Effects of duloxetine in treatment-refractory men with posttraumatic stress disorder.

INTRODUCTION: Although there is evidence that selective serotonin reuptake inhibitors provide some benefit in the treatment of post-traumatic stress disorder (PTSD), most meta-analytical reviews have concluded that effect sizes are small and, moreover, that there may be relatively little benefit for some populations (e. g., combat veterans with co-morbid major depression, MDD). This study aimed to evaluate the effectiveness and tolerability of the dual reuptake inhibitor duloxetine in the treatment of PTSD and co-morbid MDD. METHODS: Twenty-one treatment refractory, male, combat-related patients with PTSD and co-morbid MDD were enrolled in a naturalistic study and twenty completed the trial. Duloxetine was given between 60 and 120 mg daily over 8 weeks. RESULTS: Duloxetine led to a significant improvement of PTSD-characteristic symptoms as well as co-morbid MDD. Duloxetine effectively reduced nightmares, which is important because decreasing nightmares has been associated with improved sleep in PTSD. DISCUSSION: The results of this naturalistic study suggest that duloxetine is an effective and well-tolerated treatment for patients with PTSD and co-morbid MDD. These initial results need to be extended to the study of women with PTSD.

Increased pituitary and adrenal reactivity in premenopausal women with posttraumatic stress disorder.

BACKGROUND: Limited studies of hypothalamic-pituitary-adrenal axis regulation in posttraumatic stress disorder have been performed in premenopausal women. We therefore undertook a study of hypothalamic-pituitary-adrenal axis regulation in this population. METHODS: Outpatient posttraumatic stress disorder subjects were compared with healthy, age- and weight-matched nontraumatized subjects. Subjects were free from psychotropic medications, alcohol and other illicit substances for at least 4 weeks before study. Menstrual cycle phase was determined by monitoring the LH surge and plasma progesterone levels. Corticotropin releasing factor and adrenocorticotropin stimulation tests, as well as 24-hour urinary-free cortisol measurements were performed. RESULTS: Corticotropin releasing factor test: Baseline adrenocorticotropic hormone and cortisol levels did not differ between the 12 PTSD and 11 comparison subjects, but the posttraumatic stress disorder group had greater adrenocorticotropic hormone and cortisol responses to corticotropin releasing factor, as well as a later cortisol peak. Adrenocorticotropic hormone test: Baseline cortisol levels did not differ between the 10 posttraumatic stress disorder subjects and seven controls, but the posttraumatic stress disorder group showed greater cortisol responses to adrenocorticotropic hormone. Peak cortisol responses to corticotropin releasing factor and adrenocorticotropic hormone were correlated with each other and with 24-hour urinary-free cortisol excretion. CONCLUSIONS: Pituitary and adrenal hyperreactivity to exogenous corticotropin releasing factor and adrenocorticotropic hormone is demonstrated in premenopausal women with chronic posttraumatic stress disorder. Cortisol hyperreactivity thus may play a role in the pathophysiology of posttraumatic stress disorder in women.

Case series: PTSD symptoms in adolescent survivors of "ethnic cleansing." Results from a 1-year follow-up study.

OBJECTIVE: The authors describe the psychiatric sequelae of "ethnic cleansing" in adolescent Bosnian refugees, via a 1-year follow-up study. METHOD: Ten Bosnian adolescent refugees from the war in Bosnia-Herzegovina received a baseline assessment within the first year after their resettlement and a follow-up assessment 1 year later. Evaluations included an assessment scale for posttraumatic stress disorder (PTSD) symptom severity. RESULTS: At baseline, 3 subjects met criteria for PTSD. At follow-up, this diagnosis persisted in none of these subjects, though 1 subject met criteria at follow-up only. For the group, mean PTSD severity scores at baseline and at follow-up were 8.9 and 4.0, respectively. At baseline, reexperiencing symptoms were present 43% of the time, avoidance symptoms were present 33% of the time, and hyperarousal symptoms were present 33% of the time; at follow-up, these proportions were 35%, 16%, and 18%, respectively. CONCLUSIONS: Overall, rates of PTSD symptoms diminished during the 1-year follow-up interval, suggesting that they may be transient and not representative of enduring psychopathology. This finding may reflect the relative resiliency of adolescents, as well as a variety of factors that facilitated adaptation in our particular group of adolescent refugees.

PTSD symptoms in Bosnian refugees 1 year after resettlement in the United States.

OBJECTIVE: The authors' goal was to describe the characteristics of posttraumatic stress disorder (PTSD) symptoms on resettlement in the United States and at 1-year follow-up among Bosnian refugees as well as possible factors affecting the PTSD symptom profile among these refugees. METHOD: They used standardized instruments to assess 34 Bosnian refugees for PTSD at resettlement in the United States and 1 year later. RESULTS: Fifteen of the refugees were diagnosed with PTSD at 1-year follow-up, compared with 25 at initial assessment. The average PTSD severity score at follow-up was 12.5, compared with 20.6 at initial assessment. At 1-year follow-up, 25 of the refugees experienced a decrease in severity of PTSD symptoms, one remained the same, and eight experienced an increase in severity. Older refugees were significantly more likely to have PTSD than younger refugees, and older refugees had more severe symptoms. CONCLUSIONS: The level of PTSD diagnosis and symptoms in Bosnian refugees remained substantial 1 year after their resettlement in the United States, although there were notable overall decreases. Older refugees appeared to be at greater risk.

Individual change after genocide in Bosnian survivors of "ethnic cleansing": assessing personality dysfunction.

The authors used the SCID-DES (disorders of extreme stress) instrument to assess for personality change in Bosnian survivors of "ethnic cleansing." Twenty four refugees underwent systematic, trauma-focused, research assessments, including the SCID-DES interview. Overall, this group of Bosnian survivors had been severely traumatized as a result of the Serbian nationalists' genocide. However, no subject met diagnostic criteria for DES. The SCID-DES yields far lower rates of trauma-related personality change in Bosnian survivors of genocide than in adult survivors of prolonged early life traumas. Therefore, the DES construct may have better application to prolonged, interpersonal, early life traumas than to the prolonged, communal traumas of genocide.

A family survives genocide.

This is a case study of a family that survived genocide and a discussion of families and massive psychic trauma. This family, like many others from Bosnia-Herzegovina, was driven from their home by Serb forces-"ethnically cleansed"-then eventually escaped to Croatia, and was later resettled in the United States. They were referred to us, a group of mental health professionals who established the Bosnian Refugee Trauma Program at the Yale Psychiatric Institute (YPI). We have done clinical, testimony, and research work with the refugee families from Bosnia who resettled in our region, described in part in prior reports (Weine, Becker et al. 1995a, 1995b; Weine and Laub 1995).

Possible acceleration of alcoholic cirrhosis in a patient with bulimia.

We report the case of a 27-year-old Caucasian woman with a history of bulimia and alcohol abuse who developed cirrhosis at a rapid rate. We hypothesize that the patient's bulimia, in combination with other possible predisposing factors, potentially accelerated the development of her alcoholic cirrhosis and subsequent medical complications. The association between eating disorders and liver disease is discussed, and the importance of aggressive treatment of eating disorders in combination with alcohol abuse is highlighted.

Adolescent survivors of "ethnic cleansing": observations on the first year in America.

OBJECTIVE: To describe the psychiatric assessments and trauma testimonies of 12 Bosnian adolescents newly resettled in America. METHOD: Twelve Bosnian adolescents who experienced the massive psychic trauma of "ethnic cleansing" were assessed during the first year after their resettlement in the United States. Assessments consisted of systematic, trauma-focused, clinical interviews that included standard assessment scales of posttraumatic stress disorder (PTSD) and depression, as well as the opportunity to give testimony about their experiences. RESULTS: PTSD was diagnosed in 25% of subjects and depressive disorders in 17%. Reexperiencing cluster symptoms were present in 50%, avoidance cluster symptoms in 31%, and hyperarousal cluster symptoms in 29%. CONCLUSIONS: The relatively low rate of PTSD in this sample (in comparison with adult survivors of "ethnic cleansing" and with Cambodian adolescent survivors) may be attributable to normal prior development, time-limited adversity, lack of physical or sexual traumas, rejoining nuclear families, or insufficient time for the development of delayed-onset PTSD. It may also be a reflection of the resiliency of adolescence.

Psychiatric consequences of "ethnic cleansing": clinical assessments and trauma testimonies of newly resettled Bosnian refugees.

OBJECTIVE: The authors describe the psychiatric assessments and trauma testimonies of 20 Bosnian refugees of "ethnic cleansing" who have recently resettled in the United States. METHOD: Refugees referred from agencies managing refugee resettlement underwent systematic, trauma-focused, clinical interviews that included standardized assessment scales. RESULTS: The traumatic experiences of ethnic cleansing in these Bosnian refugees were genocidal in nature. The number of types of traumatic experiences correlated positively with age. Posttraumatic stress disorder (PTSD) was diagnosed in 65% of the refugees, and depressive disorders in 35%. PTSD severity scores were correlated with the number of types of traumatic events experienced. CONCLUSIONS: Ethnic cleansing has caused high rates of PTSD and depression, as well as other forms of psychological morbidity, in this group of resettled Bosnian refugees. The longitudinal sequelae of ethnic cleansing as a form of massive psychic trauma remain to be studied.