Medical traumatic stress: Integrating evidence-based clinical applications from health and trauma psychology.

Medical events in both childhood and adulthood, including components of the illness or injury and subsequent medical intervention, recovery, and disability, are increasingly being recognized as potentially traumatic. There has been an increased focus on scholarly work related to medical trauma and medically induced posttraumatic stress disorder (PTSD). Existing evidence suggests that trauma-focused treatment can promote both physical and psychological recovery. However, there continues to be a dearth of clinical guidance on how to (a) best identify and treat prior trauma exposure that complicates adjustment to illness and increases the risk for medically induced PTSD and (b) address medically induced PTSD while concurrently targeting health-related concerns (e.g., pain, adjustment to illness, acquired disability) that may negatively impact recovery. Originally presented as a premeeting institute at the 2023 Annual Meeting of the International Society for Traumatic Stress Studies, this paper describes the biopsychosocial impacts of medical trauma on adults and considerations for assessment and intervention in both traditional trauma and integrated care settings. This includes clinical applications, including assessment, case conceptualization, and health and rehabilitation interventions, that can promote health-related adjustment and coping within the context of trauma-focused treatment.

Anxiety sensitivity, finding the body, and posttraumatic stress disorder in suicide-bereaved treatment-seeking adults.

OBJECTIVE: Those bereaved by suicide are at greater risk of prolonged distress compared to those bereaved by other modes of death. Trauma- and emotion-related factors may increase this vulnerability. Finding the body of the deceased may intensify postsuicide distress. Anxiety sensitivity, fear of one's anxiety-related symptoms, has been positively associated with posttraumatic stress disorder (PTSD) in other trauma populations but has not been studied in the suicide bereaved. METHOD: This study examined the relationships among finding the body, anxiety sensitivity, and PTSD in a treatment-seeking, suicide-bereaved sample (N = 50). Pretreatment baseline data on demographics, the Anxiety Sensitivity Index, and the PTSD Checklist were analyzed. RESULTS: Younger age (r = -.31, p = .03), being a person of color (r = -.32, p = .02), and fewer days since the loss (r = -.30, p = .03) were associated with greater PTSD. Controlling for age, race, and days since the loss, PTSD was unrelated to finding the body, F(1, 45) = 0.01, p = .92, but was positively associated with anxiety sensitivity (pr = .32, p = .03). In simultaneous regression analyses, age, race, days since the loss, finding the body, and anxiety sensitivity accounted for 33% of the variance in PTSD, F(2, 44) = 4.29, p = .003; anxiety sensitivity was the only significant predictor of PTSD symptoms (ß = .36, t = 2.35, p = .02). CONCLUSIONS: Anxiety sensitivity has important implications for the development and maintenance of PTSD in the suicide bereaved and should be assessed and targeted in suicide postvention. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Supporter-focused early intervention for recent sexual assault survivors: Study protocol for a pilot randomized clinical trial.

INTRODUCTION: Sexual assault is a common form of trauma that is associated with elevated risk for negative psychosocial outcomes. Although survivors' social relationships could serve as a major protective factor against negative outcomes, survivors' supporters often lack knowledge regarding effective responses and may inadvertently respond in ways that are detrimental to healing. Communication and Recovery Enhancement (CARE) is a 2-session early intervention for survivors of a past-10-week sexual assault and their supporters that aims to improve supporters' ability to respond effectively. OBJECTIVE: In this paper, we present a study protocol for a pilot randomized clinical trial of CARE (NCT05345405). The goal of this pilot trial is to understand the feasibility, acceptability, and preliminary efficacy of two versions of CARE: a version in which survivors and supporters attend sessions together (dyadic version) and a version in which supporters attend sessions alone (supporter-only version). METHODS: Survivors aged 14+ with elevated posttraumatic stress will enroll with a supporter of their choosing. Dyads will be randomized to dyadic CARE, supporter-only CARE, or waitlist control, and will complete self-report assessments at baseline, post-session-1, and follow-ups (1, 2, and 3 months post-baseline). We will use descriptive statistics, effect sizes, and exploratory statistical tests to characterize the acceptability of both CARE versions, impact on knowledge change from baseline to 1 month, impact on disclosure experiences at 1 month, and impact on functional outcomes at 3 months. DISCUSSION: Results will be used to inform future changes to CARE and determine whether a fully-powered randomized controlled trial is warranted.

Cognitive behavioral therapy for chronic pain in veterans: Evidence for clinical effectiveness in a model program.

The U.S. Department of Veterans Affairs (VA) has been training clinicians in its cognitive behavioral therapy for chronic pain (CBT-CP) structured protocol since 2012. The aim of this project was to review patient outcomes to determine the effectiveness of the VA's CBT-CP treatment. From 2012-2018, 1,331 Veterans initiated individual CBT-CP treatment as part of the training program. Patient outcomes were assessed with measures of patient-reported pain intensity, pain catastrophizing, depression, pain interference, and quality of life (physical, psychological, social, and environmental). Mixed models of the effects of time indicated significant changes across pretreatment, midtreatment, and treatment conclusion on all outcomes. There was a large effect size (Cohen's d = 0.78) for pain catastrophizing, and there were medium to large effect sizes (d > 0.60) for worst pain intensity, pain interference, depression, and physical quality of life. Systematic training of therapists and implementation of the VA's CBT-CP protocol yielded significant patient improvements across multiple domains. This offers strong support for the VA's CBT-CP as an effective, safe treatment for Veterans with chronic pain and highlights it as a model to increase the availability of training in standardized, pain-focused, evidence-based, behavioral interventions. The findings suggest that the broad dissemination of such training, including in routine, nonpain specialty settings, would improve patient access to effective, nonpharmacological treatment options in both the public and private sectors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The mental health impacts of receiving a breast cancer diagnosis: A meta-analysis.

BACKGROUND: Receiving a breast cancer diagnosis can be a turning point with negative impacts on mental health, treatment and prognosis. This meta-analysis sought to determine the nature and prevalence of clinically significant psychological distress-related symptoms in the wake of a breast cancer diagnosis. METHODS: Ten databases were searched between March and August 2020. Thirty-nine quantitative studies were meta-analysed. RESULTS: The prevalence of clinically significant symptoms was 39% for non-specific distress (n = 13), 34% for anxiety (n = 19), 31% for post-traumatic stress (n = 7) and 20% for depression (n = 25). No studies reporting breast cancer patients' well-being in our specific time frame were found. CONCLUSION: Mental health can be impacted in at least four domains following a diagnosis of breast cancer and such effects are commonplace. This study outlines a clear need for mitigating the impacts on mental health brought about by breast cancer diagnosis. CRD42020203990.

Foster Well-being Throughout the Career Trajectory: A Developmental Model of Physician Resilience Training.

Physician burnout is common across specialties and largely driven by demands of the current health care industry. However, the obvious need for systems change does not address the unavoidable impact of providing care to those who suffer. An intentional, developmental, longitudinal approach to resiliency training would not distract from fixing a broken system or blame physicians for their distress. Existing models and approaches to resilience training are promising but limited in duration, scope, and depth. We call for and describe a career-long model, introduced early in undergraduate medical training, extending into graduate medical education, and integrated throughout professional training and continuing medical education, in intrapersonal and interpersonal skills that help physicians cope with the emotional, social, and physical impact of care provision.

Post-traumatic stress disorder and cancer.

Being diagnosed with and treated for cancer is highly stressful and potentially traumatic. An extensive literature has evaluated the prevalence, predictors, and correlates of cancer-related post-traumatic stress disorder (PTSD) symptoms and diagnoses. In this qualitative review of cancer-related PTSD literature, we highlight conceptual, methodological, and diagnostic issues, and identify clinical implications and areas for future research. Cancer-related PTSD has been documented in a minority of patients with cancer and their family members, is positively associated with other indices of distress and reduced quality of life, and has several correlates and risk factors (eg, prior trauma history, pre-existing psychiatric conditions, poor social support). The literature on treatment of cancer-related PTSD is sparse. Existing literature on cancer-related PTSD has used DSM-IV-TR diagnostic criteria; the revised DSM-5 PTSD criteria have important implications for the assessment of cancer-related distress. Application of PTSD diagnosis to patients with cancer has been critiqued on conceptual and methodological grounds, and important differential diagnosis considerations should be taken into account. Psychosocial assessment of patients with cancer should include careful evaluation of pre-cancer diagnosis trauma and psychiatric history, and diagnostic interviewing should consider concurrent conditions (eg, adjustment disorder). Treatment of cancer-related PTSD should be approached with caution and be informed by existing evidence-based approaches for traumatic stress.

Increased Suicidal Ideation in Patients with Co-Occurring Bipolar Disorder and Post-Traumatic Stress Disorder.

Suicide risk increases for those with Bipolar Disorder or PTSD, however little research has focused on risk for co-occurring Bipolar Disorder and PTSD. The aim of this article was to evaluate increased suicide risk in co-occurring disorders, and differences in suicide risk for patients with Bipolar I versus Bipolar II. This study evaluated suicide risk in patients with co-occurring PTSD and Bipolar Disorder (n = 3,158), using the MADRS and Suicide Questionnaire. Those with history of PTSD had significantly higher suicidal ideation than those without (U = 1063375.00, p < .0001). Those with Bipolar I had higher risk than those with Bipolar II. Patients with Bipolar I and PTSD were at higher risk for suicidal ideation, implying the importance of diagnosis and risk assessment.

The Psychosocial Impact of Fabry Disease on Pediatric Patients.

Fabry disease (FD) is a multisystemic disease that has previously been reported to result in poorer quality of life and psychosocial functioning in impacted adults. However, prior to the current study, limited data were available on the impact of FD in children and adolescents. Therefore, the present study examined the differences of quality of life, psychosocial functioning, and depression in children with FD as compared with a healthy sample. Results indicated that children with FD were experiencing poorer quality of life than their healthy counterparts. Notably, results consistently identified adolescents with FD as more heavily impacted than younger children, although not to the same degree as adults with FD as reported in previous studies. Therefore, adolescence may be a critical point in the development of individuals with FD during which effective multidisciplinary interventions could be utilized to prevent poor quality of life and psychosocial functioning in adulthood.

Peer-counseling for women newly diagnosed with breast cancer: A randomized community/research collaboration trial.

BACKGROUND: We conducted a randomized controlled trial of peer-counseling for newly diagnosed breast cancer (BC) patients as a community/research collaboration testing an intervention developed jointly by a community-based-organization serving women with cancer and university researchers. METHODS: We recruited 104 women newly diagnosed with BC at any disease stage. Prior to randomization, all received a one-time visit with an oncology nurse who offered information and resources. Afterwards, we randomized half to receive a match with a Navigator with whom they could have contact for up to 6 months. We recruited, trained, and supervised 30 peer counselors who became "Navigators." They were at least one-year post-diagnosis with BC. Controls received no further intervention. We tested the effect of intervention on breast-cancer-specific well-being and trauma symptoms as primary outcomes, and several secondary outcomes. In exploratory analyses, we tested whether responding to their diagnosis as a traumatic stressor moderated outcomes. RESULTS: We found that, compared with the control group, receiving a peer-counseling intervention significantly improved breast-cancer-specific well-being (p=0.01, Cohen's d=0.41) and maintained marital adjustment (p=0.01, Cohen's d=0.45) more effectively. Experiencing the diagnosis as a traumatic stressor moderated outcomes: those with a peer counselor in the traumatic stressor group improved significantly more than controls on well-being, trauma and depression symptoms, and cancer self-efficacy. CONCLUSIONS: Having a peer counselor trained and supervised to recognize and work with trauma symptoms can improve well-being and psychosocial morbidity during the first year following diagnosis of BC. Cancer 2016;122:2408-2417. © 2016 American Cancer Society.

Social constraints, loss-related factors, depression, and posttraumatic stress in a treatment-seeking suicide bereaved sample.

OBJECTIVE: Negative social responses that inhibit disclosure in the suicide bereaved may pose an obstacle to recovery. However, such social constraints have not been evaluated in this population. The purpose of this study was to evaluate extent, types, and correlates of social constraints in treatment-seeking community-based participants recently bereaved by suicide. METHOD: This cross-sectional study investigated social constraints and adjustment in a treatment-seeking sample of community-based participants (N = 33) recently bereaved by suicide; pretreatment, baseline data from a graduate school-based research clinic were analyzed. RESULTS: Participants endorsed a moderate level of social constraints; subtle negative social responses appeared more common than overt negative reactions. Social constraints were unrelated to kinship with the deceased or to finding the body. Constraints were positively associated with depression (r = .54, p = .001) and posttraumatic stress (r = .43, p = .012). CONCLUSION: Findings highlight the importance of the interpersonal context of adjustment in suicide postvention. (PsycINFO Database Record

Randomized controlled trial of a brief dyadic cognitive-behavioral intervention designed to prevent PTSD.

BACKGROUND: There is a dearth of effective interventions to prevent the development of post-traumatic stress disorder (PTSD). METHOD: We evaluated the efficacy of a brief dyadic two-session cognitive-behavioral intervention through a controlled trial involving trauma-exposed individuals recruited at the hospital's emergency room. Participants were randomly assigned to either the dyadic intervention group (n=37) or to a waiting list (assessment only) group (n=37). RESULTS: In an intent-to-treat analysis, a time-by-group interaction was found, whereby the treated participants had less PTSD symptoms at the post-treatment but not at the pre-treatment compared to controls. Controlling for the improvement observed in the control participants, the intervention yielded a net effect size of d=0.39. CONCLUSIONS: A brief, early, and effective intervention can be provided by nurses or social workers in hospital settings, at a fairly low cost to individuals presenting to the emergency room as the result of trauma exposure.

Presentation and prevalence of PTSD in a bipolar disorder population: a STEP-BD examination.

BACKGROUND: Co-occurring psychiatric diagnoses have a negative impact on quality of life and change the presentation and prognosis of bipolar disorder (BD). To date, comorbidity research on patients with BD has primarily focused on co-occurring anxiety disorders and trauma history; only recently has there been a specific focus on co-occurring PTSD and BD. Although rates of trauma and PTSD are higher in those with bipolar disorder than in the general population, little is known about differences across bipolar subtypes. METHODS: Using the NIMH STEP-BD dataset (N=3158), this study evaluated whether there were baseline differences in the prevalence of PTSD between participants with bipolar disorder I (BDI) and bipolar disorder II (BDII), using the MINI and the Davidson Trauma Scale. Differences in PTSD symptom clusters between patients with BDI and BDII were also evaluated. RESULTS: A significantly greater proportion of participants with BDI had co-occurring PTSD at time of study entry (Χ(2)(1)=12.6; p<.001). BDI and BDII subgroups did not significantly differ in re-experiencing, avoidance, or arousal symptoms. LIMITATIONS: The analysis may suggest a correlational relationship between PTSD and BD, not a causal one. Further, it is possible this population seeks treatment more often than individuals with PTSD alone. Finally, due to the episodic nature of BD and symptom overlap between the two disorders, misdiagnosis is possible. CONCLUSIONS: PTSD may be more prevalent in patients with BDI. However, the symptom presentation of PTSD appears similar across BD subtypes. Individuals should be thoroughly assessed for co-occurring diagnoses in an effort to provide appropriate treatment.

The effect of peer counseling on quality of life following diagnosis of breast cancer: an observational study.

Women with breast cancer express the greatest need for counseling at the time of diagnosis and report that the intervention they want is to be able to speak with someone who has the same cancer, but has lived through the crisis of treatment and is leading a 'normal' life. We conducted an observational study of a 6-month peer-counseling intervention testing outcomes for both newly diagnosed women (Sojourners) and peer counselors (Navigators) as a first step toward the goal of validating a peer navigator program. Significant improvement in the Sojourners was observed in trauma symptoms, emotional well-being, cancer self-efficacy, and desire for information on breast cancer resources. Navigators maintained baseline levels of the outcome variables, but increased in dissatisfaction with their interactions with their medical team and increased emotional suppression. Our findings indicate that peer navigation may halt a decline in quality of life that is commonly found in the first year following breast cancer diagnosis. In addition, Navigators were not adversely affected by their experience; however, careful training and supervision of Navigators is crucial to overall success. Randomized clinical trials are needed to demonstrate the efficacy of peer navigator programs.

Predictors of emotional adjustment following traumatic injury: personal, social, and material resources.

INTRODUCTION: The identification of factors influencing emotional adjustment after injury may elucidate the design of assessment and treatment procedures in emergency medicine settings and suggest targets for early intervention to prevent the later development of psychological impairment. Personal, social, and material resources may be influential factors and require further evaluation. HYPOTHESES: Greater experiential avoidance, social constraints on discussing the trauma experience, and loss of material resources would be associated with more of the symptoms of post-traumatic stress and depression following traumatic injury. METHODS: Participants (n = 47) at a mean of 7.4 months post-injury, completed a telephone interview assessment, including evaluation of sociodemographic characteristics, conservation of resources, social constraints, acceptance and commitment, and symptoms of post-traumatic stress disorder (PTSD) and depression. Hypotheses were tested using multivariate regression analyses. RESULTS: Only greater social constraints were uniquely predictive of greater PTSD symptomatology. Higher levels of experiential avoidance, social constraints, and loss of material resources all were associated with greater levels of depression. CONCLUSION: Assessment of personal coping style, receptivity of social network, and loss of potential material resources following traumatic injury may facilitate identification of individuals at-risk for poorer post-injury adaptation. Psychosocial interventions targeting such individuals may be promising.

Integration of disaster mental health services with emergency medicine.

Despite limited resources, emergency medical settings will be called upon to play many roles in the context of disasters and terrorist attacks that are related to preparedness, surveillance, mental health services delivery, and staff care. Such settings are a central capture site for those individuals likely to be at highest risk for developing mental health and functional problems. Because much of the potential harm to survivors of disaster or terrorism (and their families) will be related to their mental health and role functioning, preparedness requires the active integration of behavioral health into emergency medicine in every component of disaster response. There are many challenges of doing this including: (1) finding ways to integrate activities of the medical care, emergency response, and public health systems; (2) determining whether an incident has actually occurred; (3) making differential diagnoses and managing other aspects of initial medical needs; and (4) coping with the risks associated with system overload and failure. Delivery of direct mental health care must include: (1) survivor and family education; (2) identification and referral of those requiring immediate care and follow-up; (3) group education and support services; and (4) individual counseling. In order for effective response to occur, the integration of psychosocial care into disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental health care providers. At workplaces, emergency medical care centers must ensure that staff and their families are properly trained and supported with regard to their disaster functions and encouraged to develop personal/family disaster plans.

Responses to cancer diagnosis and treatment: posttraumatic stress and posttraumatic growth.

The diagnosis and treatment of cancer can be an extremely stressful, and possibly traumatic, experience. Not surprisingly, there is considerable research documenting the potential negative psychosocial sequelae of malignant disease. More recently, however, research has documented that a broad range of both positive and negative psychosocial outcomes might follow cancer diagnosis and treatment. This suggests that a sole focus on distress and dysfunction could paint an incomplete and potentially misleading picture of the cancer experience. Evidence suggesting that cancer could be a traumatic stressor for some patients is reviewed, as is evidence suggesting that it might precipitate both posttraumatic stress and posttraumatic growth, at times within the same individual. We conclude by offering a conceptual model of cancer as a psychosocial transition. Rather than viewing cancer as a trauma with uniformly negative effects on quality of life, it might be more appropriate to view cancer as a psychosocial transition with the potential for both positive and negative outcomes.

Mood disturbance in community cancer support groups. The role of emotional suppression and fighting spirit.

OBJECTIVE: In this cross-sectional study, we tested whether the coping styles of emotional suppression and fighting spirit were associated with mood disturbance in cancer patients participating in professionally led community-based support groups even when demographic, medical, and group support variables were taken into account. METHODS: A heterogeneous sample of 121 cancer patients (71% female, 29% male) completed the Courtauld Emotional Control Scale (CECS), the Mini-Mental Adjustment to Cancer Scale (Mini-MAC), a measure of perceived group support, and the Profile of Mood States (POMS). RESULTS: Consistent with hypotheses, lower emotional suppression and greater adoption of a fighting spirit, in addition to older age and higher income, were associated with lower mood disturbance. Gender, time since diagnosis, presence of metastatic disease, time in the support group, perceived group support, cognitive avoidance, and fatalism were unrelated to mood disturbance. CONCLUSION: Expression of negative affect and an attitude of realistic optimism may enhance adjustment and reduce distress for cancer patients in support groups.

Psychological distress and pain significantly increase before death in metastatic breast cancer patients.

OBJECTIVE: This study was designed to examine the course of psychological distress and pain from study entry to death in 59 women with metastatic breast cancer participating in a randomized trial of the effects of group psychotherapy on psychosocial outcomes and survival. It was hypothesized that psychological distress would increase significantly before death independent of changes in pain. METHOD: Data were collected as part of a larger study (N = 125). Analyses were based on data from a subset of women who had died and for whom we had data from at least three assessments. Mean levels of mood, trauma symptoms, depression symptoms, well-being, and pain over three time points were examined: at baseline (T1), the second-to-last assessment before death (T2), and the last assessment before death (T3). RESULTS: Results indicate that while psychological distress remained relatively constant or declined from T1 to T2, means on all measures significantly changed in the hypothesized direction from T2 to T3. Neither self-reported pain, nor the passage of time, appeared to account for these changes. Additionally, participation in group psychotherapy did not have a significant impact on this change in distress proximal to death. CONCLUSIONS: Results suggest that specialized end-stage clinical interventions are particularly needed for cancer patients as they approach death. Moreover, intervention studies for patients with deteriorating illnesses may need to take this "spike" in psychological distress and pain proximal to death into account to avoid Type II errors in evaluations of psychological outcomes.

Psychological impact of benign breast biopsy: a longitudinal, comparative study.

The impact of benign breast biopsy (BBB) on distress and perceptions of risk for breast cancer (BC) was examined. Interviews were conducted with 100 women shortly after notification of biopsy results and 4 and 8 months post-BBB. Compared with matched healthy comparison (HC) women without BBB, the BBB group evidenced greater BC-specific distress at baseline. BC-specific distress declined after BBB, remaining elevated relative to the HC group at the 8-month follow-up. Dispositional (optimism, informational coping style), demographic (education), clinical (family history of BC), and cognitive (BC risk perception) variables were associated with baseline levels of BC-specific distress or persistence of distress. Results support the monitoring process model (S. M. Miller, 1995) and the cognitive social health information processing model (S. M. Miller, Y. Shoda, & K. Hurley, 1996).