Trauma and posttraumatic stress disorder in severe mental illness

The objective of this study was to evaluate the performance of a new, compact, dynamic diffusion cell for in vitro transdermal permeation. These so-called Kelder-cells were developed as an automated alternative to the static Franz diffusion cells. The new cells were used in combination with the ASPEC-system (automatic sample preparation with extraction columns) which was initially designed for the automation of solid-phase extractions. Three variables were tested to optimize the performance of the new cell system: injection height into the inlet compartment, volume flowing through the receptor compartment and temperature. Experiments were performed using the tritium labelled anticholinergic [3H]dexetimide permeating through an artificial membrane (Silastic). The injection height of the needle into the inlet compartment of the cell should be programmed at -34 mm to ensure complete air tightness, thus forcing the buffer to flow through the cell. The volume of buffer flow through the receptor compartment is important in maintaining sink conditions: a volume of 117 microliters was chosen to replace the total content of the cell (84 microliters) every 2 min. The temperature was precisely controlled in a thermostatic cabinet to minimize variations in experimental conditions. For [3H]dexetimide, an increase in temperature of 20 degrees C reduced the lag time by a factor of approximately two, however the influence on the flux was negligible. The data for the Kelder-cells were comparable with static Franz diffusion cells at a pseudo-steady state, however Kelder-cells have the advantage of automatic sampling, continuous replacement of the receptor solution, and unattended operation over at least 24 h.     

Assessing substance use disorder in persons with severe mental illness

Assessment of dually diagnosed patients consists of three steps: detection, diagnosis, and specialized assessment for treatment planning. Each of these is informed by recent research.     

A randomized controlled trial of cognitive-behavioral treatment for posttraumatic stress disorder in severe mental illness.

A cognitive-behavioral therapy (CBT) program for posttraumatic stress disorder (PTSD) was developed to address its high prevalence in persons with severe mental illness receiving treatment at community mental health centers. CBT was compared with treatment as usual (TAU) in a randomized controlled trial with 108 clients with PTSD and either major mood disorder (85%) or schizophrenia or schizoaffective disorder (15%), of whom 25% also had borderline personality disorder. Eighty-one percent of clients assigned to CBT participated in the program. Intent-to-treat analyses showed that CBT clients improved significantly more than did clients in TAU at blinded posttreatment and 3- and 6-month follow-up assessments in PTSD symptoms, other symptoms, perceived health, negative trauma-related beliefs, knowledge about PTSD, and case manager working alliance. The effects of CBT on PTSD were strongest in clients with severe PTSD. Homework completion in CBT predicted greater reductions in symptoms. Changes in trauma-related beliefs in CBT mediated improvements in PTSD. The findings suggest that clients with severe mental illness and PTSD can benefit from CBT, despite severe symptoms, suicidal thinking, psychosis, and vulnerability to hospitalizations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of methods for detecting substance use disorder in persons with severe mental illness.

Substance use disorders are frequently undiagnosed in psychiatric settings. One possible reason for this underdiagnosis is the lack of screening procedures designed or validated specifically for psychiatric patients. To evaluate the utility of current detection methods, (a) criterion diagnoses were established of alcohol use disorder and drug (cannabis or cocaine) use disorder on 320 patients with severe mental illness recently admitted to a psychiatric hospital, using a combination of structured diagnostic interviews and clinician ratings, and (b) the classification accuracy of several substance abuse measures developed for the general population was examined. For this particular sample, demographic variables, clinical variables, medical exams, laboratory tests, and collateral reports did not yield accurate detection. Screens based on self-report were superior to these other approaches but still yielded modest sensitivity. The results suggest that many individuals are classified incorrectly with current techniques. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychometric posttraumatic stress disorder measurement techniques: A review.

The strengths and weaknesses of 12 representative psychometric posttraumatic stress disorder (PTSD) measures are reviewed. Only 5 follow Diagnostic and Statistical Manual of Mental Disorders (DSM-III)/DSM-III—Revised (DSM-III—R) criteria precisely. No comprehensive reliability assessments have appeared, but encouraging partial studies are available on 7. Consistently robust concurrent validations have appeared on 4. Weaker and/or inconsistent validations are available on 4 more, and the relationships of the remaining 4 instruments to other PTSD measures are unknown. None of the 12 have been shown to have good concurrent validity in nonclinical populations. Ten furnish both continuous severity/frequency measures and dichotomous present/absent outputs; 5 also generate continuous and binary outputs on individual symptoms, maximizing the number of uses to which they can be put. All but 1 can be administered by subprofessionals. At present, the literature seems to recommend the Mississippi Scale for Combat-Related PTSD (T. M. Keane et al; see record 1988-18888-001), R. L. Spitzer and J. B. Williams's (1986) Structured Clinical Interview for DSM-III PTSD module, and the C. G. Watson et al (in press) PTSD Interview. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of social exclusion in trauma survivors with posttraumatic stress disorder.

Trauma survivors with posttraumatic stress disorder (PTSD) often experience or report social stigmatization and isolation. Williams (2001) provided an experimental paradigm to assess behavioral effects of social exclusion. This paradigm (face-to-face version) has been applied in a 2 × 2 group × experimental condition design. Participants in the PTSD group (N = 16) and the nontraumatized control group (N = 25) were randomly assigned to an exclusion or inclusion condition. The results showed interaction effects for main psychopathological assessments (depression, anxiety, psychoticism) and expected main effects for the majority of outcome measures (psychopathology, well-being, belonging, and meaningful existence). The research concludes that a general assumption of elevated levels of self-perceived social exclusion in PTSD patients has to be considered in terms of differentiated psychopathological effects of exclusion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A qualitative approach to the evaluation of psychosocial interventions for persons with severe mental illness.

This article describes the development and assessment of a qualitative interview for comprehensively assessing both the process and the outcome of interventions for persons with severe mental illness (SMI). A open-ended 16-question Narrative Evaluation of Intervention Interview (NEII) was developed. The NEII contains questions that ask the participants to evaluate and describe both process and outcome of interventions for persons with SMI. Research participants were 64 persons with SMI attending rehabilitation programs in the community. Analysis of participants' responses to the NEII, using the open step of the grounded theory approach, produced a comprehensive set of themes. Interrater reliabilities for these themes ranged from moderate to high, and these themes differentiated between the three psychosocial interventions. Ways of modifying the NEII so as to make it more sensitive to participants' expectations and experiences are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder.

With a randomized group design, a 12-session anger treatment was evaluated with severely angry Vietnam War veterans suffering combat-related posttraumatic stress disorder (PTSD). Eight participants in anger treatment and 7 in a routine clinical care control condition completed multiple measures of anger control, anger reaction, and anger disposition, as well as measures of anxiety, depression, and PTSD at pre- and posttreatment. Controlling for pretreatment scores, significant effects were found on anger reaction and anger control measures but not on anger disposition or physiological measures. Eighteen-month follow-up (for both completers and dropouts) supported the posttreatment anger control findings. The challenges of treatment research with this refractory population are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

HIV risk reduction interventions for persons with severe mental illness

Recent seroprevalence studies have shown alarming rates of HIV infection among severely mentally ill men and women in large urban areas, and HIV behavioral epidemiology research indicates that a substantial proportion of seriously mentally ill adults engage in activities that increase their vulnerability to HIV/AIDS. In this paper, the research literature on HIV prevention interventions is reviewed including reports that have described HIV prevention programs, studies that have used uncontrolled pre- and postintervention methods to evaluate risk reduction interventions, and those that have used rigorous randomized designs and examined risk behavior change. Collectively, these studies show that intensive, small-group interventions that target a variety of risk-related dimensions-including knowledge, attitudes, and motivations, and behavioral and cognitive skills-can produce at least short-term reductions in high-risk sexual behavior among the severely mentally ill. A number of gaps in the research literature are identified including the need to: (a) better tailor interventions to risk situations encountered by the mentally ill; (b) develop gender-tailored interventions; (c) examine and implement HIV prevention programs so they help persons sustain behavior change; (d) explore one-on-one counseling and community-level intervention methods; and (e) develop risk reduction interventions for already-seropositive individuals. Implications for service provision are discussed.     

Maladaptive self-appraisals before trauma exposure predict posttraumatic stress disorder.

This study tested the proposal that negative appraisals represent a risk factor for developing posttraumatic stress disorder (PTSD) after trauma. Trainee firefighters (N = 68) were assessed during training (before trauma exposure) for PTSD, history of traumatic events, and tendency to engage in negative appraisals. Firefighters were reassessed 4 years later (N = 52), after commencing firefighter duty (after trauma exposure), for PTSD and depression using the Posttraumatic Stress Disorder Scale (E. B. Foa, L. Cashman, L. Jaycox, & K. Perry, 1997) and the Beck Depression Inventory (Version 2; A. T. Beck, R. A. Steer, & G. K. Brown, 1996). At follow-up, 12% met criteria for PTSD. Pretrauma negative appraisals about oneself accounted for 20% of variance in PTSD severity at follow-up. These data provide the first evidence that preexisting negative appraisals are a risk factor for PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does virtual trauma cause posttraumatic stress disorder?

Comments on an article by Marshall et al. (see record 2007-07130-003). Marshall et al. (2007) believe that widespread media-induced PTSD calls for a new paradigm for understanding traumatic stress. But do the post-9/11 studies really document a nationwide epidemic of what Young (in press) wryly calls "PTSD of the virtual kind"? For several reasons, we are skeptical. We question the need for a new paradigm to explain "virtual PTSD" because we question the evidence supporting its existence. Although at least some people directly exposed to danger surely developed PTSD in response to the terrorist attacks, there are good reasons to doubt whether an epidemic swept the nation in the wake of 9/11. Contrary to Marshall's (2006) view, our skepticism is neither ethically problematic nor indicative of "denial of human suffering" (p. 627). Instead, our skepticism is driven by the absence of convincing evidence that such an epidemic occurred. The more plausible interpretation of the data is that the responses of community residents reflect normal, temporary distress responses to a shocking event, not medical symptoms indicative of psychiatric illness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The helping alliance in case management for homeless persons with severe mental illness

This study examined the role of the helping alliance in case management with homeless persons who have a severe mental illness. A strong alliance after two months of treatment was marginally associated with three outcomes: higher consumer satisfaction, less severe global symptom severity, and greater hostility. The only outcome associated with the alliance after fourteen months of treatment was consumer satisfaction. Several variables predicted a strong helping alliance at month two, including: being African American, low hostility, more perceived needs, and more program contacts. The only variable that predicted a strong alliance at month fourteen was a strong alliance at month two.     

Gaining control: family members relate to persons with severe mental illness

Nine isolates of methicillin-resistant Staphylococcus aureus (MRSA) collected in a Warsaw hospital in 1996 were typed by phenotypic (resistograms) and genotypic (PFGE and plasmid restriction analysis-REAP) methods. Twenty-four (MRSA) strains collected in this hospital during a period of the same duration in 1992 and typed earlier using resistograms and PFGE were also typed by REAP. Comparison of typing results obtained for isolates from 1992 and 1996 showed that strains characterised by PFGE patterns of two distinct types described as specific of the two clonally related groups of Polish MRSA in a multicentre study in 1992 are continuously present in the hospital. However, MRSA strains representing PFGE patterns not observed before were also found within the collection from 1996. REAP typing has proved to have a discriminatory power similar to that of PFGE analysis. Nevertheless, due to the lack of plasmids or difficulties in plasmid DNA isolation in 3 out of 33 studied strains, the typability of REAP turned out to be lower than that of PFGE.     

Clinical psychologists' perceptions of persons with mental illness.

Clinical psychologists have an ethical responsibility to monitor the nature and appropriateness of their attitudes toward persons with mental illness. This article presents the results of a survey of randomly selected clinical psychologists who were asked to rate the effectiveness, understandability, safety, worthiness, desirability, and similarity (to the rater) of persons with moderate depression, borderline features, and schizophrenia. The results show that psychologists perceive these individuals differently with respect to these characteristics. The results also suggest that psychologists disidentify or distance themselves from persons with personality and psychotic conditions. Implications for quality improvement and stigma reduction in the field of professional psychology are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial comparing two vocational models for persons with severe mental illness.

The authors compared 2 approaches to vocational rehabilitation for individuals with severe mental illness: the individual placement and support (IPS) model of supported employment and the diversified placement approach (DPA), which emphasizes work readiness and offers a range of vocational options, including agency-run businesses and agency-contracted placements with community employers. In all, 187 unemployed participants with severe mental illness were randomly assigned to IPS or DPA. Over 2 years, IPS had significantly better competitive employment outcomes than DPA. Competitive employment rates over the 2-year follow-up were 75.0% for IPS and 33.7% for DPA. However, IPS and DPA did not differ on paid employment outcomes. The authors conclude that IPS is more effective than DPA in achieving competitive employment, but not paid employment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Meta-analytic evaluation of skills training research for individuals with severe mental illness.

A meta-analysis of 68 studies examined the effectiveness of skills training for individuals with severe mental illness and the influence of such factors as methodological rigor, choice of outcome measures, and service settings. The methodological quality of these studies was generally very good. Skills training was found to be moderately to strongly effective in increasing skill acquisition and reducing psychiatric symptoms. However, effect size varied by type of outcome measure, with situationally specific measures yielding larger effects than measures of skill usage and role functioning. Studies rarely examined whether acquired skills were used outside the training setting. Surprisingly, most studies were confined to inpatient settings, and most focused exclusively on social skills. Implications are discussed for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treating comorbid panic disorder in veterans with posttraumatic stress disorder.

This study compares the effectiveness of panic control treatment (PCT) with that of a psychoeducational supportive treatment (PE-SUP) in treating panic disorder among a veteran sample with a primary diagnosis of chronic posttraumatic stress disorder (PTSD). Thirty-five patients randomized to receive 10 individual sessions of either PCT or PE-SUP underwent assessments at pretreatment, at 1-week posttreatment, and at a 3-month follow-up. Intent-to-treat analyses of covariance showed that PCT participants significantly improved on panic severity at posttreatment and panic fear at the 3-month follow-up. The PCT group also showed significant reductions in anxiety sensitivity at posttreatment and follow-up compared with that of the PE-SUP group. A significantly higher proportion of persons (63%) in the PCT group was panic free by the follow-up period compared with that of the PE-SUP group (19%). Patient self-report and clinician ratings showed no changes in general anxiety, depression, and PTSD symptoms in either group. These findings indicated that PCT was superior to an active control therapy in reducing the frequency, severity, and distress associated with panic disorder and suggested that brief cognitive-behavioral therapy for panic is effective for persons with chronic PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trauma and posttraumatic stress disorder in people with schizophrenia.

This study evaluated the hypothesis that trauma and posttraumatic stress disorder (PTSD) severity would be positively associated with schizophrenia symptoms. Forty-seven clients with schizophrenia were assessed for schizophrenia severity and for lifetime trauma history and PTSD symptoms in 2 independent symptom interviews; 35 (74%) participants reported at least 1 event in which there was threat of harm or life threat and subjective distress, and 6 (13%) had current PTSD. Trauma across the life span was associated with greater severity of PTSD. Within the total sample, PTSD symptoms were associated with greater emotional distress, but not with schizophrenia-specific symptoms. Distress among clients with schizophrenia and PTSD suggests the need for routine assessment of PTSD and development of PTSD interventions in this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between acute stress disorder and posttraumatic stress disorder: A 2-year prospective evaluation.

Previous research established that 78% of a sample of motor vehicle accident survivors initially diagnosed with acute stress disorder (ASD) were subsequently diagnosed with posttraumatic stress disorder (PTSD) at 6 months posttrauma. Although the previous study (A. G. Harvey and R. A. Bryant, see record 1998-02631-007) provided initial evidence for the utility of the ASD diagnosis, the relationship between ASD and PTSD was assessed over a relatively short period. The present study reassessed that original sample 2 years following the trauma to establish the longer term relationship between ASD and PTSD. ASD was diagnosed in 13% of participants, and 21% were diagnosed with subsyndromal ASD. In terms of participants who participated in all 3 assessments, 63% who met the criteria for ASD, 70% who met the criteria for subsyndromal ASD, and 13% who did not meet the criteria for ASD were diagnosed with PTSD at 2 years posttrauma. These findings indicate the importance of considering multiple pathways to the development of PTSD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Designing websites for persons with cognitive deficits: Design and usability of a psychoeducational intervention for persons with severe mental illness.

The purpose of this study was to develop an understanding of the design elements that influence the ability of persons with severe mental illness (SMI) and cognitive deficits to use a website, and to use this knowledge to design a web-based telehealth application to deliver a psychoeducation program to persons with schizophrenia and their families. Usability testing was conducted with 98 persons with SMI. First, individual website design elements were tested. Based on these results, theoretical website design models were used to create several alternative websites. These designs were tested for their ability to facilitate use by persons with SMI. The final website design is presented. The results indicate that commonly prescribed design models and guidelines produce websites that are poorly suited and confusing to persons with SMI. Our findings suggest an alternative model that should be considered when designing websites and other telehealth interventions for this population. Implications for future studies addressing the characteristics of accessible designs for persons with SMI and cognitive deficits are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)