[Pharmacological treatment of posttraumatic stress disorder]. / Pharmakologische Behandlung der Posttraumatischen Belastungsstörung.

In addition to trauma-focussed psychotherapy, pharmacological treatment is often unavoidable, especially in patients with severe posttraumatic stress disorder (PTSD). As long as comorbid disorders do not dictate the pharmacotherapy approach, sertraline and paroxetine, along with other off-label prescribable substances approved in Germany, can be used for the treatment of PTSD. Venlafaxine, in particular, has shown good effectiveness in studies, whereas risperidone has shown lower effectiveness in augmentation. Overall, only a small to medium effect size is to be expected for all substances. Psychopharmacotherapy plays an important role in addressing sleep disorders, which are highly prevalent in PTSD. Treatment of trauma-related nightmares can be attempted with doxazosin or clonidine. In contrast, there are limited empirical data available for sleep disorders associated with PTSD, but the pharmacological treatment of insomnia can provide some guidance.

[Trauma and memory-A contribution to the current debate in law and psychotherapy]. / Trauma und Erinnerung ­ ein Beitrag zur aktuellen Debatte in Recht und Psychotherapie.

The recall of memories of past events, experiences and emotions is a complex process. When experiencing traumatic events, as is the case with sexual violence, a host of additional complexities and difficulties arise. This becomes especially important in court cases which rely mostly or exclusively on the testimony of the victim, where the problem of the fallibility of memory takes center stage. Some research studies emphasize the possibility of inducing, altering or suppressing memories, especially in the context of psychotherapy. This has led to the unfortunate reality that the testimony of victims who have undergone psychotherapy is often considered to be unreliable. This in turn can lead to the impression that a decision has to be made between treatment of the adverse effects of traumatic events and maximizing the chances for a conviction of the perpetrator in court. This article introduces some central concepts of our current understanding of memory and gives an overview of the relevant scientific literature and debate. Following this, it examines the dilemma as it pertains to the different groups of all involved parties (i.e., victims, members of the judiciary and psychotherapists). Lastly, it proposes a framework of how to approach a solution to this problem by focusing on research in critical areas, expansion of therapy guidelines and documentation procedures as well as communication of these efforts to all parties involved.

Drug-Induced Liver Injury (DILI) in Patients with Depression Treated with Antidepressants: A Retrospective Multicenter Study.

INTRODUCTION: Drug-induced liver injury (DILI) is the 4th most common cause of liver damage in Western countries and can be caused by antidepressants. METHODS: Against the background of increasing antidepressant prescriptions and increasing use of polypharmacy, we analyzed administered antidepressants and other pharmacological substances, liver toxicity, comorbid somatic secondary diseases together with the occurrence of DILI in a patient population of 6 centers throughout Germany. RESULTS: The majority of the enrolled 329 patients received polypharmacological treatment in an inpatient setting. During antidepressant treatment 5.1% of the patients had elevated serum transaminase levels, whereby exactly and not more than 1 criterion proposed to be indicative for DILI, was fulfilled by 3 patients (0.9%). DISCUSSION: During patient characterization it becomes clear that a sensitization for relevant risk constellations causing liver injury in MDD patients is relevant to prevent further serious adverse events.

[Delayed Onset of PTSD - A Problem for Diagnosis and Litigation - with Special Reference to Political Imprisonment in the GDR]. / Der "verzögerte Beginn" einer Posttraumatischen Belastungsstörung (PTBS) ­ ein diagnostisches und gutachterliches Problem mit Bezug zur politischen Inhaftierung in der DDR.

More often than is generally assumed: according to 2 metaanalyses, an average of about 25% of all cases of PTSD are not definitively diagnosed with post-traumatic stress disorder (PTSD) until 6 months or more after their trauma. Its prevalence varies widely depending on the given population. Delayed onset PTSD is diagnosed in military personnel much more often than in the civilian population (38,2 vs. 15,3%) . The divergence in PTSD's prevalence numbers is attributed to differences in its definition, methodology, and target population, as well as the type of trauma. The longer the observation period, the more likely it is that the PTSD diagnosis will be delayed. Several influencing factors have been identified for its emergence and persistence. Some experts insist that "bridge symptoms" be defined when patients are diagnosed as suffering from delayed onset PTSD. Although frequent, they are not necessarily present. We discuss an example thereof provided by political prisoners in the former GDR exhibiting different courses of PTSD as well as its delayed-manifestation subtype.

Do adjuvant interventions improve treatment outcome in adult patients with posttraumatic stress disorder receiving trauma-focused psychotherapy? A systematic review.

Background: According to clinical guidelines, trauma-focused psychotherapies (TF-PT) such as trauma-focused cognitive behavioural therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR) are recommended as first-line treatments for posttraumatic stress disorder (PTSD). TF-CBT and EMDR are equally effective and have large effect sizes. However, many patients fail to respond or have comorbid symptoms or disorders that only partially decline with TF-PT. Thus, there is growing interest in augmenting TF-PT through adjuvant interventions. Objective: The current systematic review aims to assess whether adjuvant interventions improve outcome among adult PTSD patients receiving TF-PT. Methods: We searched the databases PubMed, PILOTS, Web of Science and the Cochrane Library for controlled clinical trials examining whether adjuvant interventions lead to more symptom reduction in adult PTSD patients receiving TF-PT. Thirteen randomized controlled trials fitted the inclusion criteria. These were evaluated for internal risk of bias using the Cochrane Handbook for Systematic Review of Interventions. Results: Most studies have a substantial risk for internal bias, mainly due to small sample sizes. Thus, no strong conclusion can be drawn from the current empirical evidence. Preliminary evidence suggests that exercise and cortisol administration may have an adjuvant effect on PTSD symptom reduction. Breathing biofeedback showed a trend for an adjuvant effect and an effect for accelerated symptom reduction. Conclusions: Currently, it is not possible to formulate evidence-based clinical recommendations regarding adjuvants interventions. While several adjuvant interventions hold the potential to boost the effectiveness of TF-PT, the realization of sufficiently powered studies is crucial to separate plausible ideas from interventions proven to work in practice.

Antecedentes: De acuerdo a las guías clínicas, las psicoterapias con foco en el trauma (TF-PT, por su sigla en inglés), así como la terapia cognitivo-conductual con foco en el trauma (TF-CBT, por su sigla en inglés) y la terapia de reprocesamiento y desensibilización por movimientos oculares (EMDR) son recomendadas como tratamientos de primera línea para el Trastorno de Estrés Postraumático (TEPT). TF-CBT y EMDR son igualmente efectivas y tienen grandes tamaños de efecto. Sin embargo, muchos pacientes no responden, tienen síntomas comórbidos u otros trastornos que sólo disminuyen parcialmente con TF-PT. Por lo tanto, hay un creciente interés en aumentar las TF-PT a través de intervenciones auxiliares.Objetivo: La presente revisión sistemática busca evaluar si las intervenciones auxiliares mejoran los resultados entre adultos con TEPT que reciben TF-PT.Métodos: Buscamos en las bases de datos Pubmed, PILOTS, Web of Science y en la Biblioteca Cochrane, estudios clínicos controlados que examinaran si las intervenciones auxiliares llevan a mayor reducción de síntomas en pacientes adultos con TEPT que reciben TF-PT. Trece estudios randomizados controlados cumplieron los criterios de inclusión. En estos se evaluó el riesgo interno de sesgo usando el Manual Cochrane para la Revisión Sistemática de Intervenciones.Resultados: La mayoría de los estudios tuvo un riesgo sustancial de sesgo interno, principalmente debido al pequeño tamaño muestral. Por lo tanrto, no se puede extraer conclusiones fuertes de la evidencia empírica actual. La evidencia preliminar sugiere que el ejercicio y la administración de cortisol puede tener un efecto auxiliar en la reducción de síntomas de TEPT. El biofeedback de la respiración mostró una tendencia hacia un efecto auxiliar y un efecto en la reducción acelerada de los síntomas.Conclusiones: Actualmente, no es posible formular recomendaciones clínicas basadas en la evidencia en relación a intervenciones auxiliares. Mientras varias intervenciones auxiliares mantienen potencial para aumentar la efectividad de las TF-PT, la realización de estudios con suficiente poder es crucial para separar las ideas plausibles de las intervenciones con efectividad probada en la práctica.

[Resources, Childhood Trauma and Psychopathology in a Psychiatric Inpatient Sample]. / Ressourcen, Kindheitstraumata und Psychopathologie bei stationär psychiatrischen Patienten.

Childhood trauma can have a negative impact on the development of personal and social resources in later adulthood. This is problematic, because resources can be a protective factor against the development of psychiatric disorders and are potentially beneficial for therapy outcomes. The current study considered the association between childhood trauma and resources as well as the impact of these 2 factors on psychopathology and symptom reduction in a psychiatric in-patient sample. We anticipated negative relationships between resources and the extent of childhood traumatization as well as resources and psychiatric symptoms. We also expected a positive association between trauma and symptoms. Furthermore, we assumed that higher current resources would be associated with a higher symptom reduction and more severe traumatization in childhood with a lower reduction of symptoms. These hypotheses were tested with correlation and regression analysis in a sample of n=93 patients with depressive and posttraumatic symptomatology in a psychiatric clinic in Offenburg. As expected, we found negative associations between resources and childhood trauma as well as resources and symptoms. However, contrary to our predictions, we could only find a significant association between childhood traumatization and posttraumatic, but not depressive symptoms. Also, there was no significant association between resources or childhood trauma and therapy outcome. The reported associations are relevant concerning the prevention of psychiatric disorders and thus have multiple implications for the development and use of preventive and therapeutic interventions.

A feasibility study on violence prevention in outpatients with schizophrenia.

Patients with schizophrenia have an increased risk of violent behavior, and occupy a large percentage of forensic beds. Most patients in forensic psychiatry have already undergone general psychiatric therapy. This predestinates general psychiatrists to identify those patients presenting such a risk, and to try to intervene so that violence can be prevented. Feasibility study of violence prevention using cognitive-behavioral therapy interventions in male patients with schizophrenia on a general psychiatric ward. Of our patients admitted with schizophrenia, 39.1% had committed violent acts against others; the severity of the act was usually low. The percentage of non-participants was high (83.1%). Study subjects were younger, had not been ill for as long, and were less apt to drop out of the ongoing general psychiatric treatment than the non-participants. Study subjects and non-participants did not differ in the violent act's severity. Our therapy manual proved to be sensible and practical. Those of us attempting to prevent schizophrenic patients from committing violence must deal with individuals who are generally hard to reach. We succeeded in achieving a low drop-out rate after having recruited patients who had displayed a substantial propensity to violence against others.

Reduced amygdala responsivity during conditioning to trauma-related stimuli in posttraumatic stress disorder.

Exaggerated conditioned fear responses and impaired extinction along with amygdala overactivation have been observed in posttraumatic stress disorder (PTSD). These fear responses might be triggered by cues related to the trauma through higher-order conditioning, where reminders of the trauma may serve as unconditioned stimuli (US) and could maintain the fear response. We compared arousal, valence, and US expectancy ratings and BOLD brain responses using fMRI in 14 traumatized persons with PTSD and 14 without PTSD (NPTSD) and 13 matched healthy controls (HC) in a differential aversive conditioning paradigm. The US were trauma-specific pictures for the PTSD and NPTSD group and equally aversive and arousing for the HC; the conditioned stimuli (CS) were graphic displays. During conditioning, the PTSD patients compared to the NPTSD and HC indicated higher arousal to the conditioned stimulus that was paired with the trauma picture (CS+) compared to the unpaired (CS-), increased dissociation during acquisition and extinction, and failure to extinguish the CS/US-association compared to NPTSD. During early and late acquisition, the PTSD patients showed a significantly lower amygdala activation to CS+ versus CS- and a negative interaction between activation in the amygdala and dorsolateral prefrontal cortex (PFC), while NPTSD and HC displayed a negative interaction between amygdala and medial PFC. These findings suggest maladaptive anticipatory coping with trauma-related stimuli in patients with PTSD, indicated by enhanced conditioning, with related abnormal amygdala reactivity and connectivity, and delayed extinction.

Mobility behaviour and driving status of patients with mental disorders - an exploratory study.

BACKGROUND: Driving is an important activity of daily life and an integral part of mobility. However, impact of mental illness on road mobility is widely unexplored. METHOD: Driving status in 1497 psychiatric inpatients (PPs) and a clinical control group of 313 neurological inpatients (NPs) was investigated using a brief questionnaire. RESULTS: 67% of PPs (89% NPs) reported to have a valid driver's licence and 77% of them (92% NPs) reported to regularly use their cars. Within driver's license holders, patients with organic mental disorder (32%), substance dependence (37%) and psychotic disorder (40%) had the lowest proportion of current drivers. Higher educational qualification (odds ratio [OR] from 2.978 to 17.036) and being married/partnered (OR 3.049) or divorced (OR 4.840) significantly advanced the probability of possession of a driving license. Predictive factors for driving cessation were being female, an older age, drawing a pension and having an organic mental disease or schizophrenic disorder. CONCLUSION: Mental disease has a negative impact on driving status and this is especially true for illnesses frequently being accompanied by distinct cognitive impairments. Factors predicting road mobility elucidate the strong relationship with psychosocial status indicating that recovery of driving competence should be an integral goal of treatment strategies.

Post-traumatic stress disorder--a diagnostic and therapeutic challenge.

BACKGROUND: In Germany, the one-month prevalence of post-traumatic stress disorder (PTSD) is in the range of 1% to 3%. Soldiers, persons injured in accidents, and victims of domestic violence increasingly seek medical help for symptoms of emotional stress. Days lost from work and monetary compensation for emotional disturbances are markedly on the rise. The term "PTSD" is commonly used uncritically and imprecisely, with too little regard for the existing diagnostic criteria. It is at risk of turning into a nonspecific collective term for emotional stress of any kind. METHODS: We selectively reviewed the literature in the PubMed database and pertinent journals, with additional consideration of the recommendations and guidelines of medical societies from Germany and abroad. RESULTS: The characteristic types of reactions seen in PTSD are nightmares and an intense, repetitive, intrusive "reliving" of the traumatic event(s). Emotional traumatization manifests itself not only as PTSD but also through major effects on other mental and somatic diseases. An early, trauma-focused behavioral therapeutic intervention involving several sessions, generally on an outpatient basis, can prevent the development of PTSD. The most important components of effective treatment are a focus on the particular trauma experienced and confrontation with the patient's memories of the trauma. The best existing evidence is for cognitive therapy, behavioral therapy according to the exposure paradigm of Foa, and eye movement desensitization and reprocessing therapy. The most recent meta-analysis reveals effect strengths of g = 1.14 for all types of psychotherapy and g = 0.42 for all types of pharmacotherapy taken together (with considerable differences among psychotherapeutic methods and among drugs). The efficacy of psychodynamic therapy, systemic therapy, body-oriented therapy, and hypnotherapy has not been adequately documented in randomized controlled trials. CONCLUSION: PTSD can be precisely diagnosed and effectively treated when the diagnostic criteria and guideline recommendations are taken into account. Referral for trauma-focused psychotherapy should be considered if the acute symptoms persist for several weeks.

Protecting self-esteem from stigma: a test of different strategies for coping with the stigma of mental illness.

BACKGROUND: To date, there has been little research into effective strategies for preventing the detrimental effects of stigma on the well-being of people with mental illness. AIM: The present research set out to identify adaptive strategies for dealing with the stigma of mental illness. METHODS: On the basis of the responses of 355 people with mental illness (PWMI) a standardized questionnaire assessing 10 identity management strategies was developed. Participants also reported their personal experiences with stigma, depression and self-esteem. RESULTS: Hierarchical regression analyses showed that after controlling for depression and stigmatizing experiences, the strategies of community involvement, humour and positive ingroup stereotyping were related to higher self-esteem. Secrecy, selective disclosure and attempts at overcompensation or disproving stereotypes were related to lower self-esteem. The following strategies were unrelated to self-esteem: comparing the present social position of PWMI with that in the past, normalization of the illness within a medical model, information seeking and selective withdrawal. CONCLUSIONS: PWMI should be encouraged to seek support within their community and to develop a positive image of their ingroup.

Trauma exposure and post-traumatic stress disorder in bipolar disorder.

INTRODUCTION: There is a lack of data about post-traumatic stress disorder (PTSD) in European bipolar patients compared to the US-population. This study was conducted to ascertain the rates and types of traumatic events and PTSD in bipolar-I disorder. METHODS: Euthymic bipolar patients were screened for lifetime diagnosis of PTSD using the Post-Traumatic Stress Diagnostic Scale and the Clinician Administered Post-traumatic Stress Disorder Scale. RESULTS: A total of 74 patients (m = 30, f = 44) with diagnosis of bipolar-I disorder were assessed. 37 patients (50%) reported no trauma, 22 patients (29.7%) experienced traumatic events without diagnosis of PTSD and 15 patients (20.3%) had comorbid PTSD. Bipolar PTSD patients were at higher risk to be exposed to physical violence, parental disregard, alcohol dependence of parents, sexual assault by a family member or acquaintance. The number of siblings was higher and they had higher scores on the Hamilton Depression Rating Scale and the Global Assessment of Functioning Scale. CONCLUSIONS: Bipolar patients are more likely to experience traumatic events and PTSD is a relevant comorbid disorder. PTSD is associated with an increased illness severity of bipolar disorder.

Adherence to guidelines for treatment of depression in in-patients.

BACKGROUND: Adherence to treatment guidelines enhances treatment outcome. However, in clinical practice many patients with depression do not receive appropriate treatment. AIMS: To evaluate the treatment of depression in in-patients of German psychiatric hospitals with respect to treatment outcome and adherence to guidelines. METHOD: We recruited 1202 in-patients with depression from ten different hospitals. Quality data concerning treatment were collected at admission, during the treatment course and at discharge. RESULTS: The level of depression was significantly decreased and most patients were satisfied with treatment. Many aspects of the treatment routine adhered to guideline recommendations. Adherence to guidelines could be improved with respect to adjustment of antidepressant dosage, reduction of benzodiazepine prescription, enhanced use of electroconvulsive therapy and wider use of interpersonal therapy. CONCLUSIONS: The study reveals a high standard of psychiatric treatment of in-patients with depression. Nevertheless there is still room for improvement. Differences between hospitals in adherence to guidelines indicates the need for individual application of quality management tools.

Posttraumatic stress disorders and extent of psychosocial impairments five years after a traffic accident.

This five year long-term follow-up study estimated the prevalence of Posttraumatic Stress Disorder (PTSD) and other mental health problems in traffic accident victims. 70 patients were invited for a personal interview to assess mental disorders (DIA-X), depression (BDI), mental distress (SCL-90-R), and psychosocial (SDS) and physical impairments at least five years after their first admission to a university hospital (Department of Traumatology). Prevalence of PTSD was 10%, and another 14.2% of the patients also had a partial PTSD. Other mental disorders had a lower prevalence (7.2%). Patients with PTSD did not differ in sociodemographic characteristics from patients without PTSD. PTSD patients were more depressed and showed more general psychological distress. Furthermore, PTSD was associated with impairments in job, social interaction, and leisure activities. Persistent medical and mental problems correlated highly with PTSD. Implications for secondary prevention of persistent mental health problems of traffic accident patients are discussed in their connection with PTSD.

Comparison between paroxetine and behaviour therapy in patients with posttraumatic stress disorder (PTSD): A pilot study.

Antidepressants and cognitive-behavioural therapy (CBT) have been reported to decrease severity of psychopathology in PTSD-patients. To date, no study has been carried out which compares psychopharmacolo-gical and psychotherapeutic treatments. In a randomized pilot study, PTSD-patients were treated either with paroxetine or CBT. Diagnoses were made by structured clinical interviews (ADIS, CAPS). The duration of treatment was 3 months; the paroxetine dosage was 10-50 mg; exposure and cognitive restructuring were the main elements in cognitive-behavioural therapy. Twenty-one patients were included. Drop-outs in both groups occurred within the first 2 weeks. Paroxetine and CBT significantly decreased PTSD-symptoms (CAPS) as well as concurrent depression (MADRS) after 3 months treatment. At 6 month follow-up, symptoms of PTSD had slightly increased in the paroxetine group and further decreased in the cognitive-behavioural therapy group. (Int J Psych Clin Pract 2004; 8: 19-23).