Time course of symptoms in posttraumatic stress disorder with delayed expression: A systematic review.

OBJECTIVE: To examine the hypothesis that PTSD with delayed expression in some cases occurs without subthreshold PTSD symptoms above background levels bridging the gap between the traumatic exposure(s) and the clinical diagnosis. METHODS: We performed systematic searches of peer-reviewed papers in English referenced in Pubmed, Embase, or PsycINFO and ascertained 34 prospective studies of PTSD symptom trajectories identified by latent class growth statistical modeling. Studies with delayed and low-stable trajectories provided appropriate data for this study. We computed the difference between the delayed trajectory PTSD symptom sumscore and the low-stable PTSD sumscore at the observed points in time after the traumatic event(s). RESULTS: In 29 study populations, the latent class growth analyses displayed delayed trajectories, and in these, we identified 110 data points (% PTSD sumscore difference/months since traumatic exposure). The median PTSD symptom sumscore was 25% higher during the initial 6 months among individuals in the delayed trajectory compared to those in low-stable trajectory. From this level, the difference widened and reached a plateau of 40-50% higher. The variation was large, and the baseline participation rate and loss to follow-up were exceeding 25% in the majority of the studies. Heterogeneity of populations, measures, and analyses precluded formal meta-analysis. CONCLUSION: Delayed PTSD is preceded by PTSD symptoms during the first year in most cases. Still, few individuals may experience an asymptomatic delay. The results underpin the rationale for monitoring PTSD symptoms and may inform forensic assessments in that delayed PTSD without symptoms bridging the traumatic event is rare.

Comparative efficacy and acceptability of expressive writing treatments compared with psychotherapy, other writing treatments, and waiting list control for adult trauma survivors: a systematic review and network meta-analysis.

BACKGROUND: Expressive writing about a traumatic event is promising in treating posttraumatic stress disorder (PTSD) symptoms in adult trauma survivors. To date, the comparative efficacy and acceptability of this approach is uncertain. Therefore, we aimed to examine the comparative efficacy and acceptability of expressive writing treatments. METHODS: We included 44 RCTs with 7724 participants contributing 54 direct comparisons between expressive writing (EW), enhanced writing (i.e. including additional therapist contact or individualized writing assignments; EW+), PTSD psychotherapies (PT), neutral writing (NW), and waiting-list control (WL). RESULTS: EW, EW+, PT, and NW were statistically significantly more efficacious than WL at the longest available follow-up, with SMDs (95% CI) of -0.78 (-1.10 to -0.46) for PT, -0.81 (-1.02 to -0.61) for EW+ , -0.43 (-0.65 to -0.21) for EW, and -0.37 (-0.61 to -0.14) for NW. We found small to moderate differences between the active treatments. At baseline mean PTSD severity was significantly lower in EW+ compared with WL. We found considerable heterogeneity and inconsistency and we found elevated risk of bias in at least one of the bias dimensions in all studies. When EW+-WL comparisons were excluded from the analyses EW+ was no longer superior compared with EW. CONCLUSIONS: The summarized evidence confirms that writing treatments may contribute to improving PTSD symptoms in medium to long-term. Methodological issues in the available evidence hamper definite conclusions regarding the comparative efficacy and acceptability of writing treatments. Adequately sized comparative randomized controlled trials preferably including all four active treatment approaches, reporting long-term data, and including researchers with balanced preferences are needed.

Full and partial posttraumatic stress disorders in adults exposed to super typhoon Lekima: a cross-sectional investigation.

BACKGROUND: Super typhoon Lekima had a maximum wind force of 16 (52 m/s) and hit Wenling city, Zhejiang province in China on August 10, 2019. The typhoon left many victims showing symptoms of posttraumatic stress disorder (PTSD). OBJECTIVE: This study aimed to assess the prevalence of full and partial PTSD to inform targeted interventions for adult victims. METHOD: In total, four thousand seven hundred and forty-six adults who are parents of students in local primary and middle schools were recruited to participate in this study. Participants completed a trauma exposure scale and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition PTSD Checklist. Logistic regression analysis was used to examine the factors of full and partial PTSD. RESULTS: Nine hundred and ten (19.2%) adults had full PTSD and 1775 (37.4%) had partial PTSD. Adults with a monthly income > 10,000 RMB (about 1530 dollars) and a high education level (bachelor's degree or above) were less likely to have full or partial PTSD than those with lower income and lower education levels. In addition, married adults were less likely to have full PTSD than divorced or widowed ones. Higher rates of PTSD were observed among those aged ≥40 years, who were injured/trapped, whose family members/friends were injured/trapped, and who lost property. CONCLUSIONS: Partial and full PTSD were common among adults following super typhoon Lekima, and high income, high education level, and married status were protective factors, whereas trauma exposure was a risk factor of PTSD. Target psychological intervention should be provided to these victims who are in low income and education level, divorced and widowed, and experienced more serious trauma.

Examining the prevalence and health impairment associated with subthreshold PTSD symptoms (PTSS) among frontline healthcare workers during the COVID-19 pandemic.

The COVID-19 pandemic has increased healthcare workers' (HCWs) risk for posttraumatic stress disorder (PTSD). Although subthreshold PTSD symptoms (PTSS) are common and increase vulnerability for health impairments, they have received little attention. We examined the prevalence of subthreshold PTSS and their relationship to physical health symptoms and sleep problems among HCWs during the pandemic's second wave (01/21-02/21). Participants (N = 852; 63.1% male; Mage = 38.34) completed the Short-Form PTSD Checklist (SF-PCL), the Cohen-Hoberman Inventory of Physical Symptoms, and the PROMIS Sleep-Related Impairment-Short-Form 4a. We created three groups with the SF-PCL: scores ≥11 = probable PTSD (5.5%); scores between 1 and 10 = subthreshold PTSS (55.3%); scores of 0 = no PTSS (39.2%). After controlling for demographics, occupational characteristics, and COVID-19 status, HCWs with subthreshold PTSS experienced greater physical health symptoms and sleep problems than HCWs with no PTSS. While HCWs with PTSD reported the greatest health impairment, HCWs with subthreshold PTSS reported 88% more physical health symptoms and 36% more sleep problems than HCWs with no PTSS. Subthreshold PTSS are common and increase risk for health impairment. Interventions addressing HCWs' mental health in response to the COVID-19 pandemic must include subthreshold PTSS to ensure their effectiveness.

Suicidal ideation, post-traumatic stress disorder, and depression in traumatic spinal cord injury: What resilience tells us.

OBJECTIVE: Identification of unmet psychiatric needs, protective and risk factors for suicide are crucial for people with traumatic spinal cord injury (SCI). In this study, we aimed to explore depression, post-traumatic stress disorder (PTSD) status (non-PTSD, partial-PTSD, full-PTSD), resilience, suicidal ideation (SI) and to examine predictors and clinical correlates of current SI in traumatic SCI. METHOD: Sixty-three individuals with traumatic SCI who were at least 3 months post-injury were included in the study. The participants were evaluated in terms of PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), depression, SI, and resilience using the PCL-5, the Patient Health Questionnaire-9, the Brief Resilience Scale, and sociodemographic measures. RESULTS: 33% of our sample (n = 21) had SI over the past two weeks. 71.4% of the patients with SI (n = 15) had depression. A total of 52.4% of the patients with SI (n = 11) were diagnosed with full PTSD. Resilience was found to be significantly lower in individuals with depression and individuals with SI. While depression predicted SI in traumatic SCI, resilience stands as a protective factor against SI. CONCLUSION: SI is quite common in individuals with traumatic SCI and is accompanied by substantial psychiatric comorbidities such as depression and PTSD. Along with depression and PTSD, resilience - which has protective and predictive values and is inversely associated with SI - constitutes a significant psychotherapeutic intervention and screening area.

Crossover between diagnostic and empirical categorizations of full and subthreshold PTSD.

BACKGROUND: Most of the work on understanding subthreshold PTSD has focused on inconsistencies in defining subthreshold PTSD and how those inconsistencies impact prevalence rates. The present study distinguishes between full and subthreshold PTSD using empirical categorization and assesses the circumstances under which empirical categorization is discordant with full and subthreshold PTSD diagnoses. METHODS: Using data from the NIDA CTN Women and Trauma Study (N = 353), we use a modernized adaptation of the Jacobson and Truax (1991) framework, assessing whether patients were above or below an empirical threshold on latent PTSD severity scores estimated under categorical confirmatory factor analysis; the empirical categorizations were then crossed with the diagnoses to form four diagnostic by empirical categorization groupings. RESULTS: Compared to a reference group (full PTSD diagnosis and empirical categorization), patients who had a full PTSD diagnosis but a subthreshold empirical categorization had lower symptom endorsement rates on 15 PTSD symptoms, were more likely to be married, ethnic minorities with fewer lifetime traumas. Conversely, patients with a subthreshold PTSD diagnosis and a full PTSD empirical grouping looked similar to "Full/Fulls", only differing on avoidance symptoms. LIMITATIONS: Alternative definitions of subthreshold PTSD and coding of symptom endorsement may impact results. The use of DSM-IV symptoms (though reconciled against overlapping symptoms from DSM-5) is also a key limitation. CONCLUSIONS: Empirical categorization can be a useful supplement to diagnosis in distinguishing subthreshold PTSD from full PTSD, using a methodology that could provide a platform for melding dimensional and categorical nosology approaches in the DSM.

Disrupted topological organization in the whole-brain functional network of trauma-exposed firefighters: A preliminary study.

Given that partial posttraumatic stress disorder (pPTSD) may be a specific risk factor for the development of posttraumatic stress disorder (PTSD), it is important to understand the neurobiology of pPTSD. However, there are few extant studies in this domain. Using resting-state functional magnetic resonance imaging (rs-fMRI) and a graph theoretical approach, we compared the topological organization of the whole-brain functional network in trauma-exposed firefighters with pPTSD (pPTSD group, n=9) with those without pPTSD (PC group, n=8) and non-traumatized healthy controls (HC group, n=11). We also examined changes in the network topology of five individuals with pPTSD before and after eye movement desensitization and reprocessing (EMDR) therapy. Individuals with pPTSD exhibited altered global properties, including a reduction in values of a normalized clustering coefficient, normalized local efficiency, and small-worldness. We also observed altered local properties, particularly in the association cortex, including the temporal and parietal cortices, across groups. These disruptive global and local network properties presented in pPTSD before treatment were ameliorated after treatment. Our preliminary results suggest that subthreshold manifestation of PTSD may be due to a disruption in the optimal balance in the functional brain networks and that this disruption can be ameliorated by psychotherapy.

Clinical correlates of plasma brain-derived neurotrophic factor in post-traumatic stress disorder spectrum after a natural disaster.

Clinical correlates of plasma Brain-Derived Neurotrophic Factor (BDNF) have been investigated in a clinical population with Post Traumatic Stress Disorder (PTSD) symptoms and healthy control subjects who survived to the L'Aquila 2009 earthquake. Twenty-six outpatients and 14 control subjects were recruited. Assessments included: Structured Clinical Interview for DSM-IV Axis-I disorders Patient Version, Trauma and Loss Spectrum-Self Report (TALS-SR) for post-traumatic spectrum symptoms. Thirteen patients were diagnosed as Full PTSD and 13 as Partial PTSD. The subjects with full-blown PTSD showed lower BDNF level than subjects with partial PTSD and controls. Different relationship patterns of BDNF with post-traumatic stress spectrum symptoms have been reported in the three samples. Our findings add more insight on the mechanisms regulating BDNF levels in response to stress and further proofs of the utility of the distinction of PTSD into full and partial categories.

Subthreshold posttraumatic stress disorder in the world health organization world mental health surveys.

BACKGROUND: Although only a few people exposed to a traumatic event (TE) develop posttraumatic stress disorder (PTSD), symptoms that do not meet full PTSD criteria are common and often clinically significant. Individuals with these symptoms sometimes have been characterized as having subthreshold PTSD, but no consensus exists on the optimal definition of this term. Data from a large cross-national epidemiologic survey are used in this study to provide a principled basis for such a definition. METHODS: The World Health Organization World Mental Health Surveys administered fully structured psychiatric diagnostic interviews to community samples in 13 countries containing assessments of PTSD associated with randomly selected TEs. Focusing on the 23,936 respondents reporting lifetime TE exposure, associations of approximated DSM-5 PTSD symptom profiles with six outcomes (distress-impairment, suicidality, comorbid fear-distress disorders, PTSD symptom duration) were examined to investigate implications of different subthreshold definitions. RESULTS: Although consistently highest outcomes for distress-impairment, suicidality, comorbidity, and PTSD symptom duration were observed among the 3.0% of respondents with DSM-5 PTSD rather than other symptom profiles, the additional 3.6% of respondents meeting two or three of DSM-5 criteria B-E also had significantly elevated scores for most outcomes. The proportion of cases with threshold versus subthreshold PTSD varied depending on TE type, with threshold PTSD more common following interpersonal violence and subthreshold PTSD more common following events happening to loved ones. CONCLUSIONS: Subthreshold DSM-5 PTSD is most usefully defined as meeting two or three of DSM-5 criteria B-E. Use of a consistent definition is critical to advance understanding of the prevalence, predictors, and clinical significance of subthreshold PTSD.