, those with PTSD had significantly greater job instability, family history of psychiatric illness, parental poverty, child abuse, and separation or divorce of parents prior to age 10. PTSD was associated with greater psychiatric comorbidity and attempted suicide, increased frequency of bronchial asthma, hypertension, peptic ulcer and with impaired social support. Differences were noted between chronic and acute PTSD on a number of measures, with chronic PTSD being accompanied by more frequent social phobia, reduced social support and greater avoidance symptoms

10. Unique Identifier 20022021
Author Pitman RK, Orr SP, Shalev AY, Metzger LJ, Mellman TA
Title Psychophysiological alterations in post-traumatic stress disorder. [Review] [60 refs]
Source Seminars in Clinical Neuropsychiatry Oct. 1999 4(4) p234-241
Abstract

Psychophysiological research in trauma-exposed populations has provided objective data supporting the validity of the post-traumatic stress disorder (PTSD) diagnostic concept. Consistent with a conditioning model, PTSD patients show specific increased peripheral physiological responding to audio-visually and imaginally presented stimuli symbolizing or resembling the etiologic traumatic event. PTSD patients respond to startling stimuli with larger autonomic and electromyographic responses, especially under threat conditions. Electroencephalographic event-related potential (ERP) response abnormalities in PTSD include reduced P2 amplitude at high stimulus intensities, impaired P1 habituation, and attenuated P3 amplitude to target auditory stimuli. However, larger P3 and N1 amplitude responses and shorter P3 and N1 latencies have been reported in PTSD subjects in response to trauma-related stimuli. These ERP findings suggest sensory, cognitive, and affective processing abnormalities in PTSD. Polysomnographic sleep studies have revealed increased awakenings, reduced sleep time, and increased motor activity, or in some cases, paradoxical deepening of sleep. There is also evidence for increased phasic eye movement activity during rapid eye movement (REM) sleep and disrupted REM continuity in PTSD. Psychophysiological studies are offering valuable insights into the pathophysiology of this important neuropsychiatric condition. [References: 60]

11. Unique Identifier 20022024
Author Yehuda R
Title Linking the neuroendocrinology of post-traumatic stress disorder with recent neuroanatomic findings. [Review] [78 refs]
Source Seminars in Clinical Neuropsychiatry Oct. 1999 4(4) p256-265
Abstract

It has been hypothesized that stress damages the hippocampus and results in myriad other deleterious consequences owing to the toxic effects of cortisol, presumed to be released in excess in response to traumatic stress. Several studies have now demonstrated that hippocampal volumes of trauma survivors with post-traumatic stress disorder (PTSD) are reduced compared to those of nontraumatized persons. Interestingly, however, there is little evidence of increased cortisol release in either the acute or chronic aftermath of stress in trauma survivors who develop this disorder, raising questions about the etiology of the smaller hippocampal volumes as well as the relationship between the neuroendocrine and neuroanatomic alterations in PTSD. This article will review hypothalamic-pituitary-adrenal alterations in PTSD in an attempt to link the neuroendocrine findings with the observation of reduced hippocampal volume. It will be argued that the resolution of the neuroendocrine and neuroanatomic alterations in PTSD depends on understanding the pivotal role of glucocorticoids and their action at glucocorticoid receptors at target brain areas in response to stress and in PTSD. [References: 78]

12. Unique Identifier 97400705
Author Wonderlich SA, Brewerton TD, Jocic Z, Dansky BS, Abbott DW
Title Relationship of childhood sexual abuse and eating disorders. [Review] [73 refs]
Source Journal of the American Academy of Child & Adolescent Psychiatry Aug. 1997 36(8) p1107-1115
Abstract

OBJECTIVE: To review the literature that has examined the relationship between childhood sexual abuse and the eating disorders.
METHOD: Each of the five authors reviewed all identified empirical studies to be certain that inclusion/exclusion criteria were met. Two teams of raters then independently reviewed each study to determine whether it supported any of a series of six hypotheses that had been tested in this literature.
RESULTS: This review indicates that childhood sexual abuse is a nonspecific risk factor for bulimia nervosa, particularly when there is psychiatric comorbidity. There is some indication that childhood sexual abuse is more strongly associated with bulimic disorders than restricting anorexia, but it does not appear to be associated with severity of the disturbance.
CONCLUSION: Childhood sexual abuse is a risk factor for bulimia nervosa with significant comorbidity. Further study of the nature of this relationship is warranted. [References: 73]

13. Unique Identifier 98140306
Author Ferrada-Noli M, Asberg M, Ormstad K, Lundin T, Sundbom E
Title Suicidal behavior after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity, and assessments of suicidal behavior
Source Journal of Traumatic Stress Jan. 1998 11(1) p103-112
Abstract

The study comprises 149 refugees from various countries, reporting exposure to severe traumata, who were referred for psychiatric diagnosis and assessment of suicide risk. The stressors reported comprised both personal experience of and/or forced witnessing of combat atrocities (including explosions or missile impacts in urban areas), imprisonment (including isolation), torture and inflicted pain, sexual violence, witnessing others' suicide, and of summary and/or mock executions. Posttraumatic stress disorder (PTSD) was diagnosed in 79% of all cases, other psychiatric illness in 16% and no mental pathology in 5%. The prevalence of suicidal behavior was significantly greater among refugees with principal PTSD diagnoses than among the remainder. PTSD patients with depression comorbidity reported higher frequency of suicidal thoughts; PTSD nondepressive patients manifested increased frequency of suicide attempts

14. Unique Identifier 99298575
Author Simon RI
Title Chronic posttraumatic stress disorder: a review and checklist of factors influencing prognosis. [Review] [71 refs]
Source Harvard Review of Psychiatry Mar. 1999 6(6) p304-312
Abstract

Mental health clinicians are often asked to evaluate prognosis in individuals with posttraumatic stress disorder (PTSD) in clinical, administrative, and legal contexts. Although chronicity of PTSD has been addressed in a number of trauma studies, the data have not been integrated into a coherent approach to the assessment of prognosis. In this paper, the peer-reviewed PTSD literature is surveyed to assist clinicians in making informed prognostic evaluations of the course of PTSD in adults. Potential risk factors, grouped into 11 categories (PTSD stressors, PTSD symptoms, current comorbidity, lifetime comorbidity, childhood separation and abuse, demographics, life stressors, family history, support, treatment, and functional impairment), are reviewed. Knowledge of these risk factors, and of factors associated with chronic PTSD, is helpful in assessing the potential for or degree of chronicity present at the initial evaluation of the patient, as well as in measuring treatment response during the course of therapy. Early identification and the appropriate treatment and management of remediable risk and associated factors may help prevent the development of chronic PTSD. Longitudinally assessing the response of treatable risk factors should provide an additional means for evaluating prognosis. A PTSD Prognostic Checklist, which rates risk and associated factors in each category, is proposed. Validity and reliability have not yet been established for this instrument. It is hoped that clinicians will use and conduct research on it as an initial step toward advancing its scientific utility. [References: 71]

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