Natural Posttraumatic Stress Treatment Systems

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Section III Management of Posttraumatic Stress Disorder

Pharmacotherapy Research in Posttraumatic Stress Disorder 101 Section IV. Virtual Reality Therapy in the Treatment of Posttraumatic Stress Disorder and Related Psychiatric Conditions Scenario Self-Adaptation in Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder 135 Clinical Issues in the Application of Virtual Reality to Treatment of PTSD 183 Developing a Virtual Reality Treatment Protocol for Posttraumatic Stress Disorder Following the World Trade Center Attack 219 A Virtual Reality Exposure Therapy Application for Iraq War Military Personnel with Post Traumatic Stress Disorder From Training to Toy to Treatment 235

Biological Markers in Croatian War Veterans with Combat Related Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a severe psychiatric illness associated with disturbances in diverse neurobiological systems. The evaluation of a variety of biomarkers might facilitate a goal of modern medicine, a proper treatment for an individual patient at a given stage of disease. This is especially important in PTSD, a disorder with a complex clinical picture, diverse symptoms, and frequent comorbidities. Biological markers (platelet serotonin, platelet monoamine oxidase, plasma lipid levels, plasma dopamine beta hydroxylase, plasma cortisol and serum levels of thyroid hormones) were determined, and clinical symptoms were evaluated, in 93 male war veterans with chronic combat related PTSD, using the Clinician Administrated PTSD Scale, Positive and Negative Syndrome Scale, and the Hamilton Rating scales for Depression and Anxiety. Platelet serotonin concentration and plasma dopamine beta hydroxylase activity were similar in PTSD subjects and healthy controls....

How common are traumatic events in the population

In a large representative United States' sample, Kessler et al. (31> found that 60.7 per cent of the men and 51.2 per cent of the women had experienced at least one traumatic event meeting DSM-IIIR criteria in their lifetime. The most common types of trauma were witnessing someone being killed or severely injured, accidents, and being involved in a fire, flood, or natural disaster. Using DSM-IV criteria, Stein et al. (32) found a lifetime exposure to serious traumatic events of 81.3 per cent for men, and 74.2 per cent for women. Sudden death of a loved person was one of the most frequent traumatic stressors (DSM-IV criteria).(33.)

What types of trauma are associated with high PTSD rates

PTSD rates depend on the type of traumatic event. Rape was associated with the highest PTSD rates in several studies. For example, 65 per cent of the men and 46 per cent of the women who had been raped met PTSD criteria in the Kessler et al. (31) study. Other traumatic events associated with high PTSD rates included combat exposure, childhood neglect and physical abuse, sexual molestation and for women only, physical attack and being threatened with a weapon, kidnapped, or held hostage. Accidents, witnessing death or injury, and fire or natural disasters were associated with relatively low lifetime PTSD rates of less than 10 per cent. (31> Other research has shown high PTSD rates for torture victims,(34) survivors of the Holocaust,(35 and prisoners of war.(36) The emphasis in DSM-IV on threat to life or physical integrity has led to increasing awareness that medical illness and treatment can lead to PTSD. (37) Waking up during anaesthesia, especially if the patient experienced pain,...

What proportion of people develop PTSD in response to a traumatic stressor

Kessler et al. (31> found that the risk of developing PTSD after a traumatic event is 8.1 per cent for men, and 20.4 per cent for women. For young urban populations, higher risks have been reported Breslau et al. found an overall risk of 23.6 per cent,(38,) a risk of 13 per cent for men and 30.2 per cent for women. (39> The figures reported in these studies may be influenced by two types of biases that have opposite effects on probability estimates. First, Breslau et al. (33) have pointed out that previous studies overestimated the PTSD-risk imposed by traumatic events because participants reported on the worst trauma that they had experienced. When the symptoms induced by a traumatic event that was randomly selected from the ones that a person had experienced were assessed, the conditional risk of PTSD following exposure to trauma was found to be 9.2 per cent, using DSM-IV criteria. Second, the retrospective methodology used in the epidemiological studies may have led to...

Comorbidity of PTSD with other disorders and symptoms

PTSD shows a substantial comorbidity with affective disorders, other anxiety disorders, substance-use disorders, and somatization. In the study by Kessler et al.,(31) 88.3 per cent of the men and 78.1 per cent of the women with PTSD had comorbid psychiatric diagnoses. Studies of veterans with PTSD have also indicated an enhanced level of problems in family and marital adjustment and violent behaviour, (45> and heavy smoking.(46> Furthermore, reports of poor health and increased rates of various diseases, in particular infectious and nervous system diseases, are associated with PTSD. (4D Is PTSD primary or secondary to the comorbid diagnoses There is, as yet, little research into this question. The retrospective accounts obtained by Kessler et al. (31 suggested that PTSD was primary to comorbid affective or substance-use disorders in the majority of cases, and PTSD was primary to comorbid anxiety disorders in about half of the cases. Similarly, Breslau et al. (39> found that PTSD...

Advice on management Diagnosing PTSD

In diagnosing PTSD, clinicians need to ascertain that patients experienced a traumatic event and that they involuntarily re-experience the event. In addition, patients will show symptoms of hyperarousal, avoidance, and emotional numbing. Self-report instruments such as the Post-traumatic Stress Diagnostic Scale (29) or semistructured interviews such as the Clinician Administered PTSD Scale(25) are useful in assessing the symptom pattern. The DSM-IV criterion of a minimum of three avoidance or numbing symptoms appears too strict for clinical purposes. It does not appear justified to withhold treatment if the patient is distressed by the PTSD symptoms but fails to meet this criterion.

Special problems in the management of PTSD patients

Avoidance is one of the main symptoms of PTSD, and it can thus take years for the patient to seek help for this condition. It is important for clinicians to bear in mind that even those who seek help may find it hard to talk about the traumatic experience, and may show signs of avoidance such as irregular attendance or failure to disclose the worst moments of the trauma initially. Therapeutic techniques to deal with this problem include empathy, gradual encouragement, and giving the patient control over the timing and mode of working through the experience (e.g. writing, talking into a tape recorder, reliving with the support of the therapist). Patients with PTSD often suffer from poor sleep and concentration, and find it painful to face reminders of the trauma. For these reasons, they have difficulty in dealing with the aftermath of traumatic events such as legal procedures and continuing treatment for physical injuries, including the long delays that this usually

Aetiology of specific phobia

There is considerable evidence for a familial genetic transmission of specific phobia. (33,3Z) Specifically, 31 per cent of first-degree relatives of persons with simple phobia also met the criteria for simple phobia.(33) Further, rates of simple phobia were higher among first-degree relatives of persons with simple phobia and no other anxiety disorder than among first-degree relatives of persons who were never mentally ill. (105) Few twin studies have examined concordance for specific phobia. In the Virginia Twin Study, (3Z) concordance rates for animal phobia were 25.9 per cent and 11.0 per cent among monozygotic and dizygotic twins respectively. However, concordance rates for situational phobia were quite similar in monozygotic and dizygotic twins (22.2 per cent and 23.7 per cent respectively). Psychosocial approaches to the aetiology of specific phobia come from a broad range of theoretical orientations. Freud's case of Little Hans (106) is the model for the psychoanalytical...

Related Stimuli in PTSD Potential for Scenario Adaptation in VR Exposure Therapy

The following article reviews the use of psychophysiological tools in diagnosis and treatment assessment of posttraumatic stress disorder (PTSD). Several different psychophysiological systems are described and evaluated in terms of their diagnostic utility. The article further makes recommendations regarding strategies for the use of psychophysiology in future assessment of the disorder and for implementation within virtual reality exposure therapy. Keywords. Combat related Posttraumatic Stress Disorder, War veterans, Psychophysiological responses, Startle, Heart rate, Skin Conductance, Blood Pressure One of the central symptoms of posttraumatic stress disorder (PTSD) is hyper-arousal in response to trauma reminders. Such arousal induces physical symptoms, such as racing heart, sweating, and shortness of breath. These symptoms are controlled by the autonomic nervous system and can be measured using psychophysiological equipment. Psychophysiological measurements include...

Pharmacotherapy Research in Posttraumatic Stress Disorder

Given the high prevalence and considerable individual and societal costs of PTSD, there are relatively few randomized, placebo-controlled trials in PTSD. Four placebo controlled trials have been performed with MAOIs, three with TCAs. Only one randomized placebo controlled trial was performed with benzodiazepines class, showing no effect of alprazolam on core PTSD symptoms. The majority of trials were done with SSRIs and novel antidepressants, the most of them showing moderate effect sizes over placebo. In past clinical trials antidepressants appeared with the best overall efficacy for the treatment of PTSD, although their effect may not be present in all symptom clusters. Although duration of majority of trials in psychiatry is conventionally set to 12 weeks, clinical trials in PTSD may require the acute phase of treatment to go beyond initial 12 weeks of treatment, especially if the trial includes more severely ill patients. Further clinical research is warranted, using new...

Posttraumatic stress disorder

Post-traumatic stress disorder (PTSD) is classified under anxiety disorders in both ICD-10 and DSM-IV, and its onset may occur in individuals across the lifespan. There are no specific criteria for PTSD with onset in childhood. DSM-IV notes that children's responses to severe trauma may be more disorganized than adults and can involve agitated behaviour. However, the diagnosis is made using the adult criteria, even in young children. Thus children or adolescents must have been exposed to a traumatic event, such as an actual or near-death experience or serious injury, and their response should include intense fear, helplessness, or horror. The event must be persistently remembered and 'relived' with concomitant distress, particularly (but not exclusively) when current circumstances are associated with the original event. Until 15 years ago it was widely considered that children mainly responded to acute traumatic events with a transient brief reaction. However, data on the full...

Posttraumatic stress disorder and other cases of recurring intrusive distressing thoughts

Trauma is a most fertile ground for psychological theory, and it is no accident that right at the start of clinical psychology it figured prominently in the two paradigms which were to set the scene for the century to come Freud's and Watson's. Irrational fear lends itself to the simple explanation of inappropriate generalization. This model is at its simplest in Watson, and at its most complex in Freud, complicated by cognitive and developmental processes. Of course backwards trauma hunting has been problematic in both traditions Freud didn't know whether he had found real or fantasized trauma, and the behaviourists often failed to find the hypothesized one-trial learning in the history of patients with irrational fears. In trying to model Post Traumatic Stress Disorder we do not have this sort of problem, because generally matters are much more open to view. In the paradigm case envisaged by the standard diagnostic systems, such as DSM to be discussed below, the traumatic shock is...

Psychotic features of combat related chronic posttraumatic stress disorder and antipsychotic treatment

Combat-related posttraumatic stress disorder (PTSD) is a severe debilitating psychiatric illness associated with different comorbidities. When complicated with comorbid psychotic features, PTSD is usually refractory to treatment and requires the use of other pharmacotherapeutic strategies, i.e. typical or atypical antipsychotics. In 81 male war veterans with chronic combat related PTSD with psychotic features, treatment response, clinical symptoms and adverse events were assessed using Watson's PTSD questionnaire, Positive and Negative Syndrome Scale (PANSS), Hamilton Rating Scale for Depression (HAMD), Clinical Global Impression Severity Scale (CGI-S), CGI-Improvement (CGI-I), Patient Global Impression Improvement Scale (PGI-I) and Drug Induced ExtraPyramidal Symptoms Scale (DIEPSS). War veterans were treated for 6 weeks with fluphenazine (27 patients), olanzapine (28 patients) in a dose range of 5-10 mg day, or risperidone (26 patients) at a dose of 2-4 mg day, as...

Efforts to Improve the Diagnosis and Treatment of Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a frequent and debilitating consequence of exposure to war and other life-threatening events. PTSD often goes undiagnosed and even when it is diagnosed treatment is all too often inadequate or ineffective. It is imperative to identify more effective diagnostic and therapeutic approaches. We discuss currently available screening and treatment measures, and present approaches we are planning to try to improve each of these modalities. Keywords Posttraumatic stress disorder, combat stress, depression, pharmacotherapy, virtual reality, behavioral therapy Posttraumatic stress disorder (PTSD) became part of our lexicon in the aftermath of the Vietnam War, but the symptoms and associated functional impairment it represents have been known for centuries. Perhaps Cain was the first to suffer the torment of this disorder, and Homer certainly depicts its symptoms in his account of Achilles in The Iliad. More recently, the medical literature has...

How prevalent is PTSD in the population

Kessler et al. (31> estimated that the lifetime prevalence of PTSD is 7.8 per cent, using DSM-IIIR criteria. Women had a higher prevalence than men (10.4 versus 5.0 per cent). This was due to both a greater exposure to high-impact trauma (rape, sexual molestation, childhood neglect, and childhood physical abuse) and a greater likelihood of developing PTSD when exposed to a traumatic event. Other studies using DSM-IIIR criteria have yielded similarly high prevalence rates. (9,39,> A recent study used DSM-IV criteria and found a past-month PTSD prevalence of 2.7 per cent for women and 1.2 per cent for men. (32) Earlier studies using DSM-III criteria had reported lower lifetime prevalences of about 1 per cent. (4243> Besides differences in procedures and sampling methods, the low PTSD prevalence in these earlier studies may be due to the use of an interview schedule with low sensitivity in detecting PTSD. (44) In particular, the interview asked global questions about the occurrence...

Assessment of Available Diagnostic Instruments for Posttraumatic Stress Disorder

The under recognition of the psychological effects of trauma in medicine requires a modification of clinical evaluation strategies, given the gravity of the consequences of such conditions if left untreated. The most significant problems are Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD), along with comorbid disorders. The most significant comorbidities are abusive alcohol consumption, depressive episodes, symptoms of generalized anxiety, phobia symptoms, of panic disorders, as well as somatic complaints. We distinguish between the measures requiring the intervention of an evaluator and self-report measures. To follow a patient and adapt a treatment it is necessary to know the severity of the peritraumatic reaction. Two major characteristics of the trauma response have been clearly identified dissociation (measured with the Peri-traumatic Dissociative Experience Scale and distress (measured with the Peri-traumatic Distress Inventory). Some Instruments...

PTSD and NATO Operations

The ARW was closed out by a special session examining PTSD and NATO operations. This was opened by a graphic presentation from Dr. Zoltan Vekerdi of the Hungarian Dr. Amy Adler, a psychologist with the US Army Medical Research Unit Europe, described the results of psychological screening of soldiers returning from deployment to Afghanistan and Iraq. Their results indicated that the 4-question screen known as the PC-PTSD performed as well in this population as the 17-item PTSD Checklist for Military Populations (PCL-M). The PC-PTSD was more desirable on the basis of its brevity, and it has been incorporated in a U.S. Department of Defense form that is routinely used to screen soldiers after deployment. Dr. Adler also highlighted data that indicate screening should be done at 3-6 months after deployment since many do not develop symptoms until that point, rather than immediately upon return.

Course of specific phobia

Individuals with specific phobias acquire their fear(s) early in life, and the disorder persists for many years. (112) For many individuals, specific phobias are not sufficiently impairing for them to seek treatment. Often individuals with specific phobias adapt their lifestyle to avoid contact with the feared stimulus, such that only persons with the most severe specific phobias seek treatment. Events that commonly precipitate treatment-seeking include a change in lifestyle such that the feared stimulus becomes intolerable (for instance, accepting a job that requires frequent air travel), and the experience of a panic attack in anticipation or in the presence of the feared stimulus. Improvement in specific phobia is unlikely unless the person seeks effective treatment.

Investigating Cognitive Abnormalities in Posttraumatic Stress Disorder

Over the past decade, researchers have increasingly drawn upon concepts and methods developed in cognitive psychology to reveal cognitive processes underlying symptoms of Posttraumatic Stress Disorder (PTSD). These studies have shown that individuals with PTSD display difficulties retrieving specific autobiographical memories in response to cue words, instead recalling overgeneral memories. Moreover, they exhibit difficulty forgetting trauma-related words during directed forgetting, and exhibit enhanced false memory effects for trauma-related material. Such findings suggest that experimental methods can supplement conventional self-report inventories to elucidate cognitive abnormalities underlying PTSD symptomatology. However, to reach a better understanding of the phenomenon, one should also take symptom overreporting into account. Keywords. Posttraumatic Stress Disorder, cognitive processes, false memories, malingering Some people who are exposed to terrible events persist...

Treatment of PTSD

Several psychological and pharmacological treatments are effective in PTSD. The effect sizes (Cohen's o statistic) given below are taken from a recent meta-analysis of 61 treatment-outcome trials.(99) The difference between the pre- and post-treatment scores is divided by the pooled standard deviation of the pre- and post-treatment scores. An effect size o 1 means that the treatment led to improvement by one standard deviation. In interpreting the effect sizes, one has to bear in mind that PTSD patients in pill-placebo or waiting-list conditions also showed some improvement. Mean effect sizes for these conditions were o 0.77 and o 0.75 for observer-rated PTSD symptoms, and d 0.51 and d 0.44 for self-rated PTSD symptoms.

Materials and methods

Ninety three subjects with combat related PTSD participated in the study. All participants were Croatian male war veterans, aged 28-48 years, all Caucasians, who were hospitalized at the Referral Centre for the Stress Related Disorders of the Ministry of Health of the Republic of Croatia, Regional Center for Psychotrauma, in the University Hospital Dubrava, Zagreb, Croatia, from 1999 to 2002. The diagnosis of current and chronic PTSD was conducted according to the Structured Clinical Interview based on DSM-IV(SCID). The subjects were asked to describe their traumatic experiences and were given enough time to talk about these and other psychiatric disturbances. Different clinical symptoms (trauma-related, psychotic, and depressive), occurring in this cadre of war veterans were assessed with the CAPS, the Positive and Negative Syndrome Scale (PANSS), and the Hamilton Rating Scales for Depression (HAM-D) and Anxiety (HAM-A). All patients were war veterans who had been on active duty in...

Psychological Screening Validation with Soldiers Returning from Combat

Soldiers returning from combat military operations are at risk for developing a range of psychological problems. One way to facilitate the identification of these at-risk soldiers is to have them complete a psychological screening survey. Such a survey can be used to link soldiers reporting psychological problems with appropriate mental health services. The challenge of developing such a screen is to ensure that it is valid, short, and easy to administer. The US Army Medical Research Unit-Europe has been at the forefront of developing a valid psychological screen for use with soldiers at post-deployment. Research conducted prior to 2004 showed that screening needed to include five domains post-traumatic stress disorder, depression, alcohol problems, anger, and relationship problems. Blind validation studies conducted in 2004 led to the selection of scale items and cut-offs for each domain resulting in an effective short screen with good sensitivity and specificity values....

Cavtat June 1316 2005

In June, 2005, in the town of Cavtat on the Adriatic coast of Croatia, we brought together many of the leading researchers in the use of VR therapy in psychological disorders. The purpose of this NATO-sponsored Advanced Research Workshop (ARW) was to give these groundbreaking researchers an opportunity to share their experiences and expertise, to achieve consensus on the best methods for incorporating VR in the treatment of veterans of war and terrorism, and to foster multinational collaborative studies in this regard. To achieve this, invited experts shared the most salient findings of recent research with which they have been involved. We then divided all workshop participants into working groups to focus on four key elements of the challenges faced in utilizing VR and other new technologies in the treatment of PTSD Diagnostic and epidemiologic concerns with PTSD The workshop opened with a welcome from several Croatian hosts, including Dr. Dragica Kozaric-Kovacic, Professor Kresimir...

Special Presentation

The following morning, a special presentation was provided by Dr. Joseph Zohar, a researcher with years of experience in the evaluation of PTSD in Israeli combat veterans, who reviewed the results of a large case-control study in which PTSD patients were compared to matched controls with regard to demographic and pre-draft cognitive and behavioral testing. In general, while some of these measures were successful in predicting whether one might develop schizophrenia, they were not useful predictors of the development of PTSD. However, those who appeared to have less resources, as evidenced by such measures as having less education, more siblings, reservist status, and immigrant status, were more likely to seek help for PTSD symptoms on the battle-front rather than waiting until after deployment. While their overall prognosis did not appear different, this information can prove useful in making appropriate resources available.


This was an effective, valuable meeting, enabling many of the leading researchers in the application of VR to the treatment of PTSD to come together to share their experiences and ideas. It will undoubtedly spur greater international collaboration to further improve the diagnosis and treatment of this challenging disorder that continues to afflict more soldiers from NATO member nations on a daily basis. VR has tremendous potential that is only beginning to be realized, and it is critical to maintain international collaboration as valuable research is being conducted at many different sites. The historical response rate of PTSD to conventional therapy is poor enough to warrant the


The mean scores on the CAPS, PANSS, HAM-D and HAM-A scales are shown in Table 1 for war veterans with combat related PTSD. No significant difference (F 0.704, df 1,165 p> 0.05, one way ANOVA) was found between the age of war veterans (39.7 8.5 years) and control subjects (38.4 11.9 years). Table 1. Mean scores in CAPS, PANSS, HAMD and HAMA scales and subscales in 93 war veterans with chronic combat related PTSD Table 1. Mean scores in CAPS, PANSS, HAMD and HAMA scales and subscales in 93 war veterans with chronic combat related PTSD


In PTSD, a disorder with a complex clinical picture, diverse symptoms, and different comorbidities, the evaluation of complex biological signals might be used to improve the characterization of the baseline group characteristics, to predict a suicidal risk, to differentiate particular symptoms or syndromes, and to improve the understanding of the underlying neurobiology of PTSD. The rationale for the use of blood platelets as a limited peripheral model for the central 5-HT synaptosomes lies in the similar pharmacodynamics of 5-HT with central 5-HT neurons 25,26 . Recent reports suggest that platelet 5-HT concentration 27,28 , and platelet MAO activity 17,29,30 might serve as biological or trait markers for particular mental disturbances. The hypothesis of a deficit of the serotonergic system in PTSD is based on data showing disturbed 5-HT function in PTSD 14 . Serotonergic alterations might contribute to the cognitive disturbances and deficits in the memory systems occurring in PTSD...


Abstract The objective of this review is to outline problems which should be considered in trying to define PTSD as neurobiological disorder with abnormal neuronal circuitry. The amygdala is the central neuronal structure for expression of fear memory and fear conditioning (emotional function). Due to the prominent connections with the cingulate and prefrontal cortex and hypothalamus, the amygdala can be considered as a part of the limbic circuitry. For regulation of contextual stimulus (cognitive function), the amygdala interacts with the memory circuit of the hippocampal cortex. Limbic circuitry, which incorporates structures of the great limbic lobe, prefrontal cortex and cingulate cortex, conveys impulses to the hypothalamus, which is the main executive structure for the interaction with endocrine pituitary and brainstem tegmental autonomic and transmitter (neuromodulator ) functions. Human stress-related changes of emotional functions show specificities related to phylogenetic...

Combat Sounds

Heart-rate in response to different sounds in veterans with and without PTSD. Adapted from While the advantage of using standardized combat stimuli is that all participants have the same exposure and therefore the differences in response could be attributed to the disorder, it is possible that the standard stimuli did not encompass all possible combat experiences, i.e., that some veterans experienced different types of trauma and the standard stimuli might not serve as trauma reminders for a particular individual's unique experiences. Therefore, a veteran with PTSD may not show hyper-arousal to stimuli that are not part of his traumatic experience 2 . In order to address the problems with standardization of trauma imagery, Orr and Pitman 10 modified a procedure developed by Lang and colleagues to study phobias 11 . In this method, the participant describes an actual traumatic event from their combat experience (see Box 1). This event is then edited into a 30-second script...


Post Traumatic Stress Disorder The DSM-IV classifies Posttraumatic Stress Disorder as a heterogeneous disorder that develops following exposure to traumatic events such as a serious injury or threat of injury or death to the self or others. Symptoms of PTSD, which must persist for at least 1 month, include increased anxiety or arousal, dissociation, avoidance of stimuli associated with the trauma and numbing of general responsiveness, as well as flashbacks to the traumatic experience 8 . Both anxiety-reducing medication as well as CBT can help in recovery. In recent years, VR has been shown to improve treatment efficacy for PTSD in survivors of motor vehicle accidents (MVA), war veterans, and those involved in the 9 11 World Trade Center attacks, as well as in other areas 9-15 . The Virtual Reality Medical Center has been funded by the Office of Naval Research (ONR) to develop virtual reality worlds and test them, using our established clinical protocols in combination with...


Terrorist events, natural and man-made disasters, and intra- and international conflicts over the past 10-15 years have led to increased attention to the prevalence and adverse health consequences of posttraumatic stress disorder (PTSD). PTSD has an estimated 2-5 point prevalence and 8-12 lifetime prevalence in the general population, with higher rates in primary care settings, and even more so in combat veterans 1-9 . It is especially common after terrorism and natural disasters for example, 60 of those who sought care after terrorist sarin release still met PTSD criteria 6 months later 10 , as did 41 of victims of a terrorist bombing in a Paris subway 11 . Likewise, 43 of earthquake survivors in Turkey were diagnosed with PTSD 12 . With 24-hour television news coverage, such events impact an entire society after the terrorist attacks in the U.S. on September 11, 2001, one in six adults nationwide had persistent distress 2 months later, and this was associated with poorer function at...

Chapter References

68. van den Hout, M.A., Tenney, N., Huygens, K., and de Jong, P.J. (1997). Preconscious processing bias in specific phobia. Behaviour Research and Therapy, 35, 29-34. 114. Ehlers, A. and Skil, R. (1995). Maintenance of intrusive memories in posttraumatic stress disorder a cognitive approach. Behavioural and Cognitive Psychotherapy, 13, 217-49.

Clinical features

In contrast, acute stress disorder, as defined in DSM-IV, is only diagnosed if the psychological symptoms persist for more than 2 days. Dissociative symptoms dominate the symptom pattern. Dissociation refers to a disruption of the usually integrated feelings of consciousness, memory, identity, or perception of the environment. Symptoms include a subjective sense of numbing or detachment, reduced awareness of surroundings, derealization, depersonalization, or dissociative amnesia. In addition, patients with acute stress disorder experience symptoms that are typical of PTSD, namely re-experiencing aspects of the event, avoidance of reminders of the event, and hyperarousal symptoms. Acute stress disorder is seen in DSM-IV as a precursor of PTSD. If the re-experiencing, avoidance, and hyperarousal symptoms persist for more than 4 weeks, PTSD is diagnosed.

Differential diagnoses

Post-traumatic stress disorder In ICD-10, PTSD is conceptualized as an alternative diagnosis of acute stress reactions. The definitions of acute stress reaction and PTSD differ in terms of the stressor criterion (exceptionally stressful life event vs. exceptionally threatening or catastrophic event), the time course (symptoms start to diminish within 48 h versus no time limit), and symptom pattern (PTSD, but not acute stress reaction, includes involuntary re-experiencing the traumatic event). In DSM-IV, acute stress disorder can be distinguished from PTSD by the time-frame covered by the diagnoses. Acute stress disorder refers to the period from 2 days to 1 month post-trauma, after which a diagnosis of PTSD can be considered. The primary difference between the symptom criteria for acute stress disorder and PTSD in DSM-IV is the former's emphasis on dissociative reactions.

Psychological theories

Psychological theories have offered two major explanations for the re-experiencing symptoms following traumatic stress, characteristics of the trauma memory, and the effect of trauma on basic beliefs about the self and the world. Foa and colleagues (2,21) suggested that PTSD is characterized by a pathological network in memory that is particularly large and easily triggered. It contains many stimulus propositions erroneously linked to danger, causing fear responses to harmless stimuli associated with the traumatic event in memory. Ehlers and Clark(22> suggest that re-experiencing occurs because the trauma memory is inadequately linked to its context in time, place, and other autobiographical memories. Stimuli resembling those present during the traumatic event can thus trigger vivid memories and strong emotional responses that are experienced as if the event was happening right now. Brewin et al. (23) postulated that dual representations of the trauma are formed in memory. The...

Course and prognosis Time course of symptoms

Whereas the ICD-10 criteria define acute stress reactions as a disorder that remits within a few days, DSM-IV conceptualizes acute stress disorder as a marker of those vulnerable to the development of PTSD. (30> Evidence relating to these different assumptions was sparse at the time the diagnoses were established. Recent evidence supports the assumption that acute stress disorder is a precursor to PTSD. (1Z,18,and19,3Z,38) In general, people who have more severe symptoms of PTSD in the weeks following trauma have a poorer prognosis than those with less severe symptoms.(3,40) Nevertheless, there is a substantial rate of spontaneous remission of about 50 per cent in the first year after a traumatic event.(3,40) Whether or not initial dissociative symptoms predict PTSD over and above what can be predicted from the initial PTSD symptoms remains unclear, and a recent prospective study reported negative findings. ( 8.)

Psychological treatments Debriefing

Critical incident stress debriefing is a widely practised intervention that has the goal of promoting adaptation to traumatic events. Debriefing is generally conducted in a group within 24 to 72 h of the trauma. However, these parameters have been modified to permit more flexible interventions. Mitchell (43> proposes that debriefing comprises seven phases Cognitive-behavioural interventions are effective in treating PTSD (see Chapter 4.6.2). The results of two randomized controlled studies of rape victims and road traffic accident survivors suggest that a brief four-session version of this treatment is effective in acute stress disorder and prevents the development of chronic post-trauma reactions.'5 52> Treatment involved the following Case studies report on the utility of tricyclic antidepressants, (53) benzodiazepine anxiolytics,(54) and benzodiazepine hypnotics(55) in acutely traumatized individuals. However, no randomized controlled trials have been completed. Research on...

Advice about management

With the pressure to do something to help. Research on the predictors of PTSD suggests that normalization of symptoms and information about their time course, practical help in resuming one's life, and, if possible, facilitation of social support may be helpful (see Chapiei. .S ). Furthermore, patients may benefit from practical advice about issues such as hospital procedures, police questioning, insurance claims, legal procedures, and media pressure to tell one's story. The lack of randomized controlled trials suggests that pharmacological treatment cannot be considered a front-line treatment for acute stress disorder, but research on PTSD suggests that selective serotonin reuptake inhibitors may be helpful.

Possibilities for prevention

Identifying highly symptomatic individuals with acute stress disorder and providing a cognitive-behavioural intervention from approximately 2 weeks post-trauma may reduce the risk of later PTSD. Additional preventive methods have been explored that prepare individuals 'at risk' (e.g. emergency services and military personnel) for experiencing trauma so as to enhance their coping strategies and reduce the risk of them developing longer term symptomatology. For those individuals at high risk of experiencing a trauma, providing them with training to remain calm, evaluate the situation objectively,(57) to not identify with victims, to utilize social supports, and to express emotional reactions(58) have all been found to be associated with better coping after the trauma. However, evidence remains preliminary.

Diagnosis and differential diagnosis Diagnostic criteria in ICD10 and DSMIV

Table, compares the diagnostic criteria of ICD-10 and DSM-IV. (19 ICD-10 research diagnostic criteria, (1.9 as well as diagnostic guidelines,(5) are included. The diagnostic systems agree on the core symptoms of PTSD re-experiencing, avoidance, emotional numbing, and hyperarousal but differ in the weight assigned to them. Table 1 Diagnostic criteria for PTSD in ICD-10 and DSM-IV DSM-IV puts a stronger emphasis on the avoidance numbing cluster of symptoms by requiring a minimum of three of these symptoms. Although emotional numbing is listed prominently in the ICD-10 diagnostic guidelines, it was not included in the ICD-10 research diagnostic criteria. As a consequence, patients that meet ICD-10 criteria may not fulfil the criteria for a DSM-IV PTSD diagnosis if they have too few of the numbing symptoms. They would be diagnosed as having an adjustment disorder according to DSM-IV. The ICD-10 research diagnostic criteria require the patient to either suffer from psychogenic amnesia or...

Assessment instruments

Several semistructured interviews assess the DSM-IV criteria for PTSD. The Structured Clinical Interview for DSM-IV ( SCID)(24) allows one to establish the diagnosis of PTSD. The Clinician Administered PTSD Scale (CAPS)2) nd the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)(26 provide measures of symptom severity as well as establishing the diagnosis of PTSD. The most widely used self-report measure of PTSD symptoms used to be the Impact of Event Scale.(27) The original scale contained two scales, an intrusion and an avoidance scale. It has recently been expanded to include an additional hyperarousal scale ( IES-R).(28) The IES-R does not cover all the symptoms of PTSD specified in DSM-IV. This is why new measures that are modelled on the DSM-IV criteria are now commonly used in research studies, for example the Post-traumatic Stress Diagnostic Scale (PDS).(29)

Factors affecting recovery from trauma

Recovery is facilitated by social support and the absence of negative responses from others after the event. (15,8 9 95) Further stressful or traumatic life events impede recovery from PTSD.(9 96 and 97) This includes the stress caused by long-lasting negative effects of the event on health and personal appearance, financial difficulties, disruptions in everyday life, and ongoing litigation. (4 8 9 Excessively negative appraisals of the traumatic event impede recovery (e.g. 'Nowhere is safe', 'I cannot trust anyone', 'I am inadequate'). (1557,6.0) If individuals interpret their initial PTSD symptoms as signs that they are going mad or losing control, or as signs of a permanent change for the worse, they are less likely to recover. (1 dD

Pharmacological treatments

SSRIs (sertraline, fluvoxamine, fluoxetine) are effective in the treatment of PTSD symptoms 1.07) They affect all the PTSD symptoms, including the avoidance, numbing, and hyperarousal symptoms l08) The meta-analysis showed mean effect sizes of d 1.43 for observer-rated and d 1.38 for self-rated PTSD symptoms.(99> Across studies, the SSRIs were more effective than all other drug therapies. SSRIs are an attractive choice because they reduce alcohol consumption a relevant finding given the high comorbidity of PTSD with substance abuse or dependency. (1 8) Despite the overall impressive effects, SSRIs may not be effective in all populations of PTSD patients. One study showed that fluoxetine was significantly superior to placebo in civilians in a trauma clinic, but not in combat veterans in a Veterans Administration Hospital. (1 7) the meta-analysis did not find the MAOIs to be significantly more effective than control conditions such as a pill placebo or a waiting list. Effect sizes...

Recovered memories and false memories

Clinicians working with survivors of traumatic experiences have frequently noted the existence of memory loss with no obvious physical cause and the recovery of additional memories during clinical sessions, although little systematic research has been conducted until recently. Indeed, amnesia is described in diagnostic manuals as a feature of post-traumatic stress disorder, although its presence is not necessary for this diagnosis. In the majority of these cases, people forget details of the traumatic event or events, or forget how they reacted at the time, although they remember that the event happened. They typically report that they have endeavoured not to think about the event, but have never forgotten that it occurred. In the critical cases currently being debated, memories of traumatic events appear to be recovered after a long period of time in which there was complete forgetting that they had ever happened. Although some of Britain's leading psychologists and psychiatrists...

An emerging scientific and professional consensus

What should be clear by now is that extreme views, claiming that either false memories or genuine recovered memories are rare or impossible, cannot be supported by the available data. Nevertheless, the dispute continues about whether traumatic events, and particularly repeated traumas, can be forgotten and then remembered with essential accuracy. In my view it is safe to conclude from the evidence reviewed that the hypothesized implantation of false memories by practitioners cannot account for more than a subset of recovered memories (and at present it is entirely unclear how large or small this subset might be). False memories may certainly arise in other circumstances, but as yet there is little pertinent evidence. On the other hand, there is a great deal of plausible evidence supporting the existence of genuine recovered memories. Although members of the advisory boards of false memory societies mostly remain sceptical, on the basis of the kind of evidence reviewed above many...

Clinical features and functional impairment

The hallmark feature of specific phobia, which prior to DSM-IV was called simple phobia, is a 'marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation'. Commonly feared avoided objects include animals, aspects of nature, or blood. Most individuals may endorse a degree of fear of these stimuli. However, in specific phobia, fear and avoidance cause significant interference with an individual's normal routine, career, academic pursuits, or social interpersonal activities. Nevertheless, some individuals with specific phobias maintain a relatively normal routine by pursuing a lifestyle that minimizes exposure to the phobic stimulus. Consequently, they may present for treatment only when life changes occur that force them to face the previously avoided situation or object. More frequently, specific phobias accompany a more impairing primary disorder, which is the stimulus for seeking treatment. (97)

Empirically evaluated treatments

Drug treatments for specific phobia have consistently been shown to be less effective than behavioural treatments. b-Blockers reduce some symptoms of sympathetic arousal during exposure to feared stimuli. However, they fail to decrease subjective fear. (113) While benzodiazepines may facilitate approach to the feared stimuli, they may also reduce the efficacy of behaviour therapies by inhibiting the experience of anxiety during exposure. (H4) Because of the marginal to moderate effects of drug treatments relative to behaviour therapy, little attention has been devoted to the study of drug treatments for specific phobia. Systematic desensitization( l5) has been used successfully in the treatment of specific phobias since the mid-1960s. Combining progressive relaxation and graduated imaginal exposure to the feared stimulus, systematic desensitization has been demonstrated to be superior to psychotherapy in some cases (116,11Zand 118) but not others.(H9) Wolpe(H5) contended that...

Cognitive restructuring

Phobia-specific irrational thoughts may contribute to the development of the phobia, maintain avoidance behaviour, and contribute to physiological symptoms. (1.3Z) Cognitive restructuring treatments help patients to monitor irrational thoughts and change underlying beliefs, so that they are better able to enter feared situations. When combined with exposure to feared stimuli, cognitive restructuring has been demonstrated as effective. ( 38) However, there are relatively few studies of cognitively oriented treatments for specific phobia.

Some repercussions of the PAS hypothesis On static vs dynamic models of memory

Whereas potential prevention or amelioration of some types of amnesia is a remote possibility, prevention or amelioration of post-traumatic stress disorder (PTSD) is not. The revival of the reconsolidation literature (Sara 2000 Nader et al. 2000 Nader 2003) has incited attempts to modify or even erase long-term traumatic memories long after their formation. The PAS hypothesis supports such attempts. But additional practical implications of the PAS notion could be incited by assimilating into neuroscience a notion that is so familiar to cognitive psychologists, namely, that the life span of an item in memory persists only from one activation to another, and that memories, primarily declarative ones, change upon their use. Rites of passage, in which these changes are likely to take place, are not only windows of opportunity to peek into the mechanisms of memory they also provide potential therapeutic windows.

Neurological Disorders and Neurodegenerative Diseases

The norepinephrinergic system seems to be indirectly involved in depression. The compound reserpine can provoke depression and a variety of antidepressive agents prolong the half-life of catecholamines, either by inhibition of their re-uptake or by decreasing the metabolic rate (for example, by inhibiting monoamine oxidase MAO). Modifications to the density of epinephrinergic receptors and phasic variability in the level of norepinephrinergic metabolites have been found in patients suffering from depression. In particular, postsynaptic a2 receptor down-regulation seems to be prevalent in depression, combined with increased presynaptic receptor sensitivity and increased a2 receptor density in the LC. Decreased norepinephrinergic receptor sensitivity and increased norepinephrinergic turnover have been noted in patients with anxiety, generalized anxiety disorder and posttraumatic stress disorder.

Associated psychopathology and comorbidity

Psychogenic excoriation often co-occurs with mood and anxiety disorders. Of 34 adults with psychogenic excoriation evaluated with the Structured Clinical Interview for DSM-IV, lifetime mood disorders were diagnosed in 27 (79 per cent) of subjects, with the most common types being major depressive disorder (in 13 (38 per cent)) and bipolar disorder type II (in nine (26 per cent)). (,36> Lifetime anxiety disorders were diagnosed in 19 (59 per cent) subjects, with the most common types being panic, generalized anxiety, and specific phobia (all appearing in seven (21 per cent)). The comorbidity of psychogenic excoriation and personality disorders has not been systematically studied.

Mind and body in mental disorder

Several studies indicate that everyday stressors, and stress caused by traumatic events, can produce different grades of immunosuppression and increase a person's vulnerability to infection. (13> Psychiatric conditions such as depression, which includes certain central nervous system dysfunctions, may lead to or be associated with immunological disorders. Favourable or unfavourable placebo effects might also be explained in terms of complex interactions between the central nervous system, the immune system, and the endocrine system.

Psychiatric disorders

Hypochondriasis needs to be distinguished from anxiety disorders. (32) Patients with specific phobias of illness are fearful of, and wish to avoid, illnesses they have not yet encountered, whereas patients with hypochondriasis are preoccupied with illnesses they believe they already have. Patients with obsessive-compulsive disorder often have intrusive thoughts about disease or contamination and rituals that involve checking for signs of disease or seeking reassurance. They differ from hypochondriacal patients primarily in having other obsessions or compulsions. A diagnosis of obsessive-compulsive disorder should not be made if obsessions are restricted to having a serious illness. Obsessive-compulsive patients tend to regard their ideas as senseless and resist them, whereas those with hypochondriasis regard them with conviction.

Myofibroblastic Tumour

The aetiology of the lesion is unknown, but different infections with an exaggerated response to some unknown microorganism or post-traumatic events have been attributed as causal factors 9, 76, 167, 382 . Most reported laryngeal IMTs are polypoid or pedunculated lesions that occur in the true vocal cords or in the subglottic area. Hoarseness, foreign body sensation, dyspnoea and stridor are presenting symptoms. Patients with laryngeal IMTs are mainly adult males 382 .

Psychiatric disorders and accidents occurrence

The rate of accidental death is higher among people with schizophrenia, affective illness, and post-traumatic stress disorder ( PTSD) than in the general population, but psychiatric disorders contribute little to the overall prevalence of accidents, with the notable exception of drug and alcohol abuse and severe personality disorders 2) However, the prevalence of psychiatric disorders is higher among adults with accidental injuries (40-50 per cent) than among patients admitted to a surgical department (25-30 per cent), and is even higher if the injuries are intentional. (3) Approximately 15 to 25 per cent of persons presenting in hospital emergency rooms because of accidental injury have clinically significant blood concentrations of alcohol. In some subgroups of injuries (e.g. burn injuries at home), the prevalence rates have been reported to be over 50 per cent. There are twice as many people with antisocial personality disorders in trauma units than in psychiatric out- and...

Treatment of longterm psychiatric problems

Psychotropic drugs may help some subjects. Antidepressants should be given if there is a major depressive episode. Benzodiazepines may reduce PTSD-related anxiety, but drug treatment should be supplemented with psychological interventions. The serotonin antagonist cyproheptadine has been reported to relieve nightmares, but its efficacy compared with psychological techniques and other drugs is not known.

Compensation claims and litigation

In a few cases, there is disagreement between the insurance company and the injured party about the extent and consequences of the accident and the injury. Studies of personal injury plaintiffs indicate that a significant number report pre-injury functioning superior to that of controls and some exaggerate their symptoms. Untrained subjects have been shown to endorse symptoms on checklists to meet DSM-IIIR criteria for diagnoses of major depression, PTSD, and generalized disorder. These findings, which correspond to clinical experience, suggest the need for caution in assessing litigants. The physician should always try to obtain independent information from reliable sources (e.g. medical records, general practitioners) before coming to conclusions about the health status of the patient before

Interpersonal Functioning

The third phase of the treatment is targeted on the interpersonal difficulties that precipitate or resulted from the disorder. This is where cognitive strategies address core beliefs and schemata. The goals for this phase of the treatment include the experience of increased self-efficacy and the rebuilding of a more solid and autonomous sense of self. This takes account of the impact of the illness, which often occurs in a developmentally critical time when self-esteem and identity are formed. It further appears that the impact of mania and depression at an early age are significant, as they dramatically affect important developmental milestones such as educational achievements, early work experience, and important interpersonal relationships. Essential cognitive structures such as dysfunctional core beliefs will probably become self-perpetuating. Examples of these beliefs include a distorted sense of autonomy or personal capability, vulnerability to harm or illness, and a sense of...

Psychiatric symptoms and diagnoses

Early research describing the psychiatric status of refugee survivors, especially those who had been tortured, refrained from the use of psychiatric diagnoses because of a prevailing perception that the observed symptomatology was a normal response to horrific life experiences. (, 4) Similarly, many medical anthropologists believed that Western psychiatric diagnostic classifications were not relevant to the assessment of suffering in non-Western populations. (l5) Despite these reservations, the emergence of standardized diagnostic criteria for major depression and post-traumatic stress disorder ( PTSD) have allowed for the cultural validity of these diagnoses to be tested in a number of refugee settings. Observations since Kinzie et a .( 6) and Mollica et al.(U) first diagnosed PTSD in Cambodian refugees, have made the cultural validity of PTSD seem almost certain. However, this reality does not negate the importance of culture-specific symptoms related to trauma that are independent...

Psychiatric diagnosis

Cross-cultural research suggests that assessments of psychiatric illness should begin with phenomenological descriptions of folk diagnoses or culture-specific syndromes.(26) To date, not a single culture-specific illness associated with the mass violence and torture experienced by refugees has been defined. (27) On the contrary, the criteria for the two major diagnoses associated with violence in Western society, i.e. major depression and PTSD, have been successfully applied to refugees from many parts of the world. While epidemiological evidence suggests that high rates of pTsd, for example, are experienced by both refugee patients and non-patients, it is not known whether there are other culture-specific symptoms not part of the DSM-IV criteria that have greater clinical relevance and meaning to a specific refugee group. A general principle demonstrated by the World Health Organization cross-cultural study of depression, (28) i.e. that while some depressive symptoms may be present...

The Debate About The Value Of Antidepressant Drugs

The interactionist's perspective Here, mental processes and the development of the person are seen as the result of an interaction between the individual and her environment. Traumatic events, e.g. during childhood, can be memorized in the cognitive system and may lead to negative psychosomatic or psychological symptoms. However, traumatic events are assumed to affect both the mental processes and the brain processes at the same time. Also, there is an interaction between the mind and the brain.

Relation Between Obstructive Sleep Apnea and Depression

OSA leads to EDS, fatigue, and impairment in daytime functioning in various neu-ropsychological, cognitive, behavioral, and social domains. Thus the symptoms of OSA can mimic symptoms of an MDD, leading to an erroneous diagnosis of depression, complicating the diagnosis, and management of both conditions. For over two decades clinical studies have suggested a relationship between OSA and depression. In recent years, a number of studies have confirmed an increasing prevalence and severity of depression in patients with OSA. Sharafkhaneh et al. (49) studied the prevalence of comorbid psychiatric conditions in 4,060,504 Veterans Health Administration beneficiaries with and without sleep apnea. They found a statistically significantly greater prevalence of depression (21.8 ), anxiety (16.7 ), PTSD (11.9 ), psychosis (5.1 ), and bipolar disorders (3.3 ) in patients with sleep apnea as compared with patients without sleep apnea. While several investigators have reported an increasing...

Clinical characteristics

PTSD results in protracted symptoms and personal impairment within a few weeks of exposure to a traumatic event. The subject experiences intrusive and distressing recollections of the event, which in young children may be seen as recurring themes in play either alone with toys or in games with other children. (34) Whilst adults may experience recurrent dreams of the event, children may present with nightmares of no overtly recognizable content. Children may re-enact the traumatic event behaviourally following internal or external cues that symbolize or resemble the event. Clinical studies have suggested that the persistent symptoms of increased arousal (not present before the trauma) noted in most adult PTSD sufferers are present in children. The most troublesome symptom appears to be visual imagery, whose intensity may result in dissociative experiences (flashbacks) and which may be the mechanism for the behavioural phenotype seen in the social re-enactment of the event during play.

Remembering traumatic memories

Many of the events child witnesses are called upon to remember were unpleasant and frightening at the time. These events will have been experienced in a state of high emotional arousal. The psychological trauma associated with the witnessed event and the emotional state of the child during subsequent recall are both likely to have an influence on a child's capacity to give evidence about the event. Clinical experience suggests that emotional arousal can either enhance or diminish recalled information. For example, extremely traumatic events such as watching a parent being killed can be remembered by child witnesses in a series of highly accurate and detailed visual images that persist in memory over time. ( 3> By contrast, some children process potentially overwhelming experiences using a variety of psychological defence mechanisms, which limit the amount and accuracy of material available in explicit memory. Research is needed to understand the implications of psychological trauma...

Natural emotional healing

Counselling and psychotherapy have been used with increasing frequency to help children cope with traumatic events such as death, divorce, abuse, illness, and so on. It is arguable whether this trend is at all helpful. Fortunately, the human psyche is remarkably resilient and there are powerful healing processes that take time, which in most cases achieve a satisfactory result. There are similarities between the way the body and mind respond to trauma and the strong correspondence between the natural healing processes that accompany both physical and emotional trauma. The initial healing process starts with a brief period where no pain or distress is felt whatever the cause of the trauma, and this is often accompanied by disbelief that such a thing could have happened. This first phase of shock and 'denial' is then replaced by the full impact of what has happened and is accompanied by high levels of physical or emotional pain. During the second phase the pain may be so severe that it...

Neurodevelopment and psychological development

If the developmental processes of the kind described here are important then schizophrenia may appear after many years of mismatched and unsatisfactory interactions. There is ample evidence that the emotional atmosphere in the home, and especially the level of criticism, hostility, and over involvement, (which together are termed 'expressed emotion') influences the course of schizophrenia (Bebbington and Kuipers 1994 Butzlaff and Hooley 1998). Mueser et al. (1998) found high rates of traumatic events in patients with schizophrenia and bipolar disorder, and Garety et al. (2001) reported that severe trauma was associated with psychotic symptoms unresponsive to medication. The mechanism is unclear, but probably entail interactional processes with mutual influences between parental and (adult) child behaviours.

Evidence of the Relationship Between Stressful Life Events and MS Exacerbation

It should be noted that while the studies included in this meta-analysis (Mohr et al., 2004) were statistically homogenous, qualitative review of the study designs suggested differences in severity of the stressor. Thirteen of the studies examined the common stressful life events encountered in daily life in the United States and Europe. Many of these stressors tend to be chronic (i.e., lasting weeks or months) and of mild to moderate intensity, such as job-related stressors or family and interpersonal stressors. These 13 studies showed similar increases in risk of exacerbation associated with stressful life events. However, one study following patients in Tel Aviv, Israel, used a traumatic stressor being under daily and nightly missile attack in the first Gulf War (Nisipeanu and Korczyn, 1993). These patients showed a decrease in risk of exacerbation during and after the stressful life event. Although it is possible that this isolated finding is due to chance alone, this study...

Psychological sequelae of crime

There is good evidence that assaultative violence is more damaging to the individual's mental health than other types of traumatic events. ( 4) Good recovery from criminal victimization is largely dependent on how the victim processes and makes sense of what has happened, whether the act can be incorporated and accommodated into an existing frame of reference or whether the experience is so overwhelming and out their ordinary everyday experience as to render them incapable of reaching some kind of resolution. The effects of criminal victimization can be profound and long lasting ( 5) however, when victims of crime present to health professionals they are rarely asked about criminal victimization and are unlikely to volunteer this information spontaneously. ( 6) Victims of violent or contact crime often report a sense of detachment, depersonalization, or derealization during the act. This may have survival value, in allowing an individual to cope with an overwhelming event, to minimize...

Support services and treatment interventions

Treatment approaches are drawn from a variety of paradigms including cognitive-behavioural, psychodynamic, psychosocial, and pharmacological treatments, and are often trauma focused in general rather than being specific to problems associated with criminal victimization. Ochberg (5) categorizes them into two main approaches, the first focuses on previous personality and makes the assumption that symptoms relate to unresolved issues and pre-existing weaknesses, rather than the traumatic events and their consequences. The second approach focuses more on the events themselves, the individual strengths and coping styles of the victim and setting realistic achievable goals. Debriefing and cognitive-behavioural treatments tend to be trauma related in general, rather than being specific to the crime.

Coolidge Axis II Inventory

Like the MCMI-III, the CATI also provides assessment for many Axis I scales. These include Depression, Anxiety, Schizophrenia, and Posttraumatic Stress Disorder. The DSM-IV-TR Personality Change Due to a General Medical Condition is also evaluated, with scales measuring each of the five subtypes Apathy, Disinhibition, Emotional Lability, Aggression, and Paranoia. A unique feature of the CATI is that it has an 18-item neuropsychological dysfunction scale for assessing neuropsy-chological symptoms of brain disease, trauma, and dysfunction, with three subscales assessing language and speech dysfunction, memory and concentration difficulties, and neurosomatic complaints related to brain dysfunction. The CATI also includes a 16-item executive functions of the frontal lobe scale with three subscales measuring poor planning, decision-making difficulty, and task incompletion. Two other features of the CATI make it distinctive. First, a significant-other version of test is available so that...

Differential diagnosis Mental and somatoform disorders

In dissociative or conversion disorder the patients usually present fewer symptoms, but these are almost exclusively pseudoneurological symptoms. The onset is sudden, and closely associated in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. The symptoms are transient and often remit suddenly after a few days, although they may persist for longer but seldom for more than a few months. Episodes of dissociative or conversion disorders frequently occur in patients with other somatoform disorders.

The Evolutionary Neurodevelopmental Perspective

In a review of more than 100 studies on the comorbidity of narcissism and narcissistic personality disorder with major mental illness, Ronningstam (1996) found that narcissism is not linked systematically to any specific Axis I disorder. Instead, it would appear that a narcissistic personality only colors the expression of any Axis I disorder that develops. Although the energy, dominant control, and love of hearing themselves talk suggest some fundamentally biological relationship between the narcissistic personality and bipolar disorder, Stormberg, Ronningstam, Gunderson, and Tohen (1998) found that bipolar patients exhibit most of the criteria of pathological narcissism only while in the manic phase. When not manic, their levels of pathological narcissism are no higher than other general psychiatric patients. Some reports suggest that narcissistic personality disorder may exacerbate the severity of posttraumatic stress disorder (B. Johnson, 1995), perhaps because the omnipotent...

Presence and subjective credibility of pathogenic beliefs

Irrational beliefs about the outside world are common in anxiety disorders. Especially interesting are people with monosymptomatic phobia who tend, in contrast to other anxiety patients, not to suffer from comorbid pathology and who present the clearest case of irrational emotions and behaviour in otherwise healthy people. While egodystony in specific phobias is even a diagnostic criterion of DSM-IV ('The person recognizes that the fear is excessive or unreasonable'), systematic questioning using a paper-and-pencil task, without the social pressure of an interviewer, reveals that spider phobics tend to endorse highly irrational beliefs about the dangerousness of spiders. The credibility of these frightening ideas is especially high in the presence of the phobic cue. (102) Social phobics appear to have negative beliefs about their own social performance and about others, whom they believe to be more critical and rejecting than they actually are. M0.4and 105) Furthermore, prominent...

Freuds theory of the mental apparatus motivation structure and functioning Unconscious mental processes the topographic

Freud's starting point(4) was his study of hysterical patients and the discovery that, when he found a way to help these patients piece together a coherent account of the antecedents of their conversion symptoms, dissociative phenomena, and pathological affective dispositions, all these psychopathological phenomena could be traced to traumatic experiences in their past that had become unconscious. That is, these traumatic experiences continued to influence the patients' functioning despite an active defensive mechanism of 'repression' that excluded them from the patient's conscious awareness. In the course of a few years Freud abandoned his early efforts to recover repressed material by means of hypnosis, and replaced hypnosis with the technique of 'free association', an essential aspect of psychoanalytic technique until the present time. Freud instructed his patients to eliminate as much as possible all 'prepared agendas', and to try to express whatever came to mind, while attempting...

The DSM Multiaxial Model

The multiaxial model is divided into five separate axes (see Figure 1.1), each of which gets at a different source or level of influence in human behavior. Axis I, clinical syndromes, consists of the classical mental disorders that have preoccupied clinical psychology and psychiatry for most of the history of these disciplines. Axis I is structured hierarchically. Each family of disorders branches into still finer distinctions, which compose actual diagnoses. For example, the anxiety disorders include obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. The mood

Relation Between Sleep Apnea and Insomnia

There have been studies suggesting a higher than expected prevalence of SDB in patients with post-traumatic stress disorders (PTSDs). In one study Krakow et al. (42) reported the potential presence of SDB in 52 of female patients with PTSD, correlating positively with body mass index (BMI), increased arousal index, and PTSD severity. Improvement in insomnia and post-traumatic stress with successful treatment of SDB has also prompted the hypothesis of an arousal-based mechanism in trauma survivors and in patients with chronic insomnia (43). A greater than expected level of anxiety, depression, stress symptoms, and past history of psychiatric problems are also reported by Smith et al. (35) in patients with SDB and insomnia.

The Psychodynamic Perspective

Psychotic episodes, stating that the normal ego functions of secondary-process thinking, integration, realistic planning, adaptation to the environment, maintenance of object relations, and defenses against primitive unconscious impulses are severely weakened (p. 165). The ego of the borderline, according to Knight, is laboring badly under the stress of traumatic events and pathological relationships. Integration, concept formation, judgment, realistic planning, and defending against eruption into conscious thinking of id impulses and their fantasy elaborations are severely impaired, while other ego functions, such as conventional (but superficial) adaptation to the environment and superficial maintenance of object relationships may exhibit varying degrees of intactness (Knight, 1953, p. 165). As many writers have noted, borderlines often look much more adaptive or competent than they really are. Georgia, for example, makes good enough of a first impression to get hired but then can't...

The Case of Mickey Antisocial Personality Disorder

These individuals do not come into treatment voluntarily to work on their personalities, but are frequently encountered in hospital ERs and in prisons. Individuals with ASPD often experience dysphoria, anxiety, and rage attacks, and they typically respond to these affects by acting out or self-medicating with alcohol or drugs, or both. Trying to take a reliable clinical history is nearly impossible as these characters lie and withhold information to advance their cause, whether to appear more frightening and dangerous or more benign, bending the facts so that past behaviors can appear almost reasonable. Individuals with ASPD may claim or fake an Axis I disorder as a cover for their antisocial exploits. However, comorbid Axis I conditions are prevalent with ASPD, including Major Depression, Bipolar Disorder, Panic Disorder, and Posttraumatic Stress Disorder (PTSD). Mood disorders are especially likely to develop as the individual reaches middle age. In addition, approximately 70 of...

Psychiatric disorders after accidents burns and other trauma

The prevalence rates of PTSD depend on the research criteria adopted. Studies using DSM-IV criteria report higher rates that those using ICD-10 criteria. Prevalence of psychiatric disorders The 1-year prevalence of PTSD after accidents in a random sample of the population is probably no more than 1 to 5 per cent. ( 3) Among motor vehicle accident survivors brought to medical attention the estimates vary from 4 to 12 per cent.( J 5 Women are at greater risk than men. Similar figures have been reported for children 1. The 6-month prevalence of PTSD is about 1 per cent, and the lifetime incidence is about 5 per cent in males and 10 per cent in females. In fact, sudden unexpected death of a loved one and violent assault lead to higher rates of PTSD than accidents. Head injury with retrograde amnesia for the accident seems to reduce the rate of long-term PTSD. Brain injuries are discussed in Chapte.L.4.1.11. Chronic pain is quite frequent following accidental injury. Victims with high PTSD...

Indications and contraindications

Many problems with sexual function would be suitable for couple therapy, including those couples where there is a disparity in sexual desire, or those where one partner has a specific phobia for sex. In some such cases there is also a need for individual therapy, especially where one partner is the survivor of earlier childhood sexual abuse. Some problems are perhaps less amenable to couple work, and among these are, for example, phobias which seem unconnected with home life in any way, and post-traumatic stress reactions where the event happened away from the partner. Some alcoholic and drug-addicted patients have so much of their existence involved with the addiction that they are not available emotionally to do couple work, and the work would at that stage be wasted on them. Similarly, those with an acute psychosis would, at the time they are acutely ill, be unavailable to this kind of therapy, and should not be offered it. However, in both cases, when the acute crisis is over and...

TBI and the Neuroendocrine System

Tbi And Sleep

Given that pituitary insufficiency may have serious consequences and may aggravate the physical and neuropsychiatric morbidity observed after TBI (Agha et al. 2005), frequent assessment of the subject's endocrine status is essential. Moreover, with the more elevated and prolonged risk for psychiatric illness, including depression, posttraumatic stress disorder, anxiety and sleep wakefulness, that are persistent symptoms of TBI (Fann, Burington, Leonetti, Jaffe, Katon, and Thompson 2004 Dikmen, Bobmardier, Machamer, Fann, and Temkin 2004 Ryan and Warden 2003) and the evidence that the neuroendocrine stress system and depression share common neural pathways and hormonal mediators (Gold and Chrousos 2002), measurement of the allostatic HPA stress response should prove to be a relevant biomarker in TBI.

Cognitive content of anxiety disorders

Post-traumatic stress disorder Surveys indicate 5 that unwanted, intrusive, and distressing memories and the other symptoms of post-traumatic stress disorder (avoidance of reminders and hyperarousal numbing) are common immediately after traumatic events. Over the next few months many people recover but in a subgroup post-traumatic stress disorder becomes chronic. It is the latter group that normally present for treatment. Research indicates that chronic post-traumatic stress disorder is associated with appraising the traumatic event and or its sequelae in a manner that would produce a sense of serious current threat to one's view of oneself and or the world. (1 6) Examples are given in Table 1. There is also evidence that chronic post-traumatic stress disorder tends to be associated with a fragmented memory for the traumatic Table 1 Some examples of idiosyncratic, negative appraisals leading to a sense of current threat in post-traumatic stress disorder

What makes a stressor traumatic

In everyday language, many upsetting situations are described as 'traumatic', for example divorce, loss of job, or failing an examination. However, a field study designed to establish what kinds of stressors lead to the characteristic symptoms of PTSD, showed that only 0.4 per cent of a community sample developed the characteristic symptoms of PTSD in response to such 'low magnitude' stressors.(6) Thus, in diagnosing PTSD, it appeared necessary to employ a strict definition of what constitutes a traumatic stressor. Few people would contest that horrific events such as rape or bombings are traumatic. In an attempt to capture the essence of these stressors, the authors of DSM-IIIR required a traumatic stressor to be 'outside the range of usual human experience' and that it 'would be markedly distressing to almost anyone'. (7) However, epidemiological studies showed that stressors that can lead to PTSD are actually quite common, for example road traffic accidents (8) or sexual...

Evidence for genuine recovered memories

The quality of the research evidence supporting genuine recovered memories is mixed, and almost all the studies can be argued to have some flaws, but taken together the evidence for genuine memories of major traumatic events is far more extensive than the evidence for false memories of such events. Moreover, these observations need not, as has sometimes been claimed, contradict what we know about memory. Cognitive psychology recognizes that ordinary memory relies as much for its efficiency on the ability to inhibit unwanted material as on the ability to gain rapid access to relevant material. Experimental studies clearly demonstrate the inhibition of memory retrieval and the existence of a subgroup of individuals with poor memories for negative experiences. (, .Z>


Some very recent work has looked at implicit and explicit memory as well as attentional processes in children with generalized anxiety disorder, PTSD, and depression. Broadly speaking, the preliminary findings are in accord with the voluminous findings with adult patients, namely that depressed children tend to have biases in memory for sad things, while anxious children do not. In contrast, children with anxiety disorders (including PTSD) have biases in attention that make them attend more to threatening cues in their environment, or at least to threatening words projected on computer screens. Studies using these adult-generated paradigms but utilized within a developmental framework should greatly increase our understanding of why some children break down under stress and others do not. Biases in cognitive processing of emotional reactions are implicated and can now be studied more readily.

Stressor criterion

Both ICD-10 and DSM-IV require that acute stress responses must occur in the immediate aftermath of an exceptionally stressful event. ICD-10 uses a broad concept of what qualifies as an 'exceptional mental or physical stressor'. This includes stressors that would be regarded as traumatic (e.g. rape, criminal assault, natural catastrophe) as well as unusually sudden changes in the social position and or network of the individual (e.g. domestic fire or multiple bereavement). In contrast, DSM-IV uses a narrow definition of stressors that lead to acute stress disorder, which is identical to the stressor criterion of PTSD. It requires (1) that the traumatic event must have involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, and (2) that the person's response to the traumatic event must have involved intense fear, helplessness, or horror (or disorganized or agitated behaviour in children) (see Chapter .B. for the rationale...

Biological theories

Biological theories propose that extreme stress affects neuronal functions, and that the resulting changes are responsible for the symptoms of acute stress disorder and PTSD. Specifically, there is considerable theoretical speculation concerning the neurotransmitters involved in the responses to traumatic stressors (see also Chapter 4,6.2). Catecholamines, glucocorticoids, serotonin, and endogenous opioids have been studied as potential mediators of post-traumatic stress responses. In one of the few studies of biological correlates of acute stress, Resnick et al. (33) found that lower cortisol levels in the acute phase after rape predicted the presence of PTSD 3 months later. These findings are in line with other research showing abnormally low levels of cortisol in PTSD, suggesting that the hypothalamic-pituitary-adrenal axis is set to produce large responses to further stressors in PTSD (see Chapter4. .6.2). The degree of acute arousal during the traumatic stressor may be one of the...


Exposure treatment comprises two components.(62) In imaginal exposure, patients are asked to relive the traumatic event in their imagination, including their thoughts and feelings at the time. This is repeated until the reliving no longer evokes high levels of distress. In vivo exposure involves confronting (safe) situations that patients avoid because they remind them of the trauma (e.g. going to the site of the traumatic event, driving again after a road traffic accident). Exposure is repeated until the patient no longer responds with high levels of distress. There are probably several mechanisms for the efficacy of exposure treatment. (58,62) First, patients realize that exposure does not lead to a feared outcome (for example, going to the site of an accident will not mean that another accident will happen thinking about the trauma will not make them go mad) and thus helps in correcting dysfunctional beliefs about danger of the world and the meaning of PTSD symptoms. Second, the...

Anger management

An anger management programme for PTSD patients with severe anger reactions is more effective in reducing anger than routine clinical care. (105) Eye-movement desensitization reprocessing This is a relatively new and controversial treatment. ( 6) The patient is instructed to focus on a trauma-related image and its accompanying feelings, sensations, and thoughts, while visually tracking the therapist's fingers as they move back and forth in front of the patient's eyes. After a set of approximately 24 eye movements, cognitive and emotional reactions are discussed with the therapist. Coping statements are also introduced while the scene is being imagined. A series of studies have established that eye-movement desensitization reprocessing is effective, at least for self-rated PTSD symptoms. Mean effect sizes were o 0.69 for observer-rated and o 1.24 for self-rated PTSD symptoms. For self-rated symptoms, eye-movement desensitization reprocessing effect sizes were larger than those of...

Choice of treatment

The best treatment options of PTSD to date are cognitive-behavioural treatments and SSRIs. Effect sizes of these treatments are comparable. Psychological treatments have the advantage of lower drop-out rates. The meta-analysis found that, across studies, 14 per cent of the patients dropped out of psychological treatments, compared with 36 per cent for the SSRIs 99,) An additional advantage of cognitive-behavioural treatments is their established long-term effectiveness. Treatment gains are maintained during follow-up. (99,109) In contrast, long-term follow-up studies are lacking for pharmacological treatments, so that it is not known whether treatment-effects are maintained when medications are withdrawn or when they are continued for long periods. The advantage of SSRIs compared to cognitive-behavioural treatment is that they are more readily available. Recent expert consensus guidelines concluded that cognitive-behavioural treatments are the treatment of choice for PTSD. For very...

Diagnostic issues

The DSM-IV task force considered other refinements to the criteria of social phobia. The parenthetical name 'social anxiety disorder' was added to acknowledge the significant impairment associated with social phobia and its differentiation from specific phobia. The criteria were also modified to include features specific to children 11.) There must be evidence that children are capable of forming social relationships, and anxiety must be evident in peer relationships. It is also acknowledged that children may manifest their anxiety differently than adults they may cry, throw tantrums, freeze, or shrink from interactions with strangers, and they may not acknowledge that their fears are irrational. Also, social anxiety may develop as a result of some medical conditions. For example, persons may become excessively anxious or avoid social situations because of obesity, acne, benign essential tremor, stuttering, or Parkinson's disease. These conditions are not considered exemplars of...

Applied tension

Blood-injection-injury phobia differs from other specific phobias because it is associated with parasympathetic arousal. Applied tension, designed specifically for blood-injection-injury phobia, requires the patient to tense different muscle groups instead of relaxing them, thereby countering parasympathetic arousal. The first trial of applied tension(l22) demonstrated that persons with phobias for blood, wounds, and injuries responded equally well to applied tension, applied relaxation, or their combination. A later study demonstrated that a higher percentage of persons treated with applied tension were clinically improved post-treatment and at 1-year follow-up than were patients treated with in vivo exposure alone.(l23) Similar positive effects were reported for those treated with one versus five sessions of applied tension.(124)

Mental defeat

We did not make the distinction between feeling defeated and mental defeat. However, important research in the field of post-traumatic disorders after torture has found that severity of symptoms and duration are related to experiences of mental defeat. Ehlers et al. (2000) point out that many victims of torture may feel defeated and sign false confessions, but they may not feel inwardly or personally defeated in the sense that they have lost autonomy. Mental defeat, however, is defined as 'the perceived loss of all autonomy, a state of giving up in one's mind all efforts to retain one's identity as a human being with a will of one's own' (p. 45). Mental defeat, in this context, was also associated with total subordination, such as feeling merely an object to the other and with loss of self-identity, as if prepared to do whatever the other asked, and not caring whether one lived or died. Those who experienced mental defeat had more chronic post-traumatic stress disorder (PTSD) symptoms...

Saccular Cyst

A saccular cyst (SC) is a mucus-filled dilatation of the laryngeal saccule that has no communication with the laryngeal lumen 80, 161 . Most SCs are congenital in origin some may also appear as acquired lesions caused by various inflammatory processes, traumatic events, or tumours 1, 161, 257 . SCs, which may occur at any age, are divided into anterior and lateral. The former spread medially and posteriorly, and protrude into the laryngeal lumen between the true and false vocal cord. The latter are generally larger and extend towards the false vocal cord and aryepiglottic fold. They may rarely spread through the thyrohyoid membrane 10, 80, 161, 357 . SCs may be asymptomatic, but the most common symptoms are progressive cough, dysphagia, hoarseness, dyspnoea and foreign body sensation. Diagnosis is often made by laryngoscopy combined with CT scan 69 .


Neurotransmitter alterations in PTSD catecholamines and serotonin. Semin Clin Neuropsychiatry 1999 4(4) 242-8. between thyroid hormones and symptoms in combat-related posttraumatic stress disorder. Psychosom Med 1995 57(4) 398-402. Enhanced suppression of cortisol following dexamethasone administration in posttraumatic stress disorder. AmJPsychiatry 1993 150(1) 83-6. volume in patients with combat-related posttraumatic stress disorder. Am J Psychiatry 1995 152 973-81. hippocampal volume in chronic, combat-related post-traumatic stress disorder. Biological Psychiatry 1996 40 1091-9. volume in posttraumatic stress disorder related to childhood physical and sexual abuse-A preliminary report. Biological Psychiatry 1997 41 23-32. acetylaspartate in post traumatic stress disorder. The Annals of the New York Academy of Sciences 1997 Supplement on Psychobiology of Posttraumatic Stress Disorder(821) 516-20. resonance spectroscopy of the medial temporal lobes of subjects with combat-related...


The new antidepressants can allow formerly inhibited people to exercise power in social areas. Also, there is a value conflict on a theoretical and philosophical level. The materialists, like most of those who subscribe to a biological perspective, argue that mental processes can be reduced to brain processes. Chemical substances affect the brain and so the mental processes can also be changed. This lends a positive attitude to the use of psychotropics for depression and anxiety. On the other hand, interactionists argue that traumatic events, e.g. during childhood, can be memorized in the cognitive system and can also affect the body, e.g. causing symptoms of depression. For interactionists, psychotropics are much less important because the drug is normally not assumed to influence the individual's governing self.


Every refugee situation will have a range of traumatic events that will fall into each of these categories that are unique or characteristic of a specific conflict. It is essential that the specific types of violence experienced by a given refugee population are well known to the psychiatric clinician who can use this knowledge to assess potential traumatic outcomes.(14) In addition to many unique forms of violence occurring in different refugee settings, the meaning of violent events also differs across cultures. Although still unproven, anecdotal, clinical, and epidemiological evidence suggests that certain categories of refugee trauma are more potent than others in producing psychiatric morbidity and other traumatic outcomes. Brain injury, sexual violence, torture and other forms of bodily injury, coercion, and forced confinement have great potential of causing psychiatric harm in refugees exposed to these events. Consistent with indicators of the 'potency' of specific trauma...

MS and Stress

MS patients frequently report elevated levels of stress prior to initial diagnosis and or disease exacerbation (Warren et al., 1982 Grant et al., 1989 Ackerman et al., 2000 Mohr et al., 2000 Mohr et al., 2004). A recent metaanalysis was conducted on 14 studies investigating the impact of stressful life events on MS exacerbation. The results indicated that stressful life events significantly increased the risk of subsequent disease exacerbation (Mohr et al., 2004). Importantly, 13 of the 14 studies measured common stressful life events, mostly interpersonal stressors at family and work. However, one of the 14 studies did not observe a negative effect of stress on MS. This study examined the impact of a traumatic stressor, missile attacks during the Gulf War, finding reduced relapse rates and no change in lesion development (Nisipeanu and Korczyn, 1993). Thus, the characteristics of the stressor may alter the impact of stress on initial susceptibility and disease course in MS. Chronic...

Natural history

Amongst the many different types of accident, children or adolescents who were passengers in a car appear more likely to develop PTSD compared with those riding a bicycle or who were pedestrians at the time.(42) About 72 per cent of children involved in car accidents had high PTSD symptoms at 6 weeks post-accident, compared with around 30 per cent of bicyclists or pedestrians. Car passengers also reported more severe symptoms, supporting previous findings that the level of exposure to personal danger correlates with the severity of PTSD symptoms.(43) Although cars are associated with the greater risk, all types of accident are associated with a significantly raised rate of PTSD in children. Symptoms that are unresolved by 6 weeks and higher premorbid levels of anxiety or depression are both associated with a somewhat increased risk for chronic PTSD. Premorbid levels of hyperactivity or behavioural symptoms do not appear to be associated with either acute or chronic PTSD symptoms.(42)...

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