Parental Post-Traumatic Stress Symptoms as Predictors of Psychosocial Problems in Children Treated for Cancer.

The purpose of this study was to explore the association between psychosocial functioning of children treated for cancer and that of their parents. Factors associated with psychosocial functioning were also examined. The present study was a cross-sectional survey of 33 mothers and one father (mean age: 37.9), each of whom had a child that had been treated for cancer. The participants answered a package of questionnaires consisting of the Impact of Event Scale-Revised (IES-R), the Parent Experience of Child Illness (PECI), and the Child Behavior Checklist (CBCL). Information about the children's illnesses was collected from medical records. The CBCL total problems T score was correlated with the parental IES-R total scores. Intensity of treatment independently predicted the variance of parental long-term uncertainty. In conclusion, psychosocial problems of children with cancer were associated with parental post-traumatic stress symptoms (PTSS). Provision of early, adequate support to parents who are vulnerable to PTSS will help not only the parents, but also their children with cancer.

[Changing Forensic Mental Health in France: A Review].

This article describes the background and recent changes in French forensic mental health. The literature suggests that three law reforms have been crucial to changes in the mental health system. First, the Penal Code of 1992 redefined the provisions of criminal responsibility and introduced the category of diminished responsibility. Second, a controversial law for preventive detention (rétention de sûretê) was enacted in 2008, according to which criminals with severe personality disorders are subject to incarceration even after the completion of their prison sentences if they are still considered to pose a danger to the public. Third, the revision of mental health laws in 2011 altered the forms of involuntary psychiatric treatments, stipulating a judge's authority to decide treatment. In parallel with these legal reforms, the psychiatric treatment system for offenders with mental disorders has been reconstructed. The number of difficult patient units (unités pour malades difficiles) has increased from four to ten across the nation in order to meet the needs of patients transferred from general psychiatric institutions for the reason of being unmanageable. In the penitentiary system, new facilities have been established to cope with the growing number of inmates with mental disorders. As background to these changes, it is pointed out that the current psychiatric system has undergone deinstitutionalization and become less tolerant of aggressive behavior in patients. In the broader context, public sensitivity towards severe crime, as shown by the sensation triggered by serious crimes conducted by pedophiles, seems to urge tough policies. In the 2000 s, several homicides committed by psychiatric patients had a great impact on the public, which led President Sarkozy to issue a statement calling for stronger security in psychiatric institutions. The harsh attitude of courts towards psychiatric practices is illustrated by a 2012 ruling; after a patient escaped from the hospital and hacked an elderly man to death, his psychiatrist was sentenced to a one-year suspended prison sentence for failing to recognize the danger that the patient posed to the public. Another lawsuit was raised against a psychiatrist following this case. Apparently, a sense of crisis is growing among psychiatric professionals. Their concerns are based on several points. Introduction of diminished responsibility may narrow the possibility of acquittal by reason of insanity, and lead to the criminalization of those with mental disorders. Dangerousness (dangerosité), pivotal in the procedure of preventive detention, is not a medical concept, but is instead based on the erroneous identification of criminality and mental disorders. Therefore, it is unreasonable to entrust the evaluation of dangerousness to psychiatric expertise. Court intervention in the process of deciding appropriate treatment may intensify judicialization (judiciarisation) of psychiatry. Establishment of facilities for prisoners within the mental health system would create a new segregating function of psychiatry. Thus, French experience seems to be figuring out all the challenges that contemporary metal health is facing. Above all, effective measures should be taken to prevent patients from entering the criminal justice system. Following this recommendation would be helpful in Japan, where a new forensic mental health system has just started.

Challenges in interfacing between forensic and general mental health: a Japanese perspective.

This article highlights the characteristics of forensic mental health services in Japan, with special emphasis on outpatient treatment of offenders with mental disorders, and discusses the potential implications of the Japanese experience in view of Western trends. The literature suggests that forensic patients tend to be left behind by the overall psychiatric reforms in developed countries. The recent law reform on forensic mental health in Japan is intended to be compatible with the contemporary ideas of psychiatry, such as normalization and community-based care. The primary objective of the new legislation is to provide intensive psychiatric treatment to offenders with mental disorders, attaching great importance to their re-integration into society. However, the system has already been faced with major challenges, including the insufficiency of human and financial resources in community and the accumulation of long-stay, treatment-resistant patients in special facilities. This article stresses the importance of active participation of general mental health services in the rehabilitation of offenders with mental disorders.

[Treatment of offenders with mental disorders: focusing on prison psychiatry].

Forensic mental health services exist in a nebulous space at the intersection of two different systems-criminal justice and mental health-and the entanglement of these systems poses intricate problems for psychiatrists. This article discusses the present circumstances of forensic mental health services in Japan, focusing on trends in prison psychiatry. In the traditional Japanese system, offenders with mental disorders were treated within general psychiatry as involuntarily admitted patients, or within the prison system as mentally ill inmates. As a consequence of recent legal reform, however, this situation has radically changed. The Medical Treatment and Supervision Act of 2005 aimed to provide intensive psychiatric treatment to offenders with mental disorders, attaching great importance to their reintegration into society. Under the new system, a person who commits a serious criminal offense in a state of insanity or diminished capacity shall be referred by the public prosecutor to the district court; following a treatment order of the court, the person shall be treated in psychiatric facilities established by the law. While the new system is expected to play a role in the context of specialist forensic psychiatry, its distinction from general psychiatry remains unclear. For example, persons who commit serious crimes, such as assault, in an acute psychotic state are occasionally admitted to general psychiatric hospitals, even if they meet the criteria for a treatment order under the Medical Treatment and Supervision Act. The relationship between prison psychiatry and specialist forensic psychiatry is still more problematic. Compared to the intensive, rehabilitation-oriented care provided under the Medical Treatment and Supervision Act, mental health services in penal institutions have a number of disadvantages, and it is unlikely that mentally ill prisoners have benefited from the recent progress in forensic psychiatry. Statistics show that the number of sentenced prisoners with mental disorders has steadily increased during the last decade. Although a majority of these individuals are substance abusers, the number of patients with schizophrenia who are unable to serve a sentence due to severe illness is not insignificant. Although patients are sometimes transferred to medical prisons, a substantial number of inmates with mental disorders remain in general prisons, most of which lack adequate medical staff. Accordingly, the growing number of mentally ill inmates is imposing a heavy burden on the penal administration system. Provisions of the Mental Health and Welfare Act pertaining to general psychiatry are not applicable to patients in penal institutions. The Psychiatric Review Board established in each prefecture does not intervene in the management of these facilities. As a result, legal safeguards against the violation of patients' rights are not sufficiently guaranteed in penal institutions. There are no legal provisions for transferring patients with severe mental disorders from prisons to psychiatric hospitals. Once sentenced to imprisonment, offenders with mental disorders are treated almost exclusively within the prison system. This situation is particularly serious in the case of patients with long-term sentences. In addition, the continued availability of psychiatric care after discharge from prison, which is crucial for preventing relapse of illness and recidivism, is not assured. When a mentally ill inmate is discharged, the head of the institution is required to report the discharge to the prefectural governor, in accordance with the Mental Health and Welfare Act. Recently, although the number of such reports has sharply increased, in actuality many of the persons reported are not admitted to hospitals because they do not meet the criteria for involuntary admission, and the provisions of the Medical Treatment and Supervision Act do not apply to them. In conclusion, more attention should be paid to the reform of prison psychiatry. Coordination of the separate functions of general psychiatry, specialist forensic psychiatry, and prison psychiatry is also important.

[Community care in home-visit nursing for drug-dependent people--questionnaire survey of home-visit nursing stations].

The present study aimed to clarify the present status of home-visit nursing for drug-dependent people and awareness among their caretakers. A questionnaire was sent to 279 stations that provide home-visit psychiatric nursing care. Among the 89 stations that responded, 24 (26.9%) are currently providing home-visit nursing for drug-dependent patients, while 36 (40.4%) had experience doing so in the past. Although many stations recognized that drug-dependent patients need home-visit nursing, their practices tended to be based on trial and error due to insufficient knowledge about the actual conditions and recovery processes of drug dependence. Compared to stations that had experience with home-visit nursing for drug-dependent patients, stations without such experience were more concerned about the safety of caretakers and their insufficient specialist knowledge about drug dependence.

[Two methods of support for methamphetamine concurrent disorder--comparison of "schizophrenia support" model and "dependence support" model].

The coexistence of methamphetamine use disorder (MUD) and psychotic disorder (PSD) is common in clinical settings. These cases are defined as methamphetamine concurrent disorder (MCD). It is often hard to decide which type of support is suitable for a MCD case; the one used for schizophrenics ("schizophrenia-support" model) or for drug addicts ("dependence-support" model). In the present study, we compare the courses of two MCD cases; one was supported using the "schizophrenia-support" model, and the other by the "dependence-support" model. These cases suggest that it is preferable to switch the models from one to the other, based on the severity of dependence. After stabilizing the patient's life through the use of at least three to six months of pharmacotherapy and psychiatric rehabilitation, we can recommend that the patient attend self-help meetings convenient for them. If the MCD patient has no risk of methamphetamine use, the hospital should play a major role to urge the health and the welfare facilities to support the patient. If the patient has some risk of relapse or criminal behavior, the legal system as well as medical and welfare facilities should play the major roles to present suitable services and to prepare an appropriate care-system.

New legislation for offenders with mental disorders in Japan.

This article describes the recent law reform on forensic mental health and its background in Japan, focusing on the enactment of the Medical Treatment and Supervision Act in 2005. The new system-under which a person who commits a serious criminal offence in a state of insanity or diminished responsibility shall be referred by the public prosecutor to the District Court-aims to provide intensive psychiatric treatment to offenders with mental disorders, attaching great importance to their reintegration into society. The court panel, which consists of a judge and a specially qualified psychiatrist, plays a key role in the treatment procedure. Upon the agreement of the two panel members, the panel delivers a verdict that takes into account the outcome of psychiatric evaluation; possible verdicts are inpatient treatment order, outpatient treatment order (mental health supervision), and no treatment order. Designated facilities are currently being established for inpatient and outpatient treatment. Referring to the published data on outcomes of enforcement, this article discusses particularities, current problems, and future prospects of the system, drawing comparisons between the German and Japanese systems.

[A nationwide questionnaire survey of medical experts in mental health evaluation].

A nationwide questionnaire survey was conducted to clarify the current status of medical experts in mental health evaluation and their needs (recovery rate: 66.6%). The data were simply tabulated and then statistically analyzed with respect to past experiences of serving as expert witnesses or judges as defined by the Medical Treatment and Supervision Act and past clinical experience. The results showed that 201 respondents (53.0%) had served as medical experts an average of 2.8 +/- 2.4 times, while 173 respondents (45.6%) had not served as such experts, and that 284 respondents (74.9%) had served as judges an average of 3.0 +/- 2.5 times, while 86 respondents (22.7%) had not served as judges. Although about 70% of the respondents who had served as expert witnesses felt that their experiences were burdensome, mostly due to time-related concerns, most had favorable views of the legal process. More than 70% of the respondents indicated that they would continue to serve as expert witnesses despite their sense of burden, thus suggesting a correlation between a past experience of serving as an expert witness and a willingness to do so again in the future. Furthermore, the results indicate that medical experts in mental health evaluation who have not served as expert witnesses are more hesitant, and since physicians employed at institutions for forensic psychiatric examination are more likely to serve as expert witnesses, a relatively small group of medical experts in mental health evaluation repeatedly serve as expert witnesses. On the other hand, when compared to serving as medical experts, serving as judges was psychologically more stressful for many respondents. Since physicians are not used to being judges, they may experience feelings of resistance or burden. Also, judges are somewhat bound by expert testimony, and the fact that there is no written policy for questioning testimony adds to their stress. Therefore, it will be necessary to clarify the positioning of expert evidence and the decisions made by judges. What medical experts in mental health evaluation needed to improve their knowledge varied depending on the type and duration of work and clinical experience. Therefore, it is necessary to provide information matching the experience, skills, and information related to the practical aspect of the Medical Treatment and Supervision Act. Moreover, the results suggest the necessity for medical experts in mental health evaluation to acquire a wide range of expert knowledge in forensic psychiatry beyond that required for the Medical Treatment and Supervision Act.

[Actual condition of involuntary admission by order of the prefectural governor: focus on the effects of the Medical Treatment and Supervision Act].

A survey was conducted involving 664 individuals admitted to a public psychiatric hospital in Tokyo Prefecture between July 15, 2004 and July 14, 2007 as a result of involuntary admission by order of the prefectural governor (hereafter, involuntarily admitted patients). The characteristics of patients with a focus on the effects of the Medical Treatment and Supervision Act were investigated in 656 patients, excluding eight patients for whom information at the time of involuntary admission was unclear. The proportion of patients in the present survey who had been reported by prosecutors was markedly low compared to nationwide and previous surveys. This was thought to be a result of the fact that the proportion of patients reported by the police, which tend to include emergency cases, was high due to the characteristics of the present hospital as well as the regional characteristics of Tokyo Prefecture. The characteristics of involuntarily admitted patients tended to be similar to those observed in previous surveys on involuntarily admitted patients at the present and other hospitals in Tokyo Prefecture. Comparison of the characteristics of involuntarily admitted patients and problem behaviors that instigated admission before and after implementation of the Medical Treatment and Supervision Act showed no clear differences, indicating that the act had no marked effect on involuntary admission by order of the prefectural governor. In addition, only a small proportion of patients with problem behaviors corresponding to actions described in the Medical Treatment and Supervision Act were reported by prosecutors, suggesting that such patients were mostly reported by the police. In cases where patients faced involuntary admission by order of the prefectural governor after being reported by the police, the prosecutor may have either been unaware of the patient or, if aware, had not filed a petition. Issues may include clues for investigation in addition to the roles of judicial police officers and prosecutors in investigation procedures in the former case, and the discretion of prosecutors in the latter case. While opinions on the appropriateness of actively applying the Medical Treatment and Supervision Act to these patients vary depending on the interpretation of the act's legal characteristics, it appeared that involuntary admission by order of the prefectural governor was at present not clearly distinguished from the Medical Treatment and Supervision Act. Involuntary admission by order of the prefectural governor and the Medical Treatment and Supervision Act are systems that have significant implications for patients with mental disorders, who are likely to cause injury to themselves or others. In order to facilitate the provision of appropriate medical care, it is important to clarify the systematic relationships within the legal system.

[Correlation between childhood traumatic stress and present drug abuse: results of a nationwide survey of drug addiction rehabilitation facilities in Japan].

Child abuse is known to correlate with drug abuse and interferes with recovery from substance-related disorders. To determine the prevalence and severity of child abuse among drug addicts, we conducted a nationwide cross-sectional survey of residents and outpatients at drug addiction rehabilitation centers (DARC) in Japan. A total of 445 participants gave informed consent and completed a self-reporting questionnaire. Sixty-eight percent of participants had experienced some kind of child abuse by the time they reached junior high school. The kinds of abuse experienced were physical (53.7%), psychological (60.4%), sexual (5.4%) abuse and neglect (24.5%). Comparison of female and male participants revealed that more female than male participants had experienced psychological (76.9% vs. 58.2%) and sexual (17.5% vs. 4.0%) abuse. Comparison of participants who had experienced some kind of child abuse ("Abused" group 68.3%) and those who had not experienced abuse ("Non-abused" group 24.3%) revealed that the "Abused" group was younger than the "Non-abused" group (35.7 SD9.0 vs. 39.7 SD10.8). Participants in the "Abused" group were found to have more severe psychological difficulties than those in the "Non-abused" group for the following: anxiety (73.0% vs. 61.1%), delusional atmosphere (48.0% vs. 28.7%), lack of energy (53.9% vs. 40.7%), ideas of persecution (48.7% vs. 29.6%), depression (62.2% vs. 43.5%) and suicidal ideation in the previous year (50.7% vs. 24.3%). The present results suggest that additional program that prepared to care the drug addicts who experienced child abuse and are experiencing suicidal ideation is needed. Furthermore, intervention for families with risk factors for child abuse should be developed in order to prevent the victim from suffering not only from post traumatic stress disorder but also from substance related disorders.

Correlation between addictive behaviors and mental health in university students.

AIMS: The present study aims to clarify the relationships of addictive behaviors and addiction overlap to stress, acceptance from others and purpose in life. METHODS: A survey was conducted on 691 students at eight universities. The Eating Attitude Test-20 was used to identify students with food addiction or food addictive tendencies. The Kurihama Alcoholism Screening Test was used to identify students with alcohol addiction or alcohol addictive tendencies. The Fagerström Test for Nicotine Dependence was used to identify students with nicotine addictive tendencies or nicotine addiction. The Visual Analog Scale was used to assess stress and acceptance from others. The Purpose in Life Test was used to measure meaning and purpose in life. Results were compared between students with addictive behaviors, with addictive tendencies and without addictive behaviors. RESULTS: Significant differences among the three groups were observed for stress, acceptance from others, and Purpose in Life scores for students with food and nicotine addiction, but no significant differences existed in relation to alcohol addiction. In addition, 28.8% of students displayed addictive behaviors in one of the three areas (food, alcohol or nicotine), 8.5% displayed addictive behaviors in two of the three areas, and 0.4% had addictive behaviors in all three areas. Significant differences existed in stress and acceptance from others among students with one addictive behavior, >or=two addictive behaviors and no addictive behaviors. However, no significant differences existed in Purpose in Life scores with respect to overlapping addictions. CONCLUSION: The results suggest a relationship between mental health, addictive behaviors and overlapping addiction among university students.

Attitudes toward taking medication among outpatients with schizophrenia: cross-national comparison between Tokyo and Beijing.

OBJECTIVES: The aim of this study was to compare attitudes toward medication and associated factors for patients with schizophrenia in Japan and China. METHODS: Age-group matched samples were drawn from outpatients in Tokyo (N = 76) and Beijing (N = 76) according to the same inclusion/exclusion criteria. Psychotropic prescription and attitudes toward medication were measured using Drug Attitude Inventory-30 (DAI-30) and an original questionnaire regarding beliefs about psychiatric medication. Stepwise regression analysis of the DAI-30 data was performed for each group. RESULTS: Japanese subjects were prescribed significantly larger amounts of antipsychotics. Polypharmacy of antipsychotics and concurrent use of anticholinergics, anxiolytics, or hypnotics were more frequently found among subjects in Tokyo than among those in Beijing. However, subjects in Tokyo and Beijing had similar subjective responses to medication, subjective evaluation of side-effects, and complaints about overuse of psychotropics. Subjects in Tokyo complained less about physician's over-reliance on medication and were less concerned about medication cost than those in Beijing. In Tokyo, longer duration of illness and lower subjective distress caused by side effects predicted a more positive subjective response, while female gender, younger age, and lower Brief Psychiatric Rating Scale score were independently correlated with a better subjective response in Beijing. CONCLUSIONS: Subjective acceptance of multiple medications is greater for patients in Japan than those in China. Determinants of subjective response to medication varied between Japan and China.

[Standardization of the Japanese-language version of the Structured Interview for Disorders of Extreme Stress (SIDES)].

The reliability and validity of the Japanese version of Structured Interview for Disorders of Extreme Stress (SIDES) were evaluated in a group of normal subjects (n=60) and a group of victims of interpersonal trauma (n= 53). SIDES was developed in the United States in 1997 and is a tool for assessing Disorders of Extreme Stress Not Otherwise Specified (DESNOS). Self-reporting and semi-structured versions of the SIDES have been developed. Cronbach's alpha coefficient for the self-reporting version was .92 for an individual's lifetime, and .85 for the present. Cronbach's alpha coefficient for the semi-structured interview version was .95 for an individual's lifetime, and .88 for the present. Using the Dissociative Experiences Scale (DES) and physical symptom scale as external standards, the validity of SIDES was confirmed. Although the present results indicate that the Japanese version of SIDES has good internal reliability and validity, it remains necessary to conduct further research on more victims of many kinds of trauma.

[Study on suicide attempts among drug addicts--prevalence of suicide attempts and investigation of related risk factors].

While the relationship between substance use disorder and suicidal behavior is well known, few studies have been conducted on this issue in Japan to date. The present study aimed to investigate the profiles of drug-dependent individuals with a history of suicide attempts not including completed suicides. A survey was conducted on 101 drug-dependent patients in 8 drug rehabilitation institutions. The survey included a questionnaire that assessed various items regarding personal profiles, such as history of suicide attempts and drug abuse, physical and mental problems. In addition, the survey included the Parental Bonding Instrument (PBI) and the Center for Epidemiological Studies Depression Scale (CES-D). The results indicated that 50 patients (49.5%) had attempted suicide, and that subjects with a history of suicide attempts were significantly younger than those without suicide attempts. It was also revealed that subjects with a history of suicide attempts had started abusing drugs at an earlier age, had more psychiatric problems, and scored higher on the CES-D and lower on both the parental and maternal care scores of the PBI. These findings suggest that early-age drug abuse, psychiatric problems, depressive symptoms, and parental rearing behaviors perceived as cold and rejecting may predispose drug-dependent individuals to suicidal behavior.

[A questionnaire survey on judgment of criminal responsibility].

The authors conducted questionnaire surveys utilizing model cases with the aim of investigating the current views of psychiatrists regarding criminal responsibility judgments in forensic psychiatric evaluations. Six model cases-injury by a person with acute schizophrenia, indecent assault by a person with chronic schizophrenia, attempted murder by a woman with depression, arson by an alcohol abuser, burglary by an amphetamine abuser, rape and indecent assault by a person with personality disorder-were presented to 345 psychiatrists, who were asked about criminal responsibility and appropriate treatment for each of the cases. One hundred eighty-five of the psychiatrists responded. In the case of acute schizophrenia with hallucination and delusion, the case of severe depression, and the personality disorder case, there was a high level of agreement between the evaluations of criminal responsibility made by the different respondents, but in the case of chronic schizophrenia, the case of alcohol-induced psychotic disorder, and the case of amphetamine abuse, there were variations in the evaluation of criminal responsibility, with many respondents emphasizing the patient's symptoms and condition at the time of the offense, and relatively few emphasizing whether the disorder was endogenous. Regarding the form of treatment, many of the respondents recommended compulsory hospitalization for the case of acute schizophrenia with hallucination and delusion, while at the same time recommending treatment in a prison environment for the personality disorder case. In contrast, for the case of chronic schizophrenia and the case of alcohol-induced psychotic disorder, opinion was divided as to whether the subject should be handled with a medical or a judicial approach. Regarding treatment for the case of alcohol-induced psychotic disorder and the case of amphetamine abuse, there was a tendency to make a judgment based on the subject's condition at the point of psychiatric evaluation, which was not necessarily linked to the criminal responsibility.

[History of psychiatry and the criminally insane in Japan].

This paper illustrates how insane offenders were perceived and treated at the turn of the 20th century, focusing on legal reforms. In accordance with overall reorganization of legal systems after the Meiji Restoration in 1968, the Criminal Law of 1880 stipulated criminal responsibility, ruling that "a person, who was unable to discriminate right and wrong because of loss of mental capacity at the time of committing crime, shall not be punished." Article 39 of the current Criminal Law, which was enacted in 1907, redefined criminal responsibility, to say that "an incompetent person shall not be punished; a person with diminished competence shall be given a mitigation of punishment." Meanwhile, the Law for the Custody for Insane Persons of 1900, which was the first law dealing with the mentally ill, aimed to establish strict regulations with regard to the custody of the insane. However, neither of these laws did not provide any procedures for subsequent management of persons acquitted because of insanity. Under the social changes in the early decades of the 20th century, concern about dangerousness of the criminally insane was intensified. In connection with reform of the Criminal Law, several plans for the management of the criminally insanes were formulated. The author examines these circumstances, referring to the current debate on the management of mentally ill offenders.

[Posttraumatic stress disorder in victims of sexual assault--related to depression or physical symptoms].

UNLABELLED: To clarify the clinical characteristics of mental disorders in sexual assault victims, we investigated the victims focusing on PTSD, depression, physical symptoms, and their relationships. SUBJECTS: Participants were 46 treatment-seeking female victims of sexual assault who consulted four hospitals, one clinic and one psychological services center, between February 2000 and April 2001. The mean +/- SD age of the participants was 28.0 +/- 8.9 years, the mean +/- SD period from the traumatic event was 94.5 +/- 88.0 months. PTSD was diagnosed and evaluated using a structured interview (Clinician-Administered PTSD Scale for DSM-IV: CAPS). Depressive symptoms were assessed using Self-rating Depression Scales (SDS). Physical symptoms were assessed using the Physical symptom scale developed by the authors. RESULTS: Thirty-two participants (69.6%) met the criteria for PTSD in their current diagnosis, and 41 (89.1%) had the disorder at some point during their lives. SDS score and Physical symptom scale score of the PTSD group were significantly higher than those scores of the non-PTSD group. The SDS score correlated with the Avoidant-numbing score. The Physical symptoms scale score correlated with the Intrusion score and Hyperarousal score. We think that the PTSD group had the co-existing depression secondary to PTSD. Although previous studies have discussed the relationship between physical symptoms and Hyperarousal symptoms, this study suggested that physical symptoms were related to Intrusion symptoms as much as Hyperarousal symptoms. We found 2 patterns when PTSD patients reported physical symptoms related to Intrusion symptoms. The patterns were caused (1) by physiological reactivity on exposure to internal or external cues that symbolize an aspect of the traumatic event, and caused (2) by somatic reenactment symptoms. CONCLUSION: We discuss the importance for clinicians to distinguish Intrusion symptoms from physical symptoms as well as Avoidant-numbing symptoms from depressive symptoms on PTSD diagnosis. Because sexual assault victims have difficulty in talking about the traumatic experience, clinicians should pay attention to these findings in developing therapeutic plans for the victims.