Using Latent Class Analysis to Support the ICD-11 Complex Posttraumatic Stress Disorder Diagnosis in a Sample of Homeless Adults.

The 11th revision of the International Classification of Diseases (ICD-11), ratified at the World Health Assembly in May 2019, introduced revised diagnostic guidelines for posttraumatic stress disorder (PTSD) as well as a separate diagnosis of complex PTSD (CPTSD). We aimed to test the new ICD-11 symptom structure for PTSD and CPTSD in a sample of individuals who have experienced homelessness. Experiences of trauma exposure and the associated mental health outcomes have been underresearched in this population. A sample of adults experiencing homelessness (N = 206) completed structured and semi-structured interviews that collected information about trauma exposure and symptoms of PTSD and CPTSD. We conducted a latent class analysis (LCA) using six symptom clusters (three PTSD symptom clusters that are components of CPTSD and three CPTSD symptom clusters). All participants reported trauma exposure, with 88.6% having experienced at least one event before 16 years of age. Four distinct classes of participants emerged in relation to the potential to meet the diagnosis: LCA CPTSD (n = 122, 59.8%), LCA no diagnosis (n = 27: 13.2%), LCA PTSD (n = 33; 16.2%), and LCA disturbance in self-organization (DSO; n = 22; 10.8%). Of note, participants with an ICD-11 CPTSD as well as those with an ICD-11 PTSD diagnosis fell into the LCA CPTSD class. Our findings provide some support for the distinction between CPTSD and PTSD within this population specifically but potentially have broader implications. Clear diagnoses will allow targeted PTSD and CPTSD treatment development.

Delayed Disaster Impacts on Academic Performance of Primary School Children.

Social disruption caused by natural disasters often interrupts educational opportunities for children. However, little is known about children's learning in the following years. This study examined change in academic scores for children variably exposed to a major bushfire in Australia. Comparisons were made between children attending high, medium, and low disaster-affected primary schools 2-4 years after the disaster (n = 24,642; 9-12 years). The results showed that in reading and numeracy expected gains from Year 3 to Year 5 scores were reduced in schools with higher levels of bushfire impact. The findings highlight the extended period of academic impact and identify important opportunities for intervention in the education system to enable children to achieve their academic potential.

The impact of post-traumatic stress disorder symptomatology on quality of life: The sentinel experience of anger, hypervigilance and restricted affect.

BACKGROUND: It is unclear which specific symptoms of post-traumatic stress disorder are related to poor perceived quality of life. OBJECTIVE: To investigate the influence of post-traumatic stress disorder symptomatology on quality of life in traumatic injury survivors. METHOD: Traumatic injury survivors completed questionnaires on post-traumatic stress disorder symptomatology and quality of life at 3 months ( n = 987), 12 months ( n = 862), 24 months ( n = 830) and 6 years ( n = 613) post trauma. RESULTS: Low quality of life was reported by 14.5% of injury survivors at 3 months and 8% at 6 years post event. The post-traumatic stress disorder symptom clusters that contributed most to poor perceived quality of life were numbing and arousal, the individual symptoms that contributed most were anger, hypervigilance and restricted affect. CONCLUSIONS: There was variability in the quality of life of traumatic injury survivors in the 6 years following trauma and a consistent proportion reported low quality of life. Early intervention to reduce anger, hypervigilance and restricted affect symptoms may provide a means to improving the quality of life of traumatic injury survivors.

Adjustment of refugee children and adolescents in Australia: outcomes from wave three of the Building a New Life in Australia study.

BACKGROUND: High-income countries like Australia play a vital role in resettling refugees from around the world, half of whom are children and adolescents. Informed by an ecological framework, this study examined the post-migration adjustment of refugee children and adolescents 2-3 years after arrival to Australia. We aimed to estimate the overall rate of adjustment among young refugees and explore associations with adjustment and factors across individual, family, school, and community domains, using a large and broadly representative sample. METHODS: Data were drawn from Wave 3 of the Building a New Life in Australia (BNLA) study, a nationally representative, longitudinal study of settlement among humanitarian migrants in Australia. Caregivers of refugee children aged 5-17 (N = 694 children and adolescents) were interviewed about their children's physical health and activity, school absenteeism and achievement, family structure and parenting style, and community and neighbourhood environment. Parent and child forms of the Strengths and Difficulties Questionnaire (SDQ) were completed by caregivers and older children to assess social and emotional adjustment. RESULTS: Sound adjustment according to the SDQ was observed regularly among young refugees, with 76-94% (across gender and age) falling within normative ranges. Comparison with community data for young people showed that young refugees had comparable or higher adjustment levels than generally seen in the community. However, young refugees as a group did report greater peer difficulties. Bivariate and multivariate linear regression analyses showed that better reported physical health and school achievement were associated with higher adjustment. Furthermore, higher school absenteeism and endorsement of a hostile parenting style were associated with lower adjustment. CONCLUSIONS: This is the first study to report on child psychosocial outcomes from the large, representative longitudinal BNLA study. Our findings indicate sound adjustment for the majority of young refugees resettled in Australia. Further research should examine the nature of associations between variables identified in this study. Overall, treating mental health problems early remains a priority in resettlement. Initiatives to enhance parental capability, physical health, school achievement and participation could assist to improve settlement outcomes for young refugees.

Treatment Outcomes for Military Veterans With Posttraumatic Stress Disorder: Response Trajectories by Symptom Cluster.

Although effective posttraumatic stress disorder (PTSD) treatments are available, outcomes for veterans with PTSD are relatively modest. Previous researchers have identified subgroups of veterans with different response trajectories but have not investigated whether PTSD symptom clusters (based on a four-factor model) have different patterns of response to treatment. The importance of this lies in the potential to increase treatment focus on less responsive symptoms. We investigated treatment outcomes by symptom cluster for 2,685 Australian veterans with PTSD. We used Posttraumatic Stress Disorder Checklist scores obtained at treatment intake, posttreatment, and 3- and 9-month follow-ups to define change across symptom clusters. Repeated measures effect sizes indicated that arousal and numbing symptoms exhibited the largest changes between intake and posttreatment, dRM = -0.61 and dRM = -0.52, respectively, whereas avoidance and intrusion symptoms showed more modest reductions, dRM = -0.36 and dRM = -0.30, respectively. However, unlike the other symptom clusters, the intrusions cluster continued to show significant changes between posttreatment and 3-month follow-up, dRM = -0.21. Intrusion and arousal symptoms also showed continued changes between 3- and 9-month follow-ups although these effects were very small, dRM = -0.09. Growth curve model analyses produced consistent findings and indicated modest initial changes in intrusion symptoms that continued posttreatment. These findings may reflect the longer time required for emotional processing, relative to behavioral changes in avoidance, numbing, and arousal, during the program; they also reinforce the importance of prioritizing individual trauma-focused therapy directly targeting intrusions as the core component of programmatic treatment.

Traumatic exposure, acculturative stress and cultural orientation: the influence on PTSD, depressive and anxiety symptoms among refugees.

OBJECTIVE: Acculturation studies conducted with refugees have predominantly concentrated on investigating the impact of acculturative stress on mental health, and have neglected to investigate the impact of cultural orientations towards the host and ethnic cultures. Furthermore, exposure to traumas is highly prevalent in refugees and strongly associated with mental health outcomes, however, rarely included in investigations of acculturative process of refugees. METHOD: Using structural equation modelling, this study tested an integrated model of the relationship between traumatic exposure, acculturative stress, host and ethnic cultural orientations and posttraumatic stress disorder (PTSD), depression and anxiety symptoms among 138 Bosnian refugees resettled in Australia and Austria. RESULTS: The model showed an overall good fit and noteworthy amount of variance indicating that traumatic exposure is the strongest direct and indirect predictor of PTSD, depression and anxiety symptoms. Furthermore, acculturative stress was identified as a significant risk factor influencing host cultural orientation, mediating the effect of traumatic exposure on all mental health outcomes. CONCLUSION: Acculturative stress and cultural and social stressors that are related to acculturation need to be addressed alongside provision of effective psychotherapy, especially since they are significant impediments to host cultural orientation and constructive engagement with mental health services in refugees.

Mental Health Following Separation in a Disaster: The Role of Attachment.

Short-term separation from close family members during a disaster is a highly salient event for those involved. Yet, its subsequent impact on mental health has received little empirical attention. One relevant factor may be attachment style, which influences patterns of support-seeking under threatening conditions. Individuals (N = 914) affected by the 2009 Victorian bushfires in southeastern Australia were assessed for disaster experiences, depression, posttraumatic stress disorder (PTSD) symptoms, and attachment style 3-4 years after the fires. Using multigroup structural equation modelling, individuals who reported separation from close family members during the bushfires (n = 471) were compared to those who reported no separation (n = 443). Cross-sectional results indicated that separated individuals had higher levels of PTSD symptoms. Furthermore, attachment anxiety was more strongly positively associated with depression among separated (b = 0.62) versus not separated individuals (b = 0.32). Unexpectedly, among separated individuals, attachment avoidance had a statistically weaker association with depression (b = 0.17 vs. b = 0.35) and with PTSD symptoms (b = 0.06 vs. b = 0.22). These results suggest that attachment anxiety amplifies a negative reaction to separation; meanwhile, for avoidant individuals, separation in times of danger may facilitate defensive cognitive processes.

The role of anger and ongoing stressors in mental health following a natural disaster.

OBJECTIVE: Research has established the mental health sequelae following disaster, with studies now focused on understanding factors that mediate these outcomes. This study focused on anger, alcohol, subsequent life stressors and traumatic events as mediators in the development of mental health disorders following the 2009 Black Saturday Bushfires, Australia's worst natural disaster in over 100 years. METHOD: This study examined data from 1017 (M = 404, F = 613) adult residents across 25 communities differentially affected by the fires and participating in the Beyond Bushfires research study. Data included measures of fire exposure, posttraumatic stress disorder, depression, alcohol abuse, anger and subsequent major life stressors and traumatic events. Structural equation modeling assessed the influence of factors mediating the effects of fire exposure on mental health outcomes. RESULTS: Three mediation models were tested. The final model recorded excellent fit and observed a direct relationship between disaster exposure and mental health outcomes (b = .192, p < .001) and mediating relationships via Anger (b = .102, p < .001) and Major Life Stressors (b = .128, p < .001). Each gender was compared with multiple group analyses and while the mediation relationships were still significant for both genders, the direct relationship between exposure and outcome was no longer significant for men (p = .069), but remained significant (b = .234, p < .001) for women. CONCLUSIONS: Importantly, anger and major life stressors mediate the relationship between disaster exposure and development of mental health problems. The findings have significant implications for the assessment of anger post disaster, the provision of targeted anger-focused interventions and delivery of government and community assistance and support in addressing ongoing stressors in the post-disaster context to minimize subsequent mental health consequences.

Impact of the diagnostic changes to post-traumatic stress disorder for DSM-5 and the proposed changes to ICD-11.

BACKGROUND: There have been changes to the criteria for diagnosing post-traumatic stress disorder (PTSD) in DSM-5 and changes are proposed for ICD-11. AIMS: To investigate the impact of the changes to diagnostic criteria for PTSD in DSM-5 and the proposed changes in ICD-11 using a large multisite trauma-exposed sample and structured clinical interviews. METHOD: Randomly selected injury patients admitted to four hospitals were assessed 72 months post trauma (n = 510). Structured clinical interviews for PTSD and major depressive episode, as well as self-report measures of disability and quality of life were administered. RESULTS: Current prevalence of PTSD under DSM-5 scoring was not significantly different from DSM-IV (6.7% v. 5.9%, z = 0.53, P = 0.59). However, the ICD-11 prevalence was significantly lower than ICD-10 (3.3% v. 9.0%, z = -3.8, P<0.001). The PTSD current prevalence was significantly higher for DSM-5 than ICD-11 (6.7% v. 3.3%, z = 2.5, P = 0.01). Using ICD-11 tended to show lower rates of comorbidity with depression and a slightly lower association with disability. CONCLUSIONS: The diagnostic systems performed in different ways in terms of current prevalence rates and levels of comorbidity with depression, but on other broad key indicators they were relatively similar. There was overlap between those with PTSD diagnosed by ICD-11 and DSM-5 but a substantial portion met one but not the other set of criteria. This represents a challenge for research because the phenotype that is studied may be markedly different according to the diagnostic system used.

Utility of the Dimensions of Anger Reactions-5 (DAR-5) scale as a brief anger measure.

BACKGROUND: Anger is a common emotional sequel in the aftermath of traumatic experience. As it is associated with significant distress and influences recovery, anger requires routine screening and assessment. Most validated measures of anger are too lengthy for inclusion in self-report batteries or as screening tools. This study examines the psychometric properties of a shortened 5-item version of the Dimensions of Anger Reactions (DAR), an existing screening tool. METHODS: Responses to the DAR-5 were analysed from a sample of 486 college students with and without a history of trauma exposure. RESULTS: The DAR-5 demonstrated strong internal reliability and concurrent validity with the State Trait Anger Expression Inventory-2 (STAXI-2). Confirmatory factor analysis supported a single factor model of the DAR-5 for the trauma-exposed and nontrauma subsamples. A screening cut-off point of 12 on the DAR-5 successfully differentiated high and low scorers on STAXI-2 Trait Anger and PCL posttraumatic stress scores. Further discriminant validity was found with depression symptom scores. CONCLUSIONS: The results support use of the DAR-5 for screening for anger when a short scale is required.

Trauma and Mental Health in Resettled Refugees: Mediating Effect of Host Language Acquisition on Posttraumatic Stress Disorder, Depressive and Anxiety Symptoms.

This study examined the relationship between traumatic exposure, host language acquisition and mental health (posttraumatic stress, depressive and anxiety symptoms) in long-term resettled refugees. Participants included a community sample of Bosnian refugees ( N = 138, 55% male, mean age of 40 years old) that had resettled in Australia and Austria on average 18 years prior. Two mediation models were tested based on two competing theories. Model A examined whether language acquisition mediates the relationship between traumatic exposure and mental health problems experienced by refugees. Model B examined whether mental health symptoms mediate the relationship between exposure to traumatic events and the acquisition of host language. Model A fit the data well (CFI = 1.00, SRMR = .017, RMSEA < .001, χ2 p = .526), while Model B was rejected as an acceptable model for the data (CFI = .556, SRMR = .136, RMSEA = .352). In Model A, the indirect pathway from trauma to mental health via language acquisition was significant for PTSD ( ß = .067, p = .028) and anxiety symptoms ( ß = .063, p = .026) but not depression symptoms ( ß = .048, p = .071). Intervention strategies aimed at improving host language acquisition may be important not only in successful adaptation to daily living in the host country, but also to improve the mental health of traumatized refugees.

Does the Neurological Damage from a Traumatic Brain Injury Invalidate Measures of Psychopathology Such as the MMPI-2?

OBJECTIVE: The Gass correction model removes 14 items from the MMPI-2 which refer to neurological damage when assessing a person suffering a traumatic brain injury (TBI). Previous analysis supported ongoing inclusion of the five correction items from MMPI-2 Hs scale in individuals who suffered a TBI. This study investigates the remaining nine correction model items on the Hy and Sc scales. PARTICIPANTS: A sample of patients with a TBI (n = 242), and the MMPI-2 normative sample (n = 2,600). DESIGN MAIN MEASURES: This is a cross-sectional study testing measurement invariance of two MMPI-2 scales (Hy and Sc) between the TBI and normative samples. RESULTS: Factor models for each scale were defined and assessed across multiple samples. The Hy scale generated a four-factor model (CFI range .913-.935, RMSEA range .025-.027). The Sc scale generated a five-factor model (CFI range .911-.962, RMSEA range .013-.018). Both models met the criteria of partial measurement invariance. Sensitivity and specificity analysis supported retaining all correction items when assessing persons with a TBI. CONCLUSIONS: These results suggest continued inclusion of all 14 Gass correction model items when assessing a person with a TBI.

The role of the natural environment in disaster recovery: "We live here because we love the bush".

This mixed-methods study explored the role of connection to the natural environment in recovery from the 'Black Saturday' bushfires that blazed across Victoria, Australia, in February 2009. Qualitative findings demonstrated that many participants had a strong connection to the natural environment, experienced considerable grief as a result of its devastation in the fires and drew solace from seeing it regenerate over the following months and years. Quantitative analyses indicated that a strong attachment to the environment was associated with reduced psychological distress, fewer symptoms of major depression and fire-related PTSD, and higher levels of resilience, post-traumatic growth and life satisfaction. While social connections are increasingly recognized as supportive of disaster recovery, the influence of landscapes also needs to be recognized in terms of the impact of their destruction as well as their therapeutic potential.

Interpersonal violence and mental health outcomes following disaster.

BACKGROUND: Disasters pose a documented risk to mental health, with a range of peri- and post-disaster factors (both pre-existing and disaster-precipitated) linked to adverse outcomes. Among these, increasing empirical attention is being paid to the relation between disasters and violence. AIMS: This study examined self-reported experiences of assault or violence victimisation among communities affected by high, medium, and low disaster severity following the 2009 bushfires in Victoria, Australia. The association between violence, mental health outcomes and alcohol misuse was also investigated. METHOD: Participants were 1016 adults from high-, medium- and low-affected communities, 3-4 years after an Australian bushfire disaster. Rates of reported violence were compared by areas of bushfire-affectedness. Logistic regression models were applied separately to men and women to assess the experience of violence in predicting general and fire-related post-traumatic stress disorder, depression and alcohol misuse. RESULTS: Reports of experiencing violence were significantly higher among high bushfire-affected compared with low bushfire-affected regions. Analyses indicated the significant relationship between disaster-affectedness and violence was observed for women only, with rates of 1.0, 0 and 7.4% in low, medium and high bushfire-affected areas, respectively. Among women living in high bushfire-affected areas, negative change to income was associated with an increased likelihood of experiencing violence (odds ratio, 4.68). For women, post-disaster violence was associated with more severe post-traumatic stress disorder and depression symptoms. CONCLUSIONS: Women residing within high bushfire-affected communities experienced the highest levels of violence. These post-disaster experiences of violence are associated with post-disaster changes to income and with post-traumatic stress disorder and depression symptoms among women. These findings have critical implications for the assessment of, and interventions for, women experiencing or at risk of violence post-disaster.

The long-term psychiatric sequelae of severe injury: a 6-year follow-up study.

OBJECTIVE: The impact of mental health on disease burden associated with injury represents a major public health issue, yet almost no information is available on the associated long-term mental health outcomes. The primary aim of this study was to assess the psychiatric outcomes 6 years after a severe injury and their subsequent impact on long-term disability. The secondary aim was to investigate the relationship between a mild traumatic brain injury (mTBI) and long-term psychiatric disorder and its impact on disability. METHODS: From April 2004 to February 2006, randomly selected injury patients admitted to 4 hospitals across Australia were assessed during hospitalization and at 72 months after trauma (N = 592). Injury characteristics, the presence of an mTBI (ICD-9 criteria), and previous psychiatric history were assessed during hospitalization. Structured clinical interviews for psychiatric disorders (DSM-IV and DSM-5) and a self-report measure of disability (WHODAS II) were administered at 72 months. RESULTS: At 72 months after a severe injury, 28% of patients met criteria for at least 1 psychiatric disorder, with 45% of those presenting with comorbid diagnoses. The most prevalent psychiatric disorder was a major depressive episode (11%) followed by substance use disorder (9%), agoraphobia (9%), posttraumatic stress disorder (6%), and generalized anxiety disorder (6%). The presence of any psychiatric disorder was found to increase the risk for disability (P < .001, odds ratio = 6.04). An mTBI was found to increase the risk for having some anxiety disorders but not to increase disability by itself. CONCLUSIONS: The long-term psychiatric consequences of severe injury are substantial and represent a significant contributor to long-term disability. This study points to an important intersection between injury and psychiatric disorder as a leading contributor to disease burden and suggests this growing burden will impose new challenges on health systems.

A Longitudinal Study of Adjustment Disorder After Trauma Exposure.

OBJECTIVE: Adjustment disorder has been recategorized as a trauma- and stressor-related disorder in DSM-5. The aim of this study was to determine the prevalence of adjustment disorder in the first 12 months after severe injury; to determine whether adjustment disorder was a less severe disorder compared with other disorders in terms of disability and quality of life; to investigate the trajectory of adjustment disorder; and to examine whether the subtypes described in DSM-5 are distinguishable. METHOD: In a multisite, cohort study, injury patients were assessed during hospitalization and at 3 and 12 months postinjury (N=826). Structured clinical interviews were used to assess affective, anxiety, and substance use disorders, and self-report measures of disability, anxiety, depression, and quality of life were administered. RESULTS: The prevalence of adjustment disorder was 19% at 3 months and 16% at 12 months. Participants with adjustment disorder reported worse outcomes relative to those with no psychiatric diagnosis but better outcomes compared with those diagnosed with other psychiatric disorders. Participants with adjustment disorder at 3 months postinjury were significantly more likely to meet criteria for a psychiatric disorder at 12 months (odds ratio=2.67, 95% CI=1.59-4.49). Latent-profile analysis identified a three-class model that was based on symptom severity, not the subtypes identified by DSM-5. CONCLUSIONS: Recategorization of adjustment disorder into the trauma- and stressor-related disorders is supported by this study. However, further description of the phenomenology of the disorder is required.

Prediction of Late-Onset Psychiatric Disorder in Survivors of Severe Injury: Findings of a Latent Transition Analysis.

OBJECTIVE: There is a growing body of evidence indicating that late or delayed onset of psychiatric disorder following traumatic injury and other psychological trauma is common. This research, however, has not examined factors that pose risks for delayed development of different types of psychopathology or at different time points. Such research has considerable implications for the development of screening, assessment, and intervention practices. This article investigates risk factors for late-onset disorders up to 72 months after a severe injury. METHODS: In this 6-year longitudinal study, 1,167 hospitalized patients with severe injury recruited between April 2004 and February 2006 were analyzed with repeated measures at 3, 12, and 72 months after injury. The Mini-International Neuropsychiatric Interview (MINI) and Clinician-Administered PTSD Scale (CAPS) were employed to complete diagnoses according to DSM-IV. Latent transition analyses with continuous covariates (injury severity, social support, recent life events, and pain) and 1 dichotomous covariate (presence/absence of a psychiatric disorder before injury) were conducted to identify risk factors for transitioning out of a No Disorder class and into one of 3 previously reported psychopathology classes (PTSD [posttraumatic stress disorder]/Depression, Alcohol/Depression, and Alcohol only) between 3 and 12 months (transition 1) and between 12 and 72 months (transition 2) postinjury. RESULTS: Movement into the PTSD/Depression class was predicted by injury severity at transitions 1 (P = .003) and 2 (P = .017) and social support (P = .006) at transition 1. Past psychiatric history increased the likelihood of moving into the PTSD/Depression class, with anxiety or mood disorders specifically implicated in transition 1. Movement into the Alcohol/Depression class was predicted by social support at transitions 1 (P = .008) and 2 (P < .001) and also by injury severity (P < .001) and pain (P < .001) at transition 2. Movement into the Alcohol class was predicted only by pain (P = .011) at transition 2. A history of a substance use or alcohol use disorder before injury was implicated in movement into both of the alcohol-based classes. CONCLUSIONS: Predictors of developing a delayed-onset psychiatric disorder after severe injury differed by duration after injury and class of disorder. These findings highlight the need to offer targeted screening based on these risk factors to severe injury survivors up to 12 months postinjury, even when they present without disorder at 3 months.

Scoring correction for MMPI-2 Hs scale with patients experiencing a traumatic brain injury: a test of measurement invariance.

It has been suggested that MMPI-2 scoring requires removal of some items when assessing patients after a traumatic brain injury (TBI). Gass (1991. MMPI-2 interpretation and closed head injury: A correction factor. Psychological assessment, 3, 27-31) proposed a correction procedure in line with the hypothesis that MMPI-2 endorsement may be affected by symptoms of TBI. This study assessed the validity of the Gass correction procedure. A sample of patients with a TBI (n = 242), and a random subset of the MMPI-2 normative sample (n = 1,786). The correction procedure implies a failure of measurement invariance across populations. This study examined measurement invariance of one of the MMPI-2 scales (Hs) that includes TBI correction items. A four-factor model of the MMPI-2 Hs items was defined. The factor model was found to meet the criteria for partial measurement invariance. Analysis of the change in sensitivity and specificity values implied by partial measurement invariance failed to indicate significant practical impact of partial invariance. Overall, the results support continued use of all Hs items to assess psychological well-being in patients with TBI.

Compensation seeking and disability after injury: the role of compensation-related stress and mental health.

OBJECTIVE: Claiming for compensation after injury is associated with poor health outcomes. This study examined the degree to which compensation-related stress predicts long-term disability and the mental health factors that contribute to this relationship. METHOD: In a longitudinal, multisite cohort study, 332 injury patients (who claimed for compensation) recruited from April 2004 to February 2006 were assessed during hospitalization and at 3 and 72 months after injury. Posttraumatic stress, depression, and anxiety symptoms (using the Mini-International Neuropsychiatric Interview) were assessed at 3 months; compensation-related stress and disability levels (using the World Health Organization Disability Assessment Schedule II) were assessed at 72 months. RESULTS: A significant direct relationship was found between levels of compensation-related stress and levels of long-term disability (ß = 0.35, P < .001). Three-month posttraumatic stress symptoms had a significant relationship with compensation-related stress (ß = 0.29, P < .001) as did 3-month depression symptoms (ß = 0.39, P < .001), but 3-month anxiety symptoms did not. A significant indirect relationship was found for posttraumatic stress symptoms and disability via compensation stress (ß = 0.099, P = .001) and for depression and disability via compensation stress (ß = 0.136, P < .001). CONCLUSIONS: Stress associated with seeking compensation is significantly related to long-term disability. Posttraumatic stress and depression symptoms increase the perception of stress associated with the claims process, which in turn is related to higher levels of long-term disability. Early interventions targeting those at risk for compensation-related stress may decrease long-term costs for compensation schemes.

Longitudinal analysis of latent classes of psychopathology and patterns of class migration in survivors of severe injury.

OBJECTIVE: Little research to date has explored the typologies of psychopathology following trauma, beyond development of particular diagnoses such as posttraumatic stress disorder (PTSD). The objective of this study was to determine the longitudinal patterns of these typologies, especially the movement of persons across clusters of psychopathology. METHOD: In this 6-year longitudinal study, 1,167 hospitalized severe injury patients who were recruited between April 2004-February 2006 were analyzed, with repeated measures at baseline, 3 months, 12 months, and 72 months after injury. All patients met the DSM-IV criterion A1 for PTSD. Structured clinical interviews were used to assess psychiatric disorders at each follow-up point. Latent class analysis and latent transition analysis were applied to assess clusters of individuals determined by psychopathology. The Mini International Neuropsychiatric Interview (MINI) and Clinician-Administered PTSD Scale (CAPS) were employed to complete diagnoses. RESULTS: Four latent classes were identified at each time point: (1) Alcohol/Depression class (3 months, 2.1%; 12 months, 1.3%; and 72 months, 1.1%), (2) Alcohol class (3 months, 3.3%; 12 months, 3.7%; and 72 months, 5.4%), (3) PTSD/Depression class (3 months, 10.3%; 12 months, 11.5%; and 72 months, 6.4%), and (4) No Disorder class (3 months, 84.2%; 12 months, 83.5%; and 72 months, 87.1%). Latent transition analyses conducted across the 2 transition points (12 months and 72 months) found consistently high levels of stability in the No Disorder class (90.9%, 93.0%, respectively) but lower and reducing levels of consistency in the PTSD/Depression class (81.3%, 46.6%), the Alcohol/Depression class (59.7%, 21.5%), and the Alcohol class (61.0%, 36.5%), demonstrating high levels of between-class migration. CONCLUSIONS: Despite the array of psychiatric disorders that may develop following severe injury, a 4-class model best described the data with excellent classification certainty. The high levels of migration across classes indicate a complex pattern of psychopathology expression over time. The findings have considerable implications for tailoring multifocused interventions to class type, as well as flexible stepped care models, and for the potential development and delivery of transdiagnostic interventions targeting underlying mechanisms.