Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement.

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement.

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Control-Focused Behavioral Treatment: A brief intervention for survivors of war and torture.

This article briefly reviews the evolution and evidence-base of Control-Focused Behav-ioral Treatment (CFBT), largely self-help-based treatment that involves no cognitive interventions, focuses solely on reducing avoidance behaviors through self-exposure to anxiety-evoking trauma cues, and, unlike other interventions, aims to enhance sense of control over traumatic stressors, rather than anxiety reduction. As such, it is radi-cally different from other interventions in both theory and practice. Our studies have shown improvement rates of 80%-85% with a single treatment session in earthquake survivors. When administered in an average of 6 sessions in war and torture survivors, it achieved 82% reduction in posttraumatic stress symptoms (PTSD), leaving 97% of the cases nearly asymptomatic or with only mild PTSD symptoms. Meta-analytical compari-sons suggest that such improvement rates are substantially higher than those achieved by other evidence-based treatments.

Factors associated with posttraumatic stress disorder and depression in war-survivors displaced in Croatia.

AIM: To examine the role of perceived stressfulness of trauma exposure and economic, social, occupational, educational, and familial adaptation after trauma in posttraumatic stress disorder (PTSD) and depression in displaced war survivors. METHODS: A cross-sectional survey was conducted between March 2000 and July 2002 with a sample of 173 internally displaced persons or refugees and 167 matched controls in Croatia. Clinical measures included Structured Clinical Interview for DSM-IV and Clinician-Administered PTSD Scale. RESULTS: Displaced war survivors reported the exposure to a mean±standard deviation of 13.1±8.3 war stressors, including combat, torture, serious injury, death of close persons, and loss of property. Compared to controls, they reported higher rates of marked to severe impact of war on family (16.2% vs 51.6%), social (7.2% vs 43.5%), economic (12.6% vs 55.4%), occupational (1.8% vs 15.9%), and educational (2.4% vs 8.8%) adaptation. In two logistic regression analyses, the strongest predictor of PTSD and depression was high level of perceived distress during trauma exposure. PTSD but not depression was associated with economic, social, occupational, educational, and familial adaptation after trauma. CONCLUSION: Displaced survivors who experienced multiple war events perceived greater negative impact of war on their life domains compared to individuals who lived in a war setting but had no trauma exposure. The most important determinant of psychological outcomes was perceived stressfulness of war stressors. Although post-trauma adaptation in different life spheres had an impact, its effect was not robust and consistent across disorders. These findings suggest that it would be effective to use a trauma-focused approach in rehabilitation of war survivors.

Control-focused behavioral treatment of earthquake survivors using live exposure to conditioned and simulated unconditioned stimuli.

Earthquakes lead to increased rates of mental health problems in the communities they struck. Few attempts have been made to develop effective psychological care strategies for earthquake survivors. During the course of our 6-year work with earthquake survivors in Turkey, we developed a control-focused behavioral treatment (CFBT) that aims to enhance survivors' resilience against traumatic stressors by helping them develop a sense of control over them. CFBT exposes the client to either (a) unconditioned stimuli (i.e., earthquake tremors) in a safe and controlled environment or (b) conditioned stimuli (e.g., earthquake reminders) until the person can tolerate and control associated distress. A single session of CFBT involving instructions to conduct self-exposure to distressing earthquake reminders achieved about 60% reduction in posttraumatic stress symptoms, resulting in global improvement in 80% of the survivors. The efficacy of CFBT was maximized by exposure to simulated earthquake tremors in an earthquake simulator. In a randomized controlled trial, earthquake simulation treatment combined with therapist-delivered instructions for self-exposure to conditioned trauma cues achieved 79% improvement in PTSD symptoms, resulting in generalized improvement in 92% of the cases. The relapse rate was very low in all studies despite ongoing threat to safety caused by numerous aftershocks and expectations of another major earthquake, suggesting increased resilience against traumatic stress induced by earthquakes. Evidence also suggests that CFBT can be effectively delivered as a self-help intervention using booklets and similar media. Based on variants of CFBT, a mental health care model for disaster survivors is proposed.

A multivariate contextual analysis of torture and cruel, inhuman, and degrading treatments: implications for an evidence-based definition of torture.

Current thinking on what constitutes torture in a detention/interrogation setting focuses solely on particular procedures, without regard for contextual factors that mediate traumatic stress. The present study examined stressor interactions that determined severity and psychological impact of captivity stressors in 432 torture survivors in former Yugoslavia countries and Turkey. A principal components analysis of 46 captivity stressors measured by an Exposure to Torture Scale identified meaningful stressor clusters, which suggested that multiple detention procedures were used in combination to maximize their impact. Perceived torture severity related to 'cruel, inhuman, and degrading' treatments (CIDT) but not to physical torture. Posttraumatic stress disorder related to war-related captivity, deprivation of basic needs, sexual torture, and exposure to extreme temperatures, isolation, and forced stress positions but not to physical torture. CIDT increased posttraumatic stress disorder risk by 71%. Fear- and helplessness-inducing effects of captivity and CIDT appear to be the major determinants of perceived severity of torture and psychological damage in detainees. Considerations on what constitutes torture need to take into account the contextual processes in a captivity setting that mediate these effects.

Single-case experimental studies of a self-help manual for traumatic stress in earthquake survivors.

Studies showed that earthquake-related posttraumatic stress disorder could be reduced by a single session of therapist instructions for self-exposure to fear cues. Eight single-case experimental studies examined whether such instructions were as effective when delivered through a self-help manual after an initial assessment. After two baseline assessments conducted at the participants homes, the manual was delivered to the participants, who were then assessed at week 10 (post-treatment) and at 1-, 3-, and 6-month post-treatment. After minimal improvement during the baseline, treatment achieved marked improvement in seven survivors, leading to effect sizes comparable to those obtained by therapist-delivered treatment. Self-help appears to be a promising approach in cost-effective survivor care.

Psychological effects of earthquakes in children: prospects for brief behavioral treatment.

BACKGROUND: Treatment of child earthquake survivors is a relatively less investigated issue in disaster research. A review of the evidence on the mental health effects of earthquakes, risk factors, and findings from treatment studies may provide useful insights into effective treatment of traumatized children. DATA SOURCES: Studies of child and adolescent earthquake survivors included the PILOTS database (electronic index for literature on psychological trauma) and relevant evidence from various studies of adult earthquake survivors. RESULTS: Evidence points to elevated rates of posttraumatic stress disorder (PTSD), depression, and earthquake-related fears in children and adolescents. Traumatic stress appears to be mediated by loss of control over fear induced by exposure to unpredictable and uncontrollable earthquakes. This implies that interventions enhancing sense of control over fear are likely to be most effective. Recent studies indeed show that a control focused behavioral treatment (CFBT) involving mainly encouragement for self-exposure to feared situations is highly effective in facilitating recovery from earthquake trauma. Evidence also suggests that CFBT can be delivered through booklets and similar media. CONCLUSIONS: Pilot studies suggest that CFBT has promise in effective treatment of PTSD in children. Further research is needed to confirm these preliminary findings and to develop self-help tools for children.

Psychosocial determinants of relocation in survivors of the 1999 earthquake in Turkey.

Large-scale earthquakes in urban areas displace many people from their homes. This study examined the role of conditioned fears in determining survivors' tendency to live in shelters after the 1999 earthquake in Turkey. A total of 1655 survivors living in prefabricated housing compounds or residential units in the epicenter zone were screened using a reliable and valid instrument. Among participants whose houses were rendered uninhabitable during the earthquake 87.7% relocated to shelters, whereas others remained in the community by moving to a new house. In contrast, 38.7% of the participants whose houses were still inhabitable after the earthquake lived in the shelters. Relocation was predicted by behavioral avoidance, material losses, and loss of relatives. These findings suggested that a multitude of factors played a role in survivors' displacement from their houses and the elevated rates of mental health problems could constitute a cause rather than an effect of relocation.

Effects of live exposure on symptoms of posttraumatic stress disorder: the role of reduced behavioral avoidance in improvement.

Although the effectiveness of cognitive-behavioral treatment in posttraumatic stress disorder (PTSD) is well established, few studies examined its effects on individual PTSD symptoms and possible mechanisms of improvement in symptoms. In a previous randomized controlled study [Basog lu, M., Salciog lu, E., Livanou, M., Kalender, D., & Acar, G. (2005). Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: A randomized waitlist controlled trial. Journal of Traumatic Stress, 18, 1-11] a single session of behavioral treatment involving self-exposure instructions was highly effective in reducing earthquake-related PTSD. In the present study we examined the effects of treatment on each PTSD symptom and which symptoms improved early in treatment. Because the intervention focused solely on behavioral avoidance, we hypothesized that avoidance would be the first symptom to change and that reduction in avoidance would generalize to all other symptoms. The results showed significant between-groups treatment effect on only behavioral avoidance early in treatment (week 6). At 6 months post-treatment recovery rates ranged from 60% to 89% for 15 PTSD symptoms, including the numbing symptoms. Lack of improvement in avoidance was associated with lack of improvement in 12 symptoms. The critical process in recovery thus appeared to be increased sense of control associated with reduction in avoidance. These findings imply that live exposure to fear cues designed to enhance sense of control might be sufficient for recovery from PTSD.

Post-traumatic stress disorder and comorbid depression among survivors of the 1999 earthquake in Turkey.

This study examined the prevalence of post-traumatic stress disorder (PTSD) and comorbid depression some three years after the August 1999 earthquake in Turkey among a sample of 769 survivors relocated to a permanent housing site built for homeless survivors in the epicentre region. Time since trauma was 3.1 years for 81 per cent of the participants and 3.9 years for the remainder. Survivors were assessed using the Screening Instrument for Traumatic Stress in Earthquake Survivors, an easily administered self-rating scale with demonstrated validity. The estimated rates of PTSD and comorbid depression were 40 per cent and 18 per cent, respectively. Linear regression analyses showed that PTSD strongly related to fear during the earthquake, while depression related to loss of family members. These results suggest that catastrophic earthquakes have long-term psychological consequences and highlight the need for a cost-effective mental health care model for earthquake survivors.

Torture vs other cruel, inhuman, and degrading treatment: is the distinction real or apparent?

CONTEXT: After the reports of human rights abuses by the US military in Guantanamo Bay, Iraq, and Afghanistan, questions have been raised as to whether certain detention and interrogation procedures amount to torture. OBJECTIVE: To examine the distinction between various forms of ill treatment and torture during captivity in terms of their relative psychological impact. DESIGN AND SETTING: A cross-sectional survey was conducted with a population-based sample of survivors of torture from Sarajevo in Bosnia and Herzegovina, Banja Luka in Republica Srpska, Rijeka in Croatia, and Belgrade in Serbia. PARTICIPANTS: A total of 279 survivors of torture accessed through linkage sampling in the community (Banja Luka, Sarajevo, and Rijeka) and among the members of 2 associations for war veterans and prisoners of war (Belgrade). MAIN OUTCOME MEASURES: Scores on the Semi-structured Interview for Survivors of War, Exposure to Torture Scale, Structured Clinical Interview for DSM-IV, and Clinician-Administered PTSD (posttraumatic stress disorder) Scale for DSM-IV. RESULTS: Psychological manipulations, humiliating treatment, exposure to aversive environmental conditions, and forced stress positions showed considerable overlap with physical torture stressors in terms of associated distress and uncontrollability. In regression analyses, physical torture did not significantly relate to posttraumatic stress disorder (odds ratio, 1.41, 95% confidence interval, 0.89-2.25) or depression (odds ratio, 1.41, 95% confidence interval, 0.71-2.78). The traumatic stress impact of torture (physical or nonphysical torture and ill treatment) seemed to be determined by perceived uncontrollability and distress associated with the stressors. CONCLUSIONS: Ill treatment during captivity, such as psychological manipulations, humiliating treatment, and forced stress positions, does not seem to be substantially different from physical torture in terms of the severity of mental suffering they cause, the underlying mechanism of traumatic stress, and their long-term psychological outcome. Thus, these procedures do amount to torture, thereby lending support to their prohibition by international law.

A randomized controlled study of single-session behavioural treatment of earthquake-related post-traumatic stress disorder using an earthquake simulator.

BACKGROUND: Brief interventions are needed in dealing with traumatic stress problems in large survivor populations after devastating earthquakes. The present study examined the effectiveness of a single session of exposure to simulated tremors in an earthquake simulator and self-exposure instructions in reducing post-traumatic stress disorder (PTSD). METHOD: Participants were consecutively recruited from among survivors screened during field surveys in the disaster region in Turkey. Thirty-one earthquake survivors with PTSD were assigned either to a single session of behavioural treatment (n=16) or to repeated assessments (RA; n=15). Assessments in the treatment group were at 4, 8, 12, 24 weeks and 1-2 years post-treatment. The RA cases were assessed at baseline and 4 and 8 weeks after trial entry, after which they received the same treatment and were followed up at 4, 12, 24 weeks and 1-2 years. RESULTS: Between-group treatment effects at week 8 were significant on measures of fear, PTSD and self- and assessor-rated global improvement. Improvement rates were 40% at week 4, 72% at week 12, 80% at week 24, and 80% at 1-2-years' follow-up, with large effect sizes on fear and PTSD measures. Post-session reduction in fear of earthquakes and increased sense of control over fear at follow-up related to improvement in PTSD. CONCLUSION: The study provided further evidence of the effectiveness of a single session of behavioural treatment in reducing fear and PTSD in earthquake survivors. Future research needs to examine the usefulness of earthquake simulators in increasing psychological preparedness for earthquakes.

Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: a randomized waiting list controlled trial.

In an attempt to develop a brief treatment for disaster survivors, the present study examined the effectiveness of a single session of modified behavioral treatment in earthquake-related posttraumatic stress disorder. Fifty-nine earthquake survivors in Turkey were randomized into either single-session modified behavioral treatment (SSBT) designed to enhance sense of control over earthquake-related fears or waiting list control condition (WL). The WL group received SSBT after a second baseline assessment. Follow-ups were at weeks 6, 12, 24, and at 1-2 years posttreatment. Significant treatment effects were found on all measures at posttreatment. The improvement rate was 49% at week 6; it rose to 80% by week 12, 85% by week 24, and 83% by the 1-2-year follow-up. Brief behavioral treatment has promise as a cost-effective intervention for disaster survivors.

Psychiatric and cognitive effects of war in former yugoslavia: association of lack of redress for trauma and posttraumatic stress reactions.

CONTEXT: Although impunity for those responsible for trauma is widely thought to be associated with psychological problems in survivors of political violence, no study has yet investigated this issue. OBJECTIVE: To examine the mental health and cognitive effects of war trauma and how appraisal of redress for trauma and beliefs about justice, safety, other people, war cause, and religion relate to posttraumatic stress responses in war survivors. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey conducted between March 2000 and July 2002 with a population-based sample of 1358 war survivors who had experienced at least 1 war-related stressor (combat, torture, internal displacement, refugee experience, siege, and/or aerial bombardment) from 4 sites in former Yugoslavia, accessed through linkage sampling. Control groups at 2 study sites were matched with survivors on sex, age, and education. MAIN OUTCOME MEASURES: Semi-structured Interview for Survivors of War, Redress for Trauma Survivors Questionnaire, Emotions and Beliefs After War questionnaire, Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). RESULTS: The mean (SD) age was 39 (12) years, 806 (59%) were men, and 339 (25%) had high school or higher level of education. Participants reported experiencing a mean of 12.6 war-related events, with 292 (22%) and 451 (33%) having current and lifetime posttraumatic stress disorder (PTSD), respectively, and 129 (10%) with current major depression. A total of 1074 (79%) of the survivors reported a sense of injustice in relation to perceived lack of redress for trauma. Perceived impunity for those held responsible for trauma was only one of the factors associated with sense of injustice. Relative to controls, survivors had stronger emotional responses to impunity, greater fear and loss of control over life, less belief in benevolence of people, greater loss of meaning in war cause, stronger faith in God, and higher rates of PTSD and depression. Fear and loss of control over life were associated with PTSD and depression (odds ratio [OR], 2.91; 95% CI, 2.27-3.74 and OR, 2.30; 95% CI, 1.75-3.03, respectively), and emotional responses to impunity showed a relatively weaker association with PTSD (OR, 1.53; 95% CI, 1.16-2.02) and depression (OR, 1.39; 95% CI, 1.02-1.91). Appraisal of redress for trauma was not associated with PTSD or depression. CONCLUSIONS: PTSD and depression in war survivors appear to be independent of sense of injustice arising from perceived lack of redress for trauma. Fear of threat to safety and loss of control over life appeared to be the most important mediating factors in PTSD and depression. These findings may have important implications for reconciliation efforts in postwar countries and effective interventions for traumatized war survivors.

Earthquake-related psychological distress and associated factors 4 years after the Parnitha earthquake in Greece.

Exposure to earthquakes has been associated with psychological distress and in particular the development of post-traumatic stress disorder (PTSD). Earthquake-related psychological distress can be longstanding. The present study involved 157 Greek survivors of the 1999 Parnitha earthquake assessed approximately 4 years after the earthquake. Assessments were based on the Traumatic Stress Symptom Checklist (TSSC). Using stringent calibrations for the estimation of symptom presence 25% of the survivors endorsed at least 5 and 12% at least 10 TSSC symptoms. Approximately 22% of the survivors reported subjective distress and 15% impaired adjustment due to their symptoms. Intensity of fear during the earthquake and participation in rescue operations related to greater post-earthquake psychological distress. The results suggest that the psychological consequences of earthquakes can be serious and long-standing even when the magnitude of the earthquake is moderate. Psychological treatments that have been proven to reduce fear and PTSD symptoms need to be made available to the survivors. Such treatments may also increase the survivors' psychological preparedness and emotional resilience in view of future earthquakes.

Prevalence of posttraumatic stress disorder and comorbid depression in earthquake survivors in Turkey: an epidemiological study.

This study examined the prevalence of posttraumatic stress disorder (PTSD) and depression 14 months after the earthquake in Turkey in 2 randomly selected samples from the epicenter (n = 530) and a suburb of Istanbul 100 km from the epicenter (n = 420). The rates of PTSD and depression comorbid with PTSD were, respectively, 23 and 16% at the epicenter and 14 and 8% in Istanbul. The strongest predictor of traumatic stress symptoms was fear during the earthquake, whereas predictions with female gender, past psychiatric illness, damage to home, participation in rescue work, past trauma, and loss of close ones were significant but weak. Our findings suggest that devastating earthquakes have long-term psychological effects. Psychological interventions reducing fear may improve PTSD in survivors.