Reliability and Validity of the Korean Version of Clinician-Administered Posttraumatic Stress Disorder Scale for DSM-5

BACKGROUND: For diagnosis of post-traumatic stress disorder (PTSD), the Clinician-Administered PTSD Scale (CAPS) is one of the most widely used structured diagnostic interviews. METHODS: In this study, we aimed to develop and validate the Korean version of CAPS for the Diagnostic and Statistical Manual of Mental Disorders, 5th edition ([DSM-5] K-CAPS-5). Seventy-one subjects with PTSD, 74 with mood disorder or anxiety disorder, and 99 as healthy controls were enrolled. The Korean version of the structured clinical interview for DSM-5-research version was used to assess the convergent validity of K-CAPS-5. BDI-II, BAI, IES-R, and STAI was used to evaluate the concurrent validity. RESULTS: All subjects completed various psychometric assessments including K-CAPS-5. K-CAPS-5 presented good internal consistency (Cronbach's α = 0.92) and test-retest reliability (r = 0.91). K-CAPS-5 showed strong correlations with the structured clinical interview for DSM-5 PTSD (k = 0.893). Among the three subject groups listed above there were significant differences in the K-CAPS-5 total score. The data were best explained by a six-factor model. CONCLUSION: These results demonstrated the good reliability and validity of K-CAPS-5 and its suitability for use as a simple but structured instrument for PTSD assessment.

A Brief Screening Tool for PTSD: Validation of the Korean Version of the Primary Care PTSD Screen for DSM-5 (K-PC-PTSD-5)

The purpose of this study was to develop and evaluate psychometrically the Korean version of the Primary Care Posttraumatic Stress Disorder Screen for the Diagnostic and Statistical Manual-fifth edition (K-PC-PTSD-5). In total, 252 participants were interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual-fifth edition-research version (SCID-5-RV). The K-PC-PTSD-5 showed good internal consistency (α = 0.872), test-retest reliability (r = 0.89), and concurrent validity (r = 0.81). A score of 3 was identified as the threshold for clinically significant posttraumatic stress disorder (PTSD) symptoms. Overall, the results indicate that the K-PC-PTSD-5 is a useful, timesaving instrument for screening PTSD symptoms.

Decision Making Regarding Key Elements of Korean Disaster Psychiatric Assistance Teams Using the Analytic Hierarchy Process

OBJECTIVE: The purpose of this study was to determine the key components of Korean disaster psychiatric assistant teams (K-DPATs), to set up new mental health service providing system for the disaster victims. METHODS: We conducted an analytic hierarchy process (AHP) involving disaster mental health experts, using a pairwise comparison questionnaire to compare the relative importance of the key components of the Korean disaster mental health response system. In total, 41 experts completed the first online survey; of these, 36 completed the second survey. Ten experts participated in panel meetings and discussed the results of the survey and AHP process. RESULTS: It was agreed that K-DPATs should be independent of the existing mental health system (70.1%), funding for K-DPATs should be provided by the Ministry of Public Safety, and the system should be managed by the Ministry of Health (65.8%). Experts shared the view that K-DPAT leaders would be suitable key decision makers for all types of disaster, with the exception of those involving infectious diseases. CONCLUSION: K-DPAT, a new model for disaster mental health response systems could improve the insufficiency of the current system, address problems such as fragmentation, and fulfill disaster victims’ unmet need for early professional intervention.

Blonanserin Augmentation of Atypical Antipsychotics in Patients with Schizophrenia-Who Benefits from Blonanserin Augmentation?: An Open-Label, Prospective, Multicenter Study

OBJECTIVE: The purpose of this study was to investigate the efficacy and tolerability of atypical antipsychotics (AAPs) with augmentation by blonanserin in schizophrenic patients. METHODS: aA total of 100 patients with schizophrenia who were partially or completely unresponsive to treatment with an AAP were recruited in this 12-week, open-label, non-comparative, multicenter study. Blonanserin was added to their existing AAP regimen, which was maintained during the study period. Efficacy was primarily evaluated using the Positive and Negative Syndrome Scale (PANSS) at baseline and at weeks 2, 4, 8, and 12. Predictors for PANSS response (≥20% reduction) were investigated. RESULTS: The PANSS total score was significantly decreased at 12 weeks of blonanserin augmentation (-21.0±18.1, F=105.849, p<0.001). Moreover, 51.0% of participants experienced a response at week 12. Premature discontinuation of blonanserin occurred in 17 patients (17.0%); 4 of these patients dropped out due to adverse events. The patients who benefited the most from blonanserin were those with severe symptoms despite a treatment with a higher dose of AAP. CONCLUSION: Blonanserin augmentation could be an effective strategy for patients with schizophrenia who were partially or completely unresponsive to treatment with an AAP.

The Development and Validation of the Korean Strength Scale for Youth / 신경정신의학

OBJECTIVES: The purpose of this study was to develop a Korean Strength Scale for Youth and to examine its validity and reliability. METHODS: The Korean Strength Scale for Youth is based on a self-reporting, 100 item questionnaire that measures 25 strengths. Each scale item was given a 0–5 rating on a 6-point scale. In order to test the scale's validity and reliability, data were collected from 422 youths (aged 12–18 years). The strength measures included in our analyses were those contained within the Korean Strength Scale for Youth, the Positive Affect and Negative Affect Schedule, the Korean Well-Being Scale for Adolescents, and the Short Five Factor Personality Scale for Children. RESULTS: The results of exploratory factor analysis of the Korean Strength Scale for Youth scale-measures indicated the importance of four factors. The Korean Strength Scale for Youth was shown to have acceptable psychometric properties, including good internal consistency, test-retest reliability, and high convergent correlations. CONCLUSION: The Korean Strength Scale for Youth is a reliable and valid instrument that can be used to assess strengths in adolescents.

Somatic Symptoms after Psychological Trauma / 정신신체의학

OBJECTIVES: Somatic symptoms after the exposure of psychological trauma frequently developed. However, the somatic symptoms are not covered under the diagnostic criteria of posttraumatic stress disorder(PTSD) in detail, although they are often associated with social and occupational functioning and patient-doctor relationships. The aim of this article is to highlight the potential mechanisms, the common manifestations, and the treatment of the somatic symptoms. METHODS: This article studied the somatic symptoms searched using academic search engines like PubMed, Scopus, Google Scholar, KoreaMed and KISS from the earliest available date of indexing to March 31, 2016. RESULTS: The mechanism of somatic symptoms after the exposure was described as psychological and physiological aspects. Psychological mechanism consisted of psychodynamic theory, cognitive behavioral theory, and others. Physiological mechanism involved changes in neuroendocrine and immune system, autonomic nervous system and central nervous system. Somatization associated with psychological trauma manifested various health conditions on head and neck, chest, abdominal, musculoskeletal, and dermatological and immune system. Few studies described the standardization of treatment for the somatic symptoms. CONCLUSIONS: Clinicians and disaster behavioral health providers should think of the accompanying somatic symptoms during intervention of psychological trauma and PTSD. Further studies are needed on the somatic symptoms seen in psychological trauma and PTSD.

Prevention and Treatment of Trauma- and Stressor-Related Disorders : Focusing on Psychosocial Interventions for Adult Patients / 신경정신의학

Each year many people are exposed to life-threatening disaster and traumatic events that put them at risk for trauma- and stressor-related disorders such as posttraumatic stress disorder. This report reviews research on the psychosocial interventions currently employed for the prevention and treatment of trauma- and stressor-related disorders. Cognitive behavioral therapy, including cognitive therapy and prolonged exposure, has been shown to improve several outcomes. Considerable progress has also been made in the use of eye movement desensitization and reprocessing. Trauma- and stressor-related disorders are associated with complex outcomes and multiple comorbid emotional, social, and physical health difficulties. Further advances are required in the intervention for populations with complex and chronic forms and in the development of integrated and well-related systems of care.

Quantitative Analysis of Providers' Experiences in the Disaster Behavioral Health Services of South Korea / 신경정신의학

OBJECTIVES: This study was conducted to quantify the six dimensions of obstacles to disaster behavioral health (DBH), which was explored through the previous Qualitative Content Analysis of field workers' experiences after the Sewol Ferry accident and to determine the preference and significance of the details of every dimension. METHODS: Based on the six dimensions and their details, structured questionnaires were devised. The field workers as DBH service providers were requested to choose not only the most urgent item but also the reason for their choice. For the statistical analysis, the field workers were grouped by age, employment period, place of employment, occupation, mental health professional certificate, and experience and education of DBH interventions. Differences of the groups were analyzed using chi-square test. RESULTS: The questionnaires were distributed to 284 field workers for DBH, and a total of 79 usable questionnaires were collected and analyzed. Out of six dimensions, 43% of the field workers primarily suffered from difficulties in vertical relations of the administration system. Vague policy on DBH was the most challenging in difficulties in vertical relations of administration system (32.9%). The details of the other 5 dimensions were also discovered. Several significant differences were identified among groups according to the structured questionnaires. CONCLUSION: This study identifies the six dimensions and their significance as obstacles to DBH services. It may make a contribution to improving laws and systems when deciding on related policies and sorting out urgent problems.

Reliability and Validity of the Korean Version of the Symptom Checklist-Post-Traumatic Stress Disorder Scale

The Symptom Checklist - Post-Traumatic Stress Disorder Scale (SCL-PTSD), also known as Crime-Related PTSD Scale has been validated in survivors of interpersonal trauma in the general population. However, the psychometric properties have not been investigated in a clinical setting for patients with PTSD from diverse traumatic events. This study investigates the reliability and validity of the Korean version of the SCL-PTSD among 104 psychiatric outpatients with PTSD, caused by interpersonal (n = 50) or non-interpersonal trauma (n = 54). Self-report data of the SCL-PTSD, Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Impact of Events Scale-Revised (IES-R) were gathered. The Korean version of the SCL-PTSD showed excellent internal consistency and moderate-to-good four-week temporal stability in both the interpersonal and non-interpersonal trauma groups. In comparison with other diagnostic groups, the scores of the SCL-PTSD were significantly higher compared to those of adjustment disorder, depression, other anxiety disorders, and schizophrenia, demonstrating its criteria-related validity. Convergent validity was confirmed because the scores of the SCL-PTSD were significantly correlated with BDI, SAI and TAI scores. Concurrent validity was demonstrated by significant correlation with the IES-R score. This study demonstrated the favorable psychometric prosperities of the Korean version of the SCL-PTSD, supporting its use in clinical research and practice.

Drug Interactions between Cardiovascular Agents and Psychotropic Drugs / 정신신체의학

There are numerous drug interactions related to many psychotropic and cardiovascular medications. Firstly, the principles in predicting drug interactions are discussed. Cytochrome P (CYP) 450 plays a significant role in the metabolism of these drugs that are substrates, inhibitors, or inducers of CYP450 enzymes. The two most significant enzymes are CYP2D6 and CYP3A4. The ability of psychotropic drugs to act as inhibitors for the enzymes may lead to altered efficacy or toxicity of co-administered cardiovascular agents as a substrate for the enzymes. The following is also a review of the known interactions between many commonly prescribed cardiovascular agents and psychotropic drugs. Most beta blockers are metabolized by CYP2D6, which may lead to drug toxicity when they use in combination with potent CYP2D6 inhibitors including bupropion, chlorpromazine, haloperidol, selective serotonin reuptake inhibitors, and quinidine. Concomitant administration of lithium with angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics may increase serum lithium concentrations and toxicity. Calcium channel blockers and cholesterol lowering agents are subject to interactions with potent inhibitors of CYP3A4, such as amiodarone, diltiazem, fluvoxamine, nefazodone, and verapamil. Prescribing antiarrhythmic drugs in conjunction with medications are known to prolong QT interval and/or inhibitors on a relevant CYP450 enzyme is generally not recommended, or needs watchful monitoring. Digoxin and warfarin also have warrant careful monitoring if co-administered with psychotropic drugs.

The Relationship between Alcohol Consumption and Exposure to Traumatic Events in Male Firefighters / 신경정신의학

OBJECTIVES: This study explored the relationship between alcohol consumption and exposure to traumatic events in male firefighters. METHODS: Data was collected from a sample of 584 firefighters at urban fire stations. We surveyed the firefighters using self-administered questionnaires including sociodemographic and job-related characteristics such as the Alcohol Use Disorders Identification Test (AUDIT), Life Event Checklist (LEC), Perceived Stress Scale (PSS), Korean Occupational Stress Scale-Short Form (KOSS-SF), Impacted Event Scale-Revised (IES-R), Stait Trait Anxiety Inventory (STAI) and Beck Depression Inventory (BDI). RESULTS: There were significant differences in smoking, traumatic events (LEC), post-traumatic stress disorder symptoms (IES-R), and anxiety (STAI-T) between the two drinking groups (p<0.05). In multivariate logistic regression, smoking (OR=2.084, 95% CI=1.172-3.705), LEC (OR=1.163, 95% CI=1.010-1.339) and IES-R (OR=1.024, 95% CI=1.002-1.046) were significant predictors for AUDIT (p<0.05). CONCLUSION: These results indicate that an appropriate intervention about the exposure to traumatic events should play a useful role in preventing firefighter alcohol problems.

Platelet Serotonin Transporter Function and Heart Rate Variability in Patients with Panic Disorder

Many studies showed abnormal serotonin transporter (5-HTT) function and heart rate variability (HRV) in panic disorder patients. The present study investigated the relationship between HRV power spectral analysis findings and platelet serotonin uptake in panic disorder patients. Short-term HRV over 5 min and platelet serotonin transporter uptake parameters (V(max) and K(m)) were measured both in 45 patients with panic disorder and in 30 age-matched normal healthy control subjects. Low frequency power (LF) normalized unit (nu) and LF/high frequency power (HF) were significantly higher, whereas HF and HF nu were lower in the patient group than in the control group. V(max) and K(m) were all significantly lower (i.e., reflects decreased 5-HTT function) in patients with panic disorder than in normal controls. In the patient group, Km was negatively correlated with LF/HF and LF nu whereas no such correlations between them were found in the control group. By multivariate analysis based on multiple hierarchical linear regression, a low Km independently predicted an increased LF nu even after controlling for age, sex, and body mass index in the patient group. These results suggest that impaired 5-HTT function is closely related to dysregulation of autonomic nervous system in panic disorder.

Effect of Biofeedback-assisted Autogenic Training on Headache Activity and Mood States in Korean Female Migraine Patients

Biofeedback with or without combined autogenic training is known to be effective for the treatment of migraine. This study aimed to examine the effect of biofeedback treatment on headache activity, anxiety, and depression in Korean female patients with migraine headache. Patients were randomized into the treatment group (n=17) and monitoring group (n=15). Mood states including anxiety and depression, and psychophysiological variables such as mean skin temperature of the patients were compared with those of the normal controls (n=21). We found greater treatment response rate (defined as > or =50% reduction in headache index) in patients with biofeedback-assisted autogenic training than in monitoring group. The scores on the anxiety and depression scales in the patients receiving biofeedback-assisted autogenic training decreased after the biofeedback treatment. Moreover, the decrease in their anxiety levels was significantly related to the treatment outcome. This result suggests that the biofeedback-assisted autogenic training is effective for the treatment of migraine and its therapeutic effect is closely related to the improvement of the anxiety level.

Biofeedback-Assisted Autogenic Training for Chronic Tension-Type Headache in a Korean Population / 신경정신의학

OBJECTIVES: We aimed to evaluate the efficacy of biofeedback-assisted autogenic training for chronic tension-type headache, and to determine the relationship among the changes in electromyography (EMG) activity, headache activity, and mood states according to the psychophysiological treatment. METHODS: Chronic tension-type headache patients aged from 20 to 40 years (n=35) were randomized to the treatment group receiving biofeedback-assisted autogenic training (8 sessions) or the monitoring-only control group. EMG activities, headache index, and various psychological variables were examined. RESULTS: We found greater treatment response rate (> or =50% reduction in headache index) in patients with biofeedbackassisted autogenic training than in the monitoring group (61% vs. 18%; chi-square=6.882, df=1, p=0.01). There were no significant changes in the mean values of the pretreatment EMG activities across the sessions in either group (all p's>0.1). Mood states including anxiety and depression improved over time in the both groups, with the improvements being more prominent in the treatment group. Moreover, the reduction in depression level predicted treatment outcome in terms of headache index (95% confidence interval: 0.272-0.966, p=0.039). CONCLUSION: These results show that biofeedback-assisted autogenic training is effective for the treatment of chronic tension-type headache in a Korean population. Changes in mood states may be closely associated with the clinical outcome in the treatment of chronic tension-type headache using biofeedback-assisted autogenic training.

The Effectiveness of 6-Month Treatment with Venlafaxine Extended Release in Generalized Anxiety Disorder: Prospective, Multi-Center, Open-Labeled Trial / 대한정신약물학회지

OBJECTIVE: We aimed to examine the efficacy and the safety of venlafaxine extended release (venlafaxine-XR), and its effect on the quality of life in patients with generalized anxiety disorder. METHODS: Fifty three patients who had generalized anxiety disorder were recruited for this study. They showed scores of 18 or higher on the Hamilton Rating Scale for Anxiety (HAMA) and did not have major depression. They were scheduled to be examined 5 times (at baseline, 4, 8, 16 and 24 weeks) and took venlafaxine-XR for 24 weeks with a flexible dosing schedule. The primary efficacy variables were the response and remission rates (response: more than 50% reduction from baseline in HAMA total score ; remission: HAMA total score< or =7). Other variables were the Hamilton Ratng Scale for Depression, Beck Anxiety Inventory, Sheehan Disabilities Scale (SDS), and World Health Organization Quality of Life Assessment Instrument-Brief Form (WHOQOL-BREF). Also, the evaluation on adverse effects was performed. RESULTS: The number of patients who completed 24 weeks of treatment was 32 (60.4%). Twenty one patients who were dropped out included 8 patients with intolerable adverse effects and 7 patients with unsatisfactory treatment response. Response/remission rates were 43.4/32.1% in the last-observation-carried-forward methods and 71.9/53.1% in the observed case data. Treatment with venlafaxine-XR improved anxiety and depressive symptoms during 24 weeks on all efficacy measures. By a completed patient analysis, venlafaxine-XR also significantly improved the disability scores on SDS and the quality of life scores on WHOQOL-BREF. In this study, nausea, palpitation, and severe tremor were common reasons of venlafaxine-XR discontinuation in GAD patients, but any serious adverse effect did not occur. CONCLUSION: Treatment with venlafaxine-XR was effective and well-tolerated for the patients with GAD, and also improved quality of life in the GAD patients.

Biological Markers that Predict the Treatment Response of Paroxetine in Panic Disorder / 신경정신의학

OBJECTIVES: Previons studies reported altered beta-adrenergic receptor (betaAR) responsiveness in panic disorder, but few studies reported to see the effect of pharmacotherapy on betaAR function in panic patients. This investigation examined betaAR responsiveness in patients with panic disorder before and after pharmacotherapy with paroxetine. METHODS: After assessment using the Anxiety Disorder Interview Schedule for DSM-IV, 27 acute panic patients whose illness duration did not exceed 1 year were assigned to 12 weeks of paroxetine treatment. Twenty seven normal control subjects with no previous history of major medical and psychiatric illnesses were matched by age, sex, exercise, and body mass index. The Hamilton rating scale for anxiety (HAM-A), Hamilton rating scale for depression (HAM-D), Spielberger state-trait anxiety inventory-State (STAI-S) and Trait (STAI-T), acute panic inventory (API), anxiety sensitivity index (ASI), and Beck depression index (BDI) were performed to assess clinical states in the panic patients before and after treatment. The HAM-A, HAM-D, STAI-S and STAI-T, and BDI were also performed in the normal control subjects. We measured the betaAR density (Bmax), affinity (1/Kd), and sensitivity (cyclic AMP ratio of isoproterenol-stimulated cAMP to basal cAMP) in all subjects. RESULTS: Panic patients showed much lower scores of the HAM-A, STAI-S, STAI-T, API, ASI, HAM-D, and BDI after 12 weeks of paroxetine treatment than those before the treatment. There was no significant difference in the means of Bmax and cAMP ratio between control subjects and panic patients before and after the treatment. However, pretreatment Kd (R2=0.314, beta=-0.876, p=0.001) and Bmax (R2=0.230, beta=-0.575, p=0.019) significantly accounted for API scores after the treatment and change of Bmax according to the treatment accounted for the improvement of anxiety sensitivity (R2=0.353, beta=0.594, p=0.015). The pretreatment Kd value was significantly higher in the panic patients compared with that of control subjects (78.35+/-26.20 vs. 59.15+/-29.33, p=0.014), which was significantly reduced after the treatment (79.43+/-26.83 vs. 56.38+/-28.79, p=0.002). The pretreatment Kd value significantly accounted for the improvement of API scores (R2=0.316, beta=0.562, p=0.029) and the decrease in trait anxiety (R2=0.246, beta=-0.513, p=0.025). CONCLUSION: In acute panic patients, only betaAR affinity was reduced before the treatment, which was contrary to our expectation. Decreased betaAR affinity was normalized after paroxetine treatment. Decreased betaAR affinity and increased betaAR density before the treatment predicted good treatment response in acute panic patients. Thus, betaAR affinity and density could be useful biological markers that predict the treatment response of paroxetine in panic disorder.

Lymphocyte Subsets and Mood States in Panic Disorder Patients

This study was conducted to examine lymphocyte subset counts and mood states in panic disorder patients. Twenty patients with panic disorder and 20 age- and gendermatched normal healthy subjects were recruited for the study. We used the Spielberger State (STAIS) & Trait (STAIT) Anxiety Inventory, Hamilton Depression Rating scale (HAMD) and Hamilton Anxiety Rating scale (HAMA) to measure mood states in all subjects. Lymphocyte subsets counts were made by flow cytometry. Panic patients showed significantly higher scores for anxiety and depression than normal subjects. Panic patients showed no differences in terms of the numbers of immune cells, as compared with normal healthy subjects, other than a lower proportion of T suppressor cells and a higher T helper cell/T suppressor cell ratio. HAMA and STAIS scores were common factors that could predict T cell numbers and proportions, T helper cell numbers, and natural killer cell proportions in panic disorder patients. We suggest that anxiety levels are related to the T-cell population in panic disorder patients and that quantitative immune differences may reflect altered immunity in this disorder.