Posttraumatic stress disorder among substance users from the general population.

OBJECTIVE: The purpose of the study was to evaluate the prevalence of posttraumatic stress disorder (PTSD) among substance users in the general population. METHOD: The St. Louis Epidemiologic Catchment Area study, a survey of psychiatric illness in the general population, collected data on PTSD and substance use with the Diagnostic Interview Schedule. Among the 2,663 respondents, 430 reported a traumatic event that could qualify for PTSD; however, the rate of PTSD was low, 1.35% overall. To evaluate the relationship between PTSD and substance use, respondents were hierarchically classified into one of four substance use categories ranging from polydrug use to alcohol use only. Substance users from each category as well as substance users in general were compared with persons who did not meet the substance use threshold (comparison subjects). RESULTS: Findings indicate that cocaine/opiate users are over three times as likely as comparison subjects to report a traumatic event, report more symptoms and events, and are more likely to meet diagnostic criteria for PTSD. Physical attack, but not combat-related events, was the most prevalent event reported among cocaine/opiate users. Onset of substance use preceded onset of posttraumatic symptoms, suggesting that substance use predisposes the individual to exposure to traumatic events. When other variables--including antisocial behavior--were controlled, female gender and use of cocaine/opiates predicted PTSD. CONCLUSIONS: These analyses of the co-occurrence of substance abuse and PTSD warrant further study and suggest that PTSD is much more common among substance abusers than was previously known.

Effects of psychological stress on serum immunoglobulin, complement and acute phase protein concentrations in normal volunteers.

The aim of this study was to examine the effects of academic examination stress on serum immunoglobulins (Igs), i.e. IgA, IgG, IgM, complement factors, i.e. C3c and C4, and acute phase proteins, i.e. alpha 1-acid glycoprotein (alpha 1-S), haptoglobin (Hp) and alpha 2-macroglobulin (alpha 2-M). Thirty-seven university students participated in this study. Serum was sampled a few weeks before and after as well as one day before a difficult academic examination. On the same occasions, students completed the Perceived Stress Scale (PSS). Students were divided into two groups, i.e. those with high- and low-stress perception as defined by changes in the PSS score. Academic examination stress induced significant increases in serum IgA, IgG, IgM, and alpha 2-M in students with high-stress perception, but not in these with low-stress perception. The stress-induced changes in serum IgA, C3c, and alpha 1-S concentrations were significantly higher in students with high-stress perception than in those with a low-stress perception. The stress-induced changes in serum IgA, IgM, C3c, C4, alpha 1-S, Hp and alpha 2-M were normalized a few weeks after the stress condition, whereas IgG showed a trend toward normalization. There were significant positive relationships between the stress-induced changes in the PSS and serum IgA, IgG, IgM and alpha 2-M. These findings suggest that psychological stress is accompanied by an altered secretion of serum Igs, complement factors and some acute phase proteins.

ICD-10 and DSM-IV symptoms of somatoform disorders in different cultures.

In spite of an effort to harmonize the latest editions of International Classification of Diseases (ICD) and Diagnostic and Statistical Manual (DSM), a number of differences between the two classification systems still exist. One of these differences is related to the category of somatoform disorders. The cross-cultural applicability of ICD-10 and DSM-IV criteria for somatoform disorders have been explored in the context of the ongoing WHO International Study of Somatoform Disorders. The study demonstrated that the current diagnostic concepts of somatoform disorders are cross-culturally acceptable in spite of the differences in their descriptions and classifications. However, it was found that a number of culture specific symptoms of somatoform disorders which do not appear in ICD-10 and DSM-IV were important and necessary for their diagnosis in specific cultures.

Comparisons of alcohol and other drugs: experience from the WHO Collaborative Cross-Cultural Applicability Research (CAR) Study.

Current psychiatric classificatory systems commonly provide similar criteria for the identification of disorders relating to the use of alcohol and other drugs. However, since cultural views of substance use disorders are influenced by prevailing norms in the society, it is unlikely that a given culture will have identical threshold for the identification of disorders relating to the use of alcohol, commonly socially approved, and those relating to the use of other mood-altering substances, commonly socially disapproved. Using data derived from the WHO nine-country Cross-Cultural Applicability Research (CAR) study, we studied the cultural views on the use and abuse of alcohol and other drugs. Our observations suggest that, with a few notable exceptions, any use of addictive substances other than alcohol is commonly considered socially aberrant. Most cultures set a much lower threshold for the identification of disorders relating to these substances than they do for alcohol-related ones.

WHO cross-cultural applicability research on diagnosis and assessment of substance use disorders: an overview of methods and selected results.

The cross-cultural applicability of criteria for the diagnosis of substance use disorders and of instruments used for their assessment were studied in nine cultures. The qualitative and quantitative methods used in the study are described. Equivalents for English terms and concepts were found for all instrument items, diagnostic criteria, diagnoses and concepts, although often there was no single term equivalent to the English in the languages studied. Items assuming self-consciousness about feelings, and imputing causal relations, posed difficulties in several cultures. Single equivalent terms were lacking for some diagnostic criteria, and criteria were sometimes not readily differentiated from one another. Several criteria--narrowing of the drinking repertoire, time spent obtaining and using the drug, and tolerance for the drug--were less easy to use in cultures other than the United States. Thresholds for diagnosis used by clinicians often differed. In most cultures, clinicians were more likely to make a diagnosis of drug dependence than of alcohol dependence although behavioural signs were equivalent. The attitudes of societies to alcohol and drug use affects the use of criteria and the making of diagnoses.

The World Health Organization's global initiative on neurology and public health.

In 1993, the World Health Organization launched a global initiative aimed at increasing public and professional awareness of the public health aspects of neurological disorders. The initial phase of this project has been carried out through the organization of a series of symposia on prevalence, severity and costs of neurological disorders including dementia, stroke, epilepsy and headache. The main objective of the next phase of the project is to develop an international educational programme on neurology and public health and to establish a network of training centres in different regions of the world.

Immune markers in fibromyalgia: comparison with major depressed patients and normal volunteers.

BACKGROUND: There is a high degree of comorbidity between fibromyalgia and major depression. The latter is characterized by signs of immune activation, whereas the immune status in fibromyalgia is not yet elucidated. The aims of the present study were to examine (i) neopterin and biopterin excretion in 24-h urine of patients with fibromyalgia compared with normal volunteers and patients with major depression; and (ii) the effects of subchronic treatment with sertraline (11 weeks) on the urinary excretion of neopterin and biopterin. METHODS: Measurements of neopterin, biopterin, pseudouridine, creatinine and uric acid in 24-h urine were performed by means of HPLC in 14 fibromyalgia and ten major depressed patients and 17 normal volunteers. RESULTS: There were no significant differences in urine excretion of the above five analytes between patients with fibromyalgia and normal volunteers. Patients with major depression showed significantly higher urinary neopterin excretion than normal volunteers and fibromyalgia patients. Patients with fibromyalgia and major depression had a significantly increased neopterin/creatinine ratio. Fibromyalgia patients had significantly lower urinary excretion of creatinine than patients with major depression. In fibromyalgia patients, there were no significant effects of sertraline treatment on any of the urine analytes. CONCLUSIONS: The findings suggest that fibromyalgia, in contrast to major depression, may not be accompanied by activation of cell-mediated immunity. LIMITATION: Other immune markers should be measured in fibromyalgia before drawing definite conclusions. CLINICAL RELEVANCE: Increased urinary excretion of neopterin can be used as a marker for major depression, but not fibromyalgia.

Association between tinnitus and somatoform disorders.

Pathophysiological mechanisms are often unknown in patients suffering from "idiopathic" tinnitus, and the presence of other unexplained physical symptoms such as those seen in somatoform disorders can be assumed. This study investigates how often tinnitus exists in general medical out-patients with and without somatoform disorders. In an international study initiated by the World Health Organization (WHO), 1275 patients from 12 participating centers located in 11 different countries were examined by means of the WHO Somatoform Disorders Schedule. The overall prevalence of unexplained tinnitus was 11%; however, tinnitus was clearly more frequent among patients with somatization disorder (42%) or hypochondriacal disorder (27%). It was also more frequent than a great number of other symptoms considered to be typical of somatoform disorders. Tinnitus was also related to depression, anxiety, and to symptoms indicating autonomic arousal. Three possible conclusions are discussed: (i) tinnitus may be a somatoform symptom; (ii) the findings may indicate a substantial comorbidity of two different conditions; (iii) tinnitus and somatization may be linked through common mechanisms of arousal and somatic anxiety.

Pre- and post-disaster negative life events in relation to the incidence and severity of post-traumatic stress disorder.

There is evidence suggesting that stressful life events may precede major psychiatric illness, such as major depression, and that the severity of a traumatic event outside the range of usual human experience may provoke post-traumatic stress disorder (PTSD). The present study was carried out to examine the effects of pre- and post-disaster stressful life events on the incidence rate of PTSD following two man-made traumatic events. An epidemiological study examining 127 victims of a flash fire in a ballroom and 55 motor vehicle accident (MVA) victims was undertaken. PTSD symptoms were assessed by means of the Composite International Diagnostic Interview and the pre- and post-disaster stressful life events by means of the Diagnostic Interview Schedule, Disaster Supplement. Binary logistic and multiple linear regression analyses were employed to examine the relationships between PTSD and pre- and post-disaster life events. There were no significant relationships between stressful life events the year prior to the traumatic event and the incidence or severity of PTSD. There were highly significant relationships between the cumulative number and event severity of post-disaster negative life events and the incidence rate and severity of PTSD. The post-disaster life events were significantly more related to the avoidance-depression dimension than to the anxiety-arousal dimension of PTSD. The most significant life events were: loss of job or income, broken relationships, serious illnesses or injuries in the victims and death or illness in close acquaintances. The results of this study show that the number and severity of additional stressful life events signal a higher risk to develop PTSD and a higher severity of the avoidance-depression dimension of PTSD symptomatology.

The two-factorial symptom structure of post-traumatic stress disorder: depression-avoidance and arousal-anxiety.

UNLABELLED: The first part of this study showed that the DSM-III-R symptom structure of post-traumatic stress disorder (PTSD), i.e. criteria B (reexperience), C (avoidance-numbing), and D (arousal), and, consequently the diagnosis of PTSD, could not be validated in fire and car-accident victims. The aims of this study were to: (i) determine the factors as well as their structure in the symptoms of PTSD; and (ii) develop a new classification or typology of PTSD. Exploratory and confirmatory factor analyses and cluster analyses were employed to: (i) examine the factors in PTSD symptomatology; and (ii) find and validate adequate diagnostic criteria for PTSD. The Composite International Diagnostic Interview (CIDI), PTSD Module, was used between 7 and 9 months after the traumatic event in a study group of 185 victims of two different traumatic events, i.e. 130 fire and 55 car-accident victims. Our findings support the existence of two factors, i.e. a first labeled 'depression-avoidance (DAV) dimension', as it contains items reminiscent of depression and avoidance, and a second labeled 'the anxiety-arousal (AA) dimension', as it contains symptoms reminiscent of anxiety and increased arousal. Cluster analysis yielded two clusters, i.e. a cluster of subjects with PTSD cases and another with non-cases. Our PTSD algorithm was significantly less restrictive than the DSM-III-R diagnosis of PTSD. There are only quantitative, but no qualitative, differences between the cluster analytically derived classes. IN CONCLUSION: PTSD is not a well-delineated clinical entity, as there is a clinical continuum from PTSD non-cases to cases with less and more severe DAV and AA symptoms. It is more appropriate to express PTSD in terms of general severity of PTSD and severity of the DAV and AA dimensions.

Epidemiologic and phenomenological aspects of post-traumatic stress disorder: DSM-III-R diagnosis and diagnostic criteria not validated.

The aim of this cohort study was: (i) to validate the diagnostic criteria for post-traumatic stress disorder (PTSD) of the DSM-III-R; and (ii) to examine the incidence rate of PTSD in a study population exposed to two different traumatic events, i.e. a fire in a hotel ball-room and a multiple collision car-crash on a Belgian highway. One hundred and eighty-five victims (130 fire and 55 car accident victims) were assessed between 7 and 9 months after the traumatic event using the Composite International Diagnostic Interview (CIDI), PTSD Module, a fully structured diagnostic interview for the assessment of PTSD according to DSM-III-R criteria. Twenty-three percent of the study population met DSM-III-R criteria for PTSD. By means of unsupervised and supervised multivariate statistical analyses we were unable to validate the three-factorial structure, i.e. criteria B, C and D, of the DSM-III-R PTSD diagnosis. The latter relies heavily on the C diagnostic criteria, which appear to be too restrictive. Women were more likely to develop symptoms of reexperience (B) and arousal (D) than men. There was a significantly higher incidence of criteria B, C and D, but not of PTSD, in fire than in car-accident victims. Between 42 and 57% of the victims developed the first PTSD symptoms on the day of the trauma; within the next week these incidence rates increased to 77.1, 57.8 and 73.5% for criteria B, C and D, respectively. In conclusion, this study was unable to demonstrate the validity of the diagnostic criteria for PTSD according to DSM-III-R. The present cohort study has defined a number of factors that may predict new occurrences of PTSD symptoms after a traumatic event, i.e. gender, type of trauma and time delay between the trauma and the assessment of the diagnostic criteria.

Influence of psychological stress on immune-inflammatory variables in normal humans. Part II. Altered serum concentrations of natural anti-inflammatory agents and soluble membrane antigens of monocytes and T lymphocytes.

The effects of academic examination stress on serum concentrations of interleukin (IL)-1 receptor (R) antagonist (A), soluble(s) IL-2R, sIL-6R, soluble glycoprotein 130 (sgp130), Clara cell protein (CC16), sCD8 and sCD14 were evaluated in 38 university students. The relationships among changes in the above immune-inflammatory variables, levels of serum cortisol, and scores on the Perceived Stress Scale (PSS) or the State-Trait Anxiety Inventory (STAI) were examined. Academic examination stress was associated with significant increases in PSS and STAI scores, and in serum sgp130 and sCD8 values. Academic examination stress was associated with significantly decreased serum sCD14 concentrations in students with high, but not low, stress perception. There were stress-induced differences in serum IL-1RA, sIL-6R and CC16 concentrations between students with high vs. low stress-induced anxiety. The stress-induced increase in serum sCD8 was significantly more pronounced in male students, whereas the increase in serum sgp130 was more pronounced in female students taking contraceptive drugs. These results suggest that: (1) psychological stress induces immune-inflammatory changes pointing toward complex regulatory responses in IL-6 signalling, a decreased anti-inflammatory capacity of the serum, and interactions with T cell and monocytic activation; and that (2) sex hormones may modify stress-induced immune-inflammatory responses.

Influence of academic examination stress on hematological measurements in subjectively healthy volunteers.

Some recent reports showed that a brief exposure to a mental stressor during 3-20 min may induce hematological changes in humans. The aim of the present study was to examine the effects of academic examination stress on erythron variables, such as the number of red blood cells (RBC), hemoglobin (Hb), hematocrit (Ht), mean corpuscular volume (MCV), mean cell Hb (MCH), mean cell Hb concentration (MCHC), RBC distribution width (RDW), and serum iron and transferrin (Tf). The above variables were determined in 41 students in three conditions, i.e. the stress condition (the day before a difficult oral exam) and two baseline conditions, i.e. a few weeks earlier and later. At the same occasions, subjects completed the Perceived Stress Scale (PSS), the state version of the State-Trait Anxiety Inventory (STAI) and the Profile of Mood States (POMS). Academic examination stress significantly increased Ht, Hb, MCV, MCH and MCHC and significantly decreased RDW. There were significant relationships between the stress-induced changes in the PSS, STAI and POMS scores and those in Ht, Hb, MCV and MCH (allpositive) and RDW (negative). It is concluded that academic examination stress induces significant hematological changes indicative of an increased number of large RBC and increased hemoglobinisation, which cannot be explained by shifts of fluid out of the intravascular space, concentrating non-diffusible blood constituents.

Reliability and cultural applicability of the Greek version of the International Personality Disorders Examination.

BACKGROUND: The International Personality Disorders Examination (IPDE) constitutes the proposal of the WHO for the reliable diagnosis of personality disorders (PD). The IPDE assesses pathological personality and is compatible both with DSM-IV and ICD-10 diagnosis. However it is important to test the reliability and cultural applicability of different IPDE translations. METHODS: Thirty-one patients (12 male and 19 female) aged 35.25 +/- 11.08 years, took part in the study. Three examiners applied the interview (23 interviews of two and 8 interviews of 3 examiners, that is 47 pairs of interviews and 70 single interviews). The phi coefficient was used to test categorical diagnosis agreement and the Pearson Product Moment correlation coefficient to test agreement concerning the number of criteria met. RESULTS: Translation and back-translation did not reveal specific problems. Results suggested that reliability of the Greek translation is good. However, socio-cultural factors (family coherence, work environment etc) could affect the application of some of the IPDE items in Greece. The diagnosis of any PD was highly reliable with phi >0.92. However, diagnosis of non-specific PD was not reliable at all (phi close to 0) suggesting that this is a true residual category. Diagnosis of specific PDs were highly reliable with the exception of schizoid PD. Diagnosis of antisocial and Borderline PDs were perfectly reliable with phi equal to 1.00. CONCLUSIONS: The Greek translation of the IPDE is a reliable instrument for the assessment of personality disorder but cultural variation may limit its applicability in international comparisons.

Lower activity of serum peptidases in abstinent alcohol-dependent patients.

This study examines i) the activity of serum prolyl endopeptidase (PEP) and dipeptidlyl peptidase IV (DPP IV) in detoxified alcohol-dependent patients without liver disease versus normal controls, and ii) the relationships between serum DPP IV and PEP activity and the production of cytokines or cytokine receptors, such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), interferon-y (IFN-y), IL-1 receptor antagonist (IL-1RA), and IL-10, and granulocyte-macrophage colony stimulatory factor (GM-CSF). Alcohol-dependent patients had significantly lower serum PEP and DPP IV activity than normal controls. We found that 58.3% and 50.0% of the alcohol-dependent patients, respectively, had PEP and DPP IV activities, which were lower than the mean control values minus 2 SD. There were significant inverse correlations between lowered serum DPP IV and PEP activity and the increased production of IL-6, INF-gamma, IL-IRA, IL-10, and GM-CSF. These results show that lower serum DPP IV and PEP activity may be related to the pathophysiology of alcohol dependence.

The World Health Organization's recent work on the lexicography of mental disorders.

Standardization of nomenclature and terminology used in the field of mental health has been one of the main goals of the World Health Organization's (WHO) Mental Health Programme among recent activities undertaken to achieve this goal, is the development of definition and guidelines accompanying the chapter dealing with mental disorders in the tenth revision of the International Classification of Diseases (ICD-10) and of a set of instruments for the assessment of mental disorders. To enhance common understanding and uniformity of usage of the terms embedded in the classification and instruments and to facilitate their use in different cultures and settings, a series of lexica and glossaries has also been produced by WHO. The article describes the basic characteristics of the Lexicon of psychiatric and mental health terms, 2nd edition; Lexicon of alcohol and drug terms; Lexicon of crosscultural terms in mental health; SCAN glossary; and the ICD-10 symptom glossary for mental disorders.

The World Health Organization somatoform disorders schedule. A preliminary report on design and reliability.

The World Health Organization (WHO) Somatoform Disorders Schedule (SDS) is a highly standardized instrument for the assessment of somatoform disorders according to the tenth revision of the International Classification of Diseases (ICD-10) and the fourth edition of the Diagnostic and Statistical Manual (DSM-IV). The SDS was produced in the framework of the WHO International Study of Somatoform Disorders and tested for its reliability in Brazil, India, Italy, the USA and Zimbabwe. A sample of 180 patients from general psychiatry, primary care and general medical settings were interviewed with the SDS within a three-day interval by nonclinician and clinician interviewers. The agreement between the two interviews was tested using the intraclass correlation coefficients (ICC) and kappa statistic. The test-retest reliability of the SDS was found to be very good (the ICC for all the centres was 0.76; overall kappa value for SDS questions was 0.58; one-third of SDS questions had a kappa value of 0.60 or higher). The field test results of the SDS indicated that the instrument may be administered in larger studies by non-clinician interviewers without compromising the ability to document the prevalence of somatoform disorders in different cultures.

Psychiatric morbidity of foreign students in Yugoslavia: a 25 year retrospective analysis.

Psychiatric morbidity of hospitalized foreign students in Yugoslavia was analyzed in a 25-year retrospective study and was compared to the psychiatric morbidity of a group of Yugoslav students hospitalized in the same psychiatric institutions, over the same time period. Results showed significantly higher rates of paranoid and depressive reactions amongst foreign students, and suggested correlation between their psychiatric morbidity and maladaptation to the new living conditions.