Traumatic Stress-Induced Increases in Anxiety-like Behavior and Alcohol Self-Administration Are Mediated by Central Amygdala CRF1 Neurons That Project to the Lateral Hypothalamus.

Avoidance stress coping, defined as persistent internal and/or external avoidance of stress-related stimuli, is a key feature of anxiety- and stress-related disorders, and contributes to increases in alcohol misuse after stress exposure. Previous work using a rat model of predator odor stress avoidance identified corticotropin-releasing factor (CRF) signaling via CRF Type 1 receptors (CRF1) in the CeA, as well as CeA projections to the lateral hypothalamus (LH) as key mediators of conditioned avoidance of stress-paired contexts and/or increased alcohol drinking after stress. Here, we report that CRF1-expressing CeA cells that project to the LH are preferentially activated in male and female rats that show persistent avoidance of predator odor stress-paired contexts (termed Avoider rats), and that chemogenetic inhibition of these cells rescues stress-induced increases in anxiety-like behavior and alcohol self-administration in male and female Avoider rats. Using slice electrophysiology, we found that prior predator odor stress exposure blunts inhibitory synaptic transmission and increases synaptic drive in CRF1 CeA-LH cells. In addition, we found that CRF bath application reduces synaptic drive in CRF1 CeA-LH cells in Non-Avoiders only. Collectively, these data show that CRF1 CeA-LH cells contribute to stress-induced increases in anxiety-like behavior and alcohol self-administration in male and female Avoider rats.SIGNIFICANCE STATEMENT Stress may lead to a variety of behavioral and physiological negative consequences, and better understanding of the neurobiological mechanisms that contribute to negative stress effects may lead to improved prevention and treatment strategies. This study, performed in laboratory rats, shows that animals that exhibit avoidance stress coping go on to develop heightened anxiety-like behavior and alcohol self-administration, and that these behaviors can be rescued by inhibiting the activity of a specific population of neurons in the central amygdala. This study also describes stress-induced physiological changes in these neurons that may contribute to their role in promoting increased anxiety and alcohol self-administration.

Empathy, compassion fatigue, guilt and secondary traumatic stress in nurses.

BACKGROUND: Nurses are often faced with many stressful situations in life, including personal life challenges, the nature of work that requires standing long and being focused, commitment to patient care, and dealing with patients who need help. RESEARCH OBJECTIVE: The aim of this study was to investigate the relationship between empathy and compassion fatigue in nurses due to the mediating role of feeling guilty and secondary traumatic stress. RESEARCH DESIGN: This is a descriptive-correlation study. PARTICIPANTS: The statistical population consisted of all the nurses in Kerman hospitals in 2017. Five hospitals were randomly selected from among the private and public hospitals in Kerman. The sample size was considered 360, but after the deletion of misleading questionnaires, the final sample of study consisted of 300 nurses. ETHICAL CONSIDERATIONS: Approval from the researcher's university Institutional Review Board for ethical review was obtained. FINDINGS: The data analysis in this study was done through the path analysis method using the Amos software. The results showed the mediating role of omnipotent guilt between empathy and compassion fatigue in the nurses, the mediating role of survivor guilt between empathy and compassion fatigue in the nurses, and the mediating role of secondary traumatic stress between empathy and compassion fatigue in the nurses. Also, empathy could explain 77% of the nurses' compassion fatigue through feelings of guilt and secondary traumatic stress. DISCUSSION: Pathogenic empathy-based guilt and secondary traumatic stress may help explain some of the links between clinical empathy and symptoms of compassion fatigue. CONCLUSION: Interventions and training programs targeting pathogenic empathy-based guilt and empathic secondary traumatic stress may be particularly important to help reduce compassion fatigue.

Accelerated development of cocaine-associated dopamine transients and cocaine use vulnerability following traumatic stress.

Post-traumatic stress disorder and cocaine use disorder are highly co-morbid psychiatric conditions. The onset of post-traumatic stress disorder generally occurs prior to the development of cocaine use disorder, and thus it appears that the development of post-traumatic stress disorder drives cocaine use vulnerability. We recently characterized a rat model of post-traumatic stress disorder with segregation of rats as susceptible and resilient based on anxiety-like behavior in the elevated plus maze and context avoidance. We paired this model with in vivo fast scan cyclic voltammetry in freely moving rats to test for differences in dopamine signaling in the nucleus accumbens core at baseline, in response to a single dose of cocaine, and in response to cocaine-paired cues. Further, we examined differences in the acquisition of cocaine self-administration across groups. Results indicate that susceptibility to traumatic stress is associated with alterations in phasic dopamine signaling architecture that increase the rate at which dopamine signals entrain to cocaine-associated cues and increase the magnitude of persistent cue-evoked dopamine signals following training. These changes in phasic dopamine signaling correspond with increases in the rate at which susceptible rats develop excessive cocaine-taking behavior. Together, our studies demonstrate that susceptibility to traumatic stress is associated with a cocaine use-vulnerable phenotype and suggests that differences in phasic dopamine signaling architecture may contribute to the process by which this vulnerability occurs.

Caring for older people with dementia reliving past trauma.

BACKGROUND: The occurrence of behavioural changes and problems, and degree of paranoid thoughts, are significantly higher among people who have experienced extreme trauma such as during the Holocaust. People with dementia and traumatic past experiences may have flashbacks reminding them of these experiences, which is of relevance in caring situations. In nursing homes for people with dementia, nursing assistants are often the group of staff who provide help with personal needs. They have firsthand experience of care and managing the devastating outcomes of inadequate understanding of a person's past experiences. AIM: The aim was to describe nursing assistants' experiences of caring for older people with dementia who have experienced Holocaust trauma. RESEARCH DESIGN: A qualitative descriptive and inductive approach was used, including qualitative interviews and content analysis. PARTICIPANTS AND RESEARCH CONTEXT: Nine nursing assistants from a Jewish nursing home were interviewed. ETHICAL CONSIDERATIONS: The study was approved by the Regional Ethical Review Board, Stockholm. FINDINGS: The theme 'Adapting and following the survivors' expression of their situation' was built on two categories: Knowing the life story enables adjustments in the care and Need for flexibility in managing emotional expressions. DISCUSSION AND CONCLUSION: The world still witnesses genocidal violence and such traumatic experiences will therefore be reflected in different ways when caring for survivors with dementia in the future. Person-centred care and an awareness of the meaning of being a survivor of severe trauma make it possible to avoid negative triggers, and confirm emotions and comfort people during negative flashbacks in caring situations and environments. Nursing assistants' patience and empathy were supported by a wider understanding of the behaviour of people with dementia who have survived trauma.

Stress related disorders and subsequent risk of life threatening infections: population based sibling controlled cohort study.

OBJECTIVE: To assess whether severe psychiatric reactions to trauma and other adversities are associated with subsequent risk of life threatening infections. DESIGN: Population and sibling matched cohort study. SETTING: Swedish population. PARTICIPANTS: 144 919 individuals with stress related disorders (post-traumatic stress disorder (PTSD), acute stress reaction, adjustment disorder, and other stress reactions) identified from 1987 to 2013 compared with 184 612 full siblings of individuals with a diagnosed stress related disorder and 1 449 190 matched individuals without such a diagnosis from the general population. MAIN OUTCOME MEASURES: A first inpatient or outpatient visit with a primary diagnosis of severe infections with high mortality rates (ie, sepsis, endocarditis, and meningitis or other central nervous system infections) from the Swedish National Patient Register, and deaths from these infections or infections of any origin from the Cause of Death Register. After controlling for multiple confounders, Cox models were used to estimate hazard ratios of these life threatening infections. RESULTS: The average age at diagnosis of a stress related disorder was 37 years (55 541, 38.3% men). During a mean follow-up of eight years, the incidence of life threatening infections per 1000 person years was 2.9 in individuals with a stress related disorder, 1.7 in siblings without a diagnosis, and 1.3 in matched individuals without a diagnosis. Compared with full siblings without a diagnosis of a stress related disorder, individuals with such a diagnosis were at increased risk of life threatening infections (hazard ratio for any stress related disorder was 1.47 (95% confidence intervals1.37 to 1.58) and for PTSD was 1.92 (1.46 to 2.52)). Corresponding estimates in the population based analysis were similar (1.58 (1.51 to 1.65) for any stress related disorder, P=0.09 for difference between sibling and population based comparison, and 1.95 (1.66 to 2.28) for PTSD, P=0.92 for difference). Stress related disorders were associated with all studied life threatening infections, with the highest relative risk observed for meningitis (sibling based analysis 1.63 (1.23 to 2.16)) and endocarditis (1.57 (1.08 to 2.30)). Younger age at diagnosis of a stress related disorder and the presence of psychiatric comorbidity, especially substance use disorders, were associated with higher hazard ratios, whereas use of selective serotonin reuptake inhibitors in the first year after diagnosis of a stress related disorder was associated with attenuated hazard ratios. CONCLUSION: In the Swedish population, stress related disorders were associated with a subsequent risk of life threatening infections, after controlling for familial background and physical or psychiatric comorbidities.

The relationship between prenatal psychological stress and placental abruption in Japan, The Japan Environment and Children's Study (JECS).

BACKGROUND: Prenatal psychological stress may increase the risk of placental abruption (PA). This study aimed to clarify the effects of psychological distress during pregnancy and exposure to stressful life events in the year before or during pregnancy on the occurrence of PA in Japanese women. METHODS: Using a nationwide prospective birth cohort study, we obtained data from 103,099 women between January 2011 and March 2014. Information on exposure to 14 stressful life events and psychological distress (Kessler 6 scale) was collected using a self-administered questionnaire during pregnancy. Clinical diagnoses of PA were obtained from medical records. A total of 80,799 women with singleton births were analyzed using logistic regression models that adjusted for possible confounders. RESULTS: PA was diagnosed in 335 (0.4%) women. There was no significant difference in the Kessler 6 score during pregnancy between the PA group and non-PA group. Exposure to the death of a child in the year before or during pregnancy was significantly associated with PA in multigravid women (adjusted odds ratio [aOR] 3.57; 95% confidence interval [CI] 1.50-8.34). A spouse's loss of employment was significantly associated with PA in parous women (aOR 3.25; 95% CI 1.40-7.56). CONCLUSIONS: This study identified the possible effects of exposure to the death of a child on PA occurrence that adjusted for important confounding factors.

Pediatrician's Practical Approach to Sleep Disturbances in Children Who Have Experienced Trauma.

Sleep difficulties are a common challenge among children who have experienced trauma. Pediatricians are best positioned to work with families to address sleep challenges after traumatic events and help families return to healthy sleep patterns. In this article, we review the underlying concepts that connect trauma to disturbed sleep, types of sleep difficulties seen in children exposed to trauma, and explore ways in which pediatricians can support families as they help their child return to a normal sleep cycle, including the identification of co-occurring conditions and the use of medications. [Pediatr Ann. 2019;48(7):e280-e285.].

Early childhood trauma alters neurological responses to mental stress in patients with coronary artery disease.

BACKGROUND: Early childhood trauma is known to independently increase adverse outcome risk in coronary artery disease (CAD) patients, although the neurological correlates are not well understood. The purpose of this study was to examine whether early childhood trauma alters neural responses to acute mental stress in CAD patients. METHODS: Participants (n = 152) with CAD underwent brain imaging with High Resolution Positron Emission Tomography and radiolabeled water during control (verbal counting, neutral speaking) and mental stress (mental arithmetic, public speaking). Traumatic events in childhood were assessed with the Early Trauma Inventory (ETI-SR-SF) and participants were separated by presence (ETI+) or absence (ETI-) of early childhood trauma. Brain activity during mental stress was compared between ETI+ and ETI-. RESULTS: Compared to ETI-, ETI+ experienced greater (p < 0.005) activations during mental stress within the left anterior cingulate, bilateral frontal lobe and deactivations (p < 0.005) within the left insula, left parahippocampal gyrus, right dorsal anterior cingulate, bilateral cerebellum, bilateral fusiform gyrus, left inferior temporal gyrus, and right parietal lobe. Significant (p < 0.005) positive correlations between brain activation and ETI-SR-SF scores were observed within the left hippocampus, bilateral frontal lobe, left occipital cuneus, and bilateral temporal lobe. LIMITATIONS: Results in non-CAD samples may differ and ETI may be subject to recall bias. CONCLUSION: Early childhood trauma exacerbated activations in stress-responsive limbic and cognitive brain areas with direct and indirect connections to the heart, potentially contributing to adverse outcomes in CAD patients.

The HARMONIC trial: study protocol for a randomised controlled feasibility trial of Shaping Healthy Minds-a modular transdiagnostic intervention for mood, stressor-related and anxiety disorders in adults.

INTRODUCTION: Anxiety, mood and trauma-related disorders are common, affecting up to 20% of adults. Many of these individuals will experience symptoms of more than one disorder as diagnostically defined. However, most psychological treatments focus on individual disorders and are less effective for those who experience comorbid disorders. The Healthy and Resilient Mind Programme: Building Blocks for Mental Wellbeing (HARMONIC) trial introduces a novel transdiagnostic intervention (Shaping Healthy Minds (SHM)), which synthesises several evidence-based treatment techniques to address the gap in effective interventions for people with complex and comorbid difficulties. This early phase trial aims to estimate the efficacy and feasibility of the transdiagnostic intervention in preparation for a later-phase randomised controlled trial, and to explore mechanisms of change. METHODS/ANALYSIS: We outline a patient-level two-arm randomised controlled trial (HARMONIC) that compares SHM to treatment-as-usual for individuals aged >18 years (n=50) with comorbid mood, anxiety, obsessive-compulsive or trauma/stressor disorders diagnoses, recruited from outpatient psychological services within the UK National Health Service (NHS). The co-primary outcomes will be 3-month follow-up scores on self-report measures of depressive symptoms, anxiety symptoms, and disability and functional impairment. Secondary outcomes include changes in symptoms linked to individual disorders. We will assess the feasibility and acceptability of SHM, the utility of proposed outcome measures, and refine the treatment manuals in preparation for a later-phase trial. ETHICS AND DISSEMINATION: This trial protocol has been approved by the Health Research Authority of the NHS of the UK (East of England, Reference: 16/EE/0095). We anticipate that trial findings will inform future revisions of clinical guidelines for numerous forms of mood, anxiety and stressor-related disorders. Findings will be disseminated broadly via peer-reviewed empirical journal articles, conference presentations, clinical workshops and a trial website. TRIAL REGISTRATION: NCT03143634; Pre-results.

Association of Stress-Related Disorders With Subsequent Autoimmune Disease.

Importance: Psychiatric reactions to life stressors are common in the general population and may result in immune dysfunction. Whether such reactions contribute to the risk of autoimmune disease remains unclear. Objective: To determine whether there is an association between stress-related disorders and subsequent autoimmune disease. Design, Setting, and Participants: Population- and sibling-matched retrospective cohort study conducted in Sweden from January 1, 1981, to December 31, 2013. The cohort included 106 464 exposed patients with stress-related disorders, with 1 064 640 matched unexposed persons and 126 652 full siblings of these patients. Exposures: Diagnosis of stress-related disorders, ie, posttraumatic stress disorder, acute stress reaction, adjustment disorder, and other stress reactions. Main Outcomes and Measures: Stress-related disorder and autoimmune diseases were identified through the National Patient Register. The Cox model was used to estimate hazard ratios (HRs) with 95% CIs of 41 autoimmune diseases beyond 1 year after the diagnosis of stress-related disorders, controlling for multiple risk factors. Results: The median age at diagnosis of stress-related disorders was 41 years (interquartile range, 33-50 years) and 40% of the exposed patients were male. During a mean follow-up of 10 years, the incidence rate of autoimmune diseases was 9.1, 6.0, and 6.5 per 1000 person-years among the exposed, matched unexposed, and sibling cohorts, respectively (absolute rate difference, 3.12 [95% CI, 2.99-3.25] and 2.49 [95% CI, 2.23-2.76] per 1000 person-years compared with the population- and sibling-based reference groups, respectively). Compared with the unexposed population, patients with stress-related disorders were at increased risk of autoimmune disease (HR, 1.36 [95% CI, 1.33-1.40]). The HRs for patients with posttraumatic stress disorder were 1.46 (95% CI, 1.32-1.61) for any and 2.29 (95% CI, 1.72-3.04) for multiple (≥3) autoimmune diseases. These associations were consistent in the sibling-based comparison. Relative risk elevations were more pronounced among younger patients (HR, 1.48 [95% CI, 1.42-1.55]; 1.41 [95% CI, 1.33-1.48]; 1.31 [95% CI, 1.24-1.37]; and 1.23 [95% CI, 1.17-1.30] for age at ≤33, 34-41, 42-50, and ≥51 years, respectively; P for interaction < .001). Persistent use of selective serotonin reuptake inhibitors during the first year of posttraumatic stress disorder diagnosis was associated with attenuated relative risk of autoimmune disease (HR, 3.64 [95% CI, 2.00-6.62]; 2.65 [95% CI, 1.57-4.45]; and 1.82 [95% CI, 1.09-3.02] for duration ≤179, 180-319, and ≥320 days, respectively; P for trend = .03). Conclusions and Relevance: In this Swedish cohort, exposure to a stress-related disorder was significantly associated with increased risk of subsequent autoimmune disease, compared with matched unexposed individuals and with full siblings. Further studies are needed to better understand the underlying mechanisms.

Secondary Traumatic Stress and Burnout Among Muslim Nurses Caring for Chronically Ill Children in a Turkish Hospital.

PURPOSE: This study investigated secondary traumatic stress and its relationship to burnout among nurses working at a Turkish hospital. DESIGN: A mixed-methods design included a cross-sectional survey administering the Professional Quality of Life instrument and Maslach Burnout Inventory to 106 nurses. Interviews with a subgroup of eight participants explored nurses' experiences and coping strategies related to caring for chronically ill pediatric patients. RESULTS: High risk levels of secondary traumatic stress existed among 40.6% participants, and those over the age of 40 years were at greater risk. Two main interview themes emerged that identified (a) consequences and (b) coping strategies while caring for chronically ill children. Nurses experience emotional burdens and may purposefully distance themselves from chronically ill children. Social support from nurse colleagues and spiritual beliefs assist coping. IMPLICATIONS: Workplaces should acknowledge stressors inherent in chronic pediatric nursing care. Environments that welcome spiritual practices and actively encourage social support could address job hazards.

Traumatic Stress Disorders and Risk of Subsequent Schizophrenia Spectrum Disorder or Bipolar Disorder: A Nationwide Cohort Study.

OBJECTIVE: Traumatic stress disorders are prevalent in patients with schizophrenia and bipolar disorder. However, there is a lack of prospective longitudinal studies investigating the risk of severe mental illness for people diagnosed with traumatic stress disorders. We aimed to assess if patients with acute stress reaction (ASR) or post-traumatic stress disorder (PTSD) are at increased risk of schizophrenia spectrum disorders or bipolar disorder. METHODS: We performed a prospective cohort study covering the entire Danish population including information on inpatient and outpatient mental hospitals over 2 decades. Predictors were in- or outpatient diagnoses of ASR or PTSD. We calculated incidence rate ratios (IRR) with 95% CIs of schizophrenia, schizophrenia spectrum disorder, and bipolar disorder. RESULTS: Persons with a traumatic stress disorder had a significantly increased risk of schizophrenia (IRR 3.80, CI 2.33-5.80), schizophrenia spectrum disorder (IRR 2.34, CI 1.46-3.53), and bipolar disorder (IRR 4.22, CI 2.25-7.13). Risks were highest in the first year after diagnosis of the traumatic stress disorder and remained significantly elevated after more than 5 years. Mental illness in a parent could not explain the association. CONCLUSION: Our findings support an association between diagnosed traumatic stress disorders and subsequent schizophrenia spectrum disorder or bipolar disorder. If replicated, this may increase clinical focus on patients with traumatic stress disorders.

Genetic variant rs3750625 in the 3'UTR of ADRA2A affects stress-dependent acute pain severity after trauma and alters a microRNA-34a regulatory site.

α2A adrenergic receptor (α2A-AR) activation has been shown in animal models to play an important role in regulating the balance of acute pain inhibition vs facilitation after both physical and psychological stress. To our knowledge, the influence of genetic variants in the gene encoding α2A-AR, ADRA2A, on acute pain outcomes in humans experiencing traumatic stress has not been assessed. In this study, we tested whether a genetic variant in the 3'UTR of ADRA2A, rs3750625, is associated with acute musculoskeletal pain (MSP) severity following motor vehicle collision (MVC, n = 948) and sexual assault (n = 84), and whether this influence was affected by stress severity. We evaluated rs3750625 because it is located in the seed binding region of miR-34a, a microRNA (miRNA) known to regulate pain and stress responses. In both cohorts, the minor allele at rs3750625 was associated with increased musculoskeletal pain in distressed individuals (stress*rs3750625 P = 0.043 for MVC cohort and P = 0.007 for sexual assault cohort). We further found that (1) miR-34a binds the 3'UTR of ADRA2A, (2) the amount of repression is greater when the minor (risk) allele is present, (3) miR-34a in the IMR-32 adrenergic neuroblastoma cell line affects ADRA2A expression, (4) miR-34a and ADRA2A are expressed in tissues known to play a role in pain and stress, (5) following forced swim stress exposure, rat peripheral nerve tissue expression changes are consistent with miR-34a regulation of ADRA2A. Together, these results suggest that ADRA2A rs3750625 contributes to poststress musculoskeletal pain severity by modulating miR-34a regulation.

Psychosocial Group Intervention Among War-Affected Children: An Analysis of Changes in Posttraumatic Cognitions.

Cognitive theories point to reduction in dysfunctional posttraumatic cognitions (PTCs) as one mechanism involved in recovery from posttraumatic stress symptoms (PTSS), yet research findings have shown individual differences in the recovery process. We tested the cognitive mediation hypothesis above in a previously published psychosocial group intervention among war-affected children. We also examined heterogeneity in children's PTCs during the intervention. We used a cluster randomized trial of Smith et al.'s (2002) teaching recovery techniques (TRT) intervention among 482 Palestinians 10-13 years of age (n = 242 for intervention group, n = 240 for control group). Children reported PTSS, PTCs, and depressive symptoms at baseline, midpoint, postintervention, and at 6-month follow-up. Path analysis results showed that TRT was not effective in reducing dysfunctional PTCs, and the reductions did not mediate intervention effects on PTSS. Using latent class growth analysis, we chose the model with 3 differing trajectories in the intervention group: high, decreasing, moderate, downward trending, and severe, stable levels of PTCs. Higher PTSS and depressive symptoms at baseline were associated with membership in the severe, stable trajectory. The intervention did not produce the kind of beneficial cognitive change needed in the cognitive mediation conceptualization. Nevertheless, cognitive changes differed substantially across children during the intervention, and were associated with their preintervention mental health status. These findings call for more detailed examination of the process of cognitive mediation.

Cumulative traumatization associated with pathological dissociation in acute psychiatric inpatients.

Clinical studies of patients with dissociative disorders and prospective studies of childhood trauma survivors show inconsistent findings regarding the relationship between childhood trauma and dissociation. This study aims to resolve this inconsistency by investigating how dissociation is related to parental dysfunctions, general psychopathology, childhood trauma, and adulthood trauma. Specifically, we focus on the role of cumulative traumatization in pathological and non-taxon dissociation. Eighty acute psychiatric inpatients were administrated standardized measures on dissociation, perceived parental dysfunctions, traumatizing events, and general psychopathology. Parental dysfunctions and trauma correlated with both types of dissociation and general psychopathology. When general psychopathology and parental dysfunctions were controlled, a unique link between trauma and dissociation remained significant. Moreover, the pattern of relationships differed for non-taxon and pathological dissociations. The effect of childhood but not adulthood trauma was significant on non-taxon dissociation. In contrast, an interactive model incorporating both childhood and adulthood trauma was the best model for explaining pathological dissociation. Childhood trauma is important for developing non-taxon dissociation, and adulthood trauma exacerbates its effects on the emergence of pathological dissociation. Cumulative traumatization from childhood to adulthood should be incorporated into the trauma hypothesis of pathological dissociation.

Latent profile analyses of posttraumatic stress disorder, depression and generalized anxiety disorder symptoms in trauma-exposed soldiers.

Posttraumatic stress disorder (PTSD) is comorbid with major depressive disorder (MDD; Kessler et al., 1995) and generalized anxiety disorder (GAD; Brown et al., 2001). We aimed to (1) assess discrete patterns of post-trauma PTSD-depression-GAD symptoms using latent profile analyses (LPAs), and (2) assess covariates (gender, income, education, age) in defining the best fitting class solution. The PTSD Checklist (assessing PTSD symptoms), GAD-7 scale (assessing GAD symptoms), and Patient Health Questionnaire-9 (assessing depression) were administered to 1266 trauma-exposed Ohio National Guard soldiers. Results indicated three discrete subgroups based on symptom patterns with mild (class 1), moderate (class 2) and severe (class 3) levels of symptomatology. Classes differed in symptom severity rather than symptom type. Income and education significantly predicted class 1 versus class 3 membership, and class 2 versus class 3. In conclusion, there is heterogeneity regarding severity of PTSD-depression-GAD symptomatology among trauma-exposed soldiers, with income and education predictive of class membership.

Missing memories of death: Dissociative amnesia in the bereaved the day after a cancer death.

OBJECTIVE: The death of a loved one is one of the most stressful events of life, and such stress affects the physical and psychological well-being of the bereaved. Dissociative amnesia is characterized by an inability to recall important autobiographical information. Dissociative amnesia in the bereaved who have lost a loved one to cancer has not been previously reported. We discuss herein the case of a patient who developed dissociative amnesia the day after the death of here beloved husband. METHOD: A 38-year-old woman was referred for psychiatric consultation because of restlessness and abnormal behavior. Her 44-year-old husband had died of pancreatic cancer the day before the consultation. On the day of the death, she looked upset and began to hyperventilate. The next day, she behaved as if the deceased were still alive, which embarrassed her family. At her initial psychiatric consultation, she talked and behaved as if her husband was still alive and in the hospital. RESULTS: Her psychiatric features fulfilled the DSM-V criteria for dissociative amnesia. The death of her husband had been very traumatic for her and was considered to have been one of the causes of this dissociation. SIGNIFICANCE OF RESULTS: This report adds to the list of psychiatric symptoms in the bereaved who have lost a loved one to cancer. In an oncology setting, we should consider the impact of death, the concomitant defense mechanisms, and the background of the families.

The cortisol response to social stress in social anxiety disorder.

This study evaluated the cortisol stress response (CSR) following the Trier Social Stress Test in Social Anxiety Disorder (SAD) and control participants, to determine whether individual differences in CSR associate more with SAD diagnosis or dimensional characteristics [i.e. childhood trauma (CT)]. Twenty-one participants (11 with SAD) had full data available for both CT-scores and cortisol area-under-the-curve (AUC). Linear regression produced significant results: predicting AUCG with study group, emotional abuse (EA) scores and their interaction (F=3.14, df=5,15; p=.039); of note, the study group by EA interaction was significant at p=.015, driven by a strong positive association between EA and cortisol AUCG in the control group, and a negative association between these variables in the SAD group (standardized-beta=1.56, t=2.75, p=.015). This suggests that EA in SAD patients is associated with altered CSR, highlighting need to measure dimensional characteristics.

POTS following traumatic stress: interacting central and intracardiac neural control?

Cardiovascular autonomic dysfunction is one of the most overlooked complications in patients with diabetes. We report the case of a 19-year-old woman with a 4-year history of diabetes referred due to palpitations and light-headedness following traumatic stress. Rise of heart rate and blood pressure during tilt table testing indicated hyperadrenergic postural orthstatic tachycardia syndrome (POTS). Elevated blood pressure variability, an indirect parameter of increased sympathetic activity, remained almost stable during orthostatic stress. Short-term treatment with ivabradine in combination with psychosocial support alleviated POTS-related symptoms. Our findings suggest that traumatic stress in patients with type 1 diabetes mellitus might translate into disturbed neural heart rate control due to a central, ephemeral alteration in autonomic balance.