A Call to Follow-Up: Results Regarding Trauma Clinic Follow-Up Patterns.

The objective of this study was to assess the current practice pattern regarding posthospitalization follow-up of trauma patients among the members of the Eastern Association for the Surgery of Trauma (EAST). An anonymous online multiple-choice survey of EAST members in 2016 was conducted. Ten questions relating to the follow-up care of injured patients were presented to the Active, Senior, and Associate members of EAST. Data were screened for quantitative concerns prior to analysis. Of the 1,610 members surveyed, 289 responded (18%). Approximately 52% of respondents stated that their institution has a dedicated trauma follow-up clinic where most injured patients are seen after discharge. Less than 20% reported that nontrauma multidisciplinary providers are present in clinics. Most (89.5%) reported that follow-up is a single visit, unless a patient has long-standing issues. Only 3 respondents stated that patients are regularly seen 3+ months out from injury, and a significant minority (17.7%) acknowledged no set follow-up timeline. Only 3.6% of participants indicated that they have a psychologist embedded in the trauma team, and 11.5% reported that no system is currently in place to manage mental health. Despite more than 20 years of literature highlighting the long-term physical and mental health sequelae after trauma, these survey results demonstrate that there is a lack of standardized and multidisciplinary follow-up. Given the improvement in outcomes with the identification and treatment of these sequelae, greater attention should be paid to functional recovery, social and psychological well-being, and chronic pain.

Profiles of emotion regulation: Understanding regulatory patterns and the implications for posttraumatic stress.

Trauma survivors often experience posttraumatic stress (PTS) and report concurrent difficulties with emotion regulation (ER). Although individuals typically use multiple regulatory strategies to manage emotion, no studies yet examine the influence of a constellation of strategies on PTS in a community sample. We assessed six ER strategies and investigated whether specific profiles of ER (i.e. the typical pattern of regulation, determined by how often each strategy is used) were related to PTS. A hierarchical cluster analysis indicated that four distinct profiles were present: Adaptive Regulation, Active Regulation, Detached Regulation, and Maladaptive Regulation. Further analyses revealed that an individual's profile was not related to frequency of past trauma, but had the power to differentiate symptom severity for overall PTS and each symptom cluster of posttraumatic stress disorder. These findings highlight how profiles characterising multiple regulatory strategies offer a more complete understanding of the ways ER can account for PTS.

Interpersonal violence, PTSD, and inflammation: potential psychogenic pathways to higher C-reactive protein levels.

Interpersonal violence (IPV) is major public health concern with wide-ranging sequelae including depression, posttraumatic stress disorder (PTSD), and possible alterations of immune and inflammation processes. There is a need to identify the psycho-biological pathways through which IPV may translate to altered inflammatory processes since both PTSD and inflammation are associated with serious physical health conditions such as obesity, diabetes, and cardiovascular disease. This study investigated the relationships between IPV, psychological distress, and the inflammatory marker C-reactive protein (CRP), in a sample of 139 urban women who have a high likelihood for having experienced IPV. Participants were recruited from an outpatient gynecology clinic to complete self-report measures about their IPV histories and psychological symptoms, as well as to have their blood sampled using a finger stick. Results indicated that exposure to IPV predicted the presence of probable depression and PTSD diagnoses. Individuals who experience clinical levels of PTSD exhibited higher CRP levels, and this relationship held after adjusting for comorbid depression. Correlational analyses suggested that reexperiencing symptoms may explain the link between PTSD diagnosis and higher levels of CRP. Follow-up path analytic models provided good fit to the overall data, and indicated that the relationship between probable PTSD status and CRP is not explained by higher BMI. Overall, these findings call for increased attention to the role of PTSD in explaining links between trauma and diminished health.

Emotion regulation difficulties mediate associations between betrayal trauma and symptoms of posttraumatic stress, depression, and anxiety.

Emotion regulation difficulties following trauma exposure have received increasing attention among researchers and clinicians. Previous work highlights the role of emotion regulation difficulties in multiple forms of psychological distress and identifies emotion regulation capacities as especially compromised among survivors of betrayal trauma: physical, sexual, or emotional maltreatment perpetrated by someone to whom the victim is close, such as a parent or partner. It is unknown, however, whether links between emotion regulation difficulties and psychological symptoms differ following exposure to betrayal trauma as compared with other trauma types. In the present study, 593 male and female university undergraduates completed the Difficulties with Emotion Regulation Scale (Gratz & Roemer, 2004), the Brief Betrayal Trauma Scale (Goldberg & Freyd, 2006), the Impact of Event Scale (Horowitz, Wilner, & Alvarez, 1979), and the Trauma Symptom Checklist (Elliott & Briere, 1992). A path analytic model demonstrated that betrayal trauma indirectly impacted symptoms of intrusion (ß = .11), avoidance (ß = .13), depression (ß = .17), and anxiety (ß = .14) via emotion regulation difficulties, an effect consistent with mediation. Emotion regulation difficulties did not mediate the relationship between other trauma exposure and psychological symptoms. Results may inform treatment-matching efforts, and suggest that emotion regulation difficulties may constitute a key therapeutic target following betrayal trauma.

Circulating endocannabinoids and genetic polymorphisms as predictors of posttraumatic stress disorder symptom severity: heterogeneity in a community-based cohort.

The endocannabinoid signaling system (ECSS) regulates fear and anxiety. While ECSS hypoactivity can contribute to symptoms of established post-traumatic stress disorder (PTSD), the role of the ECSS in PTSD development following trauma is unknown. A prospective, longitudinal cohort study of 170 individuals (47% non-Hispanic Caucasian and 70% male) treated at a level 1 trauma center for traumatic injury was carried out. PTSD symptom assessments and blood were obtained during hospitalization and at follow-up (6-8 months post injury). Serum concentrations of the endocannabinoids N-arachidonoylethanolamine (AEA) and 2-arachidonoylglycerol (2-AG) were determined at both time points and selected genetic polymorphisms in endocannabinoid genes, including rs324420 in fatty acid amide hydrolase, were assessed. For the entire sample, serum concentrations of AEA at hospitalization were significantly higher in those diagnosed with PTSD at follow-up (p = 0.030). Serum concentrations of 2-AG were significantly, positively correlated with PTSD symptom severity at follow-up only in minorities (p = 0.014). Minority participants (mostly Black/African American) also demonstrated significant, negative correlations between serum AEA concentrations and PTSD symptom severity both measured at hospitalization (p = 0.015). The A/A genotype at rs324420 was associated with significantly higher PTSD symptom severity (p = 0.025) and occurred exclusively in the Black participants. Collectively, these results are contrary to our hypothesis and find positive associations between circulating endocannabinoids and risk for PTSD. Minority status is an important modulator of the association between endocannabinoids and risk for PTSD, suggesting that the ECSS contributes to risk most significantly in these individuals and the contextual factors related to these findings should be further explored.

Circulating endocannabinoids and prospective risk for depression in trauma-injury survivors.

Biological mechanisms associated with response to trauma may impact risk for depression. One such mechanism is endocannabinoid signaling (eCB), a neuromodulatory system comprised of the CB1 subtype of cannabinoid receptors (CB1R), encoded by the CNR1 gene, and two primary endogenous ligands: 2-arachidonoylglycerol (2-AG) and N-arachidonylethanolamine (AEA), hydrolyzed by monoacylglycerol lipase (gene name MGLL) and fatty acid amide hydrolase (gene name FAAH). Preclinical data suggest that eCB/CB1R signaling acts as a stress buffer and its loss or suppression increases depression-like behaviors. We examined circulating concentrations of the eCBs (2-AG and AEA) days and six months after a traumatic injury as a marker of eCB/CB1R signaling and as predictors of Center for Epidemiologic Studies of Depression Scale-Revised [CESD-R] scores as a measure of depression severity six months after injury. We also explored associations of CNR1, FAAH, and MGLL genetic variance with depression severity at six months. Results from hierarchical multiple linear regressions showed that higher 2-AG serum concentrations after trauma predicted greater depression at six months (ß = 0.23, p = 0.007); neither AEA after trauma, nor 2-AG and AEA at six months were significant predictors (p's > 0.305). Carriers of minor allele for the putative single nucleotide polymorphism in the CNR1 gene rs806371 (ß = 0.19, p = 0.024) experienced greater depression at six months. These data suggest that the eCB signaling system is highly activated following trauma and that eCB/CB1R activity contributes to long-term depression risk.

Establishment and replication of emotion regulation profiles: implications for psychological health.

BACKGROUND AND OBJECTIVES: A promising method of capturing the complex nature of emotion regulation is to assess composite profiles of regulation (i.e., default pattern of regulation across multiple strategies). However, it remains unclear whether regulatory profiles demonstrate consistency across samples and in relation to mental health. DESIGN: Two studies are presented here. Both utilized a cross-sectional design, and the second study presents a replication of the first. METHOD: Both studies utilized self-report data from independent undergraduate samples to perform latent profile analyses of emotion regulation use. RESULTS: Studies 1 and 2 demonstrated evidence for four replicable regulatory profiles: Adaptive, Accepting (with or without Suppression), Non-accepting, and Maladaptive. Profiles were also related to symptoms of depression and anxiety, such that those consistently relying on adaptive strategies reported lower symptoms than those relying more heavily on maladaptive strategies. CONCLUSIONS: These findings clarify previous work which tied regulatory profiles to psychological health by extending a person-centered approach to understanding the ways in which individuals regulate their emotions.

Six-month follow-up of the injured trauma survivor screen: Clinical implications and future directions.

BACKGROUND: The injured trauma survivor screen (ITSS) has been shown to predict posttraumatic stress disorder (PTSD) and depression risk at 1 month after traumatic injury. This study explored the ability of the ITSS to predict chronic distress after injury, as well as the impact of combining the ITSS with an additional screening measure. METHODS: Patients were enrolled following admission to a Level I trauma center. Baseline measurements were collected during initial hospitalization, and follow-up measures were collected an average of 6.5 months after injury. Receiver operating characteristic (ROC) curve analyses were run to determine predictive accuracy, controlling for participants who had mental health intervention and for those who experienced additional potentially psychologically traumatic events since their injury event. RESULTS: Utilizing a cut score of 2, the ITSS PTSD scale had a sensitivity of 85.42%, specificity of 67.35%, negative predictive value (NPV) of 91.9% and positive predictive value (PPV) of 51.4%. The combined PTSD risk group (risk positive on the baseline ITSS and the PTSD checklist for the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) had a sensitivity of 72.92%, specificity of 81.63%, NPV of 88.2%, and PPV of 61.6%. Also using a cut score of 2, the ITSS Depression Scale had a sensitivity of 72.50%, specificity of 70.29%, NPV of 91.1%, and PPV of 37.9%. CONCLUSION: The nine-item ITSS, which takes approximately 5 minutes to administer, is a stable screening tool for predicting those most at risk for PTSD and/or depression 6 months after admission to a Level I trauma center following traumatic injury. The combined PTSD risk group data provide evidence that symptom evaluation by a psychologist can improve specificity. These results further inform the recommendation of the American College of Surgeons Committee on Trauma regarding PTSD and depression screening in trauma centers. LEVEL OF EVIDENCE: Prognostic study, level III.

Exploring the gold-standard: Evidence for a two-factor model of the Clinician Administered PTSD Scale for the DSM-5.

OBJECTIVE: The latent factor structure of posttraumatic stress disorder (PTSD) remains a source of considerable variability. The current study compared several a priori factor structures, as well as a novel 2-factor structure of posttraumatic psychological distress as measured by the Clinician Administered PTSD scale for the DSM-5 (CAPS-5). In addition, variability in diagnostic rates according to the divergent DSM-5 and ICD-11 criteria were explored. METHOD: The setting for this study was a Level 1 trauma center in a U.S. metropolitan city. Data were pooled from 2 studies (N = 309) and participants were administered the CAPS-5 at 1 (n = 139) or 6 months postinjury (n = 170). Confirmatory factor analysis (CFA) was used to compare several factor models, and prevalence rates based on DSM-5 and ICD-11 criteria were compared via z tests and kappa. RESULTS: CFAs of 5 factor structures indicated good fit for all models. A novel 2-factor model based on competing models of PTSD symptoms and modification indices was then tested. The 2-factor model of the CAPS-5 performed as well or better on most indices compared to a 7-factor hybrid. Comparisons of PTSD prevalence rates found no significant differences, but agreement was variable. CONCLUSIONS: These findings indicate that the CAPS-5 can be seen as measuring 2 distinct phenomena: posttraumatic stress disorder and general posttraumatic dysphoria. This is an important contribution to the current debate on which latent factors constitute PTSD and may reduce discordance. (PsycINFO Database Record

Mindfulness-based stress reduction for posttraumatic stress symptoms: building acceptance and decreasing shame.

Mindfulness-based psychotherapies are associated with reductions in depression and anxiety. However, few studies address whether mindfulness-based approaches may benefit individuals with posttraumatic stress symptoms. The current pilot study explored whether group mindfulness-based stress reduction therapy reduced posttraumatic stress symptoms, depression, and negative trauma-related appraisals in 9 adult participants who reported trauma exposure and posttraumatic stress or depression. Participants completed 8 sessions of mindfulness-based stress reduction treatment, as well as pretreatment, midtreatment, and posttreatment assessments of psychological symptoms, acceptance of emotional experiences, and trauma appraisals. Posttraumatic stress symptoms, depression, and shame-based trauma appraisals were reduced over the 8-week period, whereas acceptance of emotional experiences increased. Participants' self-reported amount of weekly mindfulness practice was related to increased acceptance of emotional experiences from pretreatment to posttreatment. Results support the utility of mindfulness-based therapies for posttraumatic stress symptoms and reinforce studies that highlight reducing shame and increasing acceptance as important elements of recovery from trauma.

Using fMR-adaptation to track complex object representations in perirhinal cortex.

Brain regions in medial temporal lobe have seen a shift in emphasis in their role in long-term declarative memory to an appreciation of their role in cognitive domains beyond declarative memory, such as implicit memory, working memory, and perception. Recent theoretical accounts emphasize the function of perirhinal cortex in terms of its role in the ventral visual stream. Here, we used functional magnetic resonance adaptation (fMRa) to show that brain structures in the visual processing stream can bind item features prior to the involvement of hippocampal binding mechanisms. Evidence for perceptual binding was assessed by comparing BOLD (blood-oxygen-level-dependent) responses between fused objects and variants of the same object as different, non-fused forms (e.g., physically separate objects). Adaptation of the neural response to fused, but not non-fused, objects was in left fusiform cortex and left perirhinal cortex, indicating the involvement of these regions in the perceptual binding of item representations.

Emotion regulation difficulties, low social support, and interpersonal violence mediate the link between childhood abuse and posttraumatic stress symptoms.

We examined how difficulties with emotion regulation, social support, and interpersonal violence in adult relationships mediated the relationship between childhood abuse and post traumatic symptoms (PTS) in adults. We fit a multiple mediation model to data from 139 socio-economically disadvantaged women (85% African American) of whom 44% endorsed moderate to severe levels of childhood physical, sexual, or emotional abuse and 12% screened positive for probable posttraumatic stress disorder (PTSD). The model accounted for 63% of the variance in adult PTS symptoms. Child abuse exerted a direct effect on PTS symptoms and indirect effects through difficulties with emotion regulation, lower social support, and greater exposure to adult interpersonal violence. Implications of findings for the treatment of individuals at high risk of having experienced childhood abuse and PTS are discussed.