Social support moderates association between posttraumatic growth and trauma-related psychopathologies among victims of the Sewol Ferry Disaster.

Disasters have numerous harmful effects on the mental health status of trauma-exposed people. We investigated the differences in the association between trauma-related psychopathologies and posttraumatic growth according to the perceived social support level among victims of the Sewol Ferry disaster on April 16, 2014, in South Korea. Data from 241 bereaved family members, survivors, and family members of survivors were used. The Duke-UNC Functional Social Support Questionnaire, Posttraumatic Growth Inventory, PTSD Checklist-5, Posttraumatic Embitterment Disorder Self-Rating Scale, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 were used to evaluate perceived social support, posttraumatic growth, and trauma-related psychopathologies. We found that the severity of depression and anxiety showed inverse correlations with posttraumatic growth only in the low-social support group, while they did not demonstrate significant correlations in the high-social support group. The social support level had correlations with posttraumatic growth and the severity of posttraumatic stress disorder and posttraumatic embitterment disorder only in female respondents. Furthermore, there was a mediation pathway from social support level to posttraumatic growth through depressive symptoms. This study explored the complex relationship between social support, posttraumatic growth, trauma-related psychopathologies, and gender among trauma-exposed individuals in the aftermath of the Sewol Ferry disaster.

Unresponsive Wakefulness Syndrome in Children after Near-Drowning: Long-Term Outcome and Impact on the Families.

Among 131 children admitted to our institution for early phase rehabilitation after freshwater near-drowning (ND) between the year 1986 and 2000, 87 were in unresponsive wakefulness syndrome (UWS) for at least 4 weeks after the accidents. An anonymous questionnaire was sent to the families after 0.5 to 15.0 years (median: 4.6) and 48 mothers and 51 fathers of 55 of these 87 children were interviewed after 6.6 to 23.8 years (median: 13.8) of ND. At the time of the interviews, 8/55 children were able to perform daily living activities independently, 36/55 children were not able to do so (many of them suffered from chronic medical conditions like spasticity or disorders of swallowing), and 11/55 children had died. Health-related quality of life (HRQoL) was, however, similar to the normal population for mothers, and even higher for fathers. Furthermore, the ND accident had apparently not lead to a higher rate of separations of parents but had increased their likelihood to have further children. Feelings of guilt were highly prevalent (23/47 mothers, 20/47 fathers), and correlated with lower HRQoL of the respective parent. We found correlations between duty of supervision and feelings of guilt and between outcome and HRQoL for only the fathers. In conclusion, we found that after 4 weeks in UWS, the long-term neurological outcome of pediatric ND victims is often but not always poor. Despite often severe disabilities or death of the child during long-term care, parents surprisingly report little impact on their HRQoL, on the stability of their partnership or on their wish to have further children. Our findings may help parents and physicians to choose the best treatment for a child in UWS due to different etiologies striking the balance between rehabilitation and palliative care.

Brain injury after moderate drowning: subtle alterations detected by functional magnetic resonance imaging.

To describe cerebral (structural and functional MRI) and neuropsychological long term changes in moderate drowning victim's compared to healthy volunteers in working memory and motor domains. We studied 15 adult drowning victim's in chronic stage (DV - out of 157 eligible cases of sea water rescues with moderate drowning classification) paired to 18 healthy controls (HC). All participants were investigated using intelligence, memory, and attention neuropsychological standard tests and underwent functional (motor and working memory tasks) and structural magnetic resonance imaging (MRI) in a 3 T system. All images were preprocessed for head movement correction and quantitative analysis was performed using FSL and freesurfer software packages. We found no between group differences in neuropsychological assessments. No MRI brain lesion was observed in patients, neither difference on morphometric parameters in any cortical or subcortical brain structure. In constrast, functional MRI revealed that patients showed increased brain response in the motor (left putamen and insula) and memory (left cuneus and lingual gyrus - not the classical memory network) tasks. Functional brain changes in motor and visual brain regions in victims of moderate drowning may indicate reduced brain reserve, despite the lack of structural and behavior alterations. More attention should be given to investigate ageing effects in this nonfatal drowning group.

Experiencing death: an insider's perspective.

For millennia, human beings have wondered what happens after death. What is the first-person experience of dying and being brought back to life? Technological advances in resuscitation science have now added an intriguing new chapter to the literature of out-of-body or near-death experiences by eliciting detailed and vivid accounts of those who have approached the threshold of death. Steve Paulson, executive producer and host of To the Best of Our Knowledge, moderated a discussion that included neurologist Kevin Nelson, neuropsychiatrist Peter Fenwick, emergency medicine expert Sam Parnia, and orthopedic surgeon and drowning survivor Mary Neal; they share some remarkable stories and discuss how they analyze such experiences in light of their own backgrounds and training. The following is an edited transcript of the discussion from December 11, 2013, 7:00-8:30 PM, at the New York Academy of Sciences in New York City.

Underwater trauma causes a long-term specific increase in the expression of cyclooxygenase-2 in the ventral CA1 of the hippocampus.

The pro-inflammatory enzyme cyclooxygenase-2 (COX-2) is regularly expressed in the hippocampal neurons, but its role in emotional trauma is not known. Here we show that a single acute stress caused by a near-drowning experience results in heightened anxiety-like behavior one month after the trauma. Biochemical analyses of dorsal and ventral hippocampal CA1, CA3 and dentate gyrus revealed decreased ubiquitination and elevated levels of COX-2 in the traumatized animals only in the ventral CA1. To reveal the identity of the ubiquitin E3 ligase that targets COX-2, we tested the effect of several representative E3 ligases on COX-2 expression in vitro. We found that while AIP4 and Nedd4 had no effect, Mdm2 lowered COX-2 expression by nearly 50%, an effect that was not observed by its dominant negative form. To test whether this also occurs in the hippocampus, we immunoprecipitated Mdm2 from dorsal and ventral CA1 of traumatized and control animals and probed for the presence of COX-2. Our results showed that the levels of Mdm2 were not affected by the trauma but there was significantly less COX-2 associated with Mdm2 in the ventral but not dorsal CA1 of the traumatized animals. Together these data propose that an increase in COX-2 expression in ventral CA1 following trauma is likely due to its attenuated degradation. Unraveling the pathways and mechanisms that control hippocampal COX-2 degradation is important to boost the development of novel therapeutic approaches designed to treat stress-related pathologies.

Selective increase in the association of the ß2 adrenergic receptor, ß Arrestin-1 and p53 with Mdm2 in the ventral hippocampus one month after underwater trauma.

Chronic infusion of mice with a ß2 adrenergic receptor (ß2AR) analog was shown to cause long-term DNA damage in a pathway which involves ß Arresin-1-mediated activation of Mdm2 and subsequent degradation of the tumor suppressor protein p53. The objective of the present study was to test whether a single acute stress, which manifests long lasting changes in behavior, affects the interaction of Mdm2 with p53, ß2AR, and ß Arrestin-1 in the dorsal and ventral hippocampal CA1. Adult rats were subject to underwater trauma, a brief forceful submersion under water and tested a month later for behavioral and biochemical changes. Elevated plus maze tests confirmed that animals that experienced the threat of drowning present heightened levels of anxiety one month after trauma. An examination of the CA1 hippocampal areas of the same rats showed that underwater trauma caused a significant increase in the association of Mdm2 with ß2AR, ß Arrestin-1, and p53 in the ventral but not dorsal CA1. Our results provide support for the idea that stress-related events may result in biochemical changes restricted to the ventral 'emotion-related' parts of the hippocampus.

Dissociative experiences as mediators between childhood trauma and auditory hallucinations.

The purpose of this work was to study the relationship between reported traumatic experiences in childhood and positive psychotic symptoms. We hypothesized that dissociative experiences were potential mediators between childhood trauma and hallucinations, but not delusions. The sample comprised 71 patients diagnosed with psychoses. They were assessed with the Dissociative Experiences Scale (DES-II; Carlson & Putnam, 1993), a questionnaire on trauma (TQ; Davidson, Hughes, & Blazer, 1990), and the Positive and Negative Syndrome Scale (PANSS; Kay, Opler, & Lindenmayer, 1988) delusions and hallucinations items. The results showed that childhood trauma was positively associated with the dissociation scale scores (r = .40) and also the hallucination (r = .36) and delusions scale scores (r = .32). Furthermore, it was demonstrated that the dissociation variable was a potential mediator between childhood trauma and hallucinations, but not between childhood trauma and delusions. Of the 3 DES-II factors, only depersonalization showed a mediating relationship between childhood trauma and hallucinations. The main conclusion is that the impact of childhood trauma on hallucinations may not simply be direct, but mediated by dissociative experiences, especially depersonalization. Clinical implications are also briefly discussed.

Self-reported water and drowning risk exposure at surf beaches.

OBJECTIVE: To document patterns of water exposure at surf beaches by gender and identify factors that predict bather confidence to return to shore if caught in a rip current. METHOD: Recreational surf beach bathers (N=406) provided self-completed data on water exposure patterns, surf activity behaviours and potential drowning risk and protective factors. RESULTS: Relative to females, males visited surf beaches more frequently, expected to spend longer in the water and in deeper water, and more often bathed after using alcohol (p<0.05). Confidence to return to shore if caught in a rip current was predicted by confidence to identify a rip current, self-rated swimming ability, gender, times visited any beach, and age in a standard linear regression model (adjusted R(2)=0.68). CONCLUSION: The study supports explanations that high male drowning rates result from more frequent exposure to water than females at high situational risk levels. IMPLICATIONS: Controlled studies are required to determine the role in drowning of overconfidence, swimming ability, surf experience, floatation devices and response to sea conditions.

Neuropsychological outcome following near-drowning in ice water: two adult case studies.

Two men, 56 and 33 years old, (case 1 and case 2) were examined neuropsychologically after successful resuscitation from circulatory arrest following extreme accidental hypothermia and near drowning. After submersion in ice water for at least 20 minutes they received CPR for 45 to 60 minutes. Body-core temperature at start of CPB was 24 degrees C and 22 degrees C, respectively. A neuropsychological examination was performed within two months after the accident and 1 year later. An additional follow-up interview was made 3 years after the accidents. Both had severe problems with memory, visuospatial performance, executive function, and verbal fluency. The follow-up demonstrated improvement in the visuospatial test in both and in the verbal learning, recall, and logical reasoning tests in case 2. Both still had problems with executive function, and case 2 also in verbal fluency. Case 1 also had problems with flexibility, planning and abstract ability. Despite the protective effects of hypothermia and gradual improvement of symptoms over time, some of the deficits were permanent. A thorough neuropsychological examination of patients suffered from anoxia is advisable, because gross neurological examination and MRI scans may not always reveal underlying brain dysfunction.

Desensitizing a pilot with a phobic response to required helicopter underwater escape training.

INTRODUCTION: A systematic desensitization program designed to help aircrew who have a phobic anxiety of the Helicopter Underwater Escape Training (HUET) has been developed. CASE PRESENTATION: A student pilot presented with a severe phobic anxiety of the HUET course--a result of a being trapped underwater on a marine survival training course. A treatment team was assembled and concluded his phobia could be treated by a systematic desensitization method. An exposure matrix of graded difficulty of in/underwater escapes was performed over 2 d. The student reported that his confidence increased and anxiety reduced as he became accustomed to being strapped into a seat in the escape trainer while wearing increasingly difficult levels of equipment which increased the difficulty of escape, such as taking away nasal protection and goggles. At the end of Day 1, he was able to jettison the exit door/hatch while inverted underwater with a facemask and dressed in a simple coverall. At the end of Day 2, without nasal protection, inverted underwater, wearing full military equipment, he was able to cross the cabin, jettison the exit door, and successfully escape. DISCUSSION: A systematic desensitization treatment program can be used to successfully treat aircrew for phobia of the helicopter underwater escape trainer.

Miedo al atragantamiento (chocking phobia) en el diagnóstico diferencial de los trastornos de la conducta alimentaria / Chocking phobia in the differential diagnosis of eating disorders

Introducción: El «miedo al atragantamiento" se caracteriza por el temor y la aversión a ingerir alimentos sólidos, e incluso, en ocasiones, líquidos y medicamentos. Estas características, junto con la pérdida de peso y la frecuencia de síntomas obsesivo compulsivos, hacen pensar a veces en una anorexia nerviosa. Material y métodos: Estudio descriptivo longitudinal de una serie de 6 pacientes (4 niños y 2 niñas) diagnosticados de miedo al atragantamiento en los últimos 5 años. Resultados: La edad media en la primera visita fue de 9.9 años (rango de 5-16 años) y el tiempo de evolución desde el inicio del cuadro de 1,7 meses (desviación estándar [DE]1,0 meses). Los niños habían perdido como promedio un 13% del peso inicial, situándose su peso en el momento del diagnóstico en una puntuación Z media de -1.19 (DE:0,72). Tras el diagnóstico, todos los niños recibieron terapia cognitivo-conductual (Tl CC), asociada a farmacoterapia en 5 pacientes. Precisaron suplementación de la dieta con una fórmula hipercalórica 4 pacientes ( 300-900k cal/día) durante un periodo medio de 2 meses. Todos los casos evolucionaron favorablemente, con normalización de la ingesta y recuperación ponderal tras un periodo medio de 5.6 meses (DE:2.5). Conclusiones: 1. Aunque los datos clínicos de presentación pueden hacer pensar en una anorexia nerviosa de comienzo precoz, en estos pacientes no existe distorsión de la imagen corporal ni temor a la ganancia de peso. 2. El inicio de la sintomatología fue precedido por un episodio estresante y en algún caso se vio favorecido por una personalidad prepatológica. 3. El cuadro se acompaña frecuentemente de una pérdida importante de peso (entre el 7 y el 20% del peso inicial). 4. El éxito del tratamiento se basa en la colaboración entre los psiquiatras y el equipo de soporte nutricional

Background: Choking phobia is characterized by afear and avoidance of swallowing salid food and, on occasion, even liquidsor pills. These characteristics, when added to the weight loss and the frequent association of obsessive-compulsive symptoms, are suggestive of an eating disorder. Methods: The records of 6 children and adolescents (4 boys and 2 girls) who had been diagnosed as having choking phobia over the preceding five years were reviewed for inclusion in a longitudinal, descriptive study. The data are presented as the mean and standard deviation (SD). Results: The mean age at the time of the first visit was 9.9 years (range 5 to 16 y). The mean time between the first symptoms and diagnosis was 1.7 months (SD:1.0 m). On average, the patients lost 13% of their initial weight. The Z score for weight was -1.19 (SO: 0.72). All of them received cognitive behavioural therapy and, except in one case, they also received drugs. Four children had their diet supplemented with a hypercaloric enteral formula (300-900 kcal/day) for 2 months. Complete remission was achieved in every case, weight restoration took a mean period of 5.6 months (SD: 2.5 mo). Conclusions: Although the differential diagnosis should include early onset anorexia nervosa, there is no body image distortion or fear of gaining weight. The episode started after a stressful situation, generally related to food. It was accompanied by a weight loss of 7% to 20% of initial weight. The combination of cognitive-behavioural therapy plus drugs and nutritional assessment obtained good results in this young population

Usual water-related behaviour and 'near-drowning' incidents in young adults.

OBJECTIVE: To describe usual water-related behaviour and 'near-drowning' incidents in a cohort of young New Zealand adults. METHOD: This was a cross-sectional study based on data collected as part of the Dunedin Multidisciplinary Health and Development Study, which is the study of a cohort (n = 1,037) born between 1 April 1972 and 31 March 1973 in Dunedin, New Zealand. The data analysed were collected at age 21 (1993/94). Each study member was given a face-to-face interview using a structured questionnaire. RESULTS: Males reported a higher level of water confidence, exposure to risk behaviours, and exposure to unsafe locations, and more 'near-drowning' incidents, than the females, but protective behaviour did not differ. Males and females who were 'confident' in the water were more likely to be exposed to unsafe water locations, and water-confident males were more likely to drink alcohol before water activities, but not boating. A total of 169 'near-drowning' incidents were reported by 141 study members (63% males). 'Near-drowning' incidents were associated with unsafe swimming environments for males (p < 0.001) and boating within two hours of consuming alcohol for females (p = 0.002). CONCLUSIONS: This study described usual water-related behaviour and has provided preliminary evidence of the factors associated with 'near-drowning' incidents among a high-risk age group. Larger case-control studies are required to further investigate risk factors for 'near-drowning'. IMPLICATIONS FOR PRACTITIONERS: Further investigation is required to determine the effectiveness of providing water skills acquisition in both safe and unsafe environments on 'near-drowning' experience.

[Rapid enlargement of the thyroid after acute stress in a case of Hashimoto's thyroiditis]. / Agrandissement rapide de la thyroïde à la suite d'un stress aigu dans un cas de thyroïdite de Hashimoto.

The case of a female patient aged 63 with a known Hashimoto's thyroiditis is reported. She had been treated for 3 years with 0.125 mg thyroxine. A few days after she just escaped from drowning, she noticed a rapid enlargement of her thyroid gland (50% volume increase at echography). A lymphoma could be excluded by a fine needle aspiration cytology. Antimicrosomal antibodies were increased at 1/409.600. TSH was slightly increased (7.5 mU/l) but not more than the months before, when the volume of the gland was stable. She was treated with 0.15 mg thyroxine and 18 months later the volume of the thyroid gland and the level of antimicrosome antibodies came back to the pre-drowning level. The possible role of stress in the exacerbation of thyroiditis is discussed.

Near drowning in frigid water: a case study of a 31-year-old woman.

A 31-yr-old woman demonstrated intact neuropsychological functioning after being submerged for at least 30 minutes in icy cold water. Following submersion, the patient received CPR for approximately 1 hr. Eight hours after submersion, the patient's temperature was 31 degrees C (87 degrees F). She remained nonresponsive for 2 days after the accident. Extensive neuropsychological testing was completed 3 mo after the accident with no objective or subjective deficits evidenced. This case of hypothermically mediated neuroprotection from anoxia in an adult supports the need for further research on the putative neurophysiological mechanisms invoked and the potential for application of clinically induced hypothermia in the acute management of other types of cerebral insults.

The psychological effects of disaster at sea.

BACKGROUND: In March 1987, the P&O car ferry Herald of Free Enterprise capsized killing 193 passengers. Seventy-five survivors and relatives were referred by their solicitors to the authors for assessment of psychological injury. METHOD: Information was gathered retrospectively and systematically from clinical notes and legal reports. RESULTS: The commonest symptoms suffered were sleep disturbance, loss of concentration and increased anger. The commonest diagnoses were post-traumatic stress disorder, other anxiety states and depression. Depressive symptoms were commoner in those who had been bereaved, anxiety symptoms were commoner in those who had not. Reluctance to discuss symptoms and to attend a psychiatric clinic was a common feature. CONCLUSIONS: As expected, bereavement led to grief and depressive symptoms, whilst passengers who were not bereaved were more likely to suffer anxiety symptoms. Contrary to expectations, the degree of immersion during the accident did not influence the type or degree of symptoms. Those with worse symptoms were more likely to attend the clinic. Women showed more affective symptoms and men more substance abuse.