[Post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) - a clinical update of knowledge]. / Posttraumatiskt stressyndrom (PTSD) och komplex PTSD (CPTSD).

Post-traumatic stress disorder, PTSD, is a psychiatric diagnosis that describes a condition where one or more very traumatic events, that include life-threatening or extreme psychological stress, have left permanent traces of distress that induce sustained suffering.  In this clinical overview, we present current updates in diagnostic criteria and a new diagnosis of complex PTSD, and discuss the problems caused by the new PTSD diagnosis criteria partially differing in the DSM-5 and ICD-11 diagnostic manuals. Diagnostic challenges caused by symptom variations is discussed, as well as the high degree of comorbidity with other psychiatric and somatic illnesses. Combined forms of treatment that reduce both psychological PTSD and somatic symptoms is underscored, as well as the clinical value of early discovery of PTSD and treatment of comorbidity. Furthermore, the article illuminates knowledge about resilience and social support as protective factors.

[PTSD and Complex PTSD - Assessment, management and treatment]. / Utredning, handläggning och behandling av PTSD och CPTSD.

Post-traumatic stress disorder (PTSD) is a disruptive condition associated with great suffering. Fortunately, effective treatments are available. Assessment of children and adolescents with symptoms of PTSD is done within the child and adolescent mental health services. Adults are assessed in primary healthcare settings. In complex conditions with psychiatric comorbidity, assessment is conducted in specialist psychiatric services. Trauma-focused psychotherapy is the treatment of choice for both children and adults. Trauma-focused psychotherapy is also recommended for treating complex PTSD, despite a weaker evidence base. PTSD-specific treatment should normally be offered even in the presence of psychiatric comorbidities. Treatment of children and adolescents with PTSD and CPTSD is provided by child and adolescent mental health services. Adults can receive treatment both in primary and secondary healthcare settings, depending on symptomatology and comorbidities.

Alcohol Habits and Health Care Use in Patients with Psychiatric Disorders.

OBJECTIVE: It is common for persons with psychiatric disorders to also have alcohol problems. Studies in the general population as well as in clinical samples have found hazardous or harmful alcohol habits to be particularly prevalent in the presence of psychiatric disorders. This study sought to explore the relationships between drinking habits and health care utilization (psychiatric as well as general medical) in persons seeking psychiatric treatment and to investigate the associations among age, sex, and type or number of diagnoses and health care use and costs. For the planning of targeted interventions, we also sought to identify subgroups with a high prevalence of hazardous drinking habits. METHODS: From a psychiatric clinic for affective disorders at a university hospital in Sweden, patients who had been screened for hazardous drinking (N = 609) were selected. Patients with primary psychosis or substance use disorder receive treatment at other clinics and did not participate. Medical records data were grouped and compared. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) was used for diagnoses and the Alcohol Use Disorders Identification Test for screening. Patients were grouped by drinking habits and sex, age, and diagnosis group, and their psychiatric as well as general medical health care use was compared. RESULTS: Abstainers used psychiatric care more than all other drinking groups (p < .001). Psychiatric health care costs were higher in abstainers and low-risk drinkers (1.64 to 1). No differences in general medical care could be identified between drinking groups. Specific subgroups with higher rates of hazardous drinking could not be identified (44% of all males and 34% of all females reported such habits). Inconclusive results from previous research are most likely due to different methods used to classify drinking problems. CONCLUSIONS: Abstainers and low-risk drinkers used psychiatric health care to a higher cost than the other drinking groups. Possible explanations are discussed from a clinical and scientific perspective. This study clarifies the need for uniform measures when classifying alcohol use in studies of relationships between alcohol use and health care use. There is also a need to separate former drinkers from abstainers in future studies.

Psychiatric morbidity predicts perceived burn-specific health 1 year after a burn.

OBJECTIVE: Individual factors such as gender, age, coping and personality traits and injury-related factors such as injury severity have been implicated as risk factors for poor perceived health after burns. As psychiatric morbidity is common in individuals who sustain burns, the aim of this study was to examine the effect of preinjury psychiatric problems on perceived health after injury. METHOD: A total of 85 consecutive patients treated at a national burn center were prospectively assessed: the patients were interviewed during acute care with the Structured Clinical Interview for DSM-IV Axis I Disorders. One year after injury, perceived health was assessed with the Burn-Specific Health Scale-Brief (BSHS-B). Multiple regression analyses were used to evaluate the predictive effect of preinjury psychiatric history on perceived postinjury health. RESULTS: Psychiatric morbidity, especially mood disorders, affected outcome for six of the nine BSHS-B subscales, with the covariates mainly being the length of hospital stay and total burn size. CONCLUSION: The results show that a history of preinjury psychiatric disorders, especially during the year before the burn, affects perceived outcome regarding both physical and psychological aspects of health 1 year after injury and that it is a risk factor for worse perceived outcome.

Impact of physical injury on mental health after the 2004 Southeast Asia tsunami.

BACKGROUND: The risk of developing enduring post-traumatic stress reactions and mental health problems in the aftermath of disasters is substantial. However, there are inconsistencies regarding the contribution of physical injury as an independent risk factor for developing psychiatric morbidity after disasters. AIMS: The aim was to assess whether physical injury was associated with post-traumatic stress reactions and general mental health after adjusting for perceived life-threat in the aftermath of the 2004 tsunami. METHODS: A sample of 1501 highly exposed survivors from the 2004 Southeast Asia tsunami was selected from a cohort of Swedish survivors surveyed 14 and 36 months after the event. The impact of physical injury on post-traumatic stress and general mental health was assessed by regression models accounting for subjective life-threat. RESULTS: Physical injury was associated with higher levels of post-traumatic stress reactions and poorer general mental health. These associations were observed at both 14 and 36 months after the disaster. CONCLUSIONS: Physical injury has a specific contribution to the association between traumatic experience and both post-traumatic stress reactions and general mental health in victims of the 2004 tsunami. The effect is stable over several years.

Validation of a Swedish version of the Impact of Event Scale-Revised (IES-R) in patients with burns.

The Impact of Event Scale (IES) and the Impact of Event Scale-Revised (IES-R) are often used as self-report instruments for symptoms of post-traumatic stress disorder (PTSD). However, there are few validations of the IES and the IES-R against structured clinical interviews. In this study the two scales, together with the three subscales of the IES-R, were assessed for their agreement with a diagnosis of PTSD in patients with burns 1 year after injury. Sixty patients with burns were evaluated 1 year after injury using the Structured Clinical Interview for the DSM-IV Axis I (SCID-I) psychiatric disorders and a Swedish version of the IES-R. The total score of the IES-R had the best discriminant ability (0.89) with a sensitivity of 1.0 and a specificity of 0.78. In conclusion, the total IES-R had good properties as a screening tool for PTSD and subsyndromal PTSD 1 year after burn injury.

Attentional bias and symptoms of posttraumatic stress disorder one year after burn injury.

Trauma-related attentional bias is suggested to play a role in maintaining posttraumatic stress disorder (PTSD). Although being burn injured is a traumatic event for many patients, there are no prospective studies investigating attentional bias. The aims were to assess burn-specific attentional bias 1 year after burn, and its associations with risk factors for PTSD and symptoms of PTSD. A total of 38 adult patients with burns were assessed with a structured clinical interview and a Swedish version of the Impact of Event Scale-Revised up to 1-year after burn. The Emotional Stroop Task was used to assess attentional bias 1 year after burn. In total 29 participants displayed burn-specific attentional bias. This group had more previous life events, perceived life threat, larger burns, and higher PTSD symptom severity. In conclusion, the majority of the patients had burn-specific attentional bias 1 year after burn and this was related to symptoms of PTSD.

The effect of traumatic bereavement on tsunami-exposed survivors.

Fourteen months after the 2004 tsunami, mental health outcome was assessed in 187 bereaved relatives, 308 bereaved friends, and in 3,020 nonbereaved Swedish survivors. Of the bereaved relatives, 41% reported posttraumatic stress reactions and 62% reported impaired general mental health. Having been caught or chased by the tsunami in combination with bereavement was associated with increased posttraumatic stress reactions. Complicated grief reactions among relatives were almost as frequent as posttraumatic stress reactions. The highest levels of psychological distress were found among those who had lost children. Traumatic bereavement, in combination with exposure to life danger, is probably a risk factor for mental health sequelae after a natural disaster.

Validation of the EQ-5D questionnaire in burn injured adults.

BACKGROUND: Health-related quality of life (HRQoL) is an important aspect of adaptation after burn. The EQ-5D is a standardized generic instrument for assessing HRQoL. Its psychometric properties in a group of burn injured individuals are, however, not known. METHODS: Seventy-eight consecutive patients admitted to a burn unit were included in a prospective longitudinal study. The participants completed the EQ-5D during acute care, and at 3, 6, and 12 months after the burn. At 6 and 12 months after the burn they also completed the Short-Form 36 Health Survey (SF-36) and the Burn Specific Health Scale-Brief (BSHS-B). RESULTS: High feasibility of the EQ-5D was demonstrated through a high response rate and a low proportion of missing or invalid answers. The floor and ceiling effects were small. Construct validity was demonstrated through good differentiation between health states and good discrimination of health states over time. The EQ-5D was associated with burn severity and discriminated between clinical subgroups in an expected manner. Criterion validity was demonstrated through significant correlations between the EQ-5D and subscales of the SF-36 and the BSHS-B. CONCLUSIONS: The EQ-5D has good psychometric properties, it is short and easy to administer and thus useful in assessment of HRQoL after burn.

Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity.

BACKGROUND: Psychiatric history has been suggested to have an impact on long-term adjustment in burn survivors. A rigorous, prospective, longitudinal approach was used to study psychiatric history in a population-based burn sample and its impact on symptomatology of depression and posttraumatic stress disorder (PTSD) at a 12-month follow-up. METHODS: Seventy-three consecutive patients admitted to the Uppsala Burn Unit were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition for psychiatric disorders, of whom 64 were also assessed after 12 months. RESULTS: Forty-eight patients (66%) presented with at least one lifetime psychiatric diagnosis; major depression (41%), alcohol abuse or dependence (32%), simple phobia (16%), and panic disorder (16%) were most prevalent. At 12-months postburn, 10 patients (16%) met criteria for major depression, 6 (9%) for PTSD, and 11 (17%) for subsyndromal PTSD. Patients with lifetime anxiety disorder and with lifetime psychiatric comorbidity were more likely to be depressed at 12 months, whereas those with lifetime affective disorder, substance use disorder and psychiatric comorbidity were more likely to have symptoms of PTSD. CONCLUSIONS: Two-thirds of burn survivors exhibit a history of lifetime psychiatric disorders. Those with a psychiatric history have a higher risk of postburn psychiatric problems.

Return to work and health-related quality of life after burn injury.

OBJECTIVE: Although severe burn injury is associated with long-term rehabilitation and disability, research on returning to work in burn patients is limited. The aims of this study were: (i) to explore injury- and personality-related predictors of returning to work, and (ii) to compare health-related quality of life and health outcome in working versus non-working individuals. DESIGN: Cross-sectional study. SUBJECTS: Forty-eight former patients with pre-burn employment were evaluated on average 3.8 years after the burn. METHODS: Data were collected from medical records and by a questionnaire in which the patients were asked about their main activity status described in the terms: work, studies, pension, disability pension, sick leave or unemployment. It also contained the Swedish universities Scales of Personality, SF-36, Burn Specific Health Scale-Brief, items assessing fear-avoidance, Impact of Event Scale-Revised and Hospital Anxiety and Depression Scale. RESULTS: Thirty-one percent had not returned to work. In logistic regression, returning to work was associated with time since injury, the extent of full-thickness injuries, and the personality trait embitterment. Those who did not work had lower health-related quality of life, poorer burn-specific health, more fear-avoidance and more symptoms of posttraumatic stress disorder, but they did not differ from those who were working regarding general mood. CONCLUSION: Returning to work was explained by both injury severity and personality characteristics. Those who did not work were characterized by low health-related quality of life and poorer trauma-related physical and psychological health.

The presence of nightmares as a screening tool for symptoms of posttraumatic stress disorder in burn survivors.

Recurrent nightmares can be a symptom of posttraumatic stress disorder (PTSD). This study evaluated the method of asking burn survivors about nightmares as a screening tool for the presence of PTSD symptomatology. The presence of nightmares in 85 individuals treated at the Burn Center in Uppsala, Sweden, between 1996 and 2000 (23 women, 62 men, average age 47 years, average burn size 17% TBSA, average time after burn 3.6 years) was evaluated by one question from the Burn Specific Health Scale (BSHS) and by using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria for nightmares. PTSD symptomatology was assessed with the Impact of Event Scale-Revised. Sensitivity, Specificity, Discriminant Ability, and Likelihood Ratios for a positive and a negative result were calculated to evaluate the screening questions. As many as 46% of the burn survivors reported nightmares of some frequency in the BSHS and as many as 28% when using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria. Both approaches were useful tools for detecting or ruling out PTSD symptoms. The best Discriminant Ability was achieved with a screening test using the BSHS item "I have nightmares." Screening questions for presence of nightmares after burns can be useful in detecting PTSD symptomatology.

Work status and burn specific health after work-related burn injury.

UNLABELLED: Work status is a valid indicator of post burn health. There is limited information on this issue after work-related burn injury. AIM: To investigate long-term health- and work status after work-related burns. METHOD: Eighty-six former patients treated for severe work-related burn injuries an average of 9.0 years previous to follow-up were questioned about their present work status. They were also assessed with the Burn Specific Health Scale-Brief (BSHS-B) and a pain scale adopted from the abbreviated Burn Specific Health Scale. RESULTS: At follow-up 71 (83%) of the former patients were working, nine (10%) were on sick leave or had a disability pension, and six (7%) were unemployed. Those who were not working reported a poorer outcome in three of the BSHS-B psychosocial domains (Body Image, Affect and Interpersonal Relationships) and in two of the BSHS-B physical domains (Treatment Regimens and Work). They also reported significantly more pain. CONCLUSION: Only a small group of former patients with work-related accidents were not working in the sample studied after a long follow-up period. The unemployed reported more pain and worse perceived health, particularly in psychosocial domains.

Pruritus, personality traits and coping in long-term follow-up of burn-injured patients.

Pruritus is a major problem after burn injury; however, prevalence and predictors of prolonged pruritus are not known. The aims were to assess frequency of pruritus and the role of personality traits and coping in prolonged pruritus. The participants were burn patients injured 1-18 years earlier (n=248). Pruritus was assessed with an item from the Abbreviated Burn Specific Health Scale, personality was assessed with the Swedish universities Scales of Personality, and coping with the Coping with Burns Questionnaire. In all, 60% of the participants had pruritus at follow-up, however as the time after injury increased, the number of patients with persistent itch decreased. In logistic regression, 39% of the likelihood of having persistent pruritus was explained by greater extent of burn, less time after injury, and psychological features (being less assertive, and using more instrumental but less emotional support). In summary, chronic burn-related pruritus is rather common and psychological factors such as anxiety-related traits and coping are significantly associated with its presence.

Chronic nightmares after severe burns: risk factors and implications for treatment.

Although patients frequently experience sleep disturbances and nightmares in the first weeks after a severe burn, information is scarce on the course and prevention of this problem. Prolonged experience of nightmares in adults is one of the symptoms of posttraumatic stress disorder. The aim of this work was to determine risk factors for developing chronic nightmares after severe burns. Personality traits and coping strategies were assessed. As part of a follow-up study of patients treated at the Burn Center at Uppsala University Hospital, Uppsala, Sweden, between 1980 and 1995, the questionnaires of 166 patients (34 females, 132 males, average age 50 years, average burn size 25% TBSA, full-thickness burn size 10% TBSA, average time since burn 11.4 years) were analyzed. The effects of individual personality traits and coping strategies on the frequency of nightmares were evaluated by regression analysis. Nightmares were reported by 43% of the patients, by females more frequently than males. The frequency of nightmares was shown to be associated with the size of the full-thickness burn. The use of Avoidance or Revaluation/Adjustment scales as coping strategies and the presence of Somatic Trait Anxiety as a personality trait were associated with a higher frequency of nightmares after correction for gender. In contrast, persons seeking Emotional Support as a coping strategy reported significantly fewer nightmares. Certain personality traits and coping strategies apparently increase the risk of having nightmares after a severe burn. Helping persons at risk develop different coping strategies may be a possible means of prevention or treatment.