Stress Reactions
(9-30-06)

Posttraumatic Stress Disorder (PTSD)

"Although many people are exposed to trauma, only some individuals develop posttraumatic stress disorder (PTSD); most do not. Further, in a large proportion of individuals who do develop the disorder, the disorder fully remits over time. The findings suggest that chronic PTSD may represent a specific type of adaptation to trauma that is not typical of most individuals, but rather is seen in individuals who have a particular kind of vulnerability to stress." (Morgan et al., 2001, p. 1239).

Screening for PTSD

Parents (in general) appear to be relatively reliable observers of the occurrence of stressful events in the lives of their children, and in the severity of stress their children experience from these events (Yamamoto & Mahlios, 2001)

Theoretical Models

Cognitive-Behavioral model of PTSD in Children and Adolescents (Meiser-Stedman, 2002)

Dual Representation Theory of PTSD (Brewin, Dalgleish, & Joseph, 1996)

Role of Dissociation:

Ursano et al. (1999) examined peritraumatic dissociation as a predictor of PTSD following MVA's. They reported that the most common peritraumatic dissociative symptom was time distortion (56.6%); and found that subjects with peritraumatic dissociation were 4.12 times more likely than those without to have acute PTSD and 4.86 times more likely to develop chronic PTSD. Further, the risk was independent of risk associated with factors predictive of PTSD prior to the accident.

Morgan et al. (2001) found symptoms of dissociation were common in healthy military subjects exposed to high-intensity stress. Subjects with a history of perceived threat to life in response to traumatic events reported more symptoms of dissociation. Symptoms of dissociation accounted for 41% of the variance in subjects' physical health complaints after stress exposure.

Special Forces soldiers experienced significantly fewer dissociative symptoms during stress in comparison to general infantry soldiers. Previous work had shown that Special Forces subjects exhibited significantly higher plasma levels of neuropeptide Y in response to survival school stress. Neuropeptide Y has been shown to have antianxiety and antistress properties and to enhance memory, alertness, and perception during stress.

Bryant, Guthrie, & Moulds (2001) found patients with Acute Stress Disorder following traumatic experience had higher levels of hypnotizability and were more likely to display reversible posthypnotic amnesia than patients with subclinical acute stress disorder and patients with no acute stress disorder; hypothesize diathesis-stress model--individuals who develop acute stress disorder in response to traumatic experience may have stronger ability to experience dissociation.

Trauma stimuli:

MVA

Mayou, Bryant, & Ehlers (2001) reported that 1/3 of patients treated in an ER following a MVA showed persistent psychiatric disorders. More females than males suffered psychiatric disorders.

They reported four outcomes: Depression, PTSD, General Anxiety, and Phobic Travel Anxiety. There was considerable comorbidity at both 3 months and 1 year, but also sizable portions of individuals with only 1 or 2 types of problems.

Rape

Acierno et al. (1999) reported that past victimization, young age, and a diagnosis of active PTSD increased women's risk of being raped

Acierno et al. (1999) reported that a history of depression, alcohol abuse, or experiencing injury during the rape emerged as significant independent risk factors for PTSD following a rape

Physical Assault

Acierno et al. (1999) reported that past victimization, minority ethnic status, active depression, and drug use were associated with increased risk of being physically assaulted

Acierno et al. (1999) reported that only a history of depression and lower education emerged as significant independent risk factors for PTSD following a physical assault

Witnessing Domestic Violence

Risk from witnessing a threat to a caregiver has impact across child-adolescent ages, not just for younger children (Scheeringa, Wright, Hunt, & Zeanah, 2006)

Cumulative/Interactive Effects

Past history with respect to stressful events are usually significant modulators of the impact of index stressful events (c.f., Morgan et al., 2001). Feeick & Haugaard found that the effects of witnessing marital violence depended on the presence of a history of childhood abuse.

Interaction between witnessing a threat to the caregiver and pretrauma externalizing behavior effects the total number of PTSD symptoms (Scheeringa, Wright, Hunt, & Zeanah, 2006)

PTSD comorbidity with other Mental Disorders

comorbidity is common

Major Depression is most common

comorbid substance abuse varies widely, comorbid substance
abuse may be more common in combat veterans than in non-
veteran samples.

Marshall et al., (2001) reported that suicide ideation was elevated with both PTSD and subthreshold ("partial") PTSD samples, even after controlling for comorbid depression.

Partial (subthreshold, subsyndromal) forms of PTSD are common in traumatized persons, and often show "clinically meaningful levels of functional impairment." Partial PTSD may be more common in women. (Stein et al., 1997)

Complex PTSD

Herman (1992) suggested that when violence is repeated over prolonged period of time, especially starting during childhood, the effects are very wide ranging and have the appearance of a personality disorder, and that the symptoms of PTSD do not capture this range of effects. The idea of Disorders of Stress Not Otherwise Specified (DESNOS) was examined in the DSM-IV field trials. DESNOS occurred comorbid with PTSD in many cases and did not occur in the absence of PTSD: these features were listed as associated symptoms of PTSD in DSM-IV.

impaired modulation
self-destructive and impulsive behavior
dissociative symptoms
somatic complaints
feelings of ineffectiveness, shame, despair, or hopelessness
feeling permanently damaged
a loss of previously sustained beliefs
hostility
social withdrawal
feeling constantly threatened
impaired relationships with others
a change from the individual's previous personality characteristics

Alternative PTSD criteria for preschool children: see Scheeringa, Zeanah, Myers, & Putman (2003).

Carrion, Weems, Ray, & Reiss (2002) found that frequency and severity of PTSD symptoms made separate contributions of predictions of PTSD diagnosis and predictions of overall impairment, and that different symptoms predicted diagnosis and impairment (Scheeringa et al., 2002).

Frequency of distressing recollections, detachment from others, hypervigilance, and exaggerated startle; and intensity of feelings of reoccurrence, detachment, hypervigilance, and startle predicted a diagnosis in children (Scheeringa et al., 2002).

Frequency of distressing recollections, distressing dreams, feelings of reoccurrence, inability to recall important aspects of event, restricted range of affect, and sleep problems; and intensity of recollections, dreams, feelings of reoccurrence, avoiding thoughts/feeling/conversations, inability to recall important aspects, and diminished interest predicted impairment in children (Scheeringa et al., 2002).

Children fulfilling requirements for 2 symptoms clusters were not significantly different from children meetings all three cluster requirements--subthreshold cases may show clinically significant impairment and distress (Scheeringa et al., 2002).

The DSM-IV algorithm threshold of 3 symptoms for criterion C may be inappropriate for prepubertal children (under 12 years) (Scheeringa, Wright, Hunt, & Zeanah, 2006)

Symptom pictures based on combining results of parent and child interviews regarding children's symptoms are significantly higher than scores based on either informant along: "The implication for young children, for whom only a parent report is available, is that the assessed number of PTSD symptoms will always be an underestimate of the true symptom load" (Scheeringa, Wright, Hunt, & Zeanah, 2006p. 650)

Personality differences associated with different responses to childhood sexual abuse

McNally, Clancy, Schacter, & Pitman (2000) present data supporting personality differences between women with histories of childhood sexual abuse who always recalled, recovered, or repressed these memories.

"women who have always remembered their CSA did not differ from nonabused comparison participants on any personality or clinical measure. These data are consistent with reviews showing that CSA does not invariably produce long-term impairment (Rind, Tromovitch, & Bauserman, 1998)."

Data from the McNally et al. study is consistent with the predictions of both the "false memory perspective" and the "recovered memory perspective."

The repressed memory group was the most distressed.

conclusions of study:

"First, people reporting continuous, recovered, or repressed memories clearly differ on personality and clinical measures. Those who have never forgotten their abuse were indistinguishable from those who were never abused, whereas those who believe they harbor repressed memories of CSA were the most distressed of all." (pp. 1036-1037)

"Second, the absorption data were consistent with the false memory hypothesis." (p. 1037)

"Third, the dissociation data were equally consistent with both the false memory and recovered memory perspectives. Having a history of CSA, however, is not invariably linked to heightened dissociation, as evidenced by the low scores of the continuous memory group." (p. 1037).

Acute Stress Disorder

Marshall, Spitzer, & Siebowitz (1999) review the literature on Acute Stress Disorder and question the usefulness and validity of this diagnosis on two fronts:

"The validity and utility of requiring peritraumatic dissociative symptoms as the core feature are questionable,"

"as is the separation of essentially continuous clinical phenomena into two disorders with different criteria sets (acute stress disorder and PTSD) based on persistence of symptoms for 30 or more days." (p. 1677).