Faculty Bibliography

PURPOSE OF REVIEW: The development of acute and posttraumatic stress symptoms after a traumatic event is common and often leads to personal distress, functional impairment, and economic consequences in trauma victims and their loved ones. Hence, the prevention of acute and chronic posttraumatic stress is an important public health priority. This article aims to review the current evidence regarding immediate (within hours) and early (within days and weeks) psychological and behavioral interventions to prevent posttraumatic stress symptoms. RECENT FINDINGS: Acute distress management, psychological debriefing and other immediate unspecific interventions within the first hours following a traumatic event have so far not demonstrated efficacy in preventing posttraumatic stress symptoms. So far, there are no randomized controlled trials (RCTs) that have examined immediate trauma-focused cognitive behavioral interventions. In contrast, some, but not many, studies have shown that cognitive behavioral interventions are efficacious if administered within days or weeks after a traumatic event. For other early interventions after trauma exposure, there is no, or only weak, evidence in support of their efficacy. However, conclusions are limited by the small numbers of trials examining immediate and early interventions. SUMMARY: Today, there is no empirical evidence to support any immediate intervention within hours after the traumatic event to prevent posttraumatic stress symptoms. With regard to early interventions in the first days or weeks after trauma, literature is also sparse, but supports brief cognitive behavioral interventions as a first choice. There is an urgent need for RCTs to examine if behavioral interventions immediately following a traumatic event might be able to reduce the burden of acute and posttraumatic stress symptoms

Post-traumatic stress disorder (PTSD) is associated with elevated catecholamines and increased sympathetic arousal. However, it is unknown whether this condition is a pre-existing vulnerability factor for PTSD or an acquired result of either trauma exposure or the development of PTSD symptoms. We sought to examine if salivary 3-methoxy-4-hydroxy-phenylglycol (MHPG) in response to a laboratory stressor prior to critical incident exposure predicts the development of PTSD symptoms and if early childhood trauma influences this relationship. In a prospective cohort study, 349 urban police officers were assessed during academy training (baseline) and 243 were reassessed 12 months after the start of active duty (follow-up). At baseline, participants observed a video consisting of police critical incidents. Salivary MHPG was measured before and immediately after the challenge, and after 20min recovery. At follow-up, peritraumatic distress and PTSD symptoms were assessed in relationship to the worst critical incident during the past year. Participants with childhood trauma showed a trend towards higher MHPG increase to the challenge. Higher MHPG levels after 20min recovery were associated with both higher levels of peritraumatic distress and PTSD symptoms at follow-up. In a path analysis, elevated MHPG levels predicted higher peritraumatic distress which in turn predicted higher levels of PTSD symptoms while the direct effect of elevated MHPG levels on PTSD symptoms was no longer significant. Prolonged elevation of salivary MHPG in response to a laboratory stressor marks a predisposition to experience higher levels of peritraumatic distress and subsequently more PTSD symptoms following critical incident exposure

Research has consistently demonstrated that stress reactions to potentially traumatic events do not represent a unified phenomenon. Instead, individuals tend to cluster into prototypical response patterns over time including chronic symptoms, recovery, and resilience. We examined heterogeneity in a posttraumatic stress disorder (PTSD) symptom course in a sample of 178 active-duty police officers following exposure to a life-threatening event using latent growth mixture modeling (LGMM). This analysis revealed 3 discrete PTSD symptom trajectories: resilient (88%), distressed-improving (10%), and distressed-worsening (2%). We further examined whether trait and peritraumatic dissociation distinguished these symptom trajectories. Findings indicate that trait and peritraumatic dissociation differentiated the resilient from the distressed-improving trajectory (trait, p < .05; peritraumatic, p < .001), but only peritraumatic dissociation differentiated the resilient from the distressed-worsening trajectory (p < .001). It is essential to explore heterogeneity in symptom course and its predictors among active-duty police officers, a repeatedly exposed group. These findings suggest that police officers may be a highly resilient group overall. Furthermore, though there is abundant evidence that dissociation has a positive linear relationship with PTSD symptoms, this study demonstrates that degree of dissociation can distinguish between resilient and symptomatic groups of individuals

This study examined combat and mental health as risk factors of suicidal ideation among 2854 U.S. soldiers returning from deployment in support of Operation Iraqi Freedom. Data were collected as part of a postdeployment screening program at a large Army medical facility. Overall, 2.8% of soldiers reported suicidal ideation. Postdeployment depression symptoms were associated with suicidal thoughts, while postdeployment PTSD symptoms were associated with current desire for self harm. Postdeployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while postdeployment PTSD symptoms mediated the association between killing in combat and desire for self harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning veterans

In a large sample of urban police officers, 18.1% of males and 15.9% of females reported experiencing adverse consequences from alcohol use and 7.8% of the sample met criteria for lifetime alcohol abuse or dependence. Female officers had patterns of alcohol use similar to male officers and substantially more than females in the general population. Critical incident exposure and posttraumatic stress disorder (PTSD) symptoms were not associated with level of alcohol use. Greater psychiatric symptoms were related to adverse consequences from alcohol use. There was a noteworthy gender by work stress interaction: greater routine work stress related to lower current alcohol use in female officers. (Am J Addict 2010;00:1-9)

BACKGROUND: The hypothalamic-pituitary-adrenal axis is a major stress response system hypothesized to be involved in the pathogenesis of posttraumatic stress disorder (PTSD). However, few studies have prospectively examined the relationships among pre-exposure hypothalamic-pituitary-adrenal activity, acute stress reactions and PTSD. METHODS: Two hundred ninety-six police recruits were assessed during academy training before critical incident exposure and provided salivary cortisol at first awakening and after 30 minutes. A measure of cortisol awakening response (CAR) was computed as the change in cortisol level from the first to the second collection. At 12, 24, and 36 months following the start of active police service, officers were assessed for peritraumatic distress, peritraumatic dissociation, acute stress disorder (ASD) symptoms, and PTSD symptoms to their self-identified worst duty-related critical incident. Mixed models for repeated measures were used to analyze the effects of CAR on the outcome variables pooled across the three follow-up assessments. RESULTS: After controlling for time of awakening, first awakening cortisol levels, and cumulative critical incident stress exposure, CAR during academy training was associated with greater peritraumatic dissociation, beta = .14, z = 3.49, p < .0001, and greater ASD symptoms during police service assessed at 12, 24, and 36 months, beta = .09, Z = 2.03, p < .05, but not with peritraumatic distress, beta = .03, z = .81, p = .42, or PTSD symptoms, beta = -.004, z = -.09, p = .93. CONCLUSIONS: These findings suggest that greater cortisol response to awakening is a pre-exposure risk factor for peritraumatic dissociation and ASD symptoms during police service

The goal of this study was to determine whether posttraumatic stress disorder (PTSD) was associated with an increase in time-related decline in macrostructural brain volume and whether these changes were associated with accelerated cognitive decline. To quantify brain structure, three-dimensional T1-weighted MRI scans were performed at baseline and again after a minimum of 24months in 25 patients with PTSD (PTSD+) and 22 controls (PTSD-). Longitudinal changes in brain volume were measured using deformation morphometry. For the group as a whole, PTSD+ patients did not show significant ongoing brain atrophy compared to PTSD-. PTSD+ patients were then subgrouped into those with decreasing or increasing symptoms. We found little evidence for brain markers of accelerated atrophy in PTSD+ veterans whose symptoms improved over time, with only a small left parietal region showing greater ongoing tissue loss than PTSD-. PTSD patients whose symptoms increased over time showed accelerated atrophy throughout the brain, particularly brainstem and frontal and temporal lobes. Lastly, for the sample as a whole, greater rates of brain atrophy were associated with greater rates of decline in verbal memory and delayed facial recognition

This study examined the impact of killing on posttraumatic stress symptomatology (PTSS), depression, and alcohol use among 317 U.S. Gulf War veterans. Participants were obtained via a national registry of Gulf War veterans and were mailed a survey assessing deployment experiences and postdeployment mental health. Overall, 11% of veterans reported killing during their deployment. Those who reported killing were more likely to be younger and male than those who did not kill. After controlling for perceived danger, exposure to death and dying, and witnessing killing of fellow soldiers, killing was a significant predictor of PTSS, frequency and quantity of alcohol use, and problem alcohol use. Military personnel returning from modern deployments are at risk of adverse mental health symptoms related to killing in war. Postdeployment mental health assessment and treatment should address reactions to killing in order to optimize readjustment.

The Critical Incident History Questionnaire indexes cumulative exposure to traumatic incidents in police by examining incident frequency and rated severity. In over 700 officers, event severity was negatively correlated (r(s) = -.61) with frequency of exposure. Cumulative exposure indices that varied emphasis on frequency and severity-using both nomothetic and idiographic methods-all showed satisfactory psychometric properties and similar correlates. All indices were only modestly related to posttraumatic stress disorder (PTSD) symptoms. Ratings of incident severity were not influenced by whether officers had ever experienced the incident. Because no index summarizing cumulative exposure to trauma had superior validity, our findings suggest that precision is not increased if frequency is weighted by severity.

CONTEXT: Posttraumatic stress disorder (PTSD) is highly prevalent among US veterans because of combat and may impair cognition. OBJECTIVE: To determine whether PTSD is associated with the risk of developing dementia among older US veterans receiving treatment in the Department of Veterans Affairs medical centers. DESIGN: A stratified, retrospective cohort study conducted using the Department of Veterans Affairs National Patient Care Database. SETTING: Department of Veterans Affairs medical centers in the United States. PARTICIPANTS: A total of 181 093 veterans 55 years or older without dementia from fiscal years 1997 through 2000 (53 155 veterans with and 127 938 veterans without PTSD). MAIN OUTCOME MEASURES: During the follow-up period between October 1, 2000, and December 31, 2007, 31 107 (17.2%) veterans were ascertained to have newly diagnosed dementia according to International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS: The mean baseline age of the veterans was 68.8 years, and 174 806 (96.5%) were men. Veterans with PTSD had a 7-year cumulative incident dementia rate of 10.6%, whereas those without had a rate of 6.6% (P < .001). With age as the time scale, Cox proportional hazards models indicated that patients with PTSD were more than twice as likely to develop incident dementia compared with those without PTSD (hazard ratio, 2.31; 95% confidence interval, 2.24-2.39). After multivariable adjustment, patients with PTSD were still more likely to develop dementia (hazard ratio, 1.77; 95% confidence interval, 1.70-1.85). Results were similar when we excluded those with a history of head injury, substance abuse, or clinical depression. CONCLUSIONS: In a predominantly male veteran cohort, those diagnosed as having PTSD were at a nearly 2-fold-higher risk of developing dementia compared with those without PTSD. Mechanisms linking these important disorders need to be identified with the hope of finding ways to reduce the increased risk of dementia associated with PTSD.