The effect of prior trauma exposure on the development of PTSD following spinal cord injury.

Posttraumatic stress disorder (PTSD) occurs in only a subset of individuals who sustain traumatic spinal cord injuries (SCIs). Several previous studies have examined the effects of additive trauma on the development of PTSD and found that a history of prior trauma increases the risk for later development of PTSD. The present study examines additive trauma by investigating the effects of previous combat exposure on the development of PTSD following spinal cord injury. Significant differences in prevalence rates for current PTSD were found for the comparisons of war theater (both combat and noncombat) versus non-war theater veterans but not for the comparison between combat and noncombat war theater veterans. Moreover, for all the comparisons, no significant differences were found in lifetime PTSD diagnoses. This implies that veterans with SCI who served in a war zone have increased difficulty recovering from their PTSD following a spinal cord injury than do non-war theater veterans.

Depression and spinal cord injury: a monozygotic twin study.

Although, in earlier work, depression in individuals with spinal cord injury (SCI) was attributed to difficulties adjusting to SCI, more recent articles have emphasized the importance of constitutional and environmental factors not specific to SCI, as well as established theoretical models of depression. To further explore this question, 11 pairs of monozygotic twins, where one of each pair was spinal cord injured, were studied. Measures included the Beck Depression Inventory, the depression scale of the SCL-90R, and the Rosenberg Self-Esteem Scale. Using pairwise t tests, the authors did not find any significant differences between SCI and non-SCI co-twins. These findings are consistent with the idea that the occurrence of SCI does not inevitably lead to increased depression.

A comparison of posttraumatic stress disorder in veterans with and without spinal cord injury.

The authors assessed effects of paraplegic and quadriplegic spinal cord injuries (SCIs) on posttraumatic stress disorder (PTSD) by comparing severity and prevalence of PTSD in these groups to a sample of controls who experienced traumatic injuries other than SCI. The authors found that veterans with quadriplegia reported significantly less severe current PTSD symptoms than controls who were not significantly different from veterans with paraplegia. These results suggest that sustaining a quadriplegic SCI decreases risk of current PTSD, whereas sustaining a paraplegic SCI is associated with greater risk of PTSD, although the risk is no greater than that incurred from experiencing the trauma itself.

Posttraumatic stress disorder in veterans with spinal cord injury: trauma-related risk factors.

Trauma-related risk factors for posttraumatic stress disorder (PTSD) were examined in a sample of 125 veterans with spinal cord injury. Category of injury was found to be the most consistent predictor of PTSD diagnosis and symptom severity with paraplegia predicting more PTSD symptoms than quadriplegia. The occurrence of a head injury at the time of the trauma was found to predict PTSD symptom severity measures, but not PTSD diagnosis. Trauma recency consistently predicted Impact of Event score (IES) and was found to be related to current PTSD severity and lifetime PTSD diagnosis in multiple but not simple regression models. Trauma severity was found to be significantly related to self-reported PTSD symptoms and lifetime PTSD diagnosis in simple but not in multiple regression analyses. Type of trauma, alcohol or other drug (AOD) use during the trauma and loss of consciousness (LOC) during the trauma were not consistently associated with PTSD symptom severity or diagnosis.

Diazepam usage in veterans with spinal cord injury.

Diazepam is widely prescribed for persons with spinal cord injury (SCI) to treat muscular spasticity. To assess the current usage of diazepam in those persons with SCI being followed by the Department of Veterans Affairs Medical Centers (DVAMCs), a survey was mailed to all 23 DVAMCs that have specialized SCI Services. We discovered that no policy regarding the prescription of benzodiazepines existed at 65 percent of the SCI Services. At 70 percent of the SCI Services, diazepam or another benzodiazepine was routinely prescribed. One-third of patients were estimated to have taken diazepam for greater than 10 years and an additional 37 percent for six to 10 years. Despite the potential for addiction, only 10 of the 23 SCI Services reported having a program to encourage discontinuation of diazepam use; a 20 percent success rate was reported in withdrawing this medication. A need for greater understanding with regard to the prescription of diazepam exists and strategies for its withdrawal should be considered. Appropriate guidelines for its use in patients with SCI and spasticity should be developed.

Substance misuse in individuals with spinal cord injury.

The literature addressing substance misuse in spinal cord injury (SCI) is reviewed with special attention paid to differences in substance misuse in the spinal cord injury and general populations. Studies examining epidemiology indicate that while substance misuse often is present when spinal cord injuries occur, the exact prevalence of it in the SCI population has yet to be determined. The literature also suggests that risk factors unique to SCI predispose substance misuse in this population in addition to risk factors commonly present in the general population. Articles examining issues relevant to substance misuse in SCI identify some concerns specific to this population. Although treatment outcome literature for substance misuse in SCI is scarce, it is clear that treatment facilities must be adapted to suit the needs of the spinal cord injured. However, it has yet to be determined how treatment content should differ.

The role of home practice in thermal biofeedback.

The role of regular home practice of hand warming was examined in the thermal biofeedback (TBF) treatment of vascular (migraine and mixed migraine and tension) headache (HA) by giving 12 sessions (over 6 weeks) of TBF to two groups of vascular HA patients (n = 23 per group). One group was asked to practice regularly at home with a home trainer between clinic sessions, whereas no mention of practice was made to the other group. A third group merely monitored HAs. Treatment was superior to no treatment. There was no advantage for the group receiving home practice, either in headache reduction or in acquisition of the hand-warming response.

The role of regular home practice in the relaxation treatment of tension headache.

This study evaluated the contribution of regular home practice in the treatment of tension headache (HA) with progressive muscle relaxation (PMR) by giving 14 tension HA sufferers 10 sessions (over 8 weeks) of standard PMR with home practice and application instructions while 13 additional patients received the same PMR training (except for the omission of cue-controlled relaxation) with no home practice or application instruction. A third group of 6 patients merely monitored HA activity. Both treated groups showed significant reduction in HA activity, whereas the symptom monitoring group did not change. The 2 treated groups did not differ. On a measure of clinically significant reduction in HA activity (at least 50% reduction in HA activity), however, the group receiving home practice instruction (50%) showed a trend (p = .056) to improve more than did those receiving PMR without home practice (15%).

A controlled evaluation of the addition of cognitive therapy to a home-based biofeedback and relaxation treatment of vascular headache.

Seventy-six patients with vascular (migraine or mixed migraine and tension) headache (HA) participated in a controlled evaluation of a minimal-therapist-contact, largely home-based, treatment program which combined relaxation (R) training with thermal biofeedback (TBF). One group received TBF + R administered in 3 office visit over 8 weeks, supplemented by audio tapes and manuals. A second group received the TBF + R plus instruction in cognitive stress coping techniques, all of which was administered in 5 office visits over 8 weeks. A third group monitored headache activity for 8 weeks. Evaluations, based on 4 weeks of HA diary at pre-treatment and after treatment, revealed significantly greater reductions in HA activity and medication consumption for both treated groups than the HA monitoring controls who did not change. Significantly more of the treated patients had clinically significant reductions in HA activity than the controls. The two treated groups did not differ on any measure.

A controlled evaluation of thermal biofeedback and thermal biofeedback combined with cognitive therapy in the treatment of vascular headache.

One-hundred-sixteen patients suffering from vascular headache (migraine or combined migraine and tension) were, after 4 weeks of pretreatment baseline headache monitoring, randomly assigned to one of four conditions: (a) thermal biofeedback with adjunctive relaxation training (TBF); (b) TBF plus cognitive therapy; (c) pseudomediation as an ostensible attention-placebo control; or (d) headache monitoring. The first three groups received 16 individual sessions over 8 weeks, while the fourth group continued to monitor headaches. All groups then monitored headaches for a 4-week posttreatment baseline. Analyses revealed that all treated groups improved significantly more than the headache monitoring group with no significant differences among the three treated groups. On a measure of clinically significant improvement, the two TBF groups had slightly higher (51%) degree of improvement than the meditation group (37.5%). It is argued that the attention-placebo control became an active relaxation condition.

Placebo-controlled evaluation of abbreviated progressive muscle relaxation and of relaxation combined with cognitive therapy in the treatment of tension headache.

Sixty-six tension headache patients were randomly assigned to one of four conditions for 8 weeks: (a) progressive muscle relaxation (PMR) alone; (b) PMR plus cognitive therapy (PMR + Cog); (c) pseudomeditation, a credible attention-placebo control; or (d) continued headache monitoring. A comparison of overall headache activity (headache index), derived from a daily headache diary, for 4 weeks before treatment to 4 weeks after treatment, revealed that active treatment (PMR and PMR + Cog) was superior to either control condition. Moreover, level of headache medication consumption decreased significantly for the active treatment groups. Although headache-index comparisons of the two active treatments showed no advantage for adding cognitive therapy to PMR, a measure of clinically significant change showed a trend for PMR + Cog to be superior to PMR alone.

Assessment of dietary risk factors in chronic headache.

An investigation of the awareness level and potential impact of dietary risk factors on chronic headache patients revealed that (1) approximately 75% of the 130 patients in this study stated they were aware of possible food-intake/headache connections, (2) less than half reported being informed of this relationship by medical professionals, and (3) the awareness of this nutritional information did not prompt changes in subjects' dietary practices. The comparison of food-intake patterns of the headache patients and nonheadache control group revealed a significant difference only on red wine consumption.

A 1- and 2-year follow-up study of bowel sound biofeedback as a treatment for irritable bowel syndrome.

Five patients initially treated with bowel sound biofeedback were assessed at 1- and 2-year follow-up. Although variable results were reported, subjects who improved to a clinically significant extent at posttreatment maintained their improvement through 1-year and in some cases 2-year follow-up. In light of these results, this form of treatment may prove effective for some patients in the long term.

The refractory headache patient--I. Chronic, daily, high intensity headache.

Two studies on patients with Chronic, Daily, High Intensity Headache (CDHIHA) are presented. In the first, their response to various self-regulatory (biofeedback, relaxation) treatments was compared to that of case controls matched for age, duration and Ad Hoc Committee diagnoses who had 1-2 headache-free days per week (Group II) and 3-5 headache-free days per week (Group III). The CDHIHA patients had a significantly poorer response to treatment (12.7 vs 49.8% improvement for Groups II and III combined). In the second study, the psychological profiles of an enlarged sample of CDHIHA patients were compared to matched case controls from Group II and Group III. The CDHIHA patients tended to be more anxious, more hysterical and to have more non-headache somatic complaints than Groups II and III combined.

Bowel sound biofeedback as a treatment for irritable bowel syndrome.

Using an electronic stethoscope placed on subjects' abdomens, bowel sound biofeedback was administered to five subjects suffering from irritable bowel syndrome (functional diarrhea). They were instructed to alternately increase and decrease colonic sounds in an attempt to gain control over bowel activity. Using daily ratings of diarrhea as the primary dependent measure, three of five subjects reduced mean ratings enough at posttreatment to meet our 50% criterion for success (100%, 94%, and 54%). At 1-year follow-up, two of the three short-term successes had maintained their level of improvement--each had ratings 75% below those of pretreatment.