The relationship of PTSD to negative cognitions: a 17-year longitudinal study.

With the growing interest in the role of cognitions in PTSD, this prospective study examined the course and bi-directional relationship between post-trauma cognitions and symptoms of PTSD. A sample of Israeli combat veterans, including former prisoners of war, was assessed in 1991, and later followed up in 2003 and 2008. PTSD symptoms were measured at three time points. Cognitions concerning the self and the world were measured twice. Applying autoregressive cross-lagged (ARCL) modeling strategy, initial PTSD symptoms predicted subsequent negative cognitions but not vice versa. In addition, repeated measures design revealed that individuals with chronic PTSD symptoms had relatively negative cognitions that further amplified with time. More specifically, increasingly negative cognitions were documented among ex-prisoners of war. The main findings suggest that negative cognitions are fueled by PTSD and that in chronic PTSD there is an amplification of pathogenic outcomes over time. Discussion of the findings is in the context of current cognitive models of PTSD.

Prevention of posttraumatic stress disorder by early treatment: results from the Jerusalem Trauma Outreach And Prevention study.

CONTEXT: Preventing posttraumatic stress disorder (PTSD) is a pressing public health need. OBJECTIVES: To compare early and delayed exposure-based, cognitive, and pharmacological interventions for preventing PTSD. DESIGN: Equipoise-stratified randomized controlled study. SETTING: Hadassah Hospital unselectively receives trauma survivors from Jerusalem and vicinity. PARTICIPANTS: Consecutively admitted survivors of traumatic events were assessed by use of structured telephone interviews a mean (SD) 9.61 (3.91) days after the traumatic event. Survivors with symptoms of acute stress disorder were referred for clinical assessment. Survivors who met PTSD symptom criteria during the clinical assessment were invited to receive treatment. INTERVENTIONS: Twelve weekly sessions of prolonged exposure (PE; n = 63), or cognitive therapy (CT; n = 40), or double blind treatment with 2 daily tablets of either escitalopram (10 mg) or placebo (selective serotonin reuptake inhibitor/placebo; n = 46), or 12 weeks in a waiting list group (n = 93). Treatment started a mean (SD) 29.8 (5.7) days after the traumatic event. Waiting list participants with PTSD after 12 weeks received PE a mean (SD) 151.8 (42.4) days after the traumatic event (delayed PE). MAIN OUTCOME MEASURE: Proportion of participants with PTSD after treatment, as determined by the use of the Clinician-Administered PTSD Scale (CAPS) 5 and 9 months after the traumatic event. Treatment assignment and attendance were concealed from the clinicians who used the CAPS. RESULTS: At 5 months, 21.6% of participants who received PE and 57.1% of comparable participants on the waiting list had PTSD (odds ratio [OR], 0.21 [95% CI, 0.09-0.46]). At 5 months, 20.0% of participants who received CT and 58.7% of comparable participants on the waiting list had PTSD (OR, 0.18 [CI, 0.06-0.48]). The PE group did not differ from the CT group with regard to PTSD outcome (OR, 0.87 [95% CI, 0.29-2.62]). The PTSD prevalence rates did not differ between the escitalopram and placebo subgroups (61.9% vs 55.6%; OR, 0.77 [95% CI, 0.21-2.77]). At 9 months, 20.8% of participants who received PE and 21.4% of participants on the waiting list had PTSD (OR, 1.04 [95% CI, 0.40-2.67]). Participants with partial PTSD before treatment onset did similarly well with and without treatment. CONCLUSIONS: Prolonged exposure, CT, and delayed PE effectively prevent chronic PTSD in recent survivors. The lack of improvement from treatment with escitalopram requires further evaluation. Trauma-focused clinical interventions have no added benefit to survivors with subthreshold PTSD symptoms. Trial Registration clinicaltrials.gov Identifier: NCT00146900.

Barriers to receiving early care for PTSD: results from the Jerusalem trauma outreach and prevention study.

OBJECTIVES: Preventing posttraumatic stress disorder (PTSD) is a pressing public health need. Studies have shown significant barriers to obtaining early care. This study prospectively evaluated the acceptance of early assessment and treatment, the accuracy of recommending care, and the consequences of declining it. METHODS: Researchers undertook systematic outreach to survivors of traumatic events consecutively seen in a general hospital emergency department. Structured telephone interviews were conducted 9.5±3.2 days after the emergency visit. Persons with acute stress disorder symptoms were invited for clinical assessment. Those clinically assessed as having acute PTSD symptoms were offered treatment. Telephone interviews, conducted 224.9±39.1 days from the traumatic event, evaluated those included in the initial assessment and a random sample of 10% of those not included because they were deemed not to have experienced a traumatic event. RESULTS: Telephone calls were made to 5,286 individuals, and 5,053 were reached (96%). Of these, 4,743 (94%) agreed to a telephone interview, 1,502 were invited for a clinical assessment, 756 (50%) attended the assessment, 397 were eligible for treatment, and 296 (75%) started treatment. Declining clinical assessments and treatment were associated with less symptom reduction over time. The prevalence of PTSD among those deemed not to have experienced a traumatic event, not to need clinical assessment, and not to need treatment were, respectively, 4%, 11%, and 3%. CONCLUSIONS: Despite successful outreach, many symptomatic participants declined clinical care and subsequently recovered less well. Screening for DSM-IV PTSD criterion A effectively identified survivors at low risk for PTSD. Systematic outreach is costly and might be reserved for exceptionally traumatic events.

Stress hormones and post-traumatic stress disorder in civilian trauma victims: a longitudinal study. Part II: the adrenergic response.

The aim of the study was to prospectively evaluate the association between the occurrence of post-traumatic stress disorder (PTSD) and the adrenergic response to the traumatic event, and additionally, to explore the link between PTSD and the initial norepinephrine:cortisol ratio. Plasma levels and urinary excretion of norepinephrine (NE) were measured in 155 survivors of traumatic events during their admission to a general hospital emergency room (ER) and at 10 d, 1 month and 5 months later. Symptoms of peri-traumatic dissociation, PTSD and depression were assessed in each follow-up session. The Clinician-Administered PTSD Scale (CAPS) conferred a diagnosis of PTSD at 5 months. Trauma survivors with (n=31) and without (n=124) PTSD had similar levels of plasma NE, urinary NE excretion, and NE:cortisol ratio in the ER. Plasma NE levels were lower in subjects with PTSD at 10 d, 1 month, and 5 months. There was a weak but significant positive correlation between plasma levels of NE in the ER and concurrent heart rate, and a negative correlation between NE in the ER and dissociation symptoms. Peripheral levels of NE, shortly after traumatic events, are poor risk indicators of subsequent PTSD among civilian trauma victims. Simplified biological models may not properly capture the complex aetiology of PTSD.

Stress hormones and post-traumatic stress disorder in civilian trauma victims: a longitudinal study. Part I: HPA axis responses.

The aim of the study was to evaluate the association between post-traumatic disorder (PTSD) and hypothalamic-pituitary-adrenal (HPA) axis responses to the triggering trauma. A companion paper evaluates the adrenergic response and interactions between the two. We measured plasma and saliva cortisol, hourly urinary excretion of cortisol, plasma levels of adrenocorticotropin (ACTH), and the leukocyte glucocorticoid receptor (GR) density of 155 non-injured survivors of traumatic events (91 males and 64 females; 125 road traffic accidents, 19 terrorist attacks, 11 others). Measurements were taken during survivors' admissions to an emergency room (ER) of a general hospital, and in the mornings, 10 d, 1 month, and 5 months later. Symptoms of peri-traumatic dissociation, PTSD, and depression were assessed on each follow-up session. The clinician-administered PTSD scale (CAPS) conferred a diagnosis of PTSD at 5 months. Survivors with (n=31) and without (n=124) PTSD at 5 months had similar levels of hormones at all times. Plasma cortisol levels decreased with time in both groups. Female subjects had lower ACTH levels than males. PTSD in females was associated with higher levels of ACTH. In unselected cohorts of trauma survivors, PTSD is not preceded by a detectable abnormality of peripheral HPA axis hormones.

Longitudinal studies of PTSD: overview of findings and methods.

Posttraumatic stress disorder (PTSD) has a discernible starting point and typical course, hence the particular appropriateness of longitudinal research in this disorder. This review outlines the salient findings of longitudinal studies published between 1988 and 2004. Studies have evaluated risk factors and risk indicators of PTSD, the disorder's trajectory, comorbid disorders and the predictive role of acute stress disorder. More recent studies used advanced data analytic methods to explore the sequence of causation that leads to chronic PTSD. Advantages and limitations of longitudinal methods are discussed.