Posttraumatic stress disorder and the use of health services.

OBJECTIVE: Prior research has demonstrated increased use of medical services among persons with anxiety and depression. This investigation examined the possible association of posttraumatic stress disorder (PTSD) with the use of nonmental health services. METHOD: A case-comparison design enrolled 102 high users of health services and 54 low users who were assessed for PTSD diagnosis and severity of PTSD symptoms. Subjects were male veterans receiving services from the primary care clinics of the VA Boston Healthcare System during an 18-month period. Data were collected by interview by use of standardized instruments including the Clinician Administered PTSD Scale for DSM-IV, the Life Events Checklist, and the Beck Depression Inventory. Data analysis employed odds ratios, linear and logistic regression, and path analyses. RESULTS: High users of health care were almost twice as likely as low users (27.5% vs. 14.8%) to meet diagnostic criteria for current PTSD. The two groups differed significantly on both symptom frequency and intensity. Path analyses showed an indirect positive association between PTSD and health services use, with physician-diagnosed health conditions as a mediating variable. Auxiliary analysis demonstrated that the combined mental health burden of PTSD and depression symptoms also is positively associated with number of health conditions. CONCLUSIONS: The findings indicate that PTSD, alone and in combination with depression, has a direct negative relationship with physical health that, in turn, is associated with more frequent use of primary health care services. These results do not suggest that PTSD leads to inappropriate (eg, distress-motivated) use of services.

A meta-analytic examination of basal cardiovascular activity in posttraumatic stress disorder.

OBJECTIVE: The objective of this meta-analytic study was to determine whether individuals with posttraumatic stress disorder (PTSD) have higher levels of basal cardiovascular activity relative to comparable groups of individuals without PTSD. METHODS: Meta-analytic data methods were applied to 34 studies that gathered indicators of basal cardiovascular activity including: heart rate (HR), systolic blood pressure, and diastolic blood pressure on subjects diagnosed with PTSD and two types of comparison groups. In total, cardiovascular measures were analyzed for 2670 subjects across all studies. RESULTS: Results indicate that individuals with a current PTSD diagnosis have higher resting HR relative to both trauma-exposed individuals without a PTSD diagnosis and non-trauma-exposed individuals. The results also suggest that PTSD is associated with elevations in blood pressure; however, the effect sizes were smaller in magnitude than those obtained for heart rate. A subset analysis revealed that the effect sizes for comparisons on basal HR were greatest in studies with the most chronic PTSD samples. CONCLUSION: The meta-analysis supports previous qualitative reviews, finding a positive association between PTSD and basal cardiovascular activity. The discussion addresses possible mechanisms of action and the health-related implications of these findings.

Empirically supported ethical research practice: the costs and benefits of research from the participants' view.

Researchers and institutional review boards are routinely called upon to evaluate the cost-benefit status of proposed research protocols that involve human participants. Often these assessments are based on subjective judgments in the absence of empirical data. This reliance on subjective judgments is of particular concern for studies involving clinical samples where unfounded assumptions may adversely affect research progress or clinical outcomes. The Reactions to Research Participation Questionnaire (RRPQ) was designed to address this shortcoming and to help promote ethical decision making about research practice. The present study describes development of the RRPQ and presents a series of exploratory and confirmatory analyses investigating its structure. Based on these findings, a revised version of the instrument and suggestions for future research are presented. This approach provides a foundation for scientifically informed protection of human subjects.

Trauma-related psychophysiological reactivity in women exposed to war-zone stress.

Women are at particular risk for Posttraumatic Stress Disorder (PTSD), but surprisingly little is known about their objective manifestations of the disorder's hallmark symptoms. Although research suggests that people with PTSD exhibit physiological reactivity to the presentation of trauma-related cues, the majority of studies to date have focused on men. We assessed the physiological reactions of three groups of trauma-exposed female Vietnam veterans (those with current PTSD, lifetime PTSD, or no PTSD) to war-related stimuli. Responses of women with current PTSD differed significantly from those without PTSD on skin conductance and systolic blood pressure, and mean levels of reactivity for women with lifetime PTSD fell between the other two groups. Although symptom severity was correlated with physiologic reactivity overall, results suggested differential relationships at the symptom cluster level. Study results replicate earlier findings with men and extend knowledge of autonomic reactivity to an important group of female survivors.

Stimulus novelty differentially affects attentional allocation in PTSD.

BACKGROUND: This study investigated attentional allocation in 39 Vietnam combat veterans, 25 with and 14 without posttraumatic stress disorder, assessing P300 amplitudes and latencies during both three-tone and novelty "oddball" tasks. METHODS: The three-tone oddball task consisted of three stimuli: frequent tones (85%), rare target tones (7.5%), and rare distractor tones (7.5%). The novelty oddball task was identical to the three-tone task except that the rare distractor tones were replaced with nonrepeating novel sounds (7.5%). RESULTS: Combat veterans with posttraumatic stress disorder showed significant P300 amplitude enhancements at frontal sites in response to distracting stimuli during the novelty but not during the three-tone oddball tasks. There were no amplitude differences in target tones during either task. CONCLUSIONS: The data suggest that combat veterans with posttraumatic stress disorder demonstrate P300 responses consistent with a heightened orientation response to novel, distracting stimuli. This finding is consistent both with the clinical presentation of the disorder and with theoretical notions that individuals with posttraumatic stress disorder demonstrate information-processing biases towards vague or potentially threatening stimuli.

Emotional processing in posttraumatic stress disorder.

The emotional deficits associated with posttraumatic stress disorder (PTSD) are the least understood and the most understudied aspect of the syndrome. In this study, the connection was evaluated between trauma-context reactivity and subsequent emotional deficits in PTSD. Combat veterans with PTSD and well-adjusted veteran control participants were exposed to reminders of combat, after which their emotional behavior was assessed in response to a series of emotionally evocative images. Under the neutral condition, both groups exhibited emotional behavior modulated by stimulus valence. Partially consistent with the conceptual model described by B. Litz (1992), the PTSD group exhibited suppressed expressive-motor responses to positively valenced images, in comparison with the control group, only after being exposed to a trauma-related prime. Contrary to expectations, the PTSD group showed no augmentation of emotional response to negatively valenced cues after being exposed to trauma reminders. However, the PTSD group responded to all images, in both prime conditions, with higher heart rate reactivity, suggesting an automatic preparation for demand or threat in any uncertain emotional context. Possible causes and consequences of these results are discussed.

Predictors of emotional numbing, revisited: a replication and extension.

Litz et al. (1997), theorizing that emotional numbing (EN) is the result of emotional depletion caused by chronic hyperarousal, demonstrated that a cluster of hyperarousal symptoms was a robust predictor of EN symptoms. In the present study, these findings were replicated and extended in two multiple regression analyses of data from a large, multisite investigation (T. M. Keane et al., 1998) of psychophysiological responding by male combat veterans. The arousal (D) cluster of symptoms was again the most robust predictor of EN symptoms, whereas physiological indices of arousal and reactivity accounted for negligible amounts of variance in both regression equations. These findings underscore the possible link between disturbances related to arousal and the capacity of traumatized individuals to express and experience pleasant feelings.

Neural correlates of exposure to traumatic pictures and sound in Vietnam combat veterans with and without posttraumatic stress disorder: a positron emission tomography study.

BACKGROUND: Patients with posttraumatic stress disorder (PTSD) show a reliable increase in PTSD symptoms and physiological reactivity following exposure to traumatic pictures and sounds. In this study neural correlates of exposure to traumatic pictures and sounds were measured in PTSD. METHODS: Positron emission tomography and H2[15O] were used to measure cerebral blood flow during exposure to combat-related and neutral pictures and sounds in Vietnam combat veterans with and without PTSD. RESULTS: Exposure to traumatic material in PTSD (but not non-PTSD) subjects resulted in a decrease in blood flow in medial prefrontal cortex (area 25), an area postulated to play a role in emotion through inhibition of amygdala responsiveness. Non-PTSD subjects activated anterior cingulate (area 24) to a greater degree than PTSD patients. There were also differences in cerebral blood flow response in areas involved in memory and visuospatial processing (and by extension response to threat), including posterior cingulate (area 23), precentral (motor) and inferior parietal cortex, and lingual gyrus. There was a pattern of increases in PTSD and decreases in non-PTSD subjects in these areas. CONCLUSIONS: The findings suggest that functional alternations in specific cortical and subcortical brain areas involved in memory, visuospatial processing, and emotion underlie the symptoms of patients with PTSD.

Treatment for traumatic memories: review and recommendations.

The aim of this article is to provide recommendations concerning the use of exposure-based therapy for reduction of emotional responding to traumatic memories. Background for these recommendations consists of a summary of the literature on traumatic stress and symptoms of posttraumatic stress disorder (PTSD); an overview of biological, cognitive, and behavioral models for traumatic memory; and a selective review of evidence for the effectiveness of therapeutic exposure as a treatment for trauma memories and PTSD. The recommendations themselves demonstrate how clinical decision making during the course of treatment might be informed by empirical evidence and theoretical models concerning human memory, as well as ethical and legal considerations that mark this topic.

Utility of psychophysiological measurement in the diagnosis of posttraumatic stress disorder: results from a Department of Veterans Affairs Cooperative Study.

This multisite study tested the ability of psychophysiological responding to predict posttraumatic stress disorder (PTSD) diagnosis (current, lifetime, or never) in a large sample of male Vietnam veterans. Predictor variables for a logistic regression equation were drawn from a challenge task involving scenes of combat. The equation was tested and cross-validated demonstrating correct classification of approximately 2/3 of the current and never PTSD participants. Results replicate the finding of heightened psychophysiological responding to trauma-related cues by individuals with current PTSD, as well as differences in a variety of other domains between groups with and without the disorder. Follow-up analyses indicate that veterans with current PTSD who do not react physiologically to the challenge task manifest less reexperiencing symptoms, depression, and guilt. Discussion addresses the value of psychophysiological measures for assessment of PTSD.

Comorbid psychiatric disorders in PTSD. Implications for research.

It is clear from the existing data that PTSD often occurs in the context of other major psychological conditions. Evidence to support this comes from clinical studies, epidemiological studies, and studies of PTSD among substance abusers. Clearly, probably several different subgroups of PTSD patients exist including those who had psychological or behavioral problems before exposure to traumatic events (e.g., substance abuse), those who developed other problems concurrent with exposure to the traumatic events, and those who developed problems secondary to the development of PTSD, perhaps in efforts to cope with the intensely debilitating symptoms of PTSD. With this knowledge, research on PTSD must begin to contend with the comorbidity issue in systematic ways. The use of comparison groups that are carefully selected is one key way in which conclusions about PTSD can be most conservatively drawn. The use of statistical procedures to control for difference in levels of comorbidity is another responsible way in which to approach the problem. Finally, efforts to employ global measures of functioning such as the Global Assessment of Functioning to equate subjects within a study on minimally this characteristic may be the most economical method for trying to rule out the role of comorbidity and severity of condition in conclusions drawn in research studies. All these solutions presuppose the careful measurement of comorbidity in studies of PTSD, a recommendation that requires serious consideration for researchers operating in this field.

The development of a Clinician-Administered PTSD Scale.

Several interviews are available for assessing PTSD. These interviews vary in merit when compared on stringent psychometric and utility standards. Of all the interviews, the Clinician-Administered PTSD Scale (CAPS-1) appears to satisfy these standards most uniformly. The CAPS-1 is a structured interview for assessing core and associated symptoms of PTSD. It assesses the frequency and intensity of each symptom using standard prompt questions and explicit, behaviorally-anchored rating scales. The CAPS-1 yields both continuous and dichotomous scores for current and lifetime PTSD symptoms. Intended for use by experienced clinicians, it also can be administered by appropriately trained paraprofessionals. Data from a large scale psychometric study of the CAPS-1 have provided impressive evidence of its reliability and validity as a PTSD interview.

Psychological investigation of genital herpes recurrence: prospective assessment and cognitive-behavioral intervention for a chronic physical disorder.

Previous studies suggest that anxiety and/or depressed mood are associated with recurrence of genital herpes lesions. The present study sought to extend the assessment of factors associated with genital herpes and to investigate the impact of psychological therapy on features of the disorder. Sixteen genital herpes patients received 5 weeks of either structured discussion or cognitive restructuring (CR) therapy in a group format. Measures of attitude about herpes, global coping, distress, loneliness, health locus of control, and recurrence frequency were administered at pretreatment, posttreatment, and 3 months follow-up. Patients also made daily reports during the 5 weeks of treatment from which information was extracted regarding their herpes symptoms, dysphoria, anxiety, and ongoing coping process. Therapy did not produce the expected reductions in reported distress or loneliness. The CR procedure, however, was associated with reduced frequency of lesion recurrence at follow-up. Avoidant coping was associated with lower recurrence rates, and loneliness scores were associated with higher recurrence rates. Prospective data indicated that recurrences were preceded by elevated anxiety that was independent of prodromal symptoms. These results provide support for the general proposals that psychological factors influence health status and that psychological intervention may reduce disease recurrence.

Coping with dental treatment: the potential impact of situational demands.

Coping strategies and anxiety responding of dental patients were studied in order to test the generalizability of previous findings based on volunteer blood donors. State and trait coping measures were administered once, and a process coping scale was administered at three points throughout treatment. Self-report, behavioral observation, and psychophysiological measures of anxiety were sampled for the same periods as process coping. Findings included the replication of a negative relationship between avoidant coping and patient anxiety ratings. Fluctuations in coping were evident across periods, and impact of situational demands and constraints was introduced as an explanation for these variations. A method for direct assessment of coping consistency was introduced. On the basis of the replicable associations with anxiety measures, the ability to detect changes in coping within a situation, and the ability to provide direct evidence of coping consistency, the use of process methodology for coping assessment is encouraged.

Post-stroke depression: relationships to functional impairment, coping strategies, and rehabilitation outcome.

This study examined the phenomenon of post-stroke depression and evaluated its impact on rehabilitation outcome. Sixty-four patients presenting to a rehabilitation program within weeks of first stroke were evaluated for depression through self-report measures and staff ratings. Patients also rated the particular coping strategies which they used in dealing with their illness and hospital stay. Physical and occupational therapists provided measures of functional impairment at admission and discharge. A high (47%) prevalence of depression was found in this population, with no overall differences observed between patients with right or left hemisphere lesions. Depressed patients, in comparison to non-depressed, evidenced greater functional impairment at both admission and discharge. However, both groups showed similar gains over the course of rehabilitation. Coping strategies employed by depressed patients appeared to reflect a lower level of participation in the rehabilitation process. A subgroup of patients evaluated 6 weeks after discharge revealed that depression was associated with a worsening on one measure of functional status. These findings indicate that depression is a frequent companion of stroke, that it is associated with degree of functional impairment, and that it may exert a negative impact on the rehabilitation process and outcome.

Poststroke depression and lesion location. An attempted replication.

Recent evidence suggests that poststroke depression is associated with the location of the brain infarct, proximity to the frontal pole being associated with greater depression following left hemisphere injury, and an opposite relationship being seen with injury to the right hemisphere. This study was designed to replicate and extend previous investigation of this issue. Depression was assessed following recent stroke in patients with localized right (n = 16) or left (n = 19) hemisphere lesions. No overall differences between these groups were found on several measures of depression. Although there appeared to be a negative linear relationship between severity of depression and distance of the lesion from the frontal pole in left hemisphere patients, this association failed to attain statistical significance. A curvilinear relationship was evident in right hemisphere patients, with anterior and posterior lesions associated with high depression scores. These data support the notion that lesion location is associated with the severity of poststroke depression, although the nature of this association may be more complex than has previously been suggested.

Coping with a stressful medical procedure: further investigation with volunteer blood donors.

The coping strategies used by volunteer blood donors were studied in an attempt to replicate and extend the findings of Kaloupek et al. [(1984). J. Behav. Med. 7:35-60]. Specifically, coping was assessed by process, state, and trait measures that were then examined in terms of their relationships with subjective, physiological, and behavioral indices of anxiety. Ratings of anxiety made by the donors themselves and by attending nurses generally replicated the previous finding of lower distress associated with avoidant coping (e.g., distraction). Problem-focused coping was also associated with lower distress, including a lower heart rate for first-time donors. Other evidence suggests that for some individuals the expression of distress may be part of a coping strategy that is associated with reduced physiological responding. Discussion concerns links between coping and anxiety which may have relevance to stressful medical situations, including the possible need for anxiety reduction to allow successful application of avoidant coping.

Assessment of coping strategies associated with syncope in blood donors.

Characteristics associated with vasovagal syncope in blood donors were investigated in two studies. An initial goal was to examine the potential role of physical and health variables. The primary goal was to assess coping strategies that might be related to the second phase (i.e., bradycardia; hypotension) of the vasovagal reaction pattern. Findings in both studies revealed that physical characteristics and health variables were unrelated to syncope. Donors who experienced reactions were characterized, however, by fewer prior blood donations and a greater likelihood of previous syncope. Multivariate analysis also indicated that in the context of the variables just noted, reacting donors reported less awareness of anxiety-related physiological cues. Other findings suggested that Suppression, a coping strategy that has been previously associated with heart rate decrease in blood donors, may be linked to syncope. Prospective assessment of coping is suggested for future studies of psychological factors involved in syncope.