Attrition in Interpersonal Psychotherapy Among Women With Post-traumatic Stress Disorder Following Sexual Assault.

BACKGROUND: An estimated 16.9% of adult Brazilian women experience sexual assault in their lifetime. Almost half of women who suffer such trauma develop post-traumatic stress disorder (PTSD). Markowitz et al. (2015) found that an affect-focused non-exposure therapy, Interpersonal Psychotherapy (IPT), adapted to treat PTSD (IPT-PTSD) had similar efficacy to and lower dropout rates than Prolonged Exposure (PE), the "gold standard," most studied exposure therapy for PTSD. OBJECTIVE: To assess attrition rates in IPT of sexually assaulted women recently diagnosed with PTSD. METHODS: The current study derives from a two-arm, randomized controlled clinical trial of sexually assaulted women with PTSD who received 14 weeks of standardized treatment with either IPT-PTSD or sertraline. Sample: The 32 patients in the IPT treatment arm were analyzed. RESULTS: Overall attrition was 29%. One patient was withdrawn because of suicidal risk; four dropped out pre-treatment, and five dropped out during IPT-PTSD. If the excluded patient is considered a dropout, the rate increases to 31%. DISCUSSION: This is the first formal study of IPT for PTSD specifically due to sexual assault. IPT attrition approximated dropout rates in PE studies, which are often around 30%, and to the sertraline group in our study (34.5%). Further research should compare IPT and PE among sexually assaulted women to clarify our hypothesis that IPT could be an attractive alternative approach for this patient group.

Health-related quality of life in posttraumatic stress disorder: 4 years follow-up study of individuals exposed to urban violence.

Evidence suggests that Posttraumatic Stress Disorder (PTSD) is associated with substantially reduced Health-related quality of life (HRQoL). This study aimed to explore the impact of PTSD symptoms in HRQoL and its predictors in individuals exposed to urban violence. We follow-up a cohort of 267 individuals exposed to urban violence, derived from an epidemiological survey and clinical cases from an outpatient program of victims of violence, with and without PTSD, by assessing symptoms and other measures at two intervals, approximately 4 years apart. PTSD symptom severity was associated with poorer quality of life at baseline and at follow-up. Higher levels of depression and anxiety, new trauma experiences, more traumas in childhood and more PTSD arousal symptoms were all predictors of lower HRQoL over time. Results strongly suggest the need to assess HRQoL in addition to symptoms in order to assess the true severity of PTSD. These results have implications for the functional recovery in the treatment of PTSD.

Reduction of anterior cingulate in adults with urban violence-related PTSD.

BACKGROUND: To evaluate differences in limbic structure volume of subjects exposed to urban violence during adulthood, between those who developed posttraumatic stress disorder (with PTSD) and resilient matched controls (without PTSD). METHODS: Limbic volumetric measures of 32 subjects with PTSD and 32 subjects without PTSD who underwent brain MRI were analyzed in an epidemiological study in the city of Sao Paulo. The hippocampus, amygdala, cingulate, and parahipocampal gyri volumes were estimated using FreeSurfer software. We also investigated the association between limbic volumetric measurements, symptom´s severity, and early life stress history (measure by Early Trauma Inventory - ETI). RESULTS: Subjects with PTSD presented reduced volume of the right rostral part of the anterior cingulate, compared to subjects without PTSD, after controlling for intracranial volume, ETI, and depressive symptoms. Subjects with PTSD presented larger bilateral hippocampus and right amygdala, but secondary to the higher ETI. In PTSD group there was a positive correlation between ETI with bilateral hippocampus, bilateral amygdala, and left parahippocampus. LIMITATIONS: First, the cross-sectional study design precludes causal interpretation of limbic structure reduction in PTSD, consequence of PTSD, or other life events. Finally, since the sample size was not sufficiently large, we could not observe whether or not limbic structure volume could be related to the type of trauma. CONCLUSIONS: The present study provides evidence of a reduced anterior cingulate volume in subjects with PTSD than in resilient subjects exposed to urban violence. Enlargement of hippocampus and amygdala volume was observed in subjects with PTSD, however secondary to early trauma experience.

Attentional and executive functions are differentially affected by post-traumatic stress disorder and trauma.

BACKGROUND: Among the neurocognitive impairments observed in patients with Post-traumatic Stress Disorder (PTSD), attentional and executive dysfunctions appear to correlate with negative effects on education, work, daily life activities, and social relations, as well as the re-experiencing, avoidance, and hyperarousal symptoms of PTSD. However, there is no consensus regarding which aspects of attentional and executive functions are impaired in PTSD patients. METHODS: Attentional and executive functions were assessed using the digit span (WAIS-III) and spatial span (WMS-III) tests under forward and backward recall conditions, the Stroop Test, and the Wisconsin Card Sorting Test (WCST). Our sample was composed of victims of urban violence who developed PTSD (PTSD+) (n = 81), victims of urban violence who did not develop PTSD (PTSD-) (n = 70), and healthy controls not exposed to trauma (HC) (n = 50). RESULTS: The PTSD+ group had poorer performance on the spatial span forward subtest (p = 0.023; eta(2) = 0.038) and poorer execution time (p = 0.023; eta(2) = 0.042) and accuracy (p = 0.019; eta(2) = 0.044) on the Stroop Test compared to HC. CONCLUSIONS: These data suggest that there are few differences between the PTSD+ and HC groups, which are restricted to less complex measures of attentional and executive functional processes (short term capacity, selective attention, processing speed, and inhibitory control) and are related to visual stimuli. Therefore, cognitive impairments directly correlated with the manifestation of PTSD.

Relationship between structural abnormalities in the cerebellum and dementia, posttraumatic stress disorder and bipolar disorder.

New evidence suggests that the cerebellum has structural and functional abnormalities in psychiatric disorders. OBJECTIVE: In this research, the goal was to measure the volume of the cerebellum and its subregions in individuals with psychiatric disorders and to relate these findings to their symptoms. METHODS: Patients with different degrees of cognitive impairment (Epidemiology of the Elderly - UNIFESP) and patients with post-traumatic stress disorder (PTSD) from population studies were analyzed. Also, patients with bipolar disorder from an outpatient clinic (Center for the Study of Mood and Anxiety Disorders, Universidade Federal da Bahia) were recruited for this study. All subjects underwent a 1.5T structural magnetic resonance scan. Volumetric measures and symptom measurements, by psychometric scales, were performed and compared between patients and controls. RESULTS: The cerebellum volume was reduced in patients with cognitive impairment without dementia and with dementia, in patients with PTSD, and in patients with bipolar disorder compared to controls. In dementia and PTSD, the left cerebellar hemisphere and vermis volume were reduced. In bipolar disorder, volumes of both hemispheres and the vermis were reduced. In the first two studies, these cerebellar volumetric reductions correlated with symptoms of the disease. CONCLUSION: The exact nature of cerebellar involvement in mental processes is still not fully understood. However, abnormalities in cerebellar structure and its functions have been reported in some of these diseases. Future studies with larger samples are needed to clarify these findings and investigate whether they are important for treatment and prognosis.

Novas evidências sugerem que o cerebelo apresenta alterações estruturais e funcionais nos transtornos psiquiátricos. OBJETIVO: Medir o volume do cerebelo e de suas sub-regiões em indivíduos portadores de transtornos psiquiátricos e relacionar tais achados aos sintomas. MÉTODOS: Foi realizada a identificação de pacientes com diferentes graus de prejuízo cognitivo proveniente de um estudo populacional (Epidemiologia do Idoso - UNIFESP), pacientes com transtorno do estresse pós-traumático proveniente de outro estudo populacional e portadores de transtorno bipolar proveniente de um ambulatório especializado (Universidade Federal da Bahia). Todos os sujeitos foram submetidos à ressonância magnética estrutural de 1.5T. As medidas de volume, assim como os sintomas medidos por escalas psicométricas foram comparadas entre pacientes e controles. RESULTADOS: Foi observado que o volume do cerebelo está reduzido nos portadores de prejuízo cognitivo sem demência e com demência, no transtorno do estresse pós-traumático e no transtorno bipolar quando comparados aos controles. Na demência e no transtorno do estresse pós-traumático o volume do hemisfério cerebelar esquerdo e do vérmis estão reduzidos. No transtorno bipolar os volumes de ambos os hemisférios e do vérmis estão reduzidos. Nos dois primeiros estudos estas reduções correlacionaram com os sintomas. CONCLUSÃO: A natureza exata do envolvimento do cerebelo nos processos mentais ainda não é compreendida. Entretanto, anormalidades na estrutura cerebelar e em suas funções têm sido relatadas em algumas dessas doenças. Pesquisas futuras, com amostras maiores, ainda são necessárias para esclarecer tais achados e investigar se são importantes para o tratamento e prognóstico.

Reduced cerebellar left hemisphere and vermal volume in adults with PTSD from a community sample.

BACKGROUND: Traumatic events exposure is a necessary condition for developing posttraumatic stress disorder (PTSD), but not all individuals exposed to the same trauma will develop PTSD. Human studies have suggested that the cerebellum is involved in human fear perception, anticipation, and recollection. In this context, the current study evaluated whether cerebellar volume is associated with PTSD. METHODS: Eighty-four victims of violence, 42 who fulfilled the DSM-IV-TR criteria for PTSD and 42 resilient controls, were identified through an epidemiologic survey conducted in the city of São Paulo. Subjects were evaluated using the Clinician-Administered PTSD Scale (CAPS), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), and Early Trauma Inventory (ETI). All subjects underwent a magnetic resonance imaging (MRI) scan to evaluate their cerebellar hemispheres and vermis. RESULTS: PTSD subjects had relative smaller left hemisphere (p = 0.04) and vermis (p < 0.01) volumes persisted after controlling for gender, age, and brain volume. In PTSD group, left cerebellar hemisphere volume correlated negatively with PTSD (p = 0.01) and depressive symptoms (p = 0.04). Vermal volume correlated negatively with PTSD symptoms (p < 0.01), early traumatic life events (p < 0.01), depressive symptoms (p = 0.04) and anxiety (p = 0.01). CONCLUSION: The cerebellum is involved in emotion modulation, and our results suggest that cerebellar volumetric reduction is associated with mood, anxiety and PTSD symptoms. Early traumatic life experiences are related to vermal volume reduction and may be a risk factor for future PTSD development.

The accuracy of the Clinician-Administered PTSD Scale (CAPS) to identify PTSD cases in victims of urban violence.

As a consequence of the increasing urban violence in Brazil, many cases of posttraumatic stress disorder (PTSD) are now seen in the community and clinical settings. The main aim of this article is to assess the psychometric properties of the Clinician-Administered PTSD Scale (CAPS) to study factors related to the etiology, prognosis, and efficacy of interventions of PTSD in civilian populations. PTSD outpatients from a program of victims of violence and subjects identified in an epidemiological survey conducted in the city of Sao Paulo completed a battery of validated instruments and the CAPS. Instrument reliability and validity were measured. The comparison between the CAPS scores and the Structured Clinical Interview for DSM IV (SCID) interview resulted in the following validity coefficients: sensitivity=90%, specificity=95%, and misclassification rate=7.1%. The area under the receiver operating characteristic (ROC) curve was 0.97. There was a positive correlation between CAPS scores with Beck Depression Inventory (BDI; 0.70) and Beck Anxiety Inventory (BAI; 0.76) scores. The Kappa coefficients were all higher than 0.63 for all CAPS items. The internal consistency for all CAPS items resulted in a Cronbach's alpha coefficient of 0.97. The CAPS showed to be both an accurate and a reliable research instrument to identify PTSD cases in a civilian population.

Terapia Interpessoal: teoria, formação e prática clínica em um serviço de pesquisa e atendimento em violência / Interpersonal Therapy: theory, training and clinical practice in a search service and care in violence

A psicoterapia interpessoal (TIP) é uma terapia estruturada breve e focal desenvolvidainicialmente para o tratamento da depressão. Esse modelopsicoterápico foi adaptado para outros transtornos mentais, incluindo transtornodo estresse pós-traumático. O programa de atendimento e pesquisaem violência (PROVE) é um ambulatório ligado à Universidade Federal de SãoPaulo (UNIFESP) que presta assistência a vítimas de violência. A terapiainterpessoal individual e de grupo é umas das formas de atendimento psicológicoutilizado no PROVE. Um curso de formação anual é realizado com oobjetivo de produção de conhecimento e pesquisa em TIP.(AU)

Terapia interpessoal: teoria, formação e prática clínica em um serviço de pesquisa e atendimento em violência / Interpersonal therapy: theory, training and clinical practice in a search service and care in violence

A psicoterapia interpessoal (TIP) é uma terapia estruturada breve e focal desenvolvidainicialmente para o tratamento da depressão. Esse modelopsicoterápico foi adaptado para outros transtornos mentais, incluindo transtornodo estresse pós-traumático. O programa de atendimento e pesquisaem violência (PROVE) é um ambulatório ligado à Universidade Federal de SãoPaulo (UNIFESP) que presta assistência a vítimas de violência. A terapiainterpessoal individual e de grupo é umas das formas de atendimento psicológicoutilizado no PROVE. Um curso de formação anual é realizado com oobjetivo de produção de conhecimento e pesquisa em TIP.

[Early Trauma Inventory (ETI): cross-cultural adaptation and internal consistency]. / Adaptação transcultural e consistência interna do Early Trauma Inventory (ETI).

Early life stress is a strong predictor of future psychopathology during adulthood. The Early Trauma Inventory (ETI) was developed to detect the presence and impact of traumatic experiences that occurred up to 18 years of age. The ETI was translated and cross-culturally adapted and had its consistency evaluated. Victims of violence that met the inclusion and exclusion criteria were submitted to SCID-I and ETI. Ninety-one patients with post-traumatic stress disorder (PTSD) were included. Cronbach's alpha in the different domains varied from 0.595 to 0.793, and the total score was 0.878. Except for emotional abuse, most of the various domains displayed inter-item correlation rates of 0.51 to 0.99. The adapted version was useful for clinical and research purposes and showed good internal consistency and inter-item correlation. The ETI is a valid instrument with good consistency for evaluating history of childhood and adolescent trauma in adults.

Adaptação transcultural e consistência interna do Early Trauma Inventory (ETI) / Early Trauma Inventory (ETI): cross-cultural adaptation and internal consistency

As experiências traumáticas precoces são um fator de risco preditivo de problemas psicopatológicos futuros. O Early Trauma Inventory (ETI) é um instrumento que avalia em indivíduos adultos experiências traumáticas ocorridas antes dos 18 anos de idade. Tal instrumento foi traduzido, transculturalmente adaptado e sua consistência interna foi avaliada. Vítimas de violência que preencheram os critérios de inclusão e exclusão foram submetidas a uma entrevista diagnóstica (SCID-I) e ao ETI. Foram incluídos 91 pacientes com o transtorno do estresse pós-traumático (TEPT). O alfa de Cronbach nos diferentes domínios variou de 0,595-0,793, e o escore total foi de 0,878. A maior parte dos itens nos vários domínios, com exceção do abuso emocional, apresentou índices de correlação interitem entre 0,51-0,99. A versão adaptada foi útil tanto na clínica quanto na pesquisa. Apresentou boa consistência interna e na correlação interitem. O ETI é um instrumento válido, com boa consistência para se avaliar a presença de história de traumas precoces em indivíduos adultos.

Early life stress is a strong predictor of future psychopathology during adulthood. The Early Trauma Inventory (ETI) was developed to detect the presence and impact of traumatic experiences that occurred up to 18 years of age. The ETI was translated and cross-culturally adapted and had its consistency evaluated. Victims of violence that met the inclusion and exclusion criteria were submitted to SCID-I and ETI. Ninety-one patients with post-traumatic stress disorder (PTSD) were included. Cronbach's alpha in the different domains varied from 0.595 to 0.793, and the total score was 0.878. Except for emotional abuse, most of the various domains displayed inter-item correlation rates of 0.51 to 0.99. The adapted version was useful for clinical and research purposes and showed good internal consistency and inter-item correlation. The ETI is a valid instrument with good consistency for evaluating history of childhood and adolescent trauma in adults.

Efficacy of interpersonal therapy-group format adapted to post-traumatic stress disorder: an open-label add-on trial.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a highly prevalent condition, yet available treatments demonstrate only modest efficacy. Exposure therapies, considered by many to be the "gold-standard" therapy for PTSD, are poorly tolerated by many patients and show high attrition. We evaluated interpersonal therapy, in a group format, adapted to PTSD (IPT-G PTSD), as an adjunctive treatment for patients who failed to respond to conventional psychopharmacological treatment. METHODS: Research participants included 40 patients who sought treatment through a program on violence in the department of psychiatry of Federal University of São Paulo (UNIFESP). They had received conventional psychopharmacological treatment for at least 12 weeks and failed to have an adequate clinical response. After signing an informed consent, approved earlier by the UNIFESP Ethics Review Board, they received a semi-structured diagnostic interview (SCID-I), administered by a trained mental health worker, to confirm the presence of a PTSD diagnosis according to DSM-IV criteria. Other instruments were administered, and patients completed out self-report instruments at baseline, and endpoint to evaluate clinical outcomes. RESULTS: Thirty-three patients completed the trial, but all had at least one second outcome evaluation. There were significant improvements on all measures, with large effect sizes. CONCLUSIONS: IPT-G PTSD was effective not only in decreasing symptoms of PTSD, but also in decreasing symptoms of anxiety and depression. It led to significant improvements in social adjustment and quality of life. It was well tolerated and there were few dropouts. Our results are very preliminary; they need further confirmation through randomized controlled clinical trials.

Dopamine transporter density by [99mTc]-TRODAT-1 SPECT and neurocognitive performance - a preliminary pilot study

Introducción: los déficits cognitivos están relacionados con el deterioro funcional y con la baja calidad de vida en la enfermedad de Parkinson (EP). El sistema dopaminérgico de los ganglios basales es importante para el funcionamiento cognitivo y motor. Radiomarcadores de transportador de Dopamina (TAD) han sido utilizados para calcular la pérdida neuronal dopaminérgica en humanos. Objetivos: estudiar la relación entre el deterioro cognitivo y la pérdida neuronal dopaminérgica estriatal en pacientes con EP. Métodos: quince pacientes fueron escaneados con [99mTc]-TRODAT-1 y SPECT. El estriado (STR) y el lóbulo occipital (BKG) fueron definidos como regiones de interés (RIs) para la obtención del potencial de ligación (PL = [STR - BKG] / BKG). Exámenes neurocognitivos fueron aplicados, incluyendo el Rey Auditory Verbal Learning Test (RAVLT), Wisconsin Card Sorting Test (WCST), Ravens Progressive Matrices, Digit Span y Tavis 3. Resultados: El PL fue correlacionado negativamente con los exámenes de RAVLT 4 y 5, que evalúan el aprendizaje verbal. El PL también fue correlacionado negativamente con el artículo de aprendizaje de WCST y los artículos de Tavis 3, el error de acción y el número de aciertos. Conclusiones: este estudio indica que la pérdida de TAD estriatal está asociada con un desempeño mas pobre en tareas de flexibilidad cognitiva y aprendizaje verbal. Estos resultados están de acuerdo con un estudio previo con participantes sanos que encontró una relación entre la densidad de TAD del caudado y el desempeño en tareas de aprendizaje verbal. La segmentación del caudado/putamen en una muestra mayor está en desarrollo y podrá proveer más información sobre déficits cognitivos y pérdida de TAD estriatal.