Fetal and maternal factors associated with infant mortality in vervet monkeys.

BACKGROUND: Causes of infant death remain unknown in significant proportions of human and non-human primate pregnancies. METHODS: A closed breeding colony with high rates of infant mortality had pregnancies assessed (n=153) by fetal measurements and maternal characteristics. Infant outcome was classified as neonatal death (stillborn or died <48 hours from birth), postnatal death (died 2-30 days) or surviving (alive after 30 days). RESULTS: Fetal size did not predict outcome. Poor maternal glycemic control and low social ranking increased odds for adverse outcome (OR=3.72, P=0.01 and 2.27, P=0.04, respectively). Male sex was over-represented in stillbirths (P=0.04), and many were macrosomic, but size did not associate with maternal glycemic control measured as glycated hemoglobin A1c. Postnatally dead infants were smaller (P<0.01), which associated with behavioral factors and glycemic control. CONCLUSIONS: Fetal growth estimates predicted gestational age but not fetal outcome. Maternal social status and metabolic health, particularly glycemic control, increased risks of adverse pregnancy outcome.

Clinicopathologic characterization of naturally occurring diabetes mellitus in vervet monkeys.

Diabetes mellitus (DM) is a group of chronic metabolic diseases characterized by persistent fasting hyperglycemia, and it can be of either polygenic or monogenic origin. Animal models have played an important role in elucidating the pathophysiology of the polygenic Type 1 and type 2 DM forms; however, useful animal models of the monogenic forms do not exist. The authors describe 4 cases of naturally occurring DM in vervet monkeys (Chlorocebus aethiops sabaeus), 1 of which has clinicopathologic findings consistent with type 2 DM, including persistent hyperglycemia, hypertriglyceridemia, islet amyloidosis, and reduced islet insulin immunostaining. In contrast, the 3 remaining animals have clinicopathologic similarities to a monogenic form of the disease, including a lack of islet amyloidosis and hypertriglyceridemia, as well as normal islet insulin immunostaining. In addition, pedigree analysis conducted on one of these animals is consistent with either an autosomal dominant or mitochondrial inheritance pattern, which supports a monogenic form of DM. The authors thus hypothesize that a naturally occurring monogenic form of diabetes may occur in vervet monkeys, making them a potential animal model for future studies.

Architectonic distribution of the serotonin transporter within the orbitofrontal cortex of the vervet monkey.

To elucidate the organization of the serotoninergic innervation within the orbitofrontal cortex (OFC), serotonin transporter (SERT) density was quantified by autoradiography using [(3)H]cyanoimipramine binding. In six adult vervet monkeys, 15 architectonic areas were delineated according to cytoarchitectonic (Nissl), myeloarchitectonic (Gallyas) and chemoarchitectonic (acetylcholinesterase) criteria to assess SERT distribution at two levels of organization: cortical area and cortical type. For cortical type, the 15 areas were evenly divided into three different categories primarily based upon the degree of granularization of layer IV: agranular, dysgranular, and granular. Within agranular and dysgranular, but not granular cortical types, SERT density was area-specific and progressively decreased in a medial to lateral gradient. Across cortical types, SERT density decreased in a caudal to rostral gradient: agranular>dysgranular>granular. A similar caudal to rostral gradient was seen when serotonin content was measured (using high performance liquid chromatography) in areas representative of each cortical type. Collectively, these results suggest that the serotoninergic innervation is organized according to both cortical type and area, and is thus structured to differentially modulate information processing within the OFC.

Regional brain metabolic changes in patients with major depression treated with either paroxetine or interpersonal therapy: preliminary findings.

BACKGROUND: In functional brain imaging studies of major depressive disorder (MDD), regional abnormalities have been most commonly found in prefrontal cortex, anterior cingulate gyrus, and temporal lobe. We examined baseline regional metabolic abnormalities and metabolic changes from pretreatment to posttreatment in subjects with MDD. We also performed a preliminary comparison of regional changes with 2 distinct forms of treatment (paroxetine and interpersonal psychotherapy). METHODS: Twenty-four subjects with unipolar MDD and 16 normal control subjects underwent resting F 18 ((18)F) fluorodeoxyglucose positron emission tomography scanning before and after 12 weeks. Between scans, subjects with MDD were treated with either paroxetine or interpersonal psychotherapy (based on patient preference), while controls underwent no treatment. RESULTS: At baseline, subjects with MDD had higher normalized metabolism than controls in the prefrontal cortex (and caudate and thalamus), and lower metabolism in the temporal lobe. With treatment, subjects with MDD had metabolic changes in the direction of normalization in these regions. After treatment, paroxetine-treated subjects had a greater mean decrease in Hamilton Depression Rating Scale score (61.4%) than did subjects treated with interpersonal psychotherapy (38.0%), but both subgroups showed decreases in normalized prefrontal cortex (paroxetine-treated bilaterally and interpersonal psychotherapy-treated on the right) and left anterior cingulate gyrus metabolism, and increases in normalized left temporal lobe metabolism. CONCLUSIONS: Subjects with MDD had regional brain metabolic abnormalities at baseline that tended to normalize with treatment. Regional metabolic changes appeared similar with the 2 forms of treatment. These results should be interpreted with caution because of study limitations (small sample size, lack of random assignment to treatment groups, and differential treatment response between treatment subgroups).

Effects of partial sleep deprivation on the diurnal variation of mood and motor activity in major depression.

Partial sleep deprivation (PSD), keeping a subject awake from 2 AM to 9 PM produces an acute mood improvement in 60% of patients with major depression. We sought to characterize the timing, subcomponent mood, and motor activity changes of this response. Thirty-seven subjects with major depression were rated with the 6-item Hamilton Depression Scale (HAM-6) at 1 PM and completed the Profile of Mood States (POMS) every 2 hr on the day before and day of PSD. Locomotor activity was monitored continuously during the trial with an automated device. Bipolar I patients responded more frequently than other groups. Positive mood responders had greater improvement than nonresponders in POMS subscales of depression, tension, confusion, and anger. The mood improvement increased steadily during the day, peaked in late afternoon, and declined thereafter. Responders showed significantly higher levels of locomotor activity on the baseline pre-PSD day than did nonresponders. All subjects increased motor activity following sleep deprivation, however.

Apolipoprotein E genotype and noncognitive symptoms in Alzheimer's disease.

BACKGROUND: The apolipoprotein E (ApoE) epsilon 4 allele confers significant risk for Alzheimer's disease and is associated with a greater amyloid burden in the brain. Future treatments may target molecular mechanisms associated with this allele, and it is important to define any phenotypic characteristics that correspond to this genotype. We sought to clarify the relationship between ApoE status and noncognitive symptoms in Alzheimer's disease patients. METHODS: Possible and probable Alzheimer's disease patients from a clinical trial (n = 605) were assessed with the 10-item Neuropsychiatric Inventory cross-sectionally prior to treatment, and their ApoE genotype was determined. Among the population studied, the following numbers with specific genotypes were studied: 23-2/3, 17-2/4, 209-3/3, 288-3/4, 68-4/4. RESULTS: When correlations were controlled for the patient's level of cognitive impairment, there was no relationship between epsilon 4 dose and any of the 10 noncognitive symptoms assessed, including psychosis, mood changes, and personality alterations. CONCLUSIONS: Among patients with comparable disease severity, the epsilon 4 allele does not confer additional psychiatric morbidity.

Brain metabolic changes associated with symptom factor improvement in major depressive disorder.

BACKGROUND: Symptoms of major depressive disorder (MDD) have been linked to regional brain function through imaging studies of symptom provocation in normal control subjects and baseline studies of subjects with MDD. We examined associations between change in depressive symptom factors and change in regional brain metabolism from before to after treatment of MDD. METHODS: Thirty-nine outpatients with MDD underwent 18F-fluorodeoxyglucose positron emission tomography scanning before and after treatment with either paroxetine or interpersonal psychotherapy. Associations were determined between changes in regional brain metabolism and changes in four Hamilton Depression Rating Scale factors (anxiety/somatization [ANX], psychomotor retardation [PR], cognitive disturbance [COGN], and sleep disturbance) and two corresponding Profile of Mood States subscales (tension [TENS] and fatigue [FATIG]). RESULTS: Improvement in ANX, PR, TENS, and FATIG factors was associated with decreasing ventral frontal lobe metabolism. Improvement in ANX and TENS was also associated with decreasing ventral anterior cingulate gyrus (AC) and anterior insula activity, whereas improvement in PR was associated with increasing dorsal AC activity. COGN improvement was associated with increasing dorsolateral prefrontal cortex metabolism. CONCLUSIONS: Brain regions that show significant relationships with symptom provocation in normal control subjects have similar relationships with MDD symptoms as they improve with treatment.

Longitudinal assessment of symptoms of depression, agitation, and psychosis in 181 patients with Alzheimer's disease.

OBJECTIVE: The goal of this study was to define the recurrence or continuation of neuropsychiatric symptoms in patients with Alzheimer's disease who were observed serially for a 1-year period. METHOD: One hundred eighty-one patients with probable Alzheimer's disease were assessed five times at 3-month intervals with a standardized neuropsychiatric rating instrument. RESULTS: Recurrence rates of neuropsychiatric symptoms during the 1-year period were 85% for depression, 93% for agitation, and 95% for psychosis. Symptom frequency at any point in time underestimated the cumulative 1-year frequency. Recurrence rates were significantly greater among patients who had multiple symptoms. Women exhibited more symptoms than men. Patients in the oldest age group (76-87 years) had more psychosis, less depression and agitation, and slower cognitive decline. Psychosis was associated with more rapid cognitive decline, and agitation was associated with more rapid functional deterioration. CONCLUSIONS: These results indicate that once psychiatric symptoms are present in patients with Alzheimer's disease, they frequently recur. These symptoms vary with age, sex, and rate of illness progression.

Posttraumatic stress and depressive reactions among Nicaraguan adolescents after hurricane Mitch.

OBJECTIVE: This study determined the severity of posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch and the relationship of these reactions to objective and subjective features of hurricane exposure, death of a family member, forced relocation, and thoughts of revenge. METHOD: Six months after the hurricane, 158 adolescents from three differentially exposed cities were evaluated by using a hurricane exposure questionnaire, the Child Posttraumatic Stress Disorder Reaction Index, and the Depression Self-Rating SCALE: RESULTS: Severe levels of posttraumatic stress and depressive reactions were found among adolescents in the two most heavily affected cities. Severity of posttraumatic stress and depressive reactions and features of objective hurricane-related experiences followed a "dose-of-exposure" pattern that was congruent with the rates of death and destruction across cities. Level of impact (city), objective and subjective features, and thoughts of revenge accounted for 68% of the variance in severity of posttraumatic stress reaction. Severity of posttraumatic stress reaction, death of a family member, and sex accounted for 59% of the variance in severity of depression. CONCLUSIONS: After a category 5 hurricane, adolescents in heavily affected areas with extreme objective and subjective hurricane-related traumatic features of exposure experience severe and chronic posttraumatic stress and comorbid depressive reactions. The recovery of the severely affected Nicaraguan adolescents is vital to the social and economic recovery of a country ravaged by years of political violence and poverty. These findings strongly indicate the need to incorporate public mental health approaches, including systematic screening and trauma/grief-focused interventions, within a comprehensive disaster recovery program.

Posttraumatic stress disorder in elderly and younger adults after the 1988 earthquake in Armenia.

OBJECTIVE: This study was undertaken 1 1/2 years after the 1988 earthquake in Armenia to assess the frequency and severity of posttraumatic stress reactions among elderly and younger adult victims and to assess the relation of exposure, age, sex, and death of a family member to these reactions. METHOD: One hundred seventy-nine subjects of both sexes were evaluated with the Posttraumatic Stress Disorder (PTSD) Reaction Index. A subgroup of 60 individuals were also assessed for PTSD with the DSM-III-R criteria. RESULTS: There was a strong association between the presence of severe symptoms on the index and a DSM-III-R diagnosis of PTSD. Elderly and younger adult victims in cities closer to the epicenter (higher exposure) had significantly higher index scores than elderly and adult victims in more distant locations. In comparison with previous studies of natural disasters, much greater rates of chronic severe posttraumatic stress reactions were found among the highly exposed individuals. Although there was no difference in total mean score on the Posttraumatic Stress Disorder Reaction Index, a significant difference in symptom profile was found between the elderly and younger adults; the elderly scored higher on arousal symptoms and lower on intrusive symptoms. There was a positive correlation between loss of family members and severity of posttraumatic stress reaction. CONCLUSIONS: These findings indicate that after a major natural disaster with subsequent multiple adversities, a substantial proportion of the adult population may experience severe and chronic posttraumatic stress reactions. The risk factors identified in this study may prove useful in screening exposed individuals for appropriate treatment.

Outcome of psychotherapy among early adolescents after trauma.

OBJECTIVE: The authors evaluated the effectiveness of brief trauma/grief-focused psychotherapy among early adolescents exposed to the 1988 earthquake in Armenia. METHOD: Posttraumatic stress and depressive reactions among treated and not treated subjects were evaluated pre- and postintervention, at 1 1/2 and 3 years after the earthquake, respectively. RESULTS: Severity of posttraumatic stress symptoms significantly decreased among the subjects given psychotherapy, while severity of these symptoms increased significantly among the subjects not treated with psychotherapy. The improvement in posttraumatic stress symptoms was attributable to improvement in all three symptom categories (intrusion, avoidance, and arousal) of posttraumatic stress disorder (PTSD). There was no change in severity of depressive symptoms among subjects given psychotherapy. However, depressive symptoms among subjects not treated with psychotherapy significantly worsened over time. The changes in severity of posttraumatic stress and depressive symptoms were positively correlated within both groups. CONCLUSIONS: The findings demonstrate the efficacy of trauma/grief-focused brief psychotherapy in alleviating PTSD symptoms and preventing the worsening of comorbid depression among early adolescents after a catastrophic disaster. The results support the broad use of such school-based interventions after major disasters and demonstrate the cross-cultural applicability of Western psychotherapeutic approaches.

Prospective study of posttraumatic stress, anxiety, and depressive reactions after earthquake and political violence.

OBJECTIVE: The authors sought to assess the severity and longitudinal course of posttraumatic stress, anxiety, and depressive reactions among two groups of adults differentially exposed to severe and mild earthquake trauma and a third group exposed to severe violence. They also examined interrelationships among these reactions and predictors of outcome and compared posttraumatic stress disorder (PTSD) symptom category profile and course between those exposed to earthquake and those exposed to violence. METHOD: Seventy-eight non-treatment-seeking subjects were assessed with self-report instruments approximately 1.5 and 4.5 years after the 1988 Spitak earthquake in Armenia and the 1988 pogroms against Armenians in Azerbaijan. RESULTS: The two groups that had been exposed to severe trauma (earthquake or violence) had high initial and follow-up PTSD scores that did not remit over the 3-year interval. Overall, depressive symptoms subsided. Posttraumatic stress, anxiety, and depressive reactions were highly intercorrelated within and across both time intervals. No significant differences in PTSD severity, profile, or course were seen between subjects exposed to severe earthquake trauma versus those exposed to severe violence. CONCLUSIONS: After exposure to severe trauma, either an earthquake or violence, adults are at high risk of developing severe and chronic posttraumatic stress reactions that are associated with chronic anxiety and depressive reactions. Clinical evaluation and therapeutic intervention should include specific attention to these reactions. Early mental health intervention is recommended to prevent their chronicity.

Basal cortisol, dexamethasone suppression of cortisol, and MHPG in adolescents after the 1988 earthquake in Armenia.

OBJECTIVE: This study evaluated basal salivary cortisol, 3-methoxy-4-hydroxyphenylglycol (MHPG), and cortisol suppression following dexamethasone administration in adolescents exposed to two levels of earthquake-related trauma. METHOD: Five years after the 1988 earthquake, saliva samples were obtained from 37 adolescents from two cities in Armenia at different distances from the epicenter. Baseline saliva samples were obtained at 8:00 a.m., 4:00 p.m., and 11:00 p.m., following which 0.5 mg of dexamethasone was administered. Nine and 17 hours later, saliva samples were again obtained. Subjects were evaluated for posttraumatic stress and depressive reactions through use of self-report instruments. RESULTS: Significantly lower mean baseline 8:00 a.m. cortisol levels and greater day 24:00 p.m. cortisol suppression following dexamethasone were observed in the more symptomatic adolescents living in the city closer to the epicenter. Of the three symptom categories of posttraumatic stress disorder (PTSD), only intrusion (category B) symptoms were significantly correlated with basal morning cortisol levels and percent suppression by dexamethasone. The more highly exposed adolescents also exhibited a more rapid decline in MHPG levels over the course of day 1. CONCLUSIONS: The findings indicate that chronic posttraumatic stress reactions among adolescents exposed to catastrophic disaster are associated with hypothalamic-pituitary-adrenal (HPA) axis alterations. The findings are congruent with those previously described in adults with chronic PTSD. Persistent intrusion (category B) symptoms may constitute continued episodes of distress and evoke repeated physiological stress responses, which, over time, alter HPA axis function. The MHPG findings suggest that there may be diurnal changes associated with severity of posttraumatic stress symptoms.

Alzheimer disease and frontotemporal dementias. Behavioral distinctions.

BACKGROUND: Frontotemporal dementia (FTD) is a syndrome produced by lobar degeneration of the temporal and/or frontal lobes. OBJECTIVES: To quantify the behavioral disturbances of FTD and compare them with behavioral changes observed in Alzheimer disease (AD). DESIGN: Cross-sectional comparison of 2 groups defined by research diagnostic criteria and single photon emission computed tomography. Behaviors were assessed using a standardized rating scale-Neuropsychiatric Inventory. Groups were matched for dementia severity. SETTING: Patients were seen at 2 university-based outpatient dementia clinics and a Veterans Affairs medical center. PARTICIPANTS: Twenty-two patients with FTD and 30 patients with AD. RESULTS: Patients with FTD had significantly greater total Neuropsychiatric Inventory scores than patients with AD and exhibited more apathy, disinhibition, euphoria, and aberrant motor behavior. The Neuropsychiatric Inventory accurately assigned 77% of patients with FTD and 77% of patients with AD to the correct diagnostic group using disinhibition, apathy, and depression. Patients with FTD had higher levels of disinhibition and apathy with relatively lower levels of depression compared with patients with AD. CONCLUSIONS: The Neuropsychiatric Inventory provides a behavioral profile that differentiates patients with FTD from patients with AD. Patients with FTD are more behaviorally disturbed but are often less depressed than patients with AD relative to their level of apathy.

Midline cerebral morphometry distinguishes frontotemporal dementia and Alzheimer's disease.

We investigated and contrasted midline cerebral structures in frontotemporal dementia (FTD) and Alzheimer's disease (AD). FTD and AD may be difficult to distinguish clinically. FTD typically affects frontal and anterior temporal regions, whereas AD tends to involve more posterior temporal and parietal areas. We hypothesized that disease-specific cerebral alterations would be differentially reflected in corresponding regions of the corpus callosum (CC), pericallosal CSF space (PCS), or their ratio (CC:PCS). Regions-of-interest (ROIs) from midsagittal MRIs in 17 AD, 16 FTD, and 12 elderly control (EC) subjects were analyzed. ROIs were divided into four regions using an anatomic landmark-based computer algorithm and were adjusted for head size variation. FTD subjects had a much smaller anterior CC region and significantly larger PCS area, particularly in anterior regions. AD and EC subjects did not differ significantly in any total or regional ROI measure. Total and anterior CC:PCS ratios were markedly lower in FTD patients. Across groups, total CC:PCS correlated significantly with midsagittal cerebral area and was similarly associated with Mini-Mental State Examination score. Anterior CC (AD) and PCS (FTD) regions exhibited disease-specific relationships to these variables. A discriminant model using two ROI variables correctly classified 91% of AD and FTD patients, comparing favorably with blind clinical MRI diagnostic ratings. Midline cerebral structural alterations reflect differential patterns of cerebral degeneration in AD and FTD, yielding morphometric indices that may facilitate the study of brain-behavior relationships and differential diagnosis of dementia.

Social impulsivity inversely associated with CSF 5-HIAA and fluoxetine exposure in vervet monkeys.

Animal and human research suggests that the central serotonin system is involved in the inhibition of impulsive behavior. Two studies were designed to assess this relationship in male vervet monkeys (Cercopithecus aethiops sabaeus) using a standardized test of impulsivity in a social context: the Intruder Challenge. In the first study, an index of impulsivity in response to an unfamiliar adult male intruder (including latency to approach and aggressive and assertive interactions) was inversely correlated with levels of the serotonin metabolite, 5-hydroxyindoleacetic acid (5-HIAA) in cisternal cerebrospinal fluid (r = -0.33, p <.01, n = 138). The approach, but not aggressive, component of the Impulsivity Index was the primary contributor to this relationship (partial r = -0.27, p <.01). The second experiment compared responses to the Intruder Challenge after 9 weeks of daily treatment with fluoxetine (2 mg/kg, i.m.) or vehicle. Fluoxetine-treated subjects (n = 6) had significantly lower Impulsivity Index scores than controls (n = 12). The results from these two investigations provide evidence for serotonergic influences on social impulsivity.

Cerebrospinal fluid monoaminergic metabolites differ in wild anubis and hybrid (Anubis hamadryas) baboons: possible relationships to life history and behavior.

The article reports monoaminergic metabolite [homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and 3-methoxy-4-hydroxyphenylglycol (MHPG)], values from the cerebrospinal fluid (CSF) of 27 wild baboons (Papio hamadryas) aged 40 to 140 months. Animals were either anubis, or anubis with hamadryas admixture; males of the latter subspecies generally have a reduced tendency to disperse from their natal groups. Overall, the values and interrelationships among the CSF monoamine metabolites resembled data reported from closely related, captive-housed animals. For example, age was significantly correlated with HVA concentrations (r = -60, p < .05), but not with the other metabolites. Notably, males characterized by hamadryas admixture had significantly higher concentrations of HVA, 5-HIAA, and MHPG (p < .05, respectively), a result possibly driven by differences in serotonergic activity. These data provide initial evidence that variation in central monoaminergic activity, as indicated by CSF monoamine metabolite concentrations, may reflect differences in behavior and life history that have taxonomic and, perhaps, evolutionary significance.

Personality changes in adult subjects with major depressive disorder or obsessive-compulsive disorder treated with paroxetine.

BACKGROUND: Human and animal studies point to 3 dimensions of personality that change during pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI). Specifically, harm avoidance has been found to decrease, social dominance has been found to increase, and hostility in social situations has been found to decrease with SSRI treatment. We sought to determine personality changes in subjects with either major depressive disorder (MDD) or obsessive-compulsive disorder (OCD) treated with paroxetine. We also sought to determine whether or not these personality changes were associated with disease state (MDD vs. OCD) or treatment response (responders vs. nonresponders). METHOD: Thirty-seven subjects diagnosed with either MDD or OCD (according to DSM-IV criteria) completed the Cattell 16 Personality Factor Inventory (16-PF) before and after treatment with paroxetine. Treatment response was defined as a Clinical Global Impressions-Improvement rating of "much" or "very much" improved and a drop in Hamilton Rating Scale for Depression score of at least 50% for MDD or Yale-Brown Obsessive Compulsive Scale score of at least 30% for OCD. RESULTS: No significant differences were found between subjects with MDD and OCD in personality change with treatment. In the whole group, treatment responders had a greater decrease than nonresponders in 16-PF factors relating to harm avoidance. An increase in social dominance factors and a decrease in factors relating to hostility in social situations were found, but these changes were not significantly different between responders and nonresponders. CONCLUSION: These findings indicate that certain personality dimensions change with SSRI treatment and that some of these changes are independent of clinical treatment response.

Moral development and psychopathological interference in conscience functioning among adolescents after trauma.

OBJECTIVES: To compare moral development and psychopathological interference with conscience functioning (PI) among adolescents exposed to different degrees of earthquake-related trauma and to investigate the relationship of moral development and PI to exposure to trauma, severity of posttraumatic stress disorder (PTSD) symptoms, postearthquake adversities, and extent of loss of nuclear family members. METHOD: Adolescents (N = 193) from 2 cities at different distances from the epicenter were evaluated. The Stilwell Structured Conscience Interview was used to assess moral development and PI. Structured self-report instruments were used to obtain ratings of severity of earthquake-related trauma, posttraumatic stress symptoms, and postearthquake adversities. RESULTS: Adolescents in the city near the epicenter manifested advanced moral development as compared with their counterparts in the less affected city. Concomitantly, they endorsed responses indicating PI. Levels of PI were significantly correlated with severity of PTSD symptoms. CONCLUSION: In the aftermath of a catastrophic natural disaster, children assume greater responsibilities and confront a multitude of morally challenging interpersonal situations which may result in an advancement of their moral development. Yet, at the same time, PTSD symptoms and negative schematizations of self and others may give rise to disturbances in conscience functioning. The findings suggest that therapeutic consideration should be given to assisting children in integrating the horror of their traumatic experiences and the harshness of posttrauma adversities into an adaptive schema of good and evil in themselves and the world.

Psychiatric comorbidity in children after the 1988 earthquake in Armenia.

OBJECTIVE: To determine current rates of posttraumatic stress disorder (PTSD), depressive disorder, and separation anxiety disorder (SAD) among children 1 1/2 years after the 1988 earthquake in Armenia; to determine current rates of comorbid PTSD and depressive disorder; and to assess the contribution of exposure, gender, loss of family members, and loss of residence. METHOD: Two hundred eighteen school-age children from three cities at increasing distances from the epicenter were evaluated using the Child Posttraumatic Stress Disorder Reaction Index, the Depression Self-Rating Scale, and the section on SAD from the Diagnostic Interview for Children and Adolescents. RESULTS: On the basis of these evaluations, high rates of current PTSD, depressive disorder, and their co-occurrence were found among victims residing in the two heavily impacted cities. SAD was comparatively less frequent, although symptoms of SAD had been pervasive throughout the region. Severity of posttraumatic stress and depressive reactions were highly correlated. Extent of loss of family members was independently correlated with each. CONCLUSION: After a catastrophic natural disaster, children are at risk for comorbid PTSD and secondary depression. Based on the findings, an interactive model is proposed of postdisaster psychopathology. Early clinical intervention is recommended to prevent chronic posttraumatic stress reactions and secondary depression.