Faculty Bibliography

In the 2 plus years since the terrorist attacks of Sept. 11, 2001, a substantial number of children have developed psychiatric disorders, severe psychological distress, and functional impairment. Despite significant financial support, the availability of mental health services, and the presence of relatively sophisticated mental health providers, a surprisingly large gap has emerged between documented need and service use. This article identifies some of the factors that appear to have contributed to this situation and potential remedies for ongoing difficulties

Community studies indicate that 19% of men and 31% of women will develop some type of anxiety disorder during their lifetime. The impact of gender is profound in that it increases the likelihood of developing an anxiety disorder by 85% in women compared to men. Sex difference in prevalence rates are apparent as early as age 6, when girls are twice as likely as boys to have an anxiety disorder. In the National Comorbidity Survey, the prevalence rates for panic disorder in women and men were 5% and 2%, respectively. Agoraphobia, which often coexists with panic disorder, has a lifetime prevalence rate of 7% in women and 3.5% in men. Prevalence of trauma is increased in young women as well, and is experienced earlier in life; 62% of sexual assaults are inflicted on females <18 years of age, and 29% occur in children <11 years of age. Comorbidity of anxiety in women complicates other medical conditions as well. For example, panic disorder is highly comorbid with CHD, which remains the leading cause of death in women in developed countries. Fluctuations in reproductive hormone levels during the female life cycle is thought to be responsible for modulating anxiety. This is often implicated in the later age of onset, the more sudden and acute symptom emergence, and the more episodic course of OCD in women, and in the high prevalence (47.4%) of PMDD. Pregnancy appears to be a protective period for some anxiety disorders, including panic, while for others, such as OCD, it may be associated with onset. Hormonal changes during pregnancy, such as increased prolactin, oxytocin, and cortisol, may contribute to the suppression of stress response that occurs during this period. Despite a large and growing body of literature on anxiety disorders in general, the available data relating to women and girls falls short of informing aspects of diagnosis, treatment, and prevention that may entail sex differences. Additional work is required to understand the biological and psychosocial causes of these differences

This reply to the comment by Cahill, Riggs, Zoellner, and Feeny (2004; see record 2004-95166-018) on the article by Cloitre, Koenen, Cohen, and Han (2002; see record 2002-18226-001) reiterates that an important goal of treatment research among chronically traumatized populations is to address problems that impair life functioning, including not only posttraumatic stress disorder but also emotion regulation difficulties and interpersonal problems. The need for further research on symptom exacerbation and drop-out rates in exposure-based treatment for child abuse survivors is discussed. An ongoing follow-up study is described, which is designed to assess the relative utility of STAIR and modified PE individually versus their combination in meeting 'good outcome' standards as defined above. (journal abstract)

Background: Few effective pharmacotherapeutic strategies have been established for the treatment of symptoms associated with posttraumatic stress disorder (PTSD). Preliminary evidence supports the efficacy of serotonergic agents and anticonvulsants, such as divalproex sodium, for the treatment of PTSD symptoms, particularly in military populations. Objective: The aim of this study was to obtain pilot data on the use of divalproex sodium for the treatment of PTSD among adult civilian outpatients with a history of childhood physical and/or sexual abuse. Methods: Outpatients with a primary psychiatric diagnosis of PTSD received open-label, flexibly dosed divalproex sodium as adjuvant therapy or monotherapy for 8 weeks. Overall and subcluster PTSD features, as well as affective symptoms and clinical global improvement, were monitored using standardized assessment scales. Results: A total of 7 patients (5 women, 2 men; mean age, 44.1 years [range, 29-57 years]) were enrolled. At a mean (SD) peak dosage of 1500 (661) mg/d, significant improvement occurred in overall PTSD symptom severity (P<0.02) and in the diagnostic subclusters of hyperarousal and avoidance (P<0.02 for both). Depressive symptoms also were significantly improved from baseline (P<0.02). Divalproex sodium was well tolerated, except in 1 patient who prematurely discontinued treatment due to cognitive adverse events. Conclusions: These provisional findings support the possible utility of divalproex sodium therapy for adult outpatients with PTSD related to physical and/or sexual abuse during childhood. Controlled trials with larger sample sizes powered to show safety and efficacy are needed to substantiate these initial findings.

OBJECTIVE: Disturbed regulation of both the hypothalamic-pituitary-adrenal (HPA) axis and the sympathoadrenomedullary system in posttraumatic stress disorder (PTSD) suggests that immune function, which is modulated by these systems, also may be dysregulated in individuals with PTSD. METHOD: Delayed-type hypersensitivity skin test responses were measured in 16 women with PTSD due to childhood sexual or physical abuse and 15 women who did not have a history of abuse, other trauma, or psychiatric disorders. HPA axis activity was assessed by examination of circadian salivary cortisol levels and a single time point measurement of plasma cortisol. RESULTS: Delayed-type hypersensitivity was enhanced in women with PTSD. Cortisol measures did not differ between PTSD and healthy comparison subjects. CONCLUSIONS: These results suggest that cell-mediated inflammatory reactions are greater in individuals with PTSD

Combat-related posttraumatic stress disorder (PTSD) is highly comorbid with other mental disorders. However, the nature of the relationship between PTSD and other mental disorders remains unclear. A discordant high-risk twin design was used on data from a sub-sample of the male-male twin pair members of the Vietnam Era Twin Registry to examine whether patterns of comorbidity are consistent with a psychopathological response to combat exposure or reflect familial vulnerability to psychopathology. Mental disorders were assessed via the Mental Health Diagnostic Interview Schedule Version I

Stimuli associated with sources of stress have been shown to interfere with cognition. The authors hypothesized that women with the stress of having a family history of breast cancer (FH+) would exhibit greater interference on a task with cancer-related stimuli than women without cancer in the family (FH-). The authors developed a modified Stroop color-naming task to test this hypothesis in a sample of FH+ (n = 72) and FH- (n = 96) women. Consistent with the hypotheses, FH+ women had longer color-naming times and more errors (ps < .01) on a cancer word list relative to noncancer lists. This biased processing was not mediated by the significantly higher perceived risk, general distress, or cancer-specific distress in FH+ women. Maladaptive alterations in processing cancer stimuli may have important clinical implications, as these women must process complex cancer-related information critical to their health (e.g., options for chemoprevention, screening)

Relations among peritraumatic dissociation, PTSD severity, event-related fear (i.e. fear experienced during traumatic event) about death, and event-related fear about losing control were examined in the current study. Particular emphasis was placed on testing whether or not fears about death and losing control mediate the relation between peritraumatic dissociation and PTSD severity in a sample of 146 nontreatment-seeking university women. Results indicated that event-related fears about death and losing control accounted for the relation between peritraumatic dissociation and PTSD severity; that is, the effect of peritraumatic dissociation on PTSD severity was eliminated after controlling for these fears. Speculations about findings are discussed

As part of an ongoing randomized clinical trial for childhood-abuse-related PTSD, this study examined the association between PTSD and unresolved attachment as measured by the Adult Attachment Interview in a sample of 52 female childhood-abuse survivors. Results revealed that 55% of the sample was classified as preoccupied and almost 75% was classified as unresolved with regard to trauma. In a preliminary sample of 18 women who completed treatment, 13 were unresolved before treatment and 8 lost their unresolved status following treatment. This effect was significantly more pronounced in the exposure condition compared to the skills training condition