A review of post-traumatic stress disorder. Part II: Treatment.

This paper describes the history of the development of understanding of psychological responses to traumatic life-events and their treatment. One major response, post-traumatic stress disorder (PTSD), is a recognized condition which has appeared relatively recently in diagnostic manuals. PTSD is a condition of major significance, not only to mental health professionals, but also to trauma surgeons and allied professionals. This paper focuses on the current definition of PTSD in the International Classification of Diseases (ICD-10, 1992, World Health Organization) and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV, 1994). PTSD first appeared as an operational diagnosis in DSM-III (1980) and was revised in DSM-III-R (1987) and DSM-IV (1994). It made its first appearance in the ICD system later, in 1992. The paper seeks to increase awareness of PTSD across the broad spectrum of trauma management professionals, to emphasize the practical value of identifying the disorder and to encourage optimism for its treatment. This paper is in two parts. The first part deals with historical development and classification. The second part deals with treatment.

A review of post-traumatic stress disorder. Part I: Historical development and classification.

This paper describes the history of the development of understanding of psychological responses to traumatic life-events and their treatment. One major response, post-traumatic stress disorder (PTSD), is a recognized condition which has appeared relatively recently in diagnostic manuals. PTSD is a condition of major significance, not only to mental health professionals, but also to trauma surgeons and allied professionals. This paper focuses on the current definition of PTSD in the International Classification of Diseases (ICD-10, 1992, World Health Organization) and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV, 1994). PTSD first appeared as an operational diagnosis in DSM-III (1980) and was revised in DSM-III-R (1987) and DSM-IV (1994). It made its first appearance in the ICD system later, in 1992. This paper seeks to increase awareness of PTSD across the broad spectrum of trauma management professionals, to emphasize the practical value of identifying the disorder and to encourage optimism for its treatment. This paper is in two parts. The first part deals with historical development and classification. The second part (to appear in the next issue of Injury) deals with treatment.

Incorporating psychological debriefing techniques within a brief group psychotherapy programme for the treatment of post-traumatic stress disorder.

BACKGROUND: The Royal Air Force Wroughton Post-Traumatic Stress Disorder (PTSD) Rehabilitation Programme is described. It comprised a 12-day structured in-patient 'course' of group psychotherapy and day-case group follow-up sessions over a one-year period. Psychological debriefing was the main therapeutic technique employed. METHOD: This is a 'before and after' open outcome study. A comprehensive assessment protocol confirmed the presence and severity of PTSD and measured co-morbid psychopathological status, occupational and social function longitudinally. RESULTS: A highly significant global response to treatment is demonstrated in the 34 subjects included in the study, with 85.3% not fulfilling the DSM-III-R criteria for PTSD at one year after treatment. CONCLUSIONS: Further controlled studies assessing the value of psychological debriefing techniques in the treatment of established PTSD are required.

A review of military pilot selection.

Military pilot selection is a complex task involving huge cost in financial and human terms. In the United Kingdom, training a fast-jet pilot costs an estimated 3 million pounds and takes 3 years. Consequently, it is necessary that the training success rate be maximal, since failure not only represents financial loss but also wastage of human resources. Effective selection for flying training would be of special advantage at present, as the operational repertoire of military aircraft moves forwards. Personality-based selection appears to have limited value. Analysis of certain objective aptitude tests and monitoring of the learning curve appear more promising. The alternative of acquisition of flying skills through actual or simulated flying experience seems an expensive option. This paper reviews the development of selection methods and concentrates on those of current interest. Civilian aviation and other professional selection systems might also benefit from the military endeavors. The most exciting development is the linkage of computer technology and aptitude tests.

Neuroleptic malignant syndrome in a case of post-partum psychosis.

A 27-year-old woman with a post-partum psychosis developed NMS which proved difficult to diagnose because of the organic features of the presenting illness. Possible contributory factors to the development of NMS included exhaustion, a non-specific viral illness, and rapid loading with haloperidol.

Worker exposure to a herbicide applied with ground sprayers in the United Kingdom.

This study was designed to measure potential dermal and respiratory exposure of agricultural workers during the application of a typical herbicide, 2,4-dichlorophenoxy acetic acid, with five types of application equipment commonly used in the United Kingdom. The workers were monitored during filling and loading operations and during spray application. Potential dermal exposure was higher during mixing and loading all tractor-powered sprayers than during spraying. Potential dermal exposure from tractor-powered sprayers fitted with conventional hydraulic nozzles was lower than from knapsack sprayers, with exposure from a tractor-powered sprayer fitted with controlled-droplet application equipment intermediate in this regard. There was no difference in potential dermal exposure between tractor-mounted and tractor-drawn sprayers fitted with conventional hydraulic nozzles. The hands were the most highly exposed part of the body during mixing and loading operations for all sprayers, and during spraying with tractor-powered sprayers. The lower legs of the workers were exposed principally when knapsack sprayers were used. For all five sprayers, potential respiratory exposure, where detectable at all, was negligible compared with potential dermal exposure.

Relationship of body-weight gain to longevity and to risk of development of nephropathy and neoplasia in Sprague-Dawley rats.

The relationship of weight gain to survival, risk of development of chronic progressive nephropathy and risk of development of various neoplasms has been studied in the control groups from two routine chronic toxicity studies in Sprague-Dawley rats. The groups comprised 100 CFY strain rats of each sex observed up to the age of 109 wk and 120 CD strain rats of each sex observed up to 111 wk of age (females) or 121 wk (males). The eventual incidence of tumours was found to be related to body weight at several ages. There was also a statistically significant association between high body weight at various ages and increased mortality, particularly in the CD strain and particularly in females. The 'heavy' rats proved to have an increased risk of developing both progressive nephropathy and certain tumours. This relationship was particularly marked for pituitary tumours in both sexes and for benign and malignant mammary tumours in females, and was significant irrespective of whether tumours coexisting with marked or severe progressive nephropathy were classified as fatal or incidental. There was also some evidence that increased body weight was positively associated with risk of islet-cell tumours and lipomatous tumours in males and fibromatous tumours in females. The observations illustrate how non-specific factors, such as those that affect body weight, may profoundly influence mortality and tumour incidence in chronic toxicity studies. The findings also highlight the difficulty of classifying particular neoplasms as incidental or fatal where other potentially life-threatening pathology (e.g. progressive nephropathy) is present.

Animal studies on the treatment of poisoning by amitraz (a formamidine pesticide) and xylene.

In Charles River CD rats the pesticide MITAC 20 EC (containing amitraz and 75% xylene) given orally at an LD80 dose caused toxicity featuring hypothermia, reduced spontaneous activity, episodes of increased activity and minor signs of general debilitation. Recovery in survivors was complete within about 8 days. Therapies including absorption retardants, diuretics, reduction of urine pH, thermal support and treatment with phentolamine or nikethamide were given to groups showing these signs of poisoning. None of the therapies gave consistent evidence of benefit during acute poisoning in terms of reduced intensity or duration of symptoms or reduced mortality. Comparison with animals given amitraz alone suggested that the hypothermia and the later phase of reduced spontaneous activity were attributable to the pharmacological effects of amitraz. While the product was apparently more acutely toxic by the oral route than xylene alone, the evidence was that xylene caused the early signs of poisoning. This work indicates that any case of poisoning by ingestion of MITAC 20 EC should initially be treated for the xylene exposure. There is no specific therapy or antidote for the subsequent possible pharmacological effects of amitraz. Many other pesticides also contain high proportions of aromatic solvents and the importance of the solvent in cases of ingestion is seen to be applicable to a variety of pesticides as well as MITAC 20 EC.

Extrapolation from safety data to management of poisoning with reference to amitraz (a formamidine pesticide) and xylene.

Many pesticides are formulated in organic solvents. An example is amitraz, one of the formamidine group of pesticidal chemicals. As a contingency against the possibility of poisoning cases occurring, the toxicity and pharmacology of amitraz were reviewed in order to recommend medical management procedures. Amitraz has pharmacological activity, including monoamine oxidase inhibition, alpha-adrenergic agonist activity and it inhibits prostaglandin synthesis. Extrapolating from acute studies in animals, the likely signs of poisoning in humans may include bradycardia, hypotension, hyperglycaemia, CNS depression, and hypothermia. Despite the presence of amitraz, it appears that the xylene is the more aggressive component in the formulation tested, and treatment for over-exposure by the oral route is generally as for xylene ingestion, but the presence of amitraz is an indication for gastric lavage. Few cases of poisoning have occurred and these are presented.

A hypothesis for the pathogenesis of Crohn's disease based on an ultrastructural study.

The epitheloid cells forming the granulomata of Crohn's disease show striking vacuolation from the coalescing of pinocytotic vesicles with double membrane-bound bodies and their subsequent fusion with lysosomal dense bodies. The fine detail of the granulomata in each individual is uniform but varies from case to case in such a way as to suggest an episodic stimulation of pinocytosis and vacuole formation. The production of such granulomata with these cyclical appearances is consistent with an intermittent stimulus by exogenous antigen or antigen antibody complexes arriving in the diet.