The Lingering Impact of Resolved PTSD on Subsequent Functioning.

This study investigated whether impairment persists after posttraumatic stress disorder (PTSD) has resolved. Traumatically injured patients (N = 1,035) were assessed during hospital admission and at 3 (85%) and 12 months (73%). Quality of life prior to traumatic injury was measured with the World Health Organization Quality of Life-BREF during hospitalization and at each subsequent assessment. PTSD was assessed using the Clinician-Administered PTSD Scale at 3 and 12 months. After controlling for preinjury functioning, current pain, and comorbid depression, patients whose PTSD symptoms had resolved by 12 months were more likely to have poorer quality of life in psychological (OR = 3.51), physical (OR = 10.17), social (OR = 4.54), and environmental (OR = 8.83) domains than those who never developed PTSD. These data provide initial evidence that PTSD can result in lingering effects on functional capacity even after remission of symptoms. Reprinted from Clin Psychol Sci 2016; 4:493-498, with permission from Sage. Copyright © 2016.

Prolonged grief in refugees, parenting behaviour and children's mental health.

BACKGROUND: Many refugees experience bereavement, and as a result they suffer elevated rates of prolonged grief disorder. Evidence also indicates that elevated rates of psychological disturbance in refugee children can be associated with parental mental health. This study examined the extent to which prolonged grief disorder in refugees is associated with their parenting behaviour and in turn with their children's mental health. METHODS: This study recruited participants from the Building a New Life in Australia prospective cohort study of refugees admitted to Australia between October 2013 and February 2014. The current data were collected in 2015-2016 and comprised 1799 adults, as well as 411 children of the adult respondents. Adult refugees were assessed for trauma history, post-migration difficulties, harsh and warm parenting, probable prolonged grief disorder and posttraumatic stress disorder. Children were administered the Strengths and Difficulties Questionnaire. The current analyses on bereaved refugees comprise 110 caregivers and 178 children. RESULTS: In this cohort, 37% of bereaved refugees reported probable prolonged grief disorder. Path analysis indicated that caregivers' grief was directly associated with children's emotional difficulties. Caregiver warmth was associated with reduced emotional problems in children of refugees with minimal grief but associated with more emotional problems in caregivers with more severe grief. More harsh parenting was associated with children's conduct problems, and this was more evident in those with less severe grief. CONCLUSION: Severity of prolonged grief disorder is directly linked to refugee children's mental health. The association between parenting style, grief severity and children's mental health highlights that managing grief reactions in refugees can benefit both refugees and their children.

An Open Label Pilot Study of a Brief Psychosocial Intervention for Disaster and Trauma Survivors.

BACKGROUND: In the aftermath of disaster, a large proportion of people will develop psychosocial difficulties that impair recovery, but for which presentations do not meet threshold criteria for disorder. Although these adjustment problems can cause high distress and impairment, and often have a trajectory towards mental health disorder, few evidence-based interventions are available to facilitate recovery. OBJECTIVE: This paper describes the development and pilot testing of an internationally developed, brief, and scalable psychosocial intervention that targets distress and poor adjustment following disaster and trauma. METHOD: The Skills fOr Life Adjustment and Resilience (SOLAR) program was developed by an international collaboration of trauma and disaster mental health experts through an iterative expert consensus process. The resulting five session, skills-based intervention, deliverable by community-based or frontline health or disaster workers with little or no formal mental health training (known as coaches), was piloted with 15 Australian bushfire survivors using a pre-post with follow up, mixed-methods design study. RESULTS: Findings from this pilot demonstrated that the SOLAR program was safe and feasible for non-mental health frontline workers (coaches) to deliver locally after two days of training. Participants' attendance rates and feedback about the program indicated that the program was acceptable. Pre-post quantitative analysis demonstrated reductions in psychological distress, posttraumatic stress symptoms, and impairment. CONCLUSIONS: This study provides preliminary evidence that the delivery of the SOLAR program after disaster by trained, frontline workers with little or no mental health experience is feasible, acceptable, safe, and beneficial in reducing psychological symptoms and impairment among disaster survivors. Randomized controlled trials of the SOLAR program are required to advance evidence of its efficacy.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward.

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Identifying distinctive psychological symptom profiles among a nationally representative sample of refugees resettled in Australia.

OBJECTIVE: The number of refugees worldwide is unprecedented in recent history. Little is known, however, about profiles of psychological symptoms following persecution and displacement. METHODS: This study reports on a latent class analysis that identified profiles of posttraumatic stress disorder (PTSD), depression and anxiety symptoms in a nationally representative sample of 1625 refugees in Australia. The association between specific symptom profiles, exposure to potentially traumatic events and post-migration stressors, and overall health and help-seeking was examined. RESULTS: Latent class analysis yielded an optimal five-class solution. These classes comprised the Pervasive Symptom class (19.2%), the High PTSD Symptom class (17.1%), the High Depression/Anxiety Symptom class (16.4%), the Moderate PTSD Symptom class (16.2%) and the Low Symptom class (31.1%). Participants in the symptomatic classes were more likely to be female, older and report greater post-migration stressors than those in the Low Symptom class. In addition, individuals in classes characterized by PTSD symptoms had been exposed to more types of potentially traumatic events. Membership in symptomatic classes was associated with poorer overall heath and greater help-seeking. CONCLUSION: Qualitatively distinct symptom profiles were observed in a nationally representative sample of refugees. In addition to a group of people who reported high symptoms across psychological disorders and may warrant clinical intervention, we identified two subclinical classes who may be missed by existing diagnostic classification systems. Post-migration stressors play an important role in influencing refugee symptom profiles over and above exposure to potentially traumatic events. Clinicians should consider specific symptom profiles and contextual factors when planning interventions with refugees.

The impact of post-traumatic stress disorder symptomatology on quality of life: The sentinel experience of anger, hypervigilance and restricted affect.

BACKGROUND: It is unclear which specific symptoms of post-traumatic stress disorder are related to poor perceived quality of life. OBJECTIVE: To investigate the influence of post-traumatic stress disorder symptomatology on quality of life in traumatic injury survivors. METHOD: Traumatic injury survivors completed questionnaires on post-traumatic stress disorder symptomatology and quality of life at 3 months ( n = 987), 12 months ( n = 862), 24 months ( n = 830) and 6 years ( n = 613) post trauma. RESULTS: Low quality of life was reported by 14.5% of injury survivors at 3 months and 8% at 6 years post event. The post-traumatic stress disorder symptom clusters that contributed most to poor perceived quality of life were numbing and arousal, the individual symptoms that contributed most were anger, hypervigilance and restricted affect. CONCLUSIONS: There was variability in the quality of life of traumatic injury survivors in the 6 years following trauma and a consistent proportion reported low quality of life. Early intervention to reduce anger, hypervigilance and restricted affect symptoms may provide a means to improving the quality of life of traumatic injury survivors.

The effect of post-traumatic stress disorder on refugees' parenting and their children's mental health: a cohort study.

BACKGROUND: Children and adolescents, who account for most of the world's refugees, have an increased prevalence of psychological disorders. The mental health of refugee children is often associated with the severity of post-traumatic stress disorder (PTSD) in their caregivers. Despite the potential for refugee caregivers' PTSD to affect child mental health, little evidence exists concerning the underlying mechanisms of this association. This study tested the effect of refugee caregivers' previous trauma and levels of ongoing stressors on current PTSD, and in turn how this influences parenting behaviour and consequent child psychological health. METHODS: This cohort study recruited participants from the Building a New Life in Australia study, a population-based prospective cohort study of refugees admitted to 11 sites in Australia between October, 2013, and February, 2014. Eligible participants were aged 18 years or older and the principal or secondary applicant (ie, the refugee applicant within a migrating family unit) for a humanitarian visa awarded between May, 2013, and December, 2013. Primary caregiver PTSD and postmigration difficulties were assessed at Wave 1 (in 2013), and caregiver PTSD was reassessed at Wave 2 (in 2014). At Wave 3, between October, 2015, and February, 2016, primary caregivers repeated measures of trauma history, postmigration difficulties, probable PTSD, and harsh and warm parenting style, and completed the Strengths and Difficulties Questionnaire for their child. We used path analysis to investigate temporal patterns in PTSD, trauma history, postmigration stressors, parenting style, and children's psychological difficulties. FINDINGS: The current data comprised 411 primary caregivers who provided responses in relation to at least one child (660 children). 394 primary caregivers with 639 children had data on independent variables and were included in the final model. Path analyses revealed that caregivers' trauma history and postmigration difficulties were associated with greater subsequent PTSD, which in turn was associated with greater harsh parenting and in turn, higher levels of child conduct problems (ß=0·049, p=0·0214), hyperactivity (ß=0·044, p=0·0241), emotional symptoms (ß=0·041, p=0·0218), and peer problems (ß=0·007, p=0·047). There was also a direct path from primary caregiver PTSD to children's emotional problems (ß=0·144, p=0·0001). INTERPRETATION: PTSD in refugees is associated with harsh parenting styles, leading to adverse effects on their children's mental health. Programmes to enhance refugee children's mental health should account for PTSD in parents and caregivers, and the parenting behaviours that these children are exposed to. FUNDING: National Health and Medical Research Council.

A systematic review of person-centered approaches to investigating patterns of trauma exposure.

Recent research has found that exposure to traumatic events may occur in certain patterns, rather than randomly. Person-centered analyses, and specifically latent class analysis, is becoming increasingly popular in examining patterns, or 'classes' of trauma exposure. This review aimed to identify whether there are consistent homogeneous subgroups of trauma-exposed individuals, and the relationship between these trauma classes and psychiatric diagnosis. A systematic review of the literature was completed using the databases EMBASE, MEDLINE (PubMed) and PsycINFO. From an initial yield of 189, 17 studies met inclusion criteria. All studies identified a group of individuals who had a higher likelihood of exposure to a wide range of traumas types, and this group consistently exhibited worse psychiatric outcomes than other groups. Studies differed in the nature of the other groups identified although there was often a class with high levels of sexual interpersonal trauma exposure, and a class with high levels of non-sexual interpersonal trauma. There was some evidence that risk for psychiatric disorder differed across these classes. Person-centered approaches to understanding the relationship between trauma exposure and mental health may offer ways to improve our understanding of the role trauma exposure plays in increasing vulnerability to psychiatric disorder.

The contribution of gender-based violence and network trauma to gender differences in Post-Traumatic Stress Disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) occurs twice as commonly amongst women as men. Two common domains of trauma, network trauma and gender based violence (GBV), may contribute to this gender difference in PTSD rates. We examined data from a nationally representative sample of the Australian population to clarify the characteristics of these two trauma domains in their contributions to PTSD rates in men and women. METHODS: We drew on data from the 2007 Australian National Survey of Mental Health and Well-being to assess gender differences across a comprehensive range of trauma domains, including (1) prevalence of lifetime exposure; (2) identification of an index trauma or DSM-IV Criterion A event; and (3) the likelihood of developing full DSM-IV PTSD symptoms once an index trauma was identified. RESULTS: Men reported more traumatic events (TEs) overall but women reported twice the prevalence of lifetime PTSD (women, 13.4%; men, 6.3%). Women reported a threefold higher level of exposure to GBV and were seven times more likely to nominate GBV as the index trauma as compared to men. Women were twice more likely than men to identify a network trauma as the index trauma and more likely to meet full PTSD symptoms in relation to that event (women, 20.6%; men, 14.6%). CONCLUSION: Women are more likely to identify GBV and network trauma as an index trauma. Women's far greater exposure to GBV contributes to their higher prevalence of PTSD. Women are markedly more likely to develop PTSD when network trauma is identified as the index trauma. Preventing exposure to GBV and providing timely interventions for acute psychological reactions following network trauma may assist in reducing PTSD rates amongst women.

Acute and Chronic Posttraumatic Stress Symptoms in the Emergence of Posttraumatic Stress Disorder: A Network Analysis.

Importance: Little is understood about how the symptoms of posttraumatic stress develop over time into the syndrome of posttraumatic stress disorder (PTSD). Objective: To use a network analysis approach to identify the nature of the association between PTSD symptoms in the acute phase after trauma and the chronic phase. Design, Setting, and Participants: A prospective cohort study enrolled 1138 patients recently admitted with traumatic injury to 1 of 4 major trauma hospitals across Australia from March 13, 2004, to February 26, 2006. Participants underwent assessment during hospital admission (n = 1388) and at 12 months after injury (n = 852). Networks of symptom associations were analyzed in the acute and chronic phases using partial correlations, relative importance estimates, and centrality measures of each symptom in terms of its association strengths, closeness to other symptoms, and importance in connecting other symptoms to each other. Data were analyzed from March 3 to September 5, 2016. Main Outcomes and Measures: Severity of PTSD was assessed at each assessment with the Clinician-Administered PTSD Scale. Results: Of the 1138 patients undergoing assessment at admission (837 men [73.6%] and 301 women [26.4%]; mean [SD] age, 37.90 [13.62] years), strong connections were found in the acute phase. Reexperiencing symptoms were central to other symptoms in the acute phase, with intrusions and physiological reactivity among the most central symptoms in the networks in terms of the extent to which they occur between other symptoms (mean [SD], 1.2 [0.7] and 1.0 [0.9], respectively), closeness to other symptoms (mean [SD], 0.9 [0.3] and 1.1 [0.9], respectively), and strength of the associations (mean [SD], 1.6 [0.3] and 1.5 [0.3] respectively) among flashbacks, intrusions, and avoidance of thoughts, with moderately strong connections between intrusions and nightmares, being upset by reminders, and physiological reactivity. Intrusions and physiological reactivity were central in the acute phase. Among the 852 patients (73.6%) who completed the 12-month assessment, overall network connectivity was significantly stronger at 12 months than in the acute phase (global strength values, 6.57 vs 7.60; paired difference, 1.03; P < .001). The network associations among the reexperiencing symptoms were strengthened at 12 months, and physiological reactivity was strongly associated with the startle response, which was also associated with hypervigilance. Strong connectivity among emotional numbing, detachment from others, and disinterest in activities as well as moderately strong links among irritability (anger), concentration deficits, and sleep disturbance were found. Conclusions and Relevance: As time elapses after trauma, fear circuitry and dysphoric PTSD symptoms appear to emerge as connected networks. Intrusive memories and reactivity are centrally associated with other symptoms in the acute phase, potentially pointing to the utility of addressing these symptoms in early intervention strategies.

The long-term mental health impact of peacekeeping: prevalence and predictors of psychiatric disorder.

BACKGROUND: The mental health outcomes of military personnel deployed on peacekeeping missions have been relatively neglected in the military mental health literature. AIMS: To assess the mental health impacts of peacekeeping deployments. METHOD: In total, 1025 Australian peacekeepers were assessed for current and lifetime psychiatric diagnoses, service history and exposure to potentially traumatic events (PTEs). A matched Australian community sample was used as a comparator. Univariate and regression analyses were conducted to explore predictors of psychiatric diagnosis. RESULTS: Peacekeepers had significantly higher 12-month prevalence of post-traumatic stress disorder (16.8%), major depressive episode (7%), generalised anxiety disorder (4.7%), alcohol misuse (12%), alcohol dependence (11.3%) and suicidal ideation (10.7%) when compared with the civilian comparator. The presence of these psychiatric disorders was most strongly and consistently associated with exposure to PTEs. CONCLUSIONS: Veteran peacekeepers had significant levels of psychiatric morbidity. Their needs, alongside those of combat veterans, should be recognised within military mental health initiatives. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

A Longitudinal Study of Adjustment Disorder After Trauma Exposure.

OBJECTIVE: Adjustment disorder has been recategorized as a trauma- and stressor-related disorder in DSM-5. The aim of this study was to determine the prevalence of adjustment disorder in the first 12 months after severe injury; to determine whether adjustment disorder was a less severe disorder compared with other disorders in terms of disability and quality of life; to investigate the trajectory of adjustment disorder; and to examine whether the subtypes described in DSM-5 are distinguishable. METHOD: In a multisite, cohort study, injury patients were assessed during hospitalization and at 3 and 12 months postinjury (N=826). Structured clinical interviews were used to assess affective, anxiety, and substance use disorders, and self-report measures of disability, anxiety, depression, and quality of life were administered. RESULTS: The prevalence of adjustment disorder was 19% at 3 months and 16% at 12 months. Participants with adjustment disorder reported worse outcomes relative to those with no psychiatric diagnosis but better outcomes compared with those diagnosed with other psychiatric disorders. Participants with adjustment disorder at 3 months postinjury were significantly more likely to meet criteria for a psychiatric disorder at 12 months (odds ratio=2.67, 95% CI=1.59-4.49). Latent-profile analysis identified a three-class model that was based on symptom severity, not the subtypes identified by DSM-5. CONCLUSIONS: Recategorization of adjustment disorder into the trauma- and stressor-related disorders is supported by this study. However, further description of the phenomenology of the disorder is required.

The course of suicide risk following traumatic injury.

OBJECTIVE: Although traumatic injuries affect millions of patients each year and increase risk for psychiatric disorder, no evidence currently exists regarding associated suicidal risk. This study reports a longitudinal investigation of suicidal risk in the 2 years after traumatic injury. METHODS: A prospective design cohort study was conducted in 4 major trauma hospitals across Australia. A total of 1,129 traumatically injured patients were assessed during hospital admission between April 2004 and February 2006 and were followed up at 3 months (88%), 12 months (77%), and 24 months (72%). Lifetime psychiatric disorder was assessed in hospital using the Mini-International Neuropsychiatric Interview, version 5.5, which was also used to assess the prevalence of suicidality, psychiatric disorder, and exposure to adverse life events at 3, 12, and 24 months after traumatic injury. RESULTS: Approximately 6% of patients reported moderate/high suicidal risk at each assessment. At each assessment, half of suicidal patients reported no suicidal risk at the previous assessment. Suicidality at 24 months was predicted by current pain levels (odds ratio [OR] = 1.16; 95% CI, 1.09-1.23), recent life events (OR = 1.30; 95% CI,1.17-1.44), and current psychiatric disorder (OR = 17.07; 95% CI, 7.03-41.42), whereas only 36.6% of suicidal patients had consulted a mental health professional in the previous month, and 66.2% had consulted a primary care physician. CONCLUSIONS: Suicidal risk affects a significant proportion of patients who experience a traumatic injury, and the risk for suicide fluctuates markedly in the initial years following the injury. Primary care physicians need to be trained to assess for suicidal risk in the initial years after a traumatic injury.

Prediction of Late-Onset Psychiatric Disorder in Survivors of Severe Injury: Findings of a Latent Transition Analysis.

OBJECTIVE: There is a growing body of evidence indicating that late or delayed onset of psychiatric disorder following traumatic injury and other psychological trauma is common. This research, however, has not examined factors that pose risks for delayed development of different types of psychopathology or at different time points. Such research has considerable implications for the development of screening, assessment, and intervention practices. This article investigates risk factors for late-onset disorders up to 72 months after a severe injury. METHODS: In this 6-year longitudinal study, 1,167 hospitalized patients with severe injury recruited between April 2004 and February 2006 were analyzed with repeated measures at 3, 12, and 72 months after injury. The Mini-International Neuropsychiatric Interview (MINI) and Clinician-Administered PTSD Scale (CAPS) were employed to complete diagnoses according to DSM-IV. Latent transition analyses with continuous covariates (injury severity, social support, recent life events, and pain) and 1 dichotomous covariate (presence/absence of a psychiatric disorder before injury) were conducted to identify risk factors for transitioning out of a No Disorder class and into one of 3 previously reported psychopathology classes (PTSD [posttraumatic stress disorder]/Depression, Alcohol/Depression, and Alcohol only) between 3 and 12 months (transition 1) and between 12 and 72 months (transition 2) postinjury. RESULTS: Movement into the PTSD/Depression class was predicted by injury severity at transitions 1 (P = .003) and 2 (P = .017) and social support (P = .006) at transition 1. Past psychiatric history increased the likelihood of moving into the PTSD/Depression class, with anxiety or mood disorders specifically implicated in transition 1. Movement into the Alcohol/Depression class was predicted by social support at transitions 1 (P = .008) and 2 (P < .001) and also by injury severity (P < .001) and pain (P < .001) at transition 2. Movement into the Alcohol class was predicted only by pain (P = .011) at transition 2. A history of a substance use or alcohol use disorder before injury was implicated in movement into both of the alcohol-based classes. CONCLUSIONS: Predictors of developing a delayed-onset psychiatric disorder after severe injury differed by duration after injury and class of disorder. These findings highlight the need to offer targeted screening based on these risk factors to severe injury survivors up to 12 months postinjury, even when they present without disorder at 3 months.

The long-term psychiatric sequelae of severe injury: a 6-year follow-up study.

OBJECTIVE: The impact of mental health on disease burden associated with injury represents a major public health issue, yet almost no information is available on the associated long-term mental health outcomes. The primary aim of this study was to assess the psychiatric outcomes 6 years after a severe injury and their subsequent impact on long-term disability. The secondary aim was to investigate the relationship between a mild traumatic brain injury (mTBI) and long-term psychiatric disorder and its impact on disability. METHODS: From April 2004 to February 2006, randomly selected injury patients admitted to 4 hospitals across Australia were assessed during hospitalization and at 72 months after trauma (N = 592). Injury characteristics, the presence of an mTBI (ICD-9 criteria), and previous psychiatric history were assessed during hospitalization. Structured clinical interviews for psychiatric disorders (DSM-IV and DSM-5) and a self-report measure of disability (WHODAS II) were administered at 72 months. RESULTS: At 72 months after a severe injury, 28% of patients met criteria for at least 1 psychiatric disorder, with 45% of those presenting with comorbid diagnoses. The most prevalent psychiatric disorder was a major depressive episode (11%) followed by substance use disorder (9%), agoraphobia (9%), posttraumatic stress disorder (6%), and generalized anxiety disorder (6%). The presence of any psychiatric disorder was found to increase the risk for disability (P < .001, odds ratio = 6.04). An mTBI was found to increase the risk for having some anxiety disorders but not to increase disability by itself. CONCLUSIONS: The long-term psychiatric consequences of severe injury are substantial and represent a significant contributor to long-term disability. This study points to an important intersection between injury and psychiatric disorder as a leading contributor to disease burden and suggests this growing burden will impose new challenges on health systems.

Compensation seeking and disability after injury: the role of compensation-related stress and mental health.

OBJECTIVE: Claiming for compensation after injury is associated with poor health outcomes. This study examined the degree to which compensation-related stress predicts long-term disability and the mental health factors that contribute to this relationship. METHOD: In a longitudinal, multisite cohort study, 332 injury patients (who claimed for compensation) recruited from April 2004 to February 2006 were assessed during hospitalization and at 3 and 72 months after injury. Posttraumatic stress, depression, and anxiety symptoms (using the Mini-International Neuropsychiatric Interview) were assessed at 3 months; compensation-related stress and disability levels (using the World Health Organization Disability Assessment Schedule II) were assessed at 72 months. RESULTS: A significant direct relationship was found between levels of compensation-related stress and levels of long-term disability (ß = 0.35, P < .001). Three-month posttraumatic stress symptoms had a significant relationship with compensation-related stress (ß = 0.29, P < .001) as did 3-month depression symptoms (ß = 0.39, P < .001), but 3-month anxiety symptoms did not. A significant indirect relationship was found for posttraumatic stress symptoms and disability via compensation stress (ß = 0.099, P = .001) and for depression and disability via compensation stress (ß = 0.136, P < .001). CONCLUSIONS: Stress associated with seeking compensation is significantly related to long-term disability. Posttraumatic stress and depression symptoms increase the perception of stress associated with the claims process, which in turn is related to higher levels of long-term disability. Early interventions targeting those at risk for compensation-related stress may decrease long-term costs for compensation schemes.

Longitudinal analysis of latent classes of psychopathology and patterns of class migration in survivors of severe injury.

OBJECTIVE: Little research to date has explored the typologies of psychopathology following trauma, beyond development of particular diagnoses such as posttraumatic stress disorder (PTSD). The objective of this study was to determine the longitudinal patterns of these typologies, especially the movement of persons across clusters of psychopathology. METHOD: In this 6-year longitudinal study, 1,167 hospitalized severe injury patients who were recruited between April 2004-February 2006 were analyzed, with repeated measures at baseline, 3 months, 12 months, and 72 months after injury. All patients met the DSM-IV criterion A1 for PTSD. Structured clinical interviews were used to assess psychiatric disorders at each follow-up point. Latent class analysis and latent transition analysis were applied to assess clusters of individuals determined by psychopathology. The Mini International Neuropsychiatric Interview (MINI) and Clinician-Administered PTSD Scale (CAPS) were employed to complete diagnoses. RESULTS: Four latent classes were identified at each time point: (1) Alcohol/Depression class (3 months, 2.1%; 12 months, 1.3%; and 72 months, 1.1%), (2) Alcohol class (3 months, 3.3%; 12 months, 3.7%; and 72 months, 5.4%), (3) PTSD/Depression class (3 months, 10.3%; 12 months, 11.5%; and 72 months, 6.4%), and (4) No Disorder class (3 months, 84.2%; 12 months, 83.5%; and 72 months, 87.1%). Latent transition analyses conducted across the 2 transition points (12 months and 72 months) found consistently high levels of stability in the No Disorder class (90.9%, 93.0%, respectively) but lower and reducing levels of consistency in the PTSD/Depression class (81.3%, 46.6%), the Alcohol/Depression class (59.7%, 21.5%), and the Alcohol class (61.0%, 36.5%), demonstrating high levels of between-class migration. CONCLUSIONS: Despite the array of psychiatric disorders that may develop following severe injury, a 4-class model best described the data with excellent classification certainty. The high levels of migration across classes indicate a complex pattern of psychopathology expression over time. The findings have considerable implications for tailoring multifocused interventions to class type, as well as flexible stepped care models, and for the potential development and delivery of transdiagnostic interventions targeting underlying mechanisms.

Trajectory of post-traumatic stress following traumatic injury: 6-year follow-up.

BACKGROUND: Traumatic injuries affect millions of patients each year, and resulting post-traumatic stress disorder (PTSD) significantly contributes to subsequent impairment. AIMS: To map the distinctive long-term trajectories of PTSD responses over 6 years by using latent growth mixture modelling. METHOD: Randomly selected injury patients (n = 1084) admitted to four hospitals around Australia were assessed in hospital, and at 3, 12, 24 and 72 months. Lifetime psychiatric history and current PTSD severity and funxctioning were assessed. RESULTS: Five trajectories of PTSD response were noted across the 6 years: (a) chronic (4%), (b) recovery (6%), (c) worsening/recovery (8%), (d) worsening (10%) and (e) resilient (73%). A poorer trajectory was predicted by female gender, recent life stressors, presence of mild traumatic brain injury and admission to intensive care unit. CONCLUSIONS: These findings demonstrate the long-term PTSD effects that can occur following traumatic injury. The different trajectories highlight that monitoring a subset of patients over time is probably a more accurate means of identifying PTSD rather than relying on factors that can be assessed during hospital admission.

Latent structure of the proposed ICD-11 post-traumatic stress disorder symptoms: implications for the diagnostic algorithm.

BACKGROUND: The latent structure of the proposed ICD-11 post-traumatic stress disorder (PTSD) symptoms has not been explored. AIMS: To investigate the latent structure of the proposed ICD-11 PTSD symptoms. METHOD: Confirmatory factor analyses using data from structured clinical interviews administered to injury patients (n = 613) 6 years post-trauma. Measures of disability and psychological quality of life (QoL) were also administered. RESULTS: Although the three-factor model implied by the ICD-11 diagnostic criteria fit the data well, a two-factor model provided equivalent, if not superior, fit. Whereas diagnostic criteria based on this two-factor model resulted in an increase in PTSD point prevalence (5.1% v. 3.4%; z = 2.32, P<0.05), they identified individuals with similar levels of disability (P = 0.933) and QoL (P = 0.591) to those identified by the ICD-11 criteria. CONCLUSIONS: Consistent with theorised reciprocal relationships between re-experiencing and avoidance in PTSD, these findings support an alternative diagnostic algorithm requiring at least two of any of the four re-experiencing/avoidance symptoms and at least one of the two hyperarousal symptoms.

A comparison of the capacity of DSM-IV and DSM-5 acute stress disorder definitions to predict posttraumatic stress disorder and related disorders.

OBJECTIVE: This study addresses the extent to which DSM-IV and DSM-5 definitions of acute stress disorder (ASD) predict subsequent posttraumatic stress disorder (PTSD) and related psychiatric disorders following trauma. METHOD: Patients with randomized admissions to 5 hospitals across Australia (N = 596) were assessed in hospital and reassessed for PTSD at 3 (n = 508), 12 (n = 426), 24 (n = 439), and 72 (n = 314) months using the Clinician-Administered PTSD Scale; DSM-IV definition of PTSD was used at each assessment, and DSM-5 definition was used at 72 months. The Mini-International Neuropsychiatric Interview (MINI) was used at each assessment to assess anxiety, mood, and substance use disorders. RESULTS: Forty-five patients (8%) met DSM-IV criteria, and 80 patients (14%) met DSM-5 criteria for ASD. PTSD was diagnosed in 93 patients (9%) at 3, 82 patients (10%) at 12, 100 patients (12%) at 24, and 26 patients (8%) at 72 months; 19 patients (6%) met DSM-5 criteria for PTSD at 72 months. Comparable proportions of those diagnosed with ASD developed PTSD using DSM-IV (3 months = 46%, 12 months = 39%, 24 months = 32%, and 72 months = 25%) and DSM-5 (43%, 42%, 33%, and 24%) ASD definitions. Sensitivity was improved for DSM-5 relative to DSM-IV for depression (0.18 vs 0.30), panic disorder (0.19 vs 0.41), agoraphobia (0.14 vs 0.40), social phobia (0.12 vs 0.44), specific phobia (0.24 vs 0.58), obsessive-compulsive disorder (0.17 vs 0.47), and generalized anxiety disorder (0.20 vs 0.47). More than half of participants with DSM-5-defined ASD had a subsequent disorder. CONCLUSIONS: The DSM-5 criteria for ASD results in better identification of people who will subsequently develop PTSD or another psychiatric disorder relative to the DSM-IV criteria. Although prediction is modest, it suggests that the new ASD diagnosis can serve a useful function in acute trauma settings for triaging those who can benefit from either early intervention or subsequent monitoring.