Faculty Bibliography

Patients with posttraumatic stress disorder (PTSD) experience psychological and physiological distress. However, imaging research has mostly focused on the psychological aspects of the disorder. Considered an expression of distress, heart rate (HR) in PTSD is often elevated. In the current study, we sought to identify brain regions associated with increased HR in PTSD. Nine patients with PTSD and six healthy trauma survivors were scanned while resting, clenching teeth, and listening to neutral and traumatic scripts. Brain function was evaluated using H2O15 positron emission tomography (PET). HR was monitored by electrocardiogram. Data were analyzed using statistical parametric mapping (SPM). Subjects with PTSD exhibited a significant increase in HR upon exposure to traumatic scripts, while trauma survivors did not. Correlations between regional cerebral blood flow and HR were found only in patients with PTSD, in orbitofrontal, precentral and occipital regions. Neither group showed correlation between rCBF and HR in the amygdala or hippocampus. These preliminary results indicate that "top down" central nervous system regulation of autonomic stress response in PTSD may involve associative, sensory and motor areas in addition to regions commonly implicated in fear conditioning.

CONTEXT: Preventing posttraumatic stress disorder (PTSD) is a pressing public health need. OBJECTIVES: To compare early and delayed exposure-based, cognitive, and pharmacological interventions for preventing PTSD. DESIGN: Equipoise-stratified randomized controlled study. SETTING: Hadassah Hospital unselectively receives trauma survivors from Jerusalem and vicinity. PARTICIPANTS: Consecutively admitted survivors of traumatic events were assessed by use of structured telephone interviews a mean (SD) 9.61 (3.91) days after the traumatic event. Survivors with symptoms of acute stress disorder were referred for clinical assessment. Survivors who met PTSD symptom criteria during the clinical assessment were invited to receive treatment. INTERVENTIONS: Twelve weekly sessions of prolonged exposure (PE; n = 63), or cognitive therapy (CT; n = 40), or double blind treatment with 2 daily tablets of either escitalopram (10 mg) or placebo (selective serotonin reuptake inhibitor/placebo; n = 46), or 12 weeks in a waiting list group (n = 93). Treatment started a mean (SD) 29.8 (5.7) days after the traumatic event. Waiting list participants with PTSD after 12 weeks received PE a mean (SD) 151.8 (42.4) days after the traumatic event (delayed PE). Main Outcome Measure Proportion of participants with PTSD after treatment, as determined by the use of the Clinician-Administered PTSD Scale (CAPS) 5 and 9 months after the traumatic event. Treatment assignment and attendance were concealed from the clinicians who used the CAPS. RESULTS: At 5 months, 21.6% of participants who received PE and 57.1% of comparable participants on the waiting list had PTSD (odds ratio [OR], 0.21 [95% CI, 0.09-0.46]). At 5 months, 20.0% of participants who received CT and 58.7% of comparable participants on the waiting list had PTSD (OR, 0.18 [CI, 0.06-0.48]). The PE group did not differ from the CT group with regard to PTSD outcome (OR, 0.87 [95% CI, 0.29-2.62]). The PTSD prevalence rates did not differ between the escitalopram and placebo subgroups (61.9% vs 55.6%; OR, 0.77 [95% CI, 0.21-2.77]). At 9 months, 20.8% of participants who received PE and 21.4% of participants on the waiting list had PTSD (OR, 1.04 [95% CI, 0.40-2.67]). Participants with partial PTSD before treatment onset did similarly well with and without treatment. CONCLUSIONS: Prolonged exposure, CT, and delayed PE effectively prevent chronic PTSD in recent survivors. The lack of improvement from treatment with escitalopram requires further evaluation. Trauma-focused clinical interventions have no added benefit to survivors with subthreshold PTSD symptoms. Trial Registration clinicaltrials.gov Identifier: NCT00146900

OBJECTIVES: Preventing posttraumatic stress disorder (PTSD) is a pressing public health need. Studies have shown significant barriers to obtaining early care. This study prospectively evaluated the acceptance of early assessment and treatment, the accuracy of recommending care, and the consequences of declining it. METHODS: Researchers undertook systematic outreach to survivors of traumatic events consecutively seen in a general hospital emergency department. Structured telephone interviews were conducted 9.5+/-3.2 days after the emergency visit. Persons with acute stress disorder symptoms were invited for clinical assessment. Those clinically assessed as having acute PTSD symptoms were offered treatment. Telephone interviews, conducted 224.9+/-39.1 days from the traumatic event, evaluated those included in the initial assessment and a random sample of 10% of those not included because they were deemed not to have experienced a traumatic event. RESULTS: Telephone calls were made to 5,286 individuals, and 5,053 were reached (96%). Of these, 4,743 (94%) agreed to a telephone interview, 1,502 were invited for a clinical assessment, 756 (50%) attended the assessment, 397 were eligible for treatment, and 296 (75%) started treatment. Declining clinical assessments and treatment were associated with less symptom reduction over time. The prevalence of PTSD among those deemed not to have experienced a traumatic event, not to need clinical assessment, and not to need treatment were, respectively, 4%, 11%, and 3%. CONCLUSIONS: Despite successful outreach, many symptomatic participants declined clinical care and subsequently recovered less well. Screening for DSM-IV PTSD criterion A effectively identified survivors at low risk for PTSD. Systematic outreach is costly and might be reserved for exceptionally traumatic events

This paper examined the hypothesis that PTSD-unique symptom clusters of re-experiencing, active avoidance and hyperarousal were more related to the fear/phobic disorders, while shared PTSD symptoms of dysphoria were more closely related to Anxious-Misery disorders (MDD/GAD). Confirmatory factor and correlation analyses examining PTSD, anxiety and mood disorder data from 714 injury survivors interviewed 3, 12 and 24-months following their injury supported this hypothesis with these relationships remaining robust from 3-24 months posttrauma. Of the nine unique fear-oriented PTSD symptoms, only one is currently required for a DSM-IV diagnosis. Increasing emphasis on PTSD fear symptoms in DSM-V, such as proposed DSM-V changes to mandate active avoidance, is critical to improve specificity, ensure inclusion of dimensionally distinct features and facilitate tailoring of treatment

OBJECTIVE: The diagnosis of posttraumatic stress disorder (PTSD) is unique in that its criteria are embedded with a presumed causal agent, viz, a traumatic event. This assumption has come under scrutiny as a number of recent studies have suggested that many symptoms of PTSD may not necessarily be the result of trauma and may merely represent general psychiatric symptoms that would have existed even in the absence of a trauma event but are subsequently misattributed to it. The current study tests this hypothesis. METHOD: A case-control twin study conducted between 1996-2001 examined psychopathologic symptoms in a national convenience sample of 104 identical twin pairs discordant for combat exposure in Vietnam, with (n = 50) or without (n = 54) combat-related PTSD (DSM-IV-diagnosed) in the exposed twin. Psychometric measures used were the Symptom Checklist-90-Revised, the Clinician-Administered PTSD Scale, and the Mississippi Scale for Combat-Related PTSD. If a psychopathologic feature represents a factor that would have existed even without traumatic exposure, then there is a high chance that it would also be found at elevated rates in the non-trauma-exposed, identical cotwins of trauma-exposed twins with PTSD. In contrast, if a psychopathologic feature is acquired as a result of an environmental factor unique to the exposed twin, eg, the traumatic event, their cotwins should not have an increased incidence of the feature. RESULTS: Combat veterans with PTSD demonstrated significantly higher scores (P < .0001) on the Symptom Checklist-90-Revised and other psychometric measures of psychopathology than their own combat-unexposed cotwins (and than combat veterans without PTSD and their cotwins). CONCLUSIONS: These results support the conclusion that the majority of psychiatric symptoms reported by combat veterans with PTSD would not have been present were it not for their exposure to traumatic events

BACKGROUND: Controversy exists about the utility of DSM-IV posttraumatic stress disorder (PTSD) criterion A2 (A2): that exposure to a potentially traumatic experience (PTE; PTSD criterion A1) is accompanied by intense fear, helplessness, or horror. METHODS: Lifetime DSM-IV PTSD was assessed with the Composite International Diagnostic Interview in community surveys of 52,826 respondents across 21 countries in the World Mental Health Surveys. RESULTS: Of 28,490 representative PTEs reported by respondents, 37.6% met criterion A2, a proportion higher than the proportions meeting other criteria (B-F; 5.4%-9.6%). Conditional prevalence of meeting all other criteria for a diagnosis of PTSD given a PTE was significantly higher in the presence (9.7%) than absence (.1%) of A2. However, as only 1.4% of respondents who met all other criteria failed A2, the estimated prevalence of PTSD increased only slightly (from 3.64% to 3.69%) when A2 was not required for diagnosis. Posttraumatic stress disorder with or without criterion A2 did not differ in persistence or predicted consequences (subsequent suicidal ideation or secondary disorders) depending on presence-absence of A2. Furthermore, as A2 was by far the most commonly reported symptom of PTSD, initial assessment of A2 would be much less efficient than screening other criteria in quickly ruling out a large proportion of noncases. CONCLUSIONS: Removal of A2 from the DSM-IV criterion set would reduce the complexity of diagnosing PTSD, while not substantially increasing the number of people who qualify for diagnosis. Criterion A2 should consequently be reconceptualized as a risk factor for PTSD rather than as a diagnostic requirement

Traumatic events can shatter faith and beliefs. The responses of Ultra-Orthodox survivors of deadly terrorist attacks illustrate an effort to reconcile dreadful experiences with deeply embedded beliefs. Qualified clinicians prospectively evaluated self-reported and interviewer-generated posttraumatic stress disorder (PTSD) symptoms and cognitive appraisal in Ultra-Orthodox (n = 20) and non-Ultra-Orthodox (n = 33) survivors of suicide bus-bombing incidents in Jerusalem. Ultra-Orthodox survivors reported higher levels of PTSD symptoms and more personal guilt. Their narratives reflected an unshaken belief in Just Providence, within which being a victim of terror was perceived as a Just retribution for known or unknown wrongdoing. Survivors' reactions to trauma often reflect an effort to reconcile incongruous experiences with previously held beliefs. When treating strict believers, helpers should be sensitive to the identity-preserving function of posttraumatic cognitions

OBJECTIVE: When positioned in a combat situation, soldiers may be subjected to extreme stress. However, only a few combat-exposed soldiers develop long-term disturbance, namely, posttraumatic stress disorder (PTSD). This study aimed to explore risk factors for developing PTSD in order to improve the psychiatric screening process of new recruits. METHOD: In a semiprospective design, we compared 2,362 war veterans who developed PTSD (according to DSM-IV criteria) with an equal number of war veterans who did not develop PTSD. Controls were matched on the basis of sequential army identification numbers, that is, the soldier drafted immediately after the index PTSD veteran (usually on the same day). This method ensured similar demographic variables such as socioeconomic level and education. Data were collected from the Israeli Defense Force database and used in a comprehensive survey conducted between January 2000 and March 2001. Comparisons were made on predrafting personal factors (behavioral assessment, cognitive assessment, linguistic ability, and education) and pretrauma army characteristics (ie, rank and training). RESULTS: Neither behavioral assessment nor training were found to predict PTSD. The predictive factors that were found were essentially nonspecific, such as cognitive functioning, education, rank, and position during the trauma, with little effect from training. CONCLUSIONS: In an armed force that uses universal recruitment, carefully structured predrafting psychological assessment of social and individual qualifications (including motivation) failed to identify increased risk factors for PTSD. However, nonspecific factors were found to be associated with an increased risk for PTSD. This study suggests that the focus of future research on risk factors for PTSD should incorporate other domains rather than behavioral assessment alone. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00229359

Posttraumatic stress disorder (PTSD) is a prevalent anxiety disorder. Symptoms present shortly after an exposure to a traumatic event, abate with time in the majority of those who initially express them, and leave a significant minority with chronic PTSD. PTSD may be treated with pharmacotherapy or psychotherapy. Treatment of the early expressions of the disorder constitutes a separate domain of theory and research. Treatment of chronic PTSD often stabilizes the condition but rarely produces stable remission. This article reviews the empirical evidence on the treatment of acute and chronic PTSD, outlines similarities and differences between PTSD and other Axis I disorders, evaluates new therapeutic approaches, and discusses the implications of current knowledge for the forthcoming DSM-V

Depression and posttraumatic stress disorder (PTSD) are highly comorbid conditions that may arise following exposure to psychological trauma. This study examined their temporal sequencing and mutual influence using bivariate latent difference score structural equation modeling. Longitudinal data from 182 emergency room patients revealed level of depression symptom severity to be positively associated with changes in PTSD intrusion, avoidance, and hyperarousal over 3 time intervals, beginning shortly after the traumatic event. Higher scores on depression anticipated increases (or worsening) in PTSD symptom severity. The pattern of influence from PTSD symptom severity to change in depression symptom severity simply followed the general trend toward health and well-being. Results are discussed in terms of the dynamic interplay and associated mechanisms of posttrauma depression and PTSD symptom severity.