Fatty acid concentrations in patients with posttraumatic stress disorder compared to healthy controls.

BACKGROUND: Although fatty acid (FA)-supplementation studies are currently being implemented, in fact little is known about FA-profiles in posttraumatic stress disorder (PTSD). Therefore, the present study aimed at comparing FA-concentrations between PTSD-patients and healthy controls. METHODS: A cross-sectional study comparing a mixed-gender sample of 49 patients with PTSD due to civilian trauma to 46 healthy controls regarding erythrocyte FAs including docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), arachidonic acid (AA), and nervonic acid (NA). RESULTS: DHA was found to be significantly lower in PTSD-patients compared to controls after adjusting for sociodemographic and dietary factors (p =0.043). Additionally, exploratory analyses showed lower vaccenic acid (p =0.035) and eicosatrienoic acid (p =0.006), but higher erucic acid (p =0.032) in PTSD-patients. The effect of erucic acid remained after adjustment for sociodemographic factors (p =0.047); with the additional adjustment for dietary factors none of these FAs were found to be significant. LIMITATIONS: Statistical power for differences with small effect sizes was limited, and dietary assessment could be optimized. CONCLUSIONS: We found little evidence for a considerable role of FA-metabolism in PTSD. Apart from lower DHA after adjusting for confounders, no differences were observed in the hypothesized long-chained polyunsaturated FA-concentrations. Additionally, we found few alterations in the long-chained monounsaturated FAs, which may be explained by dietary factors. Nevertheless, the observed small effect sizes and limited extent of the alterations emphasize the importance of further investigating the assumed role of FA-metabolism and its underlying mechanisms in PTSD, before implementing further FA-supplementation studies.

Response to psychotherapy for posttraumatic stress disorder: the role of pretreatment verbal memory performance.

OBJECTIVE: Neuropsychological studies have consistently demonstrated impaired verbal memory in posttraumatic stress disorder (PTSD). Trauma-focused treatment for PTSD is thought to rely on memory, but it is largely unknown whether treatment outcome is influenced by memory performance. The aim of the study, therefore, was to examine the relationship between verbal memory performance and treatment response to trauma-focused psychotherapy. METHOD: Participants were referred to our outpatient clinic and recruited between December 2003 and January 2009 upon diagnosis of PTSD according to DSM-IV. Secondary analyses of a randomized controlled trial comparing eye movement desensitization and reprocessing therapy (n = 70) and brief eclectic psychotherapy (n = 70), a cognitive-behavioral intervention, are reported. Response to treatment was measured by self-reported PTSD symptom severity (Impact of Event Scale-Revised) over 17 weeks. Pretreatment verbal memory measures (California Verbal Learning Test, Rivermead Behavioral Memory Test) were included in the mixed linear model analyses in order to investigate the influence of memory on treatment outcome. RESULTS: Pretreatment encoding, short-term retrieval, long-term retrieval, and recognition performance were significantly associated with treatment response in terms of self-reported PTSD symptom severity for both treatments (P ≤ .013). Receiver operating characteristic curves predicting treatment response with pretreatment memory indices showed that 75.6% of the patients could be correctly classified as responder. CONCLUSIONS: Poor verbal memory performance represents a risk factor for worse treatment response to trauma-focused psychotherapy. Memory measures can be helpful in determining which patients are unable to benefit from trauma-focused psychotherapy. Future research should explore how treatment perspectives of patients with poor verbal memory can be improved. CLINICAL TRIALS REGISTRATION: ISRCTN.com identifier: ISRCTN64872147.

Altered one-carbon metabolism in posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with increased morbidity and mortality through somatic conditions, particularly cardiovascular disease. The one-carbon metabolism in connection with the hypothalamic-pituitary-adrenal (HPA)-axis may be an important mediator of this increased cardiovascular risk. METHODS: In a mixed-gender sample of 49 PTSD patients and 45 healthy controls we therefore investigated: (1) alterations in the one-carbon metabolism as reflected in fasting plasma concentrations of homocysteine, folate, vitamins B6 and B12, and (2) associations of these one-carbon metabolites with the HPA-axis hormones cortisol, dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S). RESULTS: After correction for confounders, PTSD patients had significantly elevated homocysteine (z = 2.963, p = .003) compared to controls, but normal levels of folate, vitamin B6 and B12. Comorbid depression did not explain the observed higher homocysteine levels. Patients showed increased risk for moderate hyperhomocysteinemia (OR = 7.0, χ(2) = 7.436, p = .006). Additionally, homocysteine was associated with PTSD severity (z = 2.281, p = .005). Moreover, all HPA-axis hormones were associated with folate in both patients and controls (all p's ≤ .011), while DHEA-S influenced folate in patients (z = 2.089, p = .037). LIMITATIONS: Our clinical sample is relatively small and therefore small-sized effects may have remained undetected. CONCLUSIONS: Our study indicates that: (1) the one-carbon metabolism is altered in PTSD patients, (2) earlier findings of higher homocysteine in male PTSD patients are generalized to female patients, (3) homocysteine is negatively associated with PTSD severity, and (4) HPA-axis alterations are associated with the one-carbon metabolism. Longitudinal studies are needed to determine whether elevated homocysteine levels reflect preexisting risk factors and/or consequences of psychological trauma.

Parental child-rearing attitudes are associated with functional constipation in childhood.

OBJECTIVE: Parenting factors are assumed to play a role in the development and maintenance of childhood constipation. However, knowledge about the association between parenting factors and childhood constipation is limited. This study investigates the association between parental child-rearing attitudes and prominent symptoms of functional constipation and assesses the strength of this association. DESIGN: Cross-sectional data of 133 constipated children and their parents were collected. SETTING: The gastrointestinal outpatient clinic at the Emma Children's Hospital in the Netherlands. PATIENTS: Children with functional constipation aged 4-18 years referred by general practitioners, school doctors and paediatricians. MAIN OUTCOME MEASURES: Parental child-rearing attitudes were assessed by the Amsterdam version of the Parental Attitude Research Instrument (A-PARI). Symptoms of constipation in the child were assessed by a standardised interview. Negative binomial and logistic regression models were used to test the association between child-rearing attitudes and constipation symptoms. RESULTS: Parental child-rearing attitudes are associated with defecation and faecal incontinence frequency. Higher and lower scores on the autonomy attitude scale were associated with decreased defecation frequency and increased faecal incontinence. High scores on the overprotection and self-pity attitude scales were associated with increased faecal incontinence. More and stronger associations were found for children aged ≥6 years than for younger children. CONCLUSIONS: Parental child-rearing attitudes are associated with functional constipation in children. Any parenting issues should be addressed during treatment of children with constipation. Referral to mental health services is needed when parenting difficulties hinder treatment or when the parent-child relationship is at risk. TRIAL REGISTRATION NUMBER: ISRCTN2518556.

Internet-based early intervention to prevent posttraumatic stress disorder in injury patients: randomized controlled trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) develops in 10-20% of injury patients. We developed a novel, self-guided Internet-based intervention (called Trauma TIPS) based on techniques from cognitive behavioral therapy (CBT) to prevent the onset of PTSD symptoms. OBJECTIVE: To determine whether Trauma TIPS is effective in preventing the onset of PTSD symptoms in injury patients. METHODS: Adult, level 1 trauma center patients were randomly assigned to receive the fully automated Trauma TIPS Internet intervention (n=151) or to receive no early intervention (n=149). Trauma TIPS consisted of psychoeducation, in vivo exposure, and stress management techniques. Both groups were free to use care as usual (nonprotocolized talks with hospital staff). PTSD symptom severity was assessed at 1, 3, 6, and 12 months post injury with a clinical interview (Clinician-Administered PTSD Scale) by blinded trained interviewers and self-report instrument (Impact of Event Scale-Revised). Secondary outcomes were acute anxiety and arousal (assessed online), self-reported depressive and anxiety symptoms (Hospital Anxiety and Depression Scale), and mental health care utilization. Intervention usage was documented. RESULTS: The mean number of intervention logins was 1.7, SD 2.5, median 1, interquartile range (IQR) 1-2. Thirty-four patients in the intervention group did not log in (22.5%), 63 (41.7%) logged in once, and 54 (35.8%) logged in multiple times (mean 3.6, SD 3.5, median 3, IQR 2-4). On clinician-assessed and self-reported PTSD symptoms, both the intervention and control group showed a significant decrease over time (P<.001) without significant differences in trend. PTSD at 12 months was diagnosed in 4.7% of controls and 4.4% of intervention group patients. There were no group differences on anxiety or depressive symptoms over time. Post hoc analyses using latent growth mixture modeling showed a significant decrease in PTSD symptoms in a subgroup of patients with severe initial symptoms (n=20) (P<.001). CONCLUSIONS: Our results do not support the efficacy of the Trauma TIPS Internet-based early intervention in the prevention of PTSD symptoms for an unselected population of injury patients. Moreover, uptake was relatively low since one-fifth of individuals did not log in to the intervention. Future research should therefore focus on innovative strategies to increase intervention usage, for example, adding gameplay, embedding it in a blended care context, and targeting high-risk individuals who are more likely to benefit from the intervention. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 57754429; http://www.controlled-trials.com/ISRCTN57754429 (Archived by WebCite at http://webcitation.org/6FeJtJJyD).

The role of injury and trauma-related variables in the onset and course of symptoms of posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) affects a minority of trauma-exposed persons and is associated with significant impairment. This longitudinal study examined risk factors for PTSD. We tested whether the presence of injuries resulting from trauma exposure predicted the course of PTSD symptoms. In addition, we tested whether gender, trauma type, perceived life threat, and peritraumatic dissociation predicted the onset of PTSD symptoms. 236 trauma-exposed civilians were assessed for PTSD symptoms with a structured interview at four occasions during 6 months posttrauma. Path analysis showed that a model in which the female gender, assault, perceived life threat, and peritraumatic dissociation predicted PTSD severity at 1 week, and injury predicted PTSD severity 8 weeks after the traumatic event showed the best fit. However, a similar model without injury showed comparable fit. It is concluded that injuries have a negligible effect on the course of PTSD.

The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands.

Little information exists on the lifetime prevalence of traumatic events and posttraumatic stress disorder (PTSD) in the general population of the Netherlands. A national representative sample of 1087 adults aged 18 to 80 years was selected using random digit dialing and then surveyed by telephone using the Composite International Diagnostic Interview (CIDI) to determine the prevalence of trauma and DSM-IV PTSD. The lifetime prevalence of any potential trauma was 80.7%, and the lifetime prevalence of PTSD was 7.4%. Women and younger persons showed higher risk of PTSD. It was concluded that PTSD is a fairly common disorder and exposure to trauma is high throughout the population. Unexpectedly, prevalence rates resemble those found in the United States and are higher than in several other European countries.

Behavioral therapy for childhood constipation: a randomized, controlled trial.

OBJECTIVE: It has been suggested that the addition of behavioral interventions to laxative therapy improves continence in children with functional fecal incontinence associated with constipation. Our aim was to evaluate the clinical effectiveness of behavioral therapy with laxatives compared with conventional treatment in treating functional constipation in childhood. PATIENTS AND METHODS: In this randomized, controlled trial conducted in a tertiary hospital in The Netherlands, 134 children aged 4 to 18 years with functional constipation were randomly assigned to 22 weeks (12 visits) of either behavioral therapy or conventional treatment. Primary outcomes were defecation frequency, fecal incontinence frequency, and success rate. Success was defined as defecation frequency of > or = 3 times per week and fecal incontinence frequency of < or = 1 times per 2 weeks irrespective of laxative use. Secondary outcomes were stool-withholding behavior and behavior problems. Outcomes were evaluated at the end of treatment and at 6-months follow-up. All of the analyses were done by intention to treat. RESULTS: Defecation frequency was significantly higher for conventional treatment. Fecal incontinence frequency showed no difference between treatments. After 22 weeks, success rates did not differ between conventional treatment and behavioral therapy (respectively, 62.3% and 51.5%), nor did it differ at 6 months of follow-up (respectively, 57.3% and 42.3%). The proportion of children withholding stools was not different between interventions. At follow-up, the proportion of children with behavior problems was significantly smaller for behavioral therapy (11.7% vs 29.2%). CONCLUSION: Behavioral therapy with laxatives has no advantage over conventional treatment in treating childhood constipation. However, when behavior problems are present, behavioral therapy or referral to mental health services should be considered.

Cortisol and post-traumatic stress disorder in adults: systematic review and meta-analysis.

BACKGROUND: Post-traumatic stress disorder (PTSD) has inconsistently been associated with lower levels of cortisol. AIMS: To compare basal cortisol levels in adults with current PTSD and in people without psychiatric disorder. METHOD: Systematic review and meta-analysis. Standardised mean differences (SMD) in basal cortisol levels were calculated and random-effects models using inverse variance weighting were applied. RESULTS: Across 37 studies, 828 people with PTSD and 800 controls did not differ in cortisol levels (pooled SMD=-0.12, 95% CI=-0.32 to 0.080). Subgroup analyses revealed that studies assessing plasma or serum showed significantly lower levels in people with PTSD than in controls not exposed to trauma. Lower levels were also found in people with PTSD when females were included, in studies on physical or sexual abuse, and in afternoon samples. CONCLUSIONS: Low cortisol levels in PTSD are only found under certain conditions. Future research should elucidate whether low cortisol is related to gender or abuse and depends on the measurement methods used.

Changes in cortisol and DHEA plasma levels after psychotherapy for PTSD.

Post-traumatic stress disorder (PTSD) has been associated with dysregulation of the neuroendocrine system. In this study we examine the effects of psychotherapy in 21 PTSD patients, with and without coexisting depression, on the levels of six stress-related hormones: cortisol, dehydroepiandrosterone (DHEA), and dehydroepiandrosterone-sulfate (DHEA-S), prolactin, thyrotropin (TSH) and free thyroxin (fT4). The results show that after brief eclectic psychotherapy (BEP) significant changes occurred in levels of cortisol and DHEA. Responders showed an increase in cortisol and DHEA levels, while in non-responders both hormone levels decreased. Differences were only found after controlling for depressive symptoms. In conclusion, effective psychotherapy for PTSD may alter dysregulations in the Hypothalamus-pituitary-adrenal (HPA)-axis, but comorbid depressive symptoms should be taken into account.

HPA- and HPT-axis alterations in chronic posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) has been associated with dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis as well as of the hypothalamus-pituitary-thyroid (HPT) axis. Findings have not been consistent and may depend on methodological issues like controlling for relevant variables. This study examines the levels of six HPA and HPT-axis related hormones in civilian PTSD patients without psychotropic medication. In a cross sectional study, 39 chronic PTSD patients and 44 healthy volunteers were included. Psychometric instruments included SCID, SI-PTSD, IES-R and BDI. The plasma hormones levels assessed were cortisol, dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEA-S), prolactin, thyrotropin (TSH), and free thyroxin (fT4). Results showed that patients had significantly lower plasma cortisol, prolactin and TSH levels compared to the comparison group. The difference between TSH levels in patients and comparison subjects only emerged after controlling for relevant background variables. Furthermore, the severity of PTSD symptoms was negatively related to cortisol levels. Secondary analyses revealed no statistically significant effect of comorbid depression (26% of patients) on any of the hormone levels. Complex feedback mechanisms are likely to result in altered levels of stress related hormones in PTSD, and results depend on controlling for relevant variables. Further research with longitudinal designs is needed to find out whether these lower hormone levels are preexisting risk factors or consequence of trauma and whether these alterations are deleterious or adaptive.

Disaster-related posttraumatic stress symptoms and sustained attention: evaluation of depressive symptomatology and sleep disturbances as mediators.

Research about attentional functioning following trauma has almost exclusively been performed in patient populations with combat-related posttraumatic stress disorder (PTSD). In this study the relationship between sustained attention and PTSD symptoms was examined in a community sample of survivors of a major disaster using the Paced Auditory Serial Addition Task (PASAT) and the Self-Rating Scale for PTSD (SRS-PTSD) 2-3 years postdisaster. Analyses revealed low but significant partial correlations between PTSD symptoms and the least difficult subtests, ruling out the effects of age, education, depressive symptomatology, and sleep disturbances. These results demonstrate that PTSD symptoms link to attentional dysfunction 2-3 years postdisaster.

Mental health symptoms following war and repression in eastern Afghanistan.

CONTEXT: Decades of armed conflict, suppression, and displacement resulted in a high prevalence of mental health symptoms throughout Afghanistan. Its Eastern province of Nangarhar is part of the region that originated the Taliban movement. This may have had a distinct impact on the living circumstances and mental health condition of the province's population. OBJECTIVES: To determine the rate of exposure to traumatic events; estimate prevalence rates of symptoms of posttraumatic stress disorder (PTSD), depression, and anxiety; identify resources used for emotional support and risk factors for mental health symptoms; and assess the present coverage of basic needs in Nangarhar province, Afghanistan. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional multicluster sample survey of 1011 respondents aged 15 years or older, conducted in Nangarhar province during January and March 2003; 362 households were represented with a mean of 2.8 respondents per household (72% participation rate). MAIN OUTCOME MEASURES: Posttraumatic stress disorder symptoms and traumatic events using the Harvard Trauma Questionnaire; depression and general anxiety symptoms using the Hopkins Symptom Checklist; and resources for emotional support through a locally informed questionnaire. RESULTS: During the past 10 years, 432 respondents (43.7%) experienced between 8 and 10 traumatic events; 141 respondents (14.1%) experienced 11 or more. High rates of symptoms of depression were reported by 391 respondents (38.5%); anxiety, 524 (51.8%); and PTSD, 207 (20.4%). Symptoms were more prevalent in women than in men (depression: odds ratio [OR], 7.3 [95% confidence interval [CI], 5.4-9.8]; anxiety: OR, 12.8 [95% CI, 9.0-18.1]; PTSD: OR, 5.8 [95% CI, 3.8-8.9]). Higher rates of symptoms were associated with higher numbers of traumas experienced. The main resources for emotional support were religion and family. Medical care was reported to be insufficient by 228 respondents (22.6%). CONCLUSIONS: In this survey of inhabitants of Nangarhar province, Afghanistan, prevalence rates of having experienced multiple traumatic events and having symptoms of anxiety, depression, and PTSD were high. These findings suggest that mental health symptoms in this region should be addressed at the population and primary health care level.

Attentional and oculomotor capture with static singletons.

Previous research has shown that in visual search static singletons have the ability to capture attention (Theeuwes, 1991a, 1992). The present study investigated whether these singletons also have the ability to capture the eyes. Participants had to make an eye movement and respond manually to a shape singleton while a color singleton was present. When participants searched for a unique shape while a unique color singleton was present there was strong attentional and oculomotor capture (Experiment 1). However, when participants searched for a specific-shape singleton (a green circle) when a specific-color singleton (a red element) had to be ignored, there was attentional capture but no oculomotor capture (Experiment 2). The results suggest that an attentional set for a specific feature value defining both the target and the distractor (as in Experiment 2) allows such a fast disengagement of attention from the location of the distractor that a saccade execution to that location is prevented.