Open trial of nefazodone for combat-related posttraumatic stress disorder

BACKGROUND: Because of its ability to block 5-HT2 receptors postsynaptically and inhibit 5-HT reuptake presynaptically and/or its enhancement of sleep quality, nefazodone may be useful for symptom management in posttraumatic stress disorder (PTSD) patients. METHOD: Ten patients with combat-related DSM-IV posttraumatic stress disorder (PTSD) entered an open-label 12-week trial of nefazodone with a 4-week follow-up, beginning with 100 mg/day and increasing as necessary to achieve a maximal response or until reaching a maximum dosage of 600 mg/day. RESULTS: Nefazodone was well tolerated, and no significant changes in sexual function were reported. Based on Clinical Global Impressions-Improvement scores, all 10 patients were rated as much improved. All PTSD symptoms (except self-reported PTSD reexperiencing symptoms), sleep, and clinician-rated depression significantly improved at week 12. At follow-up, significant changes were maintained, and self-reported PTSD reexperiencing symptoms had also significantly improved. Effect sizes for all changed symptoms were moderate to large at week 12 and at follow-up. Self-reported and clinician-rated anger significantly improved. Self-reported depression failed to improve. Improvement in social and occupational functioning was minimal. CONCLUSION: These preliminary data suggest that nefazodone may be effective in reducing the 3 primary PTSD symptom clusters and may be particularly helpful in improving sleep and decreasing anger.     

Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder

OBJECTIVE: A two-part study was conducted to examine the health status of Vietnam veterans with posttraumatic stress disorder (PTSD). In part 1, veterans with and without PTSD were compared on health behaviors and on self-reported and physician-rated health problems. Consistency of self-report with physician rating for health problems across the two groups was compared. In part 2, the association between health status and PTSD symptom severity, depression, somatization, and health behaviors in PTSD patients was evaluated. METHOD: In part 1, 276 combat veterans (225 with PTSD and 51 without PTSD) provided health status information, and medical records were reviewed. In part 2, 225 PTSD patients completed standardized PTSD severity, somatization, and depression measures. RESULTS: When analyses controlled for age, socioeconomic status, minority status, combat exposure, alcohol use, and pack-year history, veterans with PTSD reported and were rated as having a greater number of health problems than veterans without PTSD. Agreement between self-report and physician ratings for both groups ranged from low to moderate. Level of agreement between patient and physician was similar across groups. In the analysis of veterans with PTSD, somatization and PTSD symptom severity were significantly related to self-report of health problems, whereas only PTSD symptom severity was related to physician-rated health. Pack-year history was significantly related to self-reported health status in both groups. CONCLUSIONS: The presence and severity of PTSD in veterans were associated with greater physical health problems and conditions. Psychological variables (e.g., PTSD status, PTSD severity, somatization) and a behavioral variable (pack-year history) were related to health status.     

Treatment of Department of Veterans Affairs primary care patients with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is common among Veterans Affairs (VA) primary care patients and may be managed via multiple treatment pathways. Using the Behavioral Model of Health Service Use (Anderson, 1995), this retrospective study based on medical chart review examined factors associated with three types of mental health treatment: intervention by a 1) primary care provider (PCP), 2) primary care-mental health integration (PC-MHI) provider, and 3) specialty mental health (SMH) provider. A second goal was to describe PTSD treatment services for patients not receiving SMH by detailing the content of mental health treatment provided by PCPs and PC-MHI providers. Electronic medical record data for a five year time period for 133 Veterans were randomly selected for review from a population 6,637 primary care patients with PTSD. Results indicated that the evaluated needs of participants (i.e., number of unique medical and psychiatric disorders) were associated with Veterans receiving more intensive services (i.e., SMH). PCPs commonly addressed patients' mental health concerns, but patients often declined referrals for mental health treatment. PC-MHI consultations most often focused on medication management and supportive psychotherapy. (PsycINFO Database Record (c) 2011 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)     

Fear-potentiated startle in posttraumatic stress disorder

Exaggerated startle is reputed to be one of the cardinal symptoms of posttraumatic stress disorder (PTSD); however, objective studies have given conflicting results as to whether or not startle is increased in PTSD. The present study investigated startle in PTSD during the threat of shock (fear-potentiated startle). The eyeblink component of the startle reflex was measured at various times preceding and following the anticipation of unpleasant electric shocks in 9 PTSD subjects and 10 age-matched, healthy controls. Startle amplitude was significantly greater during baseline and during shock anticipation in the PTSD subjects, compared to the controls. Habituation of the startle reflex was normal. Because other studies in the literature, as well as in our own laboratory, have failed to find exaggerated startle at baseline (i.e., absence of stress) in PTSD patients, it is unlikely that the present results reflect a chronic elevation of startle in this group. Instead, the higher levels of startle in the PTSD group probably resulted from a greater conditioned emotional response in this group, triggered by anticipation of electric shocks that generalized to the unfamiliar experimental context in which testing occurred. Hence, emotionally charged test procedures may be especially informative in distinguishing PTSD patients from other psychiatric diagnostic groups.     

Client compliance with exposure treatments for posttraumatic stress disorder

Clients with posttraumatic stress disorder (PTSD) do not wish to "relive" their trauma, but exposure based treatments try to ensure that they do. While such treatments have proven efficacy in controlled outcome studies, how acceptable are they in routine clinical practice? The attempted clinical application of two such exposure treatments is briefly reported here. In the first, only 1 of 14 clients completed the image habituation procedure for homework in the manner described by its authors. In the second (N = 37), only 57% complied with an audiotape exposure treatment, and compliance was related to initial symptom severity and to severity of comorbid depression. Exposure based treatments are not 'treatment of choice' for some clients.     

The psychobiological basis of posttraumatic stress disorder

Posttraumatic stress disorder is a disorder with an identifiable etiological factor (exposure to a traumatic event) and with a complex symptomatology (i.e. intrusive memories, avoidance, hyperarousal) that suggests dysfunction in multiple psychobiological systems. This review considers studies of the neurobiological consequences of acute and chronic stress showing that traumatic experiences can produce long-lasting alterations in multiple neurochemical systems. The role of the locus coeruleus noradrenergic system, prefrontal cortex dopaminergic system, endogenous opiates, hypothalamic-pituitary-adrenal axis, and cortico-releasing factors are reviewed. Several models of PTSD are highlighted, including fear conditioning, kindling, and sensitization. In particular, fear conditioning to explicit and contextual cues is proposed as a model for intrusive memories reactivated by trauma-related stimuli and hyperarousal, respectively. It is argued that the amygdala plays a crucial role in the encoding and retrieval of fear memories activated by specific stimuli that have been associated with aversive events. Association involving more complex environmental stimuli and aversive events may require the involvement of the hippocampus and the bed nucleus of the stria terminalis. Repeated activation of conditioned fear memories may produce a kindling-like process which results in spontaneous intrusive memories.     

Emotional processing in posttraumatic stress disorder.

The emotional deficits associated with posttraumatic stress disorder (PTSD) are the least understood and the most understudied aspect of the syndrome. In this study, the connection was evaluated between trauma-context reactivity and subsequent emotional deficits in PTSD. Combat veterans with PTSD and well-adjusted veteran control participants were exposed to reminders of combat, after which their emotional behavior was assessed in response to a series of emotionally evocative images. Under the neutral condition, both groups exhibited emotional behavior modulated by stimulus valence. Partially consistent with the conceptual model described by B. Litz (1992), the PTSD group exhibited suppressed expressive-motor responses to positively valenced images, in comparison with the control group, only after being exposed to a trauma-related prime. Contrary to expectations, the PTSD group showed no augmentation of emotional response to negatively valenced cues after being exposed to trauma reminders. However, the PTSD group responded to all images, in both prime conditions, with higher heart rate reactivity, suggesting an automatic preparation for demand or threat in any uncertain emotional context. Possible causes and consequences of these results are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Awareness during anesthesia and posttraumatic stress disorder

The prevalence of tarsal coalition is probably 1% or less. The two sites most commonly affected are the calcaneonavicular joint and the middle facet of the talocalcaneal joint. Diagnosis should be suspected in the preteen or teenage patient with insidious or sudden onset of pain in the midfoot to hindfoot associated with a lack of motion in the subtalar joint. Initial treatment with immobilization or an orthosis may relieve symptoms, but most patients will have persistent symptoms that warrant surgical correction. Long-term results indicate that excision of the coalition is moderately successful in relieving symptoms in the calcaneonavicular bar. Long-term success with excision of subtalar bars is less clear, although early relief of symptoms is usually possible.     

Gender differences in posttraumatic stress disorder.

One of the most consistent findings in the epidemiology of posttraumatic stress disorder (PTSD) is the higher risk of this disorder in women. Explanations reviewed within a psychobiological model of PTSD suggest that women's higher PTSD risk may be due to the type of trauma they experience, their younger age at the time of trauma exposure, their stronger perceptions of threat and loss of control, higher levels of peritraumatic dissociation, insufficient social support resources, and greater use of alcohol to manage trauma-related symptoms like intrusive memories and dissociation, as well as gender-specific acute psychobiological reactions to trauma. This review demonstrates the need for additional research of the gender differences in posttraumatic stress. Recommendations are made for clinical practice. (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)     

Predictors of posttraumatic stress disorder following cancer.

This study investigated the predictors of posttraumatic stress disorder (PTSD) following a diagnosis of cancer. Individuals who were recently diagnosed with 1st onset head and neck or lung malignancy (N = 82) were assessed within 1 month of diagnosis for acute stress disorder (ASD) and other psychological responses including depression; individuals were reassessed (N = 63) for PTSD 6 months following their cancer diagnosis. At the initial assessment ASD was diagnosed in 28% of participants, and 22% met criteria for PTSD at 6-months follow-up. Peritraumatic dissociative symptoms at the time of receiving one's cancer diagnosis was the sole predictor of PTSD severity at 6-months follow-up. Elevated dissociative symptoms and greater distress at the initial assessment were the best predictors of PTSD caseness at 6-months follow-up. This study provides evidence for identifying recently diagnosed cancer patients who may benefit from psychological assistance in order to prevent chronic psychopathology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Positive symptoms of psychosis in posttraumatic stress disorder

The possible presence of hallucinations and delusional thoughts in posttraumatic stress disorder (PTSD) was investigated. Other symptom clusters were also assessed in order to further clarify the nature of PTSD. Twenty combat veterans with PTSD were compared to 18 combat veterans without PTSD on symptom rating scales. The subjects with PTSD exhibited a greater degree of depression, anxiety, agitation, anhedonia, and positive symptoms of psychosis than the comparison group. Specifically, the PTSD group manifested increased hallucinations, delusions, and bizarre behavior. Some of these positive symptoms did not appear to be due to reexperiencing of the trauma. The groups were not significantly different on indices of mania, thought disorder, or inertia. The clinical and diagnostic implications of the results are discussed. A diagnosis of PTSD should be considered with patients who have positive symptoms in the absence of thought disorder.     

Processing threatening information in posttraumatic stress disorder.

The authors used a modified Stroop task to study how people with posttraumatic stress disorder (PTSD) process threatening information. Participants were motor vehicle accident (MVA) survivors with either PTSD (n?=?15), simple phobia of driving (n?=?15), or low anxiety (n?=?15). Participants named colors of 4 types of words: strong threat words (MVA related), mild threat words (MVA related), positive words, and neutral words. Participants with PTSD demonstrated greater interference on strong threat words than those with simple phobia or low anxiety. Contrary to expectation, participants with simple phobia did not display an interference effect. Findings suggest that individuals with PTSD and simple phobia may process threatening information differently. The nature of attentional bias in different anxiety conditions following trauma is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Noradrenergic and serotonergic function in posttraumatic stress disorder

BACKGROUND: Yohimbine hydrochloride produces marked behavioral and cardiovascular effects in combat veterans with posttraumatic stress disorder (PTSD). In the present study, yohimbine was used as a probe of noradrenergic activity, and meta-chlorophenylpiperazine (m-CPP) as a probe of serotonergic activity. To our knowledge, this is the first study to describe the behavioral and cardiovascular effects of meta-CPP in patients with PTSD, and to compare these effects with those of yohimbine. METHOD: Twenty-six patients with PTSD and 14 healthy subjects each received an intravenous infusion of yohimbine hydrochloride (0.4 mg/kg), m-CPP (1.0 mg/kg), or saline solution on 3 separate test days in a randomized balanced order and in double-blind fashion. Behavioral and cardiovascular measurements were determined at multiple times. RESULTS: Eleven (42%) of the patients with PTSD experienced yohimbine-induced panic attacks and had significantly greater increases compared with controls in anxiety, panic, and PTSD symptoms, but not in cardiovascular measurements. Eight patients (31%) with PTSD experienced m-CPP-induced panic attacks and had significantly greater increases compared with controls in anxiety, panic, and PTSD symptoms, and in standing diastolic blood pressure. Yohimbine-induced panic attacks tended to occur in different patients from m-CPP-induced panic attacks. CONCLUSION: These data suggest the presence of 2 neurobiological subgroups of patients with PTSD, one with a sensitized noradrenergic system, and the other with a sensitized serotonergic system.     

Attributional style and combat-related posttraumatic stress disorder.

This study examined the relations of attributions for good and bad events on the one hand and combat-related posttraumatic stress disorder (PTSD) on the other. The sample consisted of 262 Israeli soldiers who suffered a combat stress reaction episode during the 1982 Lebanon War and were followed 2 and 3 years after their participation in combat. Cross-sectional analyses revealed significant relations between attributions and PTSD at the two points of assessment. Changes in PTSD from Time 1 to Time 2 were also associated with changes in attribution. Theoretical and clinical implications of the findings are discussed. (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)     

Prostitution, violence, and posttraumatic stress disorder

One hundred and thirty people working as prostitutes in San Francisco were interviewed regarding the extent of violence in their lives and symptoms of posttraumatic stress disorder (PTSD). Fifty-seven percent reported that they had been sexually assaulted as children and 49% reported that they had been physically assaulted as children. As adults in prostitution, 82% had been physically assaulted; 83% had been threatened with a weapon; 68% had been raped while working as prostitutes; and 84% reported current or past homelessness. We differentiated the types of lifetime violence as childhood sexual assault; childhood physical abuse; rape in prostitution; and other (non-rape) physical assault in prostitution. PTSD severity was significantly associated with the total number of types of lifetime violence (r = .21, p = .02); with childhood physical abuse (t = 2.97, p = .004); rape in adult prostitution (Student's t = 2.77, p = .01); and the total number of times raped in prostitution (Kruskal-Wallace chi square = 13.51, p = .01). Of the 130 people interviewed, 68% met DSM III-R criteria for a diagnosis of PTSD. Eighty-eight percent of these respondents stated that they wanted to leave prostitution, and described what they needed in order to escape.     

Cognitive processing therapy for veterans with military-related posttraumatic stress disorder.

Sixty veterans (54 men, 6 women) with chronic military-related posttraumatic stress disorder (PTSD) participated in a wait-list controlled trial of cognitive processing therapy (CPT). The overall dropout rate was 16.6% (20% from CPT, 13% from waiting list). Random regression analyses of the intention-to-treat sample revealed significant improvements in PTSD and comorbid symptoms in the CPT condition compared with the wait-list condition. Forty percent of the intention-to-treat sample receiving CPT did not meet criteria for a PTSD diagnosis, and 50% had a reliable change in their PTSD symptoms at posttreatment assessment. There was no relationship between PTSD disability status and outcomes. This trial provides some of the most encouraging results of PTSD treatment for veterans with chronic PTSD and supports increased use of cognitive- behavioral treatments in this population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)