Peritraumatic tonic immobility in a large representative sample of the general population: association with posttraumatic stress disorder and female gender.

BACKGROUND: Tonic immobility is an involuntary response to inescapable life-threatening events. Peritraumatic tonic immobility has been reported in convenience samples of female victims of sexual assault and in mixed-gender victims of different types of trauma. This study evaluated peritraumatic tonic immobility in a representative general population sample and its association with posttraumatic stress disorder (PTSD) and gender. METHODS: 3231 victims of traumatic events aged 15-75 years responded to the Tonic Immobility Scale. PTSD and traumatic events were assessed using the Composite International Diagnostic Interview (CIDI 2.1). We calculated the means and the standard deviations of Tonic Immobility Scale scores stratified by PTSD and gender. The association between tonic immobility scores and gender was explored controlling for potential confounders through a multiple linear regression model. RESULTS: Tonic immobility scores were more than double in those who met criteria for PTSD and were almost four points higher in women. Gender differences remained statistically significant even after adjustment for confounding variables. LIMITATIONS: The cross-sectional and retrospective design may have given rise to recall bias. Results presented here may not apply to small and medium rural areas and the CIDI 2.1 can lead to a certain degree of misclassification. CONCLUSIONS: We have expanded the scope of previous investigations on peritraumatic tonic immobility which were based on convenience samples only, showing its occurrence in victims of traumatic events using a large representative sample of the general population. Furthermore, we confirmed in an unbiased sample the association between peritraumatic tonic immobility and PTSD and female gender.

Comorbid depressive symptoms in treatment-seeking PTSD outpatients affect multiple domains of quality of life.

PURPOSE: No study has examined the impact of the comorbid Axis I conditions on the quality of life (QoL) of patients with a primary diagnosis of PTSD. Our goal was to investigate the influence of comorbid disorders on the QoL of treatment-seeking outpatients with PTSD. METHODS: The diagnoses of PTSD and of the comorbid disorders were established using the SCID-I. The 54 volunteers also completed the Posttraumatic Stress Disorder Checklist - Civilian Version, the BDI, the BAI, the Trauma History Questionnaire, and a socio-demographic questionnaire. Quality of life was assessed by means of the WHOQOL-BREF, a 26-item self-administered scale that measures four domains of QoL: psychological, physical, social, and environmental. Multiple linear regression models were fitted to investigate the relationship between the severity of post-traumatic, mood, and anxiety symptoms; the presence of specific current comorbid disorders and of psychotic symptoms, the number of current comorbid conditions, and a history of child abuse for each of the four domains of QoL, after adjusting for the effect of socio-demographic characteristics. RESULTS: The severity of PTSD symptoms impacted negatively on the psychological and physical domains. The severity of depressive symptoms correlated negatively with QoL in all domains, independently of sex, age, occupation, and marital status. The psychotic symptoms impacted negatively on the environmental domain. A history of child abuse was negatively associated with the psychological and the social domains. CONCLUSIONS: The severity of comorbid depressive symptoms is one of the most important factors in the determination of the QoL in patients with PTSD.

Peritraumatic tonic immobility predicts a poor response to pharmacological treatment in victims of urban violence with PTSD.

INTRODUCTION: Tonic immobility is the last defense against predation in animals and is characterized by paralysis and analgesia. In humans, it has only been reported in women victims of sexual abuse. OBJECTIVE: This study evaluated the prevalence of peritraumatic tonic immobility (PTI) in patients with PTSD and investigated its association with response to treatment. METHOD: Victims of urban violence with PTSD diagnosed through the SCID-IV (n=23) underwent a naturalistic pharmacological treatment according to the recommended guidelines for PTSD. The Post-Traumatic Stress Disorder Checklist--Civilian Version (PCL-C) and the Clinical Global Impressions (CGI) Severity scores were applied at baseline and endpoint. PTI was assessed using the Tonic Immobility Scale. RESULTS: PTI was reported by both genders in 43% of the sample. Patients with PTI responded significantly poorly to treatment than those without it, either considering the PCL-C or the CGI scores. LIMITATIONS: This study probed PTI retrospectively and was based on a small sample recruited in a tertiary clinic. CONCLUSIONS: We have expanded the scope of the two previous investigations on PTI by showing its occurrence also in men and during non-sexual violence. In addition, the finding of a significant relationship between PTI and poor response to treatment of PTSD indicates that PTI may carry a prognostic value in this disorder and suggests that PTI should be routinely assessed in traumatized patients.

The cross-cultural adaptation to Portuguese of the Trauma History Questionnaire to identify traumatic experiences.

BACKGROUND: Despite the high prevalence of exposure to traumatic events in Brazil, there are few studies on trauma and post-traumatic stress disorder. This paper presents the cross-cultural adaptation to Portuguese of the Trauma History Questionnaire. METHODS: Two translations and their respective back-translations were made, as well as the evaluation of the semantic equivalence, the preparation of the synthesis version, the pre-testing in the target population and the definition of the final version. DISCUSSION: Similar levels of referential meaning between the two back-translations and the original instrument were observed. Priority was given to the first translation in the decision process for the elaboration of the synthesis version. The pre-testing of this version in the target population confirmed the goal to achieve the semantic and the operational equivalence criteria. This work offers the first adaptation of a specific instrument to detect traumatic experiences in the Brazilian context.

Quantitative electroencephalography (qEEG) to discriminate primary degenerative dementia from major depressive disorder (depression).

Electroencephalography (EEG) can be a valuable technique to assess electrophysiological changes related to dementia. In patients suspected of having dementia, the EEG is often quite informative. The sensitivity of the EEG to detect correlates of psychiatric disorders has been enhanced by means of quantitative methods of analysis (quantitative EEG). Quantitative features are extracted from, at least, 2 minutes of artifact-free, eyes closed, resting EEG, log-transformed to obtain Gaussianity, age-regressed, and Z-transformed relative to population norms (Neurometrics database). Using a subset of quantitative EEG (qEEG) features, forward stepwise discriminant analyses are used to construct classifier functions. Along this vein, the main objective of this experiment is to distinguish profiles of qEEG, which differentiate depressive from demented patients (n = 125). The results showed that demented patients present deviations above the control group in variables associated to slow rhythms: Normed Monopolar Relative Power Theta for Cz and Normed Bipolar Relative Power Theta for Head. On the other hand, the deviation below the control group occurs with the variable associated to alpha rhythm: Normed Monopolar Relative Power Alpha for P3, in dementia. Using this method, the present investigation demonstrated high discriminant accuracy in separating Primary Degenerative Dementia from Major Depressive Disorder (Depression).

Neurocortical electrical activity tomography in chronic schizophrenics.

Functional imaging of brain electrical activity was performed in 25 chronic medicated schizophrenics and 40 controls, analyzing the classical frequency bands (delta, theta, alpha, and beta) of 19-channel EEG during resting state to identify brain regions with deviant activity of different functional significances, using LORETA (Low Resolution Tomography) and SPM99 (Statistical Parametric Mapping). Patients differed from controls due to an excess of slow activity comprising delta + theta frequency bands (inhibitory pattern) located at the right middle frontal gyrus, right inferior frontal gyrus, and right insula, as well as at the bilateral anterior cingulum with a left preponderance. The high temporal resolution of EEG enables the specification of the deviations not only as an excess or a deficit of brain electrical activity, but also as inhibitory (delta, theta), normal (alpha), and excitatory (beta) activities. These deviations point out to an impaired functional brain state consisting of inhibited frontal and prefrontal areas that may result in inadequate treatment of externally or internally generated information.

[The cross-cultural adaptation to Portuguese of the Dissociative Experiences Scale for screening and quantifying dissociative phenomena]. / A adaptação transcultural para o português do instrumento Dissociative Experiences Scale para rastrear e quantificar os fenômenos dissociativos.

OBJECTIVE: This paper presents the cross-cultural adaptation to Portuguese of the Dissociative Experiences Scale, the worldwide most employed questionnaire for screening and quantifying dissociative phenomena. METHODS: Two translations and their respective back-translations were performed, as well as the evaluation of the semantic equivalence, the preparation of the synthetic version, the pre-testing on the target population, the definition of the final version and a second pre-testing on the target population. RESULTS: A high level of semantic equivalence between the original instrument and the two pairs of translations and back-translations was observed regarding the referential and general meanings. The two pre-testing in the target population led to alterations in order to achieve the semantic and operational equivalence criteria. CONCLUSION: This work provides the first adaptation of a specific instrument to detect and quantify dissociative symptoms in the Brazilian context.

Decreased premotor cortex volume in victims of urban violence with posttraumatic stress disorder.

BACKGROUND: Studies addressing posttraumatic stress disorder (PTSD) have demonstrated that PTSD patients exhibit structural abnormalities in brain regions that relate to stress regulation and fear responses, such as the hippocampus, amygdala, anterior cingulate cortex, and ventromedial prefrontal cortex. Premotor cortical areas are involved in preparing to respond to a threatening situation and in representing the peripersonal space. Urban violence is an important and pervasive cause of human suffering, especially in large urban centers in the developing world. Violent events, such as armed robbery, are very frequent in certain cities, and these episodes increase the risk of PTSD. Assaultive trauma is characterized by forceful invasion of the peripersonal space; therefore, could this traumatic event be associated with structural alteration of premotor areas in PTSD? METHODOLOGY/PRINCIPAL FINDINGS: Structural magnetic resonance imaging scans were acquired from a sample of individuals that had been exposed to urban violence. This sample consisted of 16 PTSD patients and 16 age- and gender-matched controls. Psychometric questionnaires differentiated PTSD patients from trauma-exposed controls with regard to PTSD symptoms, affective, and resilience predispositions. Voxel-based morphometric analysis revealed that, compared with controls, the PTSD patients presented significant reductions in gray matter volume in the ventral premotor cortex and in the pregenual anterior cingulate cortex. CONCLUSIONS: Volume reduction in the premotor cortex that is observed in victims of urban violence with PTSD may be associated with a disruption in the dynamical modulation of the safe space around the body. The finding that PTSD patients presented a smaller volume of pregenual anterior cingulate cortex is consistent with the results of other PTSD neuroimaging studies that investigated different types of traumatic events.

Peritraumatic tonic immobility is associated with posttraumatic stress symptoms in undergraduate Brazilian students.

OBJECTIVE: Tonic immobility is a defensive reaction occurring under extreme life threats. Patients with posttraumatic stress disorder (PTSD) reporting peritraumatic tonic immobility show the most severe symptoms and a poorer response to treatment. This study investigated the predictive value of tonic immobility for posttraumatic stress symptoms in a non-clinical sample. METHODS: One hundred and ninety-eight college students exposed to various life threatening events were selected to participate. The Posttraumatic Stress Disorder Checklist - Civilian Version (PCL-C) and tonic immobility questions were used. Linear regression models were fitted to investigate the association between peritraumatic tonic immobility and PCL-C scores. Peritraumatic dissociation, peritraumatic panic reactions, negative affect, gender, type of trauma, and time since trauma were considered as confounding variables. RESULTS: We found significant association between peritraumatic tonic immobility and PTSD symptoms in a non-clinical sample exposed to various traumas, even after regression controlled for confounding variables (ß = 1.99, p = 0.017). CONCLUSIONS: This automatic reaction under extreme life threatening stress, although adaptive for defense, may have pathological consequences as implied by its association with PTSD symptoms.

Predictors of PTSD symptoms in brazilian police officers: the synergy of negative affect and peritraumatic dissociation.

BACKGROUND: Exposure to traumatic events is a necessary but not a sufficient condition for the development of posttraumatic stress disorder (PTSD). Pretrauma, peritrauma and posttrauma factors interact to impact on symptom severity. The aim of the present study is to determine risk factors for PTSD symptoms in Brazilian police officers. METHOD: In a cross-sectional sample of active duty officers (n = 212), participants were asked to complete a socio-demographic questionnaire and self-report scales on affective traits, cumulative critical incident exposure, peritraumatic distress and dissociation, PTSD symptoms, and social support. Hierarchical linear regression analysis was conducted to examine predictors of PTSD symptoms. RESULTS: Variables related to negative affect, job duration, frequency of critical incident exposure, peritraumatic dissociation, and lack of social support remained significant in the final model and explained 55% of the variance in PTSD symptoms. When interaction terms were evaluated, a synergistic effect between negative affect and peritraumatic dissociation was found. CONCLUSIONS: The risk factors found in this study provide clues on how to elaborate primary prevention strategies regarding PTSD symptoms in police officers. Such initiatives may lessen the impact of repeated exposure to traumatic events on police officers over the course of their careers.

Is there tonic immobility in humans? Biological evidence from victims of traumatic stress.

Tonic immobility, characterized by profound motor inhibition, is elicited under inescapable threat in many species. To fully support the existence of tonic immobility in humans, our aim was to elicit this reaction in a laboratory setting and measure it objectively. To mimic exposure to life-threatening events in the lab, trauma-exposed participants with PTSD (n=18) and without PTSD (n=15) listened to the script of their autobiographical trauma. Posturography and electrocardiography were employed. Reports of script-induced immobility were associated with restricted area of body sway and were correlated with accelerated heart rate and diminished heart rate variability, implying that tonic immobility is preserved in humans as an involuntary defensive strategy. Immobility reports seemed more evident in PTSD, suggesting that, in some patients, tonic immobility may be elicited during re-experiencing episodes in daily life. This study provided a measure of tonic immobility, a peritraumatic reaction for which cumulative clinical evidence had linked to the severity of PTSD.

The impact of tonic immobility reaction on the prognosis of posttraumatic stress disorder.

Tonic immobility is the last defense reaction to entrapment by a predator. In humans, peritraumatic tonic immobility was correlated with PTSD severity and poor response to treatment. This study compared the role of peritraumatic dissociation, panic physical symptoms and tonic immobility as predictors of response to standard pharmacotherapy for PTSD. Thirty-six PTSD patients underwent a naturalistic pharmacological treatment. The Posttraumatic Stress Disorder Checklist - Civilian Version (PCL-C) and the Clinical Global Impressions Severity of Illness item scores (CGI-S) were employed at baseline and endpoint to examine treatment outcome. Peritraumatic reactions were assessed using the Physical Reactions Subscale, the Peritraumatic Dissociative Experiences Questionnaire and four motor questions of the Tonic Immobility Scale. After controlling for confounders, tonic immobility was the best predictor of a poor response to treatment, either considering the PCL-C or the CGI-S scores. Tonic immobility seems to have a greater negative impact on PTSD prognosis than peritraumatic panic or dissociation. Additional translational and clinical research may inform about particular mechanisms underlying tonic immobility and open new avenues for prevention and treatment of PTSD.

Is tonic immobility the core sign among conventional peritraumatic signs and symptoms listed for PTSD?

BACKGROUND: Previous studies suggested the importance of peritraumatic reactions as predictors of PSTD symptoms severity. Despite mounting evidence that tonic immobility occurs under intense life threats its role as predictor of PTSD severity remains by and large understudied. The objective of this study was to investigate the role of peritraumatic reactions (tonic immobility, panic and dissociation) as predictors of PTSD symptoms severity. METHODS: Participants were 32 victims of urban violence with PTSD diagnosed through the SCID-I. In order to evaluate PTSD symptoms at baseline, we used the Post-Traumatic Stress Disorder Checklist-Civilian Version. To assess peritraumatic reactions we employed the Physical Reactions Scale, the Peritraumatic Dissociative Experiences Questionnaire and Tonic Immobility questions. As confounding variables, we considered negative affect (measured by the Positive and Negative Affect Schedule-Trait Version), sex and time elapsed since trauma. RESULTS: Tonic immobility was the only predictor of PTSD symptoms severity that kept the statistical significance after controlling for potential confounders. LIMITATIONS: This study was based on a relatively small sample recruited in a tertiary clinic, a fact that may limit the generalizability of its findings. The retrospective design may have predisposed to recall bias. CONCLUSIONS: Our study provides good reason to conduct more research on tonic immobility in PTSD with other samples and with different time frames in an attempt to replicate these stimulating results.

O uso da sugestão no diagnóstico e tratamento de cegueira conversiva: um relato de caso / The use of suggestion in diagnosis and treatment of conversion blindness: a case report

O transtorno conversivo é definido pelo Manual Diagnóstico e Estatístico de Transtornos Mentais - Quarta Edição (DSM-IV) por sintomas que afetam a função sensorial ou motora voluntária, assemelhando-se a uma condição neurológica, mas que, após investigação, não podem ser explicados por essa condição, e sim por fatores psicológicos. Em raras ocasiões, o exame neurológico e os exames complementares não são suficientes para estabelecer o diagnóstico do transtorno conversivo. Este artigo descreve um caso para o qual a aplicação de uma técnica de sugestão (torpedeamento) confirmou o diagnóstico de cegueira conversiva e também se mostrou eficaz no tratamento. A sugestão, aliada a psicoterapia e psicofarmacologia, pode ser uma ferramenta valiosa no tratamento desses pacientes.

Conversion disorder is defined by Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) as symptoms affecting voluntary motor or sensory function, resembling a neurological condition, and, after investigation, cannot be explained by this condition, but by psychological factors. On rare occasions, neurological examination and laboratory tests are not sufficient to establish the diagnosis of conversion disorder. This article describes a case for which the use of a technique of suggestion (torpedoing) confirmed the diagnosis of conversion blindness and also proved to be effective for its treatment. Suggestion, combined with psychotherapy and psychopharmacology, can be a valuable tool in the treatment of these patients.

Peritraumatic tonic immobility is associated with posttraumatic stress symptoms in undergraduate Brazilian students / A imobilidade tônica peritraumática está associada aos sintomas do transtorno de estresse pós-traumático em estudantes brasileiros de graduação

OBJECTIVE: Tonic immobility is a defensive reaction occurring under extreme life threats. Patients with posttraumatic stress disorder (PTSD) reporting peritraumatic tonic immobility show the most severe symptoms and a poorer response to treatment. This study investigated the predictive falue of tonic immobility for posttraumatic stress symptoms in a non-clinical sample. METHODS: One hundred and ninety-eight college students exposed to various life threatening events were selected to participate. The Posttraumatic Stress Disorder Checklist - Civilian Version (PCL-C) and tonic immobility questions were used. Linear regression models were fitted to investigate the association between peritraumatic tonic immobility and PCL-C scores. Peritraumatic dissociation, peritraumatic panic reactions, negative affect, gender, type of trauma, and time since trauma were considered as confounding variables. RESULTS: We found significant association between peritraumatic tonic immobility and PTSD symptoms in a non-clinical sample exposed to various traumas, even after regression controlled for confounding variables (β = 1.99, p = 0.017). CONCLUSIONS: This automatic reaction under extreme life threatening stress, although adaptive for defense, may have pathological consequences as implied by its association with PTSD symptoms.

OBJETIVO: A imobilidade tônica é uma resposta defensiva que ocorre sob ameaça extrema à vida. Pacientes com transtorno de estresse pós-traumático (TEPT) que relatam imobilidade tônica peritraumática são os que apresentam os sintomas mais graves e a pior resposta ao tratamento. Este estudo investigou o valor preditivo da imobilidade tônica para os sintomas de TEPT em uma amostra não clínica. MÉTODOS: Os participantes da pesquisa foram 198 estudantes universitários expostos a traumas diversos. A versão brasileira do Post-Traumatic Stress Disorder Checklist Civilian Version (PCL-C) e questões referentes à imobilidade tônica foram empregadas. Modelos de regressão linear foram utilizados para investigar a associação dos sintomas de estresse pós-traumático com a imobilidade tônica peritraumática. Foram consideradas como variáveis de confusão a dissociação peritraumática, as reações físicas de pânico peritraumática, o traço de afeto negativo, o gênero, o tipo de trauma e o tempo de trauma. RESULTADOS: Encontrou-se uma associação significativa entre a imobilidade tônica peritraumática e os sintomas de TEPT em uma amostra não clínica exposta a traumas diversos mesmo quando controlada por variáveis de confusão (β = 1,99; p = 0,017). CONCLUSÕES: Esta reação defensiva que ocorre sob intensa ameaça, apesar de adaptativa para a defesa, pode ter consequências patológicas como sugere sua associação aos sintomas de TEPT.

Predictors of PTSD symptoms in brazilian police officers: the synergy of negative affect and peritraumatic dissociation / Preditores de sintomas de transtorno de estresse pós-traumático em policiais brasileiros: a interação entre afeto negativo e dissociação peritraumática

BACKGROUND: Exposure to traumatic events is a necessary but not a sufficient condition for the development of posttraumatic stress disorder (PTSD). Pretrauma, peritrauma and posttrauma factors interact to impact on symptom severity. The aim of the present study is to determine risk factors for PTSD symptoms in Brazilian police officers. METHOD: In a cross-sectional sample of active duty officers (n = 212), participants were asked to complete a socio-demographic questionnaire and self-report scales on affective traits, cumulative critical incident exposure, peritraumatic distress and dissociation, PTSD symptoms, and social support. Hierarchical linear regression analysis was conducted to examine predictors of PTSD symptoms. RESULTS: Variables related to negative affect, job duration, frequency of critical incident exposure, peritraumatic dissociation, and lack of social support remained significant in the final model and explained 55 percent of the variance in PTSD symptoms. When interaction terms were evaluated, a synergistic effect between negative affect and peritraumatic dissociation was found. CONCLUSIONS: The risk factors found in this study provide clues on how to elaborate primary prevention strategies regarding PTSD symptoms in police officers. Such initiatives may lessen the impact of repeated exposure to traumatic events on police officers over the course of their careers.

INTRODUÇÃO: A exposição a eventos traumáticos é uma condição necessária, porém não única, para o desenvolvimento de transtorno de estresse pós-traumático (TEPT). Fatores individuais pré, peri e pós-trauma exercem impacto sobre a gravidade dos sintomas. O objetivo do presente estudo é determinar os fatores de risco para o desenvolvimento de sintomas de TEPT em policiais brasileiros. MÉTODO: Uma amostra transversal de policiais em atividade (n = 212) foi convidada a responder um questionário sóciodemográfico e escalas autoaplicáveis sobre afeto positivo e negativo, frequência de incidentes críticos, sofrimento e dissociação peritraumáticos, sintomas de TEPT e apoio social. Regressão linear hierárquica foi utilizada para avaliar fatores de risco. RESULTADOS: Afeto negativo, tempo de trabalho, frequência de exposição a eventos traumáticos, dissociação peritraumática e apoio social diminuído permaneceram no modelo final e explicaram 55 por cento das variações dos sintomas de TEPT. Foi observado efeito sinérgico entre dissociação peritraumática e afeto negativo. CONCLUSÃO: Baseados nos achados os autores discutem estratégias de prevenção que visam diminuir o impacto da exposição a eventos traumáticos em policiais ao longo de suas carreiras.

Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review.

Although video-EEG monitoring has revolutionized the diagnosis of psychogenic nonepileptic seizure (PNES), the etiology of this condition remains poorly understood. This article is a critical review of studies on the prevalence of traumatic events, abuse, and/or posttraumatic stress disorder (PTSD) in patients with PNES. Searches carried out on MEDLINE (1966-2004) and Web of Science (1945-2004) identified 17 relevant studies. PNES samples showed very high rates of trauma (44-100%) and abuse (23-77%), which were 15-40% higher than those found in control groups. This suggests that traumatic experiences may be a potential risk factor for PNES. PNES samples also showed a higher prevalence of PTSD than control groups, raising the possibility that PNES may arise as a clinical expression of a hypothetical PTSD subtype the core symptoms of which are dissociative. Methodological limitations do not permit the confirmation of these hypotheses. Stronger research designs are needed, such as prospective and case-control studies in both hospital and community settings.

As crises não-epilépticas psicogênicas como manifestações clínicas do transtorno de estresse pós-traumático / Psychogenic nonepileptic seizures as clinical manifestations of posttraumatic stress disorder

As crises não epilépticas psicogênicas (CNEP) ainda são pouco entendidas. Como não existem critérios clínicos positivos para as CNEP, não há consenso sobre sua definição, assim como não se tem clareza em relação à nosologia de base, à fisiopatologia e ao tratamento apropriado. As CNEP manifestam-se principalmente por sintomas conversivos e dissociativos, os quais estão ligados historicamente a uma doença considerada de origem traumática, a histeria. Recentemente, observou-se que pacientes com CNEP apresentam taxas elevadas de experiências traumáticas, em particular abuso na infância, e de transtorno de estresse pós-traumático (TEPT). Estes achados sugerem que a CNEP pode ocorrer como expressão clínica de um padrão de TEPT cuja característica central é a predominância de fenômenos dissociativos e conversivos. Algumas evidências levantam a possibilidade de que este subtipo de TEPT dissociativo/conversivo seja resultante de maus cuidados parentais e disfunção familiar na infância, os quais estão associados a - e, portanto podem causar - sintomas somatoformes, incluindo as CNEP. Limitações metodológicas impedem a confirmação destas hipóteses, sendo necessários desenhos de pesquisa mais fortes, tais como prospectivos e de caso-controle.

Psychogenic nonepileptic seizures (PNES) are still poorly understood. Because there are no positive clinical criteria for PNES, there is no consensus about its definition, nor clarity about the underlying nosology, pathophysiology, or the suitable treatment. PNES most commonly occur in the form of conversion and dissociative symptoms, which are historically linked to a trauma-related disease called hysteria. Recently, it has been observed that PNES patients show high rates of traumatic experiences, in particular childhood abuse, and posttraumatic stress disorder (PTSD). This suggests that PNES may arise as a clinical expression of a PTSD pattern whose cardinal feature is the predominance of dissociative and conversion phenomena. Emerging evidence also raise the possibility that the dissociative/conversion subtype of PTSD may occur as a result of poor parental care and family dysfunction, which are associated with - and may therefore cause - somatoform symptoms, including PNES. Methodological limitations do not permit the confirmation of these hypotheses. Stronger research designs are needed, such as prospective and case-control studies.

Negligência das classificações diagnósticas atuais com os fenômenos dissociativos do transtorno de estresse pós-traumático / Negligence of current diagnostic classifications in dissociative phenomena of posttraumatic stress disorder

CONTEXTO: Apesar da importância crescente da dissociação no transtorno de estresse pós-traumático (TEPT), os sintomas dissociativos não são contemplados pelos critérios diagnósticos das classificações oficiais (CID-10 e DSM-IV). A hipótese de um subtipo dissociativo para o TEPT tem sido corroborada por pesquisas em psicofisiologia, neuroimagem funcional, psicoendocrinologia e sistemas opióides. Pretende-se demonstrar a insuficiência dos critérios vigentes na detecção dos sintomas dissociativos no TEPT mediante relato de um caso com sintomas dissociativos persistentes desde o trauma. RELATO DE CASO: O paciente preenche critérios para TEPT e transtorno depressivo maior pelo DSM-IV. Embora também preencha critérios para transtorno de despersonalização, esse diagnóstico é impossibilitado na presença de TEPT. O paciente apresentou sintomas conversivos peritraumáticos, avaliados pela Escala de Imobilidade Tônica, e sintomas dissociativos proeminentes, peritraumáticos e atuais, já que obteve escores significativos no Questionário de Experiências Dissociativas Peritraumáticas e na Escala de Experiências Dissociativas. Após 3 anos de tratamento, não houve melhora do quadro. CONCLUSÃO: O reconhecimento da importância dos fenômenos dissociativos/conversivos no TEPT poderá contribuir para o aprimoramento do diagnóstico, investigações sobre sua fisiopatologia e o desenvolvimento de tratamentos mais eficazes.

BACKGROUND: In spite of the growing importance of dissociation in post traumatic stress disorder (PTSD), dissociative symptoms are not included in the diagnostic criteria of official classifications (CID-10, DSM-IV). Research in psychophysiology, functional neuroimaging, psycho-endocrinology and opioid systems provides support for a dissociative subtype of PTSD. CASE REPORT: A case study on a PTSD patient with persistent dissociative symptoms since the trauma will show that current criteria are insufficient for detecting dissociative symptoms in PTSD. The patient meets criteria for PTSD and major depressive disorder according to the DSM-IV. He also meets criteria for depersonalization disorder, although this diagnosis is not possible with PTSD. The patient showed peritraumatic conversive symptoms, evaluated by the tonic immobility scale. Further, he obtained significant scores on the Peritraumatic Dissociative Experiences Questionnaire and the Dissociative Experiences Scale, revealing prominent peritraumatic and current dissociative symptoms. There was no improvement in the patients condition after three years of treatment. CONCLUSION: Recognition of the importance of dissociative/conversive phenomena in PTSD will allow practitioners to perfect their diagnoses, as well as improve research on the physiopathology of these phenomena and help develop more effective treatments.

The cross-cultural adaptation to Portuguese of the Trauma History Questionnaire to identify traumatic experiences

INTRODUÇAO: Apesar da prevalência elevada de exposição a eventos traumáticos no Brasil, há poucos estudos sobre trauma e transtorno de estresse pós-traumático. Este artigo apresenta a adaptação transcultural para o português do Trauma History Questionnaire. MÉTODOS: Foram feitas duas traduções e suas respectivas retraduções, avaliação da equivalência semântica, elaboração da versão síntese, pré-teste na população-alvo e realização da versão final. DISCUSSAO: Observaram-se níveis semelhantes de significado referencial das duas retraduções em relação ao instrumento original. Deu-se primazia à primeira tradução no processo de decisão para a elaboração da versão síntese. O pré-teste na população-alvo confirmou o objetivo de atingir os critérios de equivalência semântica e equivalência operacional. Este trabalho torna disponível a primeira adaptação para o contexto brasileiro de um instrumento específico para a detecção de experiências traumáticas.