Longitudinal assessment of cognitive performance in Holocaust survivors with and without PTSD.

BACKGROUND: There are currently no longitudinal studies of cognitive performance in older patients with Posttraumatic Stress Disorder (PTSD). It is therefore unclear whether relationships between memory and symptoms differ over time among older persons with and without PTSD. METHODS: Twenty-eight Holocaust survivors and nineteen comparison subjects were evaluated 5 years after they had received a memory assessment including paired-associates learning and the California Verbal Learning Test (CVLT). RESULTS: While Holocaust survivors with PTSD showed a diminution in symptom severity (t = 2.99, df = 12, p = .011), they still manifested a decline in paired associates learning, suggesting an acceleration in age-related memory impairment (related word pairs: t = 2.87, df = 13, p = .013; unrelated word pairs: t = 2.06, df = 13, p = .060). The survivors with PTSD showed improvements on several CVLT measures over time. These improvements correlated with symptom improvements, such that group differences at the follow-up were no longer detected. CONCLUSIONS: The discrepancy in the pattern of performance on these two tests of memory following symptom improvement suggests possible differentiation between of aspects of memory functions associated with aging and trauma exposure and those associated with the severity of PTSD symptoms. Performance on the CVLT appeared related to clinical symptom severity while paired associate learning worsened over time in Holocaust survivors with PTSD, consistent with earlier cross-sectional findings.

Longitudinal assessment of dissociation in Holocaust survivors with and without PTSD and nonexposed aged Jewish adults.

The trajectory of posttraumatic stress disorder (PTSD) and PTSD-related symptoms in relation to aging is not well understood. We previously observed higher levels of dissociation as measured by the Dissociative Experiences Scale (DES) among older Holocaust survivors with, compared to those without, PTSD, though scores on the DES in Holocaust survivors were markedly lower than those that had been reported for younger cohorts. We undertook a longitudinal evaluation of dissociation in Holocaust survivors. Twenty-six Holocaust survivors with current PTSD, 30 Holocaust survivors without current PTSD, and 19 nonexposed were evaluated at the initial evaluation and subsequently 8.11 years later. Repeated measures analysis of variance (ANOVA) on the DES scores from these times demonstrated a significant main effect for time and a significant group by time interaction, reflecting a marked decline in Holocaust survivors, particularly those with PTSD. Controlling for age obliterated the effect of time, but not the group by time interaction. A similar pattern was shown with The Clinician Administered PTSD Scale (CAPS) scores. Different symptoms related to PTSD show different trajectories of change with age, with dissociation appearing to be less prominent with age.

Assessment of posttraumatic stress symptoms in children who are medically ill and children presenting to a child trauma program.

To test the utility of the UCLA posttraumatic stress disorder (PTSD) Index for DSM-IV (U-PTSD-I)(c) for predicting PTSD diagnosis in children with and without medical illnesses. The U-PTSD-I and a standard psychiatric interview were administered to medically ill children (n = 76) and children who experienced other traumatic events (n = 31). We found U-PTSD-I's sensitivity and specificity was better in the nonmedical illness cohort. Only intrusion symptoms were significantly associated with the diagnosis of PTSD in the medically ill. In conclusion, the U-PTSD-I performs better among general trauma versus medically ill patients. Intrusion symptoms should be focused on when assessing PTSD in medically ill children.

Assessment of depression in medically ill children presenting to pediatric specialty clinics.

OBJECTIVE: Self-report measures of depression may be inaccurate when applied to medically ill children because of the overlap between medical and psychiatric symptoms. The American Academy of Pediatrics endorses the use of self-reports as diagnostic aids (used in patients who are suspected of having an emotional problem by their pediatricians). This approach has not been validated. We evaluated the diagnostic accuracy of the Children's Depression Inventory (CDI) in medically ill children who were referred for evaluation by their pediatricians. METHOD: The evaluation included the CDI and a best estimate diagnostic procedure that incorporated results from semistructured and other interviews. Evaluators were not aware of the CDI scores when making a diagnostic determination. RESULTS: One hundred twenty-five patients, 8-19 years old, were referred between September 2000 and May 2003. Eighty-one completed the diagnostic procedure. The CDI summary score performed well in identifying best estimate depressive disorder determinations in this cohort. A cutoff of 11 and above correctly identified 80% of cases, with a specificity of 70%. DISCUSSION: A self-report measure of depression (CDI) could be used as a diagnostic aid in medically ill children who are suspected of having an emotional problem by their pediatricians. This finding supports the "two-tier" depression screening approach endorsed by the American Academy of Pediatrics for use in pediatricians' offices.

The impact of terrorism on brain, and behavior: what we know and what we need to know.

Following the recent US experience with terrorism, including bioterrorism, significant biomedical research resources have been appropriately focused on bioterror weapons. Far less research attention has been focused on the behavioral and psychobiological effects of terrorism. Yet, the psychological responses to terrorism exert significant effects on mental and physical health and on society. We present a research agenda, based on a comprehensive review of the literature, to address the troubling gaps in our knowledge about the long-term effects of terrorism on brain, behavior, and physical health, the risk factors for predicting who will be most affected by terrorism, and interventions that might promote resilience at an individual and population level.

Childhood emotional abuse and neglect as predictors of psychological and physical symptoms in women presenting to a primary care practice.

OBJECTIVE: There were two aims to this study: first to examine whether emotional abuse and neglect are significant predictors of psychological and somatic symptoms, and lifetime trauma exposure in women presenting to a primary care practice, and second to examine the strength of these relationships after controlling for the effects of other types of childhood abuse and trauma. METHOD: Two-hundred and five women completed the Childhood Trauma Questionnaire (Bernstein et al., 1994), Trauma History Questionnaire (Green, 1996), the Symptom Checklist-revised (Derogatis, 1997), and the Revised Civilian Mississippi Scale for posttraumatic stress disorder (Norris & Perilla, 1996) when presenting to their primary care physician for a visit. Hierarchical multiple regression analyses were conducted to examine unique contributions of emotional abuse and neglect variables on symptom measures while controlling for childhood sexual and physical abuse and lifetime trauma exposure. RESULTS: A history of emotional abuse and neglect was associated with increased anxiety, depression, posttraumatic stress and physical symptoms, as well as lifetime trauma exposure. Physical and sexual abuse and lifetime trauma were also significant predictors of physical and psychological symptoms. Hierarchical multiple regressions demonstrated that emotional abuse and neglect predicted symptomatology in these women even when controlling for other types of abuse and lifetime trauma exposure. CONCLUSIONS: Long-standing behavioral consequences may arise as a result of childhood emotional abuse and neglect, specifically, poorer emotional and physical functioning, and vulnerability to further trauma exposure.

Pediatric emergency department assessment of psychological trauma and posttraumatic stress.

OBJECTIVES: This study aimed to describe the kinds of stressors and the extent of symptoms of posttraumatic stress disorder (PTSD) that were reported by children and their parents in a pediatric emergency department and to examine the response rate to an emotional trauma questionnaire in this setting. METHODS: Three self-report questionnaires were given to patients aged eight to 21 years and to their primary caretakers: a brief assessment of service use, the Posttraumatic Stress Reaction Index (PTSRI), and the Impact of Event Scale (IES). RESULTS: Sixty-four of 81 families who were approached agreed to participate (consent rate of 79 percent), and 62 completed the questionnaires. Fifty-six patients reported at least one event that met DSM-IV-TR criteria for emotional trauma. The average number of reported events per child was 3.14 (range, 0 to 7). Eighteen patients met threshold criteria for severity of PTSD symptoms. Twenty-five patients reported that the most distressing traumatic event that they experienced was related to a medical illness. Patients with PTSD reported exposure to more adverse life events than patients without PTSD. IES scores reported by caretakers who identified the same event as their child as the most stressful were as high as those of caretakers who reported a different event as the most stressful. CONCLUSIONS: Exposures to emotionally traumatic events and PTSD symptoms are commonly reported in the pediatric emergency department. Asking children and their parents about their history of emotional trauma when they visit the emergency department is possible and can be well received.