The role of childhood cumulative trauma in the risk of lifetime PTSD: An epidemiological study.

Cumulative trauma is usually devastating and can lead to severe psychological consequences, including posttraumatic stress disorder (PTSD). Exposure to various types of traumas, particularly during childhood, can be even more deleterious than the sheer number of events experienced. This epidemiological study is the first to investigate the impact of discrete childhood traumatic exposure on the risk of developing lifetime PTSD in a representative sample of the general population of the two biggest Brazilian cities. Participants were aged between 15 and 75 years old, living in São Paulo and Rio de Janeiro, Brazil, who had experienced traumatic events (N = 3,231). The PTSD diagnosis was assessed using the DSM-IV criteria through the version 2.1 of Composite International Diagnostic Interview. To operationalize childhood cumulative trauma, we considered the sum of 15 different childhood trauma categories that occurred before PTSD onset. The final multivariate logistic regression model indicated a strong relationship between the number of discrete types of childhood traumas and the likelihood of the lifetime PTSD development. The lifetime PTSD risk increased 28 % with each different type of childhood trauma when adjusted by confounds. Our study strengthens the evidence associating childhood cumulative trauma to increased lifetime PTSD risk.

High depressive symptomatology reduces emotional reactions to pictures of social interaction.

Individuals with severe depressive symptoms present diminished facial expressions compared to healthy individuals. This reduced facial expression, which occurs in most depressive patients could impair social relationships. The current study sought to investigate whether pictures with social interaction cues could elicit different modulations of facial expressions and mood states in individuals with depressive symptoms compared to healthy individuals. A total of 85 individuals were divided into depressive and non-depressive groups based on their beck depression inventory scores. Participants viewed pictures containing neutral (objects), affiliative (people interacting socially), and control (people not interacting) scenes. Electromyographic signals were collected during the entire period of visualization of the blocks, and emotional questionnaires were evaluated after each block to assess sociability and altruism (prosocial states). In non-depressed individuals, affiliative pictures increased the activity of the zygomatic muscle compared to both neutral and control pictures and reduced fear of rejection compared to neutral pictures. During the visualization of the affiliative block, zygomatic major muscle activation was higher and fear of rejection was lower in the non-depressive individuals than in the depressive. These effects reflected the low expressions of smiling and sociability to affiliative pictures in depressive individuals. These findings highlight the importance of smiling and prosocial states in social interactions, especially in these individuals.

A bright side of adversity? A systematic review on posttraumatic growth among refugees.

Until the third trimester of 2022, 103 million people worldwide had been forced to leave their homes and become refugees. The traumatic experiences of refugees can lead not only to mental disorders but also to Posttraumatic Growth (PTG). (1) To find the variables positively and negatively associated with PTG in refugees. (2) To investigate the relationship between PTG and Posttraumatic Stress Disorder (PTSD) among refugees. We systematically searched Medline, Web of Knowledge, PsycInfo, Scopus, and PTSD Pubs for studies about PTG in refugees. Epidemiological studies using the Posttraumatic Growth Inventory. Grey literature, reviews, and meta-analysis. Risk of bias was assessed by the 'The Joanna Briggs Institute Prevalence Critical Appraisal Tool'. We included 24 studies investigating PTG and associated factors. The factors positively associated with PTG were social support, regular migration status, religiosity, satisfaction with life, time, and problem-focussed and emotion-focussed coping. The factors negatively associated with PTG were: irregular migration status, emotional suppression, and avoidance coping. Studies on PTG in refugees are essential to finding new ways to address mental health in this field. Few studies offered risk of bias, particularly regarding the sample selection. We conclude that PTG may be influenced by many factors and it would be of importance that the centres for support, as well as public policies, took that into account to foster the outcome and not only to focus on disease. This study was partially supported by CAPES and registered on PROSPERO (CRD42020215607).

The different impacts of COVID-19 on the mental health of distinct health care worker categories.

The present study sought to explore the factors associated with the odds of having probable depression and posttraumatic stress disorder (PTSD) related to traumatic COVID-19 experiences and their impact on health care workers in distinct categories. In this cross-sectional study, 1843 health care workers (nurses, nurse technicians, physicians, physical therapists, and other healthcare workers) were recruited via convenience sampling. A survey was administered to obtain information regarding sociodemographic, occupational, and mental health status. Descriptive statistics and multivariable logistic regression were used for the analyses. Being a nurse technician was associated with an odds ratio of 1.76 for probable PTSD. No relation was observed between health care worker categories and the odds of probable depression. Additionally, being female and not receiving adequate PPE were related to greater odds of having probable PTSD and depression.

The top-100 cited articles on post-traumatic stress disorder: a historical bibliometric analysis.

This is a bibliometric analysis of the most-cited articles on post-traumatic stress disorder (PTSD) with the objective of identifying citation patterns for researchers, journals, centers, periods, topics, and nations. A search was conducted in Thomson Reuters' WoS Core Collection employing the expression TI = (posttraumatic stress disorder OR post-traumatic stress disorder OR PTSD). The 100 most-cited articles were downloaded, and the relevant data were extracted and analyzed. These studies had a total of 69,649 citations, ranging from a minimum of 360 to a maximum of 6029 citations, with an average of 696.49, a standard deviation of 720.92, mode of 369, and a median of 512. Eighty-eight percent of the most-cited articles on PTSD originated from the USA, with just six cities accounting for 52% of the publications and the Boston area alone responsible for almost one-fifth of the total output. The universities of Yale and Harvard headed the ranking of institutions with larger numbers of highly-cited articles. Female researchers represented 42.3% of all authors, 51% of the first authors, and 48% of the corresponding authors. The proportion of M.D. authors decreased significantly between the 1980-1999 (42%) and the 2000-2019 (27.2%) periods while that of Ph.D. authors increased from 44% to 57.4%. The most studied population was military veterans (28%). Female victims of sexual or physical violence, traumatized children, and adult survivors of childhood abuse were assessed in only 6-7% of the most-cited publications. Ten clinical trials evaluated psychological interventions but only three investigated pharmacotherapy. We concluded that influential research on PTSD remains centralized in the USA. A balanced gender representation in publications was found. There was a heavy reliance on combat veterans as the study population. Few highly-cited studies on the pharmacotherapy for PTSD were identified. Focused efforts are needed to address these challenges.

Tonic immobility is associated with posttraumatic stress symptoms in healthcare professionals exposed to COVID-19-related trauma.

The Coronavirus Disease 2019 (COVID-19) pandemic has exposed healthcare workers (HCW) to traumatic situations that might lead to the development of posttraumatic stress disorder (PTSD). An important vulnerability factor for PTSD is the peritraumatic tonic immobility (TI) reaction, an involuntary and reflexive defensive response evoked by an intense and inescapable threat. TI is largely understudied in humans and has not been investigated during trauma related to COVID-19. For HCW, the pandemic context might be experienced as an intense and potentially inescapable threat, i.e., an overwhelming situation. Here, we investigated if TI response occurred during traumatic events related to the pandemic and its association with posttraumatic stress symptoms (PTSS). An online survey of 1001 HCW investigated COVID-19-related traumatic experiences, TI and PTSS. TI was reported for all types of traumatic events, and multivariate regression models revealed that TI was significantly associated with PTSS severity. HCW who reported high TI scores exhibited an increase of 9.08 times the probability of having a probable diagnosis of PTSD. Thus, TI was evoked by pandemic-related traumatic situations and associated with PTSS severity and higher odds of a PTSD diagnosis. Tonic immobility occurrence should be screened, and psychoeducation about its reflexive biological nature should be introduced.

To BDZ or not to BDZ? That is the question! Is there reliable scientific evidence for or against using benzodiazepines in the aftermath of potentially traumatic events for the prevention of PTSD? A systematic review and meta-analysis.

BACKGROUND: Most international guidelines suggest that benzodiazepines (BDZs) may be inefficient or iatrogenic in the aftermath of a potentially traumatic event (PTE). The goal of this study was to assess the strength of the evidence on whether the use of BDZs in the aftermath of a PTE negatively affects the incidence and severity of post-traumatic stress disorder (PTSD). METHODS: We systematically scrutinized the ISI Web of Knowledge, MEDLINE, SCOPUS, and PTSDpubs electronic databases in addition to citation searching. We included original studies providing data about the development of PTSD in adults after BDZ administration in the aftermath of a PTE. We screened 387 abstracts and selected eight studies for the qualitative synthesis and seven for the meta-analysis. We performed two separate meta-analyses, one for randomized clinical trials (RCTs) and the other for cohort studies. Heterogeneity between studies was evaluated with Higgins I² statistic and tested using the χ². This study was registered at PROSPERO (number 127170). RESULTS: The meta-analysis of the cohort studies showed an increased risk of PTSD in patients who received BDZs compared to those who did not (risk ratio (RR) = 1.53; 95% confidence interval (CI): 1.05-2.23) with a modest heterogeneity among studies (I2 = 41.8, p = 0.143). Regarding the RCTs, the combined measure revealed a tendency toward an increased severity of the PTSD symptoms (standardized mean difference (SMD): 0.24; 95% CI: 0.32-0.79). CONCLUSION: The studies reviewed showed a possible harmful effect of BDZs when used immediately after a PTE. However, these conclusions were based on a small number of studies of poor to moderate methodological quality.

The growth and development of research on personality disorders: A bibliometric study.

This study objective was to investigate publication trends on personality disorders (PD) and to identify patterns of historical development. Publication rates were determined using the Results by Year Timeline feature of PubMed. Time series autoregressive integrated moving average models were used to analyse the publication rates for PDs in quinquennial periods beginning in 1980 and ending in 2019 and to predict the number of publications in the 2024-2029 period. More than 300 articles on antisocial and borderline PD are being published each year, and the models suggest an accelerating growth rate. Approximately 100 articles are being published on average every year on schizotypal PD, and the regression model indicates linear growth in the near future. The mean number of publications per year for obsessive-compulsive, narcissistic and avoidant PDs is in the range of 10-30 with the corresponding models indicating linear growth. Fewer than 10 articles are being published each year on dependent, paranoid, histrionic and schizoid PD, whereas dependent PD shows modest growth and paranoid PD rates tended to stability, histrionic and schizoid PD exhibit declining rates. Personality disorders are a group of conditions with diverse etiological, prognostic, therapeutic, legal, research, social and cultural implications that influence publication rates.

The Jornal Brasileiro de Psiquiatria: a bibliometric survey of the one hundred most cited articles in the last 15 years / Jornal Brasileiro de Psiquiatria: uma pesquisa bibliométrica sobre os 100 artigos mais citados nos últimos 15 anos

OBJECTIVE: Bibliometrics is a group of statistical and mathematical methods employed to measure and analyze the quantity and the quality of scientific articles, books, and other forms of publications. The objective of the present study was to conduct a bibliometric analysis of the Jornal Brasileiro de Psiquiatria (JBP) by listing its 100 most highly cited articles in the scientific literature and identifying their main characteristics in terms of authorship and research topics and design. METHODS: The 100 topcited references in the JBP were identified through a search with Google Scholar. The main author, last author, corresponding author, the total number of authors, gender of the authors, year of publication, research institution, geographic origin, language, and the research design and subject of each reference were recorded and analyzed. RESULTS: A marked increase in the number of citations in the last 15 years, a relatively balanced distribution of publications among the Brazilian states and research centers, absence of gender bias among authors, and a varied range of published topics suggest a good current editorial performance by the JBP. Relative lack of systematic reviews and longitudinal studies, dearth of articles published in the English language, and modest participation of foreign authors were points requiring improvement. CONCLUSION: The present study suggests that a survey of the 100 most cited articles in the JBP can provide a historical overview of the progress of this journal, as well as highlight the main obstacles, constraints, and challenges faced by its editors and authors.

OBJETIVO: Bibliometria é um grupo de métodos estatísticos e matemáticos empregados para medir e analisar a quantidade e a qualidade de artigos científicos, livros e outras formas de publicações. O objetivo do presente estudo foi realizar uma análise bibliométrica do Jornal Brasileiro de Psiquiatria (JBP), relacionando seus 100 artigos mais citados na literatura científica e identificando suas principais características em termos de autoria e questões de pesquisa e delineamento experimental. MÉTODOS: As 100 referências mais citadas no JBP foram identificadas por meio de uma busca no Google Scholar. Foram registradas e analisadas as seguintes informações: autor principal, último autor, autor correspondente, número total de autores, gênero dos autores, ano de publicação, instituição de pesquisa, origem geográfica e idioma de cada referência e seu tema de investigação e delineamento metodológico. RESULTADOS: O aumento acentuado no número de citações nos últimos 15 anos, a boa distribuição das publicações entre os estados e centros de pesquisa brasileiros, a ausência de viés de gênero entre os autores e a variada gama de tópicos publicados sugerem um bom desempenho editorial atual do JBP. A relativa falta de revisões sistemáticas e estudos longitudinais, os poucos artigos publicados em inglês e a pequena participação de autores estrangeiros são pontos que requerem melhorias. CONCLUSÃO: O presente estudo sugere que o levantamento dos 100 artigos mais citados no JBP pode fornecer um panorama histórico da evolução dessa revista, bem como destacar os principais obstáculos, restrições e desafios enfrentados por seus editores e autores.

Tonic Immobility is Associated with PTSD Symptoms in Traumatized Adolescents.

PURPOSE: Growing evidence suggests that peritraumatic tonic immobility, an involuntary defensive response that involves extreme physical immobility and the perceived inability to escape, is a significant predictor of post-traumatic stress disorder (PTSD) symptomatology. However, this issue has not been specifically addressed in adolescents. Here, we investigated whether tonic immobility response experienced during the worst childhood or adolescent trauma is associated with PTSD symptom severity in a non-clinical student sample. METHODS: The sample was composed of students in 9th grade who were attending public and private schools. Symptoms of post-traumatic stress and tonic immobility were assessed using questionnaires. We performed bivariate and multivariate negative binomial regressions to examine whether tonic immobility was associated with PTSD symptomatology after controlling for confounders (peritraumatic dissociation, peritraumatic panic reactions, gender, age and time since trauma). RESULTS: We found an association between tonic immobility and PTSD symptom severity, even after controlling for confounders. Therefore, tonic immobility is associated with PTSD symptoms in trauma-exposed adolescents. CONCLUSION: These findings highlight tonic immobility as a possible risk factor that could be used to provide direction for more targeted trauma interventions for individuals, particularly those at risk for developing PTSD. Therefore, it contributes to preventing and reducing the psychiatric burden in adolescence and later in life.

Unveiling the neural underpinnings of optimism: a systematic review.

Optimism is a personality trait strongly associated with physical and psychological well-being, with correlates in nonhuman species. Optimistic individuals hold positive expectancies for their future, have better physical and psychological health, recover faster after heart disease and other ailments, and cope more effectively with stress and anxiety. We performed a systematic review of neuroimaging studies focusing on neural correlates of optimism. A search identified 14 papers eligible for inclusion. Two key brain areas were linked to optimism: the anterior cingulate cortex (ACC), involved in imagining the future and processing of self-referential information; and the inferior frontal gyrus (IFG), involved in response inhibition and processing relevant cues. ACC activity was positively correlated with trait optimism and with the probability estimations of future positive events. Behavioral measures of optimistic tendencies investigated through the belief update task correlated positively with IFG activity. Elucidating the neural underpinnings of optimism may inform both the development of prevention and treatment strategies for several mental disorders negatively associated with optimism, such as depression, as well as help to foster new resilience promotion interventions targeting healthy, vulnerable, and mentally ill individuals.

The invisible scars of emotional abuse: a common and highly harmful form of childhood maltreatment.

BACKGROUND: Childhood maltreatment (CM) is unfortunately widespread globally and has been linked with an increased risk of a variety of psychiatric disorders in adults, including posttraumatic stress disorder (PTSD). These associations are well established in the literature for some maltreatment forms, such as sexual and physical abuse. However, the effects of emotional maltreatment are much less explored, even though this type figures among the most common forms of childhood maltreatment. Thus, the present study aims to investigate the impact of each type of childhood maltreatment, both individually and conjointly, on revictimization and PTSD symptom severity using a nonclinical college student sample. METHODS: Five hundred and two graduate and undergraduate students participated in the study by completing questionnaires assessing lifetime traumatic experiences in general, maltreatment during childhood and PTSD symptoms. Bivariate and multivariate negative binomial regressions were applied to examine the associations among childhood maltreatment, revictimization, and PTSD symptom severity. RESULTS: Our results showed that using bivariate models, all types of CM were significantly associated with revictimization and PTSD symptom severity. Multivariate models showed that emotional abuse was the type of maltreatment associated with the highest incidence rates of revictimization and PTSD symptom severity. CONCLUSIONS: These data provide additional evidence of the harmful effects of childhood maltreatment and its long-term consequences for individuals' mental health. Notably, the findings highlight the importance of studying the impacts of emotional abuse, which seems to be a highly prevalent, understudied, and chronic form of maltreatment that is as toxic as other maltreatment forms.

Possible outcomes of cumulative trauma in mental-health: a case report / Possíveis desfechos para trauma cumulativo na saúde mental: um relato de caso

ABSTRACT To discuss the resilience factors that may have prevented a patient from developing post-traumatic stress disorder (PTSD) after exposure to a variety of severe potentially traumatic events. A thirty-eight-year-old civilian has been exposed to at least ten dramatic situations of violence in his work and personal life. He developed only a few mild post-traumatic symptoms after being exposed to a particularly gruesome incident during work. Even though the number and severity of potentially traumatic events may be alarming, this does not determine that the patient will inexorably develop PTSD, or other disorders. The study of protective factors is mandatory so that we can acknowledge and develop more effective ways to prevent and treat disorders.

RESUMO Discutir fatores de resiliência que podem ter prevenido que um paciente desenvolvesse transtorno do estresse pós-traumático (TEPT) após a exposição a uma variedade de eventos potencialmente traumáticos severos. Um civil de 38 anos que foi exposto a, ao menos, 10 situações dramáticas de violência em seu trabalho e vida pessoal. Ele desenvolveu apenas alguns sintomas leves após o trauma de ter sido exposto a um evento particularmente desconcertante durante seu trabalho. Apesar de o número e a severidade dos eventos potencialmente traumáticos serem alarmantes, isso não determina que o paciente invariavelmente apresentará o TEPT ou outros transtornos. O estudo dos fatores protetivos é essencial para que possamos reconhecer e desenvolver maneiras efetivas de prevenir e tratar os transtornos mentais.

Comorbidity in post-traumatic stress disorder: A population-based study from the two largest cities in Brazil.

BACKGROUND: This study investigated the patterns of comorbidity between PTSD and depression, other anxiety disorders, alcohol-related disorders using the DSM-IV and ICD-10 criteria. The temporal sequence of the comorbid diagnoses was also investigated. METHODS: We used data from a large population-based survey carried out between 2007 and 2008 in the two largest cities in Brazil: São Paulo and Rio de Janeiro. RESULTS: Diagnoses of depression, other anxiety disorders, and alcohol-related disorder were more prevalent in the people with PTSD than in those without PTSD. Using the DSM-IV criteria, approximately 67% of cases presenting PTSD were also diagnosed with another mental disorder. The diagnosis category of other anxiety disorders presented the highest proportion of comorbidity (53%). Depression was found in 34% person with PTSD whilst alcohol-related disorders were observed in 7%. Considering the temporal relationship, the onset of comorbid depression was uniformly distributed through the periods before, within the same year and after PTSD's onset. When other anxiety disorders were comorbid with PTSD, in almost 90% of the cases the other anxiety disorders preceded PTSD. For comorbidity between of alcohol-related disorders and PTSD, in 50% of the cases alcohol-related disorders preceded the diagnosis of PTSD. LIMITATIONS: The cross-sectional design imposes limitations on establishing a temporal relationship between the onset of psychiatric disorders due to memory bias. CONCLUSIONS: Our findings indicate that among individuals presenting comorbid PTSD and other anxiety disorders, this diagnosis tend to precede PTSD. Comorbid cases are more frequent and more severe, and this should be taken into account in therapeutic research and clinical practice.

Sexual trauma is more strongly associated with tonic immobility than other types of trauma - A population based study.

BACKGROUND: Tonic immobility is an involuntary motor and vocal inhibition reaction, considered the last-ditch response of the defensive cascade model. It is elicited in context of inescapable threat and perception of entrapment. Our aim was to investigate the association between different traumatic events and peritraumatic tonic immobility (PTI) in a representative sample of the general population. METHODS: This is a cross-sectional study of general population from Rio de Janeiro and São Paulo with 3231 victims of traumatic events aged 15-75 years who completed the Tonic Immobility Scale (TIS). We calculated the frequency of the different traumatic events and estimated the mean scores with 95% confidence intervals for each traumatic event, controlling for the potential confounders using multiple linear regression models. Finally, we calculated the proportion of individual scoring zero in TIS for the 16 traumatic events. RESULTS: PTI scores in child sexual abuse and adult sexual violence were almost twice as high as in other types of traumatic events, even when controlled for gender and educational level. Torture and war also showed high PTI scores, but these were based on very small number of cases and need to be interpreted with caution. Furthermore, victims of sexual trauma had the lowest proportion of individuals with total absence of PTI symptoms. LIMITATIONS: This is a cross-sectional study and causal inferences must be drawn with caution. CONCLUSIONS: Peritraumatic tonic immobility is more strongly associated with sexual trauma, particularly in childhood, than to other types of trauma in the general population.

Conditional risk for posttraumatic stress disorder in an epidemiological study of a Brazilian urban population.

INTRODUCTION: Conditional risk for PTSD is the risk of developing PTSD after exposure to traumatic events. This epidemiological study of the general urban population from the two largest cities in Brazil reports exposure to traumatic events; conditional risk for PTSD; and proportion/estimated number of PTSD cases secondary to each type of traumatic event. METHOD: Cross-sectional study of general population (15-75 y.o.) from Rio de Janeiro and São Paulo. PTSD was assessed through Composite International Diagnostic Interview 2.1. RESULTS: Our main findings, from 3744 participants, were: 1) high prevalence of traumatic events (86%), urban violence being the most common; 2) conditional risk for PTSD was 11.1%; 3) women (15.9%) have overall conditional risk 3 times higher than men (5.1%); 4) war-related trauma (67.8%), childhood sexual abuse (49.1%) and adult sexual violence (44.1%) had the highest conditional risks; 5) 35% of PTSD cases (estimated 435,970 individuals) were secondary to sudden/unexpected death of a close person, and 40% secondary to interpersonal violence. CONCLUSIONS: Brazilian urban population is highly exposed to urban violence, and overall conditional risk for PTSD was 11.1%. Violence prevention and enhancement of resilience should be part of public policies, and mental health sequelae of trauma should be better recognized and treated.

Peritraumatic tonic immobility in a large representative sample of the general population: association with posttraumatic stress disorder and female gender.

BACKGROUND: Tonic immobility is an involuntary response to inescapable life-threatening events. Peritraumatic tonic immobility has been reported in convenience samples of female victims of sexual assault and in mixed-gender victims of different types of trauma. This study evaluated peritraumatic tonic immobility in a representative general population sample and its association with posttraumatic stress disorder (PTSD) and gender. METHODS: 3231 victims of traumatic events aged 15-75 years responded to the Tonic Immobility Scale. PTSD and traumatic events were assessed using the Composite International Diagnostic Interview (CIDI 2.1). We calculated the means and the standard deviations of Tonic Immobility Scale scores stratified by PTSD and gender. The association between tonic immobility scores and gender was explored controlling for potential confounders through a multiple linear regression model. RESULTS: Tonic immobility scores were more than double in those who met criteria for PTSD and were almost four points higher in women. Gender differences remained statistically significant even after adjustment for confounding variables. LIMITATIONS: The cross-sectional and retrospective design may have given rise to recall bias. Results presented here may not apply to small and medium rural areas and the CIDI 2.1 can lead to a certain degree of misclassification. CONCLUSIONS: We have expanded the scope of previous investigations on peritraumatic tonic immobility which were based on convenience samples only, showing its occurrence in victims of traumatic events using a large representative sample of the general population. Furthermore, we confirmed in an unbiased sample the association between peritraumatic tonic immobility and PTSD and female gender.

Building resilience for future adversity: a systematic review of interventions in non-clinical samples of adults.

BACKGROUND: Potentially traumatic events happen in people's lives, leading to the risk of the development of posttraumatic stress disorder, depression and even suicide. Resilience is an individual's ability to maintain or regain his/her mental health in the face of significant adversity or risk of death. The aim of this study was to conduct a systematic review of studies evaluating the effectiveness of resilience promotion interventions in adults. METHODS: Electronic searches were conducted in databases ISI, PsycINFO and PubMed, including every language and every year until January 20, 2013. We selected studies with nonclinical samples of adults that evaluated the effectiveness of the intervention through randomized and non-randomized controlled trials and open-ended studies. We also considered valid constructs directly related to resilience, such as hardiness. RESULTS: Among 2.337 studies, 13 were selected for the review, 5 through electronic databases and 8 through search in references or the "times cited list" (list of articles that cited the selected papers). Of these, 7 are randomized controlled trials, 5 non-randomized controlled trials, and one an open-ended trial. Most of the studies included reported some degree of improvement in resilience-like variables among those subjects exposed to resilience-promoting programs. Furthermore, positive findings were more consistent among randomized controlled trials--six out of the seven suggested efficacy. CONCLUSION: There is evidence pointing towards some degree of effectiveness of resilience promotion programs, despite the poor operationalization of the construct and great heterogeneity in the studies. Indeed, the analysis of the methodological quality of the selected studies was hampered by the poor quality of reporting. There were faults in reporting in most studies on almost all items (random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, description of concurrent treatment and intent-to-treat analysis), except for the item "selective reporting". Additional efforts should be made to determine the actual effect size of the interventions, since this is crucial for calculating the cost-effectiveness of resilience promotion strategies.

Resilience to trauma in the two largest cities of Brazil: a cross-sectional study.

BACKGROUND: Resilience is a dynamic process involving the interaction between intrapsychic and social factors of risk and protection. For resilience to be recognized there must be a significant threat to the individual, such as a traumatic event, and a good quality of adjustment. The aim of this study was to identify predisposing factors and possible mechanisms associated with resilience to traumatic events in the general population. METHODS: We conducted a cross-sectional study with a random sample, aged 15-75 years, living in the two largest cities in Brazil, who were exposed to trauma (N = 3,231). Positive adaptation to trauma was defined as the lifetime absence of anxiety (including posttraumatic stress disorder), depression and alcohol related disorders in the presence of at least one traumatic event. Logistic regression models predicting resilience were used to estimate the incidence density ratio. This measure expresses the extent to which the rate of resilience differs from the exposed group to the non-exposed group. Moreover, we explored the relationship between positive/negative affect and resilience, using linear regression models. RESULTS: Male gender was a predisposing factor to positive adaptation (incidence density ratio [IDR] = 1.34; p < 0.001). There was an inverse linear relationship between childhood violence and resilience (IDR = 0.67; 0.53; 0.19; p < 0.001). Our findings suggest that the absence of parental mental disease (IDR = 1.35; p = 0.07) also predisposes individuals to positive adaptation. CONCLUSIONS: This study provides results that help to identify vulnerable groups and protective factors that may lead to a positive adaptation following traumatic experiences.