Cognitive Processing Therapy (CPT) for Trauma and PTSD

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The Patient with Posttraumatic Stress Disorder

Although the effects of natural calamities and their aftermaths have been recognized since the time of ancient Greece, it is only since 1980 that the American Psychiatric Association included post-traumatic stress disorder (PTSD) in its handbook of psychiatric disorders, the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III). One of the first descriptions of PTSD was made by the Greek historian Herodotus. In 490 bce, he described an Athenian soldier who suffered no injury in the Battle of Marathon but became permanently blind after witnessing the death of a fellow soldier. Health-care providers are only beginning to recognize the enormous toll that trauma can take in personal suffering and functional impairment. PTSD may also have an impact on future generations through effects on parental (or guardian) behavior and competence. For many years, PTSD was considered only a wartime affliction. During World War I, PTSD was called ''shell shock,'' and during...

Post Traumatic Stress Disorder

The original definition of post-traumatic stress disorder (PTSD) awarded causal pre-eminence to the traumatic event The definition of a traumatic stressor was one ''that would evoke significant symptoms of distress in almost everyone'' (American Psychiatric Association, 1980). However, it has subsequently emerged that only about 25 of individuals who experience a traumatic event such as a traffic accident (Koren et al., 1999 Ursano et al., 1999), a mass shooting (North et al., 1997), or an earthquake (Wang et al., 2000) subsequently meet criteria for PTSD. What are the risk factors for development of PTSD among survivors of trauma What places some individuals at risk for PTSD while others appear to be protected In recent years research has begun to focus on vulnerability factors for PTSD (McNally, 2001). It is becoming evident that events from early childhood or even prenatal life may ''sensitize'' individuals to develop PTSD in response to later trauma in adulthood (Bramsen et al.,...

Posttraumatic stress disorder PTSD

Posttraumatic stress disorder is characterised by the development of characteristic anxiety symptoms following exposure to an extreme traumatic stressor. The revision of the criteria included in the DSM-IV-TR (APA, 2000) includes the fact that the individual should experience fear, helplessness or horror at the time of the event (Harvey, Brewin, Jones, & Kopelman, 2003). PTSD is defined (APA, 2000) by the following criteria (APA, 2000) Harvey et al. (2003) contended that the features of PTSD exist along a continuum and that Many patients are seen in clinical practice who show several features of PTSD, but who fall just short of a strict formal diagnosis in some way PTSD is essentially a syndrome or cluster of symptoms whose number and severity vary along a continuum, and that strict hard-and-fast categories (PTSD no PTSD) may miss important pathology and may be the source of apparent conflicts in the literature. (p. 664) Although approximately 69 of the population will be exposed to a...

Informationprocessing biases in PTSD

There have been a number of studies of PTSD using information-processing methodologies derived from the cognitive psychology literature. Again, as with panic and generalised anxiety, we can only consider a selection of this research here. The most direct investigation of attention in PTSD used the dichotic-listening task with a group of Vietnam veterans with PTSD (Trandel & McNally, 1987). The participants repeated a message presented to one ear while ignoring an (unattended) message relayed simultaneously to the other ear. The variable of interest was the amount of processing that items in the unattended message received. This reflects the degree of attentional bias to those items. Trandel and McNally found no evidence of attentional bias for seven PTSD-related target items in the unattended message. However, given the error variance associated with this paradigm, it is possible that the number of target stimuli was too small to pick up any attentional effects. Other studies of...

Mood Disorders Posttraumatic Stress Disorder

Motor vehicle accidents, assaults, falls, drive-by shootings, and injury during a natural disaster may produce posttraumatic stress disorder (PTSD) in addition to a TBI, SCI, or other neurologic impairment. Although little is yet known about the risk in a rehabilitation population, the rate of PTSD among urban young adults is 24 and the lifetime prevalence is 9 .240 A 2-month follow-up of patients hospitalized after serious trauma found that 24 met full criteria for PTSD and an aditional 22 had two of the three symptom clusters.241 Early symptoms of heightened arousal and coping with disengagement were early predictors of PTSD. Posttraumatic stress disorder does interfere with functional gains after SCI in affected youth.242 may take considerable detective work to identify environmental events that symbolize or resemble the traumatic event and produce the equivalent of a startle response. Posttraumatic amnesia and other memory, cognitive, and behavioral disorders can mask or delay...

Past Views Of Traumatic Events

Effective treatments for traumas will be identified, but first it is important to examine how attitudes toward traumas have evolved over the years in our society. It has only been in the last thirty years that traumatic events have been recognized by the mental health community as the cause of psychological symptoms and in more severe cases, psychological diagnoses. Recognition first began with large numbers of Vietnam War Veterans presenting to therapists with psychological symptoms after their return from combat in Vietnam. When combat Veterans from past wars presented with fatigue and anxiety symptoms, these were first labeled combat fatigue, shell-shocked, or warrior's heart 1 then labels were directly related to the Vietnam War, like Post-Vietnam Syndrome. In a hallmark research project, the National Vietnam Veterans Readjustment Study,2 a set of symptoms was documented as the direct result of the Veterans' combat experiences. This set of symptoms was identified as post-traumatic...

Psychological Reactions To Rapeposttraumatic Stress Disorder And Other Symptoms

Any number of psychological symptoms can and do occur at high rates soon after a rape or sexual assault. In fact, it has been reported4 that one week after a rape, up to 94 of women experienced PTSD symptoms. The percentage dropped to 65 after one month, continued to drop to 47 after three months, and after one year, ended up between 15 and 25 . It is quite common to have psychological symptoms after a rape. While this chapter emphasizes PTSD and its treatment, it is important to recognize that there are many reactions to trauma, such as anxiety, depression, irritability, suicidal thoughts, and alcohol drug use. Feelings of worthless-ness that contribute to depression may occur, as might anxiety about being around people or going to work. And the survivor may use alcohol or drugs to help manage anxiety symptoms, nightmares, or poor sleep. While a number of different symptoms occur after a rape, the most common are PTSD symptoms. There are a total of seventeen PTSD symptoms5 within the...

Intrusive Memories in PTSD

Spontaneously occurring memories are a core diagnostic feature of PTSD (see Krans, Woud, Naring, Becker, & Holmes, Chapter 13, and Verwoerd & Wessel, Chapter 14, this volume). Intrusive memories in this context are defined by the involuntary reliving of a past traumatic event, and may be experienced in either typical autobiographical form or in flashback form. They can include visual representations and other sensory modalities such as auditory, olfactory, and kinetic re-experiencing (Bryant & Harvey, 1998 Ehlers & Steil, 1995 Ehlers et al., 2002). In the context of PTSD, intrusive memories are conceptualized as indices of unsuccessful emotional processing of the trauma. Emotional processing was first described by Rachman (1980) as a process whereby emotional disturbances are absorbed, and decline to the extent that other experiences and behavior can proceed without disruption (p. 51). Therefore, unsuccessful emotional processing in the context of PTSD is indicated by the persistence...

Interpretations and appraisals of intrusive memories in PTSD

Appraisals of the significance of intrusions have also been implicated in the persistence of PTSD symptomatology. Ehlers and Steil (1995) proposed that negative interpretations assigned to intrusive memories, rather than their presence or frequency per se, results in the persistence of PTSD. Indeed, Steil and Ehlers (2000) found that idiosyncratic, dysfunctional meanings (e.g., I am going crazy ) assigned to intrusive symptoms significantly predicted PTSD severity, over and above intrusion frequency. The role of negative interpretations in predicting PTSD maintenance has been consistently demonstrated in additional retrospective and prospective studies (Dunmore, Clark, & Ehlers, 2001 Halligan, Michael, Clark, & Ehlers, 2003 Mayou, Ehlers, & Bryant, 2002). Furthermore, negative appraisals and beliefs about intrusions may remain if individuals engage in safety behaviors. Safety behaviors include both cognitive and behavioral strategies that are employed to reduce symptoms (in this case,...

Summary of Intrusive Memories in PTSD

Investigations of the content, form, characteristics, and management of intrusive memories have culminated in the emergence of a clearer understanding of these memories in PTSD. In addition, such research has demonstrated the importance of these variables in maintaining and predicting the course of the disorder, as well as their potential to interfere with treatment regimes. This body of research has not only advanced understanding of intrusive trauma memories, but has served as a useful database for guiding hypotheses regarding intrusive memories in depression.

Characteristics of intrusive memories in PTSD

There is evidence that key characteristics of intrusive memories play an important role in contributing to the maintenance of PTSD. Ehlers, Hackmann, and Michael (2004), Ehlers et al. (2002), and Hackmann, Ehlers, Speckens, and Clark (2004) conducted detailed analyses of the content and qualities of intrusive memories of trauma survivors. Participants were questioned about a range of features of the memories e.g., whether intrusions consisted of sensory experiences (visual, sound, smell) and bodily sensations, the presence of any triggers of the intrusive memory, and whether the intrusion content corresponded with the worst moment of the trauma. These studies demonstrated that the content of intrusive memories typically consist of stimuli that were present prior to the moments of the trauma with the largest emotional impact, rather than the worst (i.e., most traumatic) aspect of the trauma per se (Ehlers et al., 2002), prompting the conclusion that intrusive memories function as a...

Cognitive avoidance of intrusive memories in PTSD

Cognitive conceptualizations of PTSD (e.g., Ehlers & Clark, 2000 Ehlers & Steil, 1995 Foa, Steketee, & Rothbaum, 1989) posit that successful emotional processing of the trauma is prevented when the individual employs avoidant cognitive strategies. Cognitive avoidance includes intentional attempts at thought memory suppression, efforts to dissociate or detach oneself from the affective qualities of the trauma experience, and engaging in rumination (Ehlers & Clark, 2000). Various forms of cognitive avoidance, and the evidence of the supporting role of each in the management of intrusive memories in PTSD, are now reviewed. Empirical studies support the role of thought suppression in PTSD symptom maintenance (Aaron, Zagul, & Emery, 1999 Amir et al., 1997 Ehlers, Mayou, & Bryant, 1998) and in memory reoccurrence (Shipherd & Beck, 1999). Suppression of trauma memories has also been hypothesized to contribute to re-experiencing symptoms by preventing information from being processed...

Hormonal Response in Posttraumatic Stress Disorder

In a well-functioning person, stress produces rapid and pronounced hormonal responses. However, chronic and persistent stress inhibits the effectiveness of the stress response and induces desensitization. PTSD develops following exposure to events that overwhelm the individual's capacity to reestablish homeostasis. Instead of returning to baseline, there is a progressive kindling of the individual's stress response. Initially only intense stress is accompanied by the release of endogenous, stress-responsive neurohormones, such as cortisol, epinephrine, norepinephrine (NE), vasopressin, oxytocin, and endogenous opioids. In PTSD even minor reminders of the trauma may precipitate a full-blown neuroendocrine stress reaction It permanently alters how an organism deals with its environment on a day-to-day basis, and it interferes with how it copes with subsequent acute stress. A review of the neuroendocrine findings in PTSD to date shows very specific abnormalities in this disorder,...

Dimensional Diagnosis in Litigation Subthreshold Posttraumatic Stress Disorder

Subthreshold Ptsd

Subthreshold PTSD is an example of a disorder with dimensional features that has not received official diagnostic recognition yet clearly exists and frequently causes significant functional impairment. Subthreshold PTSD can be conceptualized as a dimensional entity that manifests categorical characteristics (defined symptoms causing impairment) and is a good example of such a model (Frank et al. 1998 Maser and Patterson 2002 Ruscio et al. 2002). The diagnosis of PTSD may present clinically with significant variations from the prototype. Subthreshold PTSD, although not a formally recognized DSM diagnosis, has been recognized in the professional literature (Sch tzwohl and Maercker 1999 Stein et al. 1997). It is common in Vietnam veterans (Warshaw et al. 1993 Weiss et al. 1992) and Iraq and Afghanistan war veterans (Jakupcak et al. 2007) and is highly represented among sexual abuse survivors and in other traumatized persons (Blanchard et al. 1996 Carlier and Gersons 1995). The number of...

Cognitive theoretical models of PTSD

A number of psychological paradigms provide frameworks for understanding PTSD, for example psychodynamic (e.g., Freud, 1919), learning theory (e.g., Keane, Zimmering, & Caddell, 1985), and cognitive (e.g., Horowitz, 1986). While all of these paradigms encompass theories that offer interesting insights into the nature of the disorder, it is the cognitive approach that we feel is the most fully developed and offers the greatest explanatory and predictive power. Cognitive theories of PTSD have a certain theoretical family resemblance. They propose that individuals bring to the traumatic experience a set of pre-existing beliefs and models of the world and of themselves. The experience of trauma provides information that is not only highly salient but also incompatible with these preexisting meaning structures. The attempt to integrate the new trauma-related information with the existing models leads, it is argued, to the various phenomena that characterise post-traumatic reactions....

Vignette 1 Malingered PTSD

A Vietnam-era veteran was admitted to a PTSD partial hospitalization program upon referral from an outpatient clinician. Shortly after entering the program, In individual sessions with his psychiatrist, the patient tended to report how PTSD had caused all of his problems and declared that the government should make up for it by granting him disability payments. He further reported that as a result of PTSD, he isolated from the rest of society by purchasing a home in a rural setting and never leaving the house. In contrast to his reports of isolating from others constantly, he reported seeking out Mardi Gras parades and downtown casinos while on day passes in a heavily urban environment. Other veterans in the program said they wouldn't go to Mardi Gras if you made me because of the loud noises that bothered them and the large crowds that would diminish their ability to survey the area and perceived ability to stay out of harm's way. A psychologist on the unit felt the patient might be...

Hemispheric Lateralization in PTSD

Both Rauch et al. (1996) and Teicher and his group (2002) found marked hemispheric lateralization in PTSD subjects who were exposed either to a negative memory or to a personalized trauma script. This suggests that there is differential hemispheric involvement in the processing of traumatic memories. The right hemisphere, which developmentally comes on-line' earlier than the left hemisphere (Schore, 1994), is involved in the expression and comprehension of global nonverbal emotional communication (tone of voice, facial expression, visual spatial communication), and allows for a dynamic and holistic integration across sensory modalities (Davidson, 1989). This hemisphere is particularly integrated with the amygdala, which assigns emotional significance to incoming stimuli and helps regulate the autonomic and hormonal responses to that information. While the right hemisphere is specialized in detecting emotional nuances, it has only a rudimentary capacity to communicate analytically, to...

Disintegration of Experience Accompanying PTSD

In a series of studies we demonstrated that memories of trauma initially tend to have few autobiographical elements When PTSD patients have their flashbacks, the trauma is relived as isolated sensory, emotional, and motoric imprints, without much of a storyline. We have shown this in victims of childhood abuse (van der Kolk and Fisler, 1995), assaults, and accidents in adulthood (van der Kolk et al., 1997) and in patients who gained awareness during surgical procedures (van der Kolk et al., 2000). These studies support the notion that traumatic memories result from a failure of the CNS to synthesize the sensations related to the event into an integrated semantic memory. While most patients with PTSD construct a narrative of their trauma over time, it is characteristic of PTSD that sensory elements of the trauma itself continue to intrude as flashbacks and nightmares, in states of consciousness where the trauma is relived, unintegrated with an overall sense of current time, place, and...

Coping with Terrorism and Other Traumatic Events

We should expect to experience a full spectrum of strong emotions, ranging from stunned disbelief and shock to anger, grief, fear, numbness, guilt, and or resolve. These feelings are normal. Some might experience post-traumatic stress disorder (PTSD), an understandable response to overwhelmingly dangerous and sudden events. Although PTSD is more likely to occur following stressful events, it is not inevitable. 1. Accept the full range of feelings as normal. At some point, when it is appropriate, allow yourself to feel the painful feelings, to cry, to shake, or to experience whatever naturally occurs. As calmly as possible, process what has happened by writing or talking about the troubling events what happened, and what you are thinking and feeling. This kind of journaling talking has been found to significantly improve mood and physical health, following an initial drop in mood as we confront the reality of what has happened. Feelings are part of who we are. Confronting the depths of...

Posttraumatic stress disorder and its distinction from TBI

Considerable controversy has surrounded the issue of differential diagnosis of the organic sequelae associated with a TBI and PTSD, and whether indeed these two conditions can coexist. Both Price (1994) and Sbordone (1991) have argued that PTSD and MTBI are mutually incompatible disorders since patients who sustain PTSD simply cannot 'forget' the traumatic event, whereas patients who sustain MTBI (e.g., cerebral concussion) have no recollection of the traumatic event Thus, patients who sustain PTSD, if given the opportunity, can provide exquisite and highly detailed chronological, as well as emotionally charged, recollections of the traumatic event in comparison to patients who sustain MTBI, who have no recollection of the traumatic event (Sbordone & Liter, 1995, p. 406). Warden et al. (1997) have noted no cases of PTSD that met full criteria in their sample of 47 TBI-affected active duty military personnel, although they did note that 6 met the avoidance and arousal criteria and of...

Cancer as a Post Traumatic Stress Disorder

When people believe the diagnosis of cancer is a life-threatening event, they may be thrown into a series of psychological changes that are similar to those triggered by combat, rape, physical, sexual abuse, or other traumatic events that are outside the range of everyday experience. These psychological changes are collectively called post-traumatic stress disorder (PTSD), and in the cancer patient may include attempts to avoid all thoughts or feelings associated with the illness forgetfulness about what the doctor has said a sudden loss of interest in things that used to be meaningful, such as young children or a job one loved feeling and acting estranged from others inability to have or express loving feelings and a sense of a suddenly foreshortened future.

Posttraumatic Stress Disorder

Post-traumatic stress disorder is a state characterized by high levels of anxiety after a traumatic incident. Panic attacks, phobic reactions related to stimuli involving the original traumatic event, and pain symptoms predominate. Symptoms consistent with PTSD in chronic pain patients are associated with affective distress1 and depression.1 The PCPT has been developed as a screening instrument to aid in early detection of PTSD. Patients who attribute their pain to a specific traumatic event, even in the absence of PTSD, report higher emotional distress, life interference, and pain severity and have greater disability.1 Accident-related high PTSD scores are associated with increased pain, increased affective distress, and greater disability. The potential for bizarre and exaggerated responses after invasive therapies is increased in the presence of both PTSD and anxiety disorders. Psychological clearance after stabilization is suggested before nerve block, or any invasive procedures,...

Hippocampus in PTSD

A number of PTSD studies have reported significantly decreased hippocampal volume in patients with PTSD (e.g., Bremner 1997, 1999 Gurvits et al., 1998) and depression. For example, Bremner et al. (1997) compared hippocampal volume in adult survivors of childhood abuse to matched controls. PTSD patients had a 12 percent smaller left hippocampal volume relative to the matched controls (p .05), without smaller volumes of comparison regions (amygdala, caudate, and temporal lobe), while Gurvits and her colleagues found both significantly smaller left and right hippocampi in combat veterans with PTSD compared to combat controls without PTSD and normal controls. However, several well-controlled studies have failed to replicate these findings (e.g., DeBellis et al., 1999 Bonne et al., 2001). In the studies in which hippocampal atrophy has been found, investigators have proposed that excessively high levels of cortisol caused hippocampal cell death, resulting in hippocampal atrophy. At this...

PTSD within SPAARS

In this section we shall consider how the SPAARS model of emotion accounts for the processing of trauma-related information at the time of the traumatic event and also how that information and the individual's reactions to it are processed subsequent to the traumatic event. The SPAARS approach to PTSD has been spelled out in considerable detail elsewhere (Dalgleish, 1999, 2004a Dalgleish & Power, 2004b), so only a summary of the approach is presented here. Following a traumatic event, the individual possesses representations of trauma-related information in memory at the analogical, propositional, and schematic model levels. Within SPAARS, however, this information is unintegrated with the individual's dominant models of the self, world, and others. We submit that this pattern of representation within SPAARS accounts for the constellation of symptoms that characterise PTSD and related problems following the trauma and we turn to a discussion of these issues next.

PTSD Theories

Currently, information processing theories of PTSD are very influential in inspiring research on involuntary recall in trauma. However, other theoretical explanations have been put forward in the past. For example, in a pioneering series of laboratory studies, Horowitz (1969) applied a combination of psychoanalytic and psychobiological theory based on ideas by Freud and Breuer to explain the occurrence of intrusive images from stressful film material in healthy participants. Horowitz suggested that normally the individual is in an emotional homeostasis where psychological processes are functioning in an integrated fashion. However, the overwhelming experience of a traumatic event can interfere with the psychological processes and disrupt homeostasis. As a consequence, a repetition compulsion occurs, in which the individual attempts to repress the traumatic memory but is unsuccessful because of weakened psychological defenses, which results in intrusive images. At other times, the...

Anxiety and Obsessive Compulsive Disorder Syndromes

Anxiety is an extremely common occurrence that affects everyone at some time and is characterized by an unpleasant and unjustified sense of fear that is usually associated with autonomic symptoms including hypervigilance, palpitations, sweating, lightheadedness, hyperventilation, diarrhea, and urinary frequency as well as fatigue and insomnia. Anxiety is thought to be mediated through the limbic system, particularly the cingulate gyrus and the septal-hippocampal pathway, as well as the frontal and temporal cortex. The term anxiety disorder is used to denote significant distress and dysfunction resulting from anxiety, including panic attacks and anxiety with specific phobias. Chronic, moderately severe anxiety tends to run in families and may be associated with other anxiety disorders or depression. The differential diagnosis of anxiety states includes other psychiatric conditions such as anxious depression as well as schizophrenia, which may present as a panic attack with disordered...

Neuroimaging of Fear Anxiety

1999) and vocalizations (Phillips et al., 1998), as well as in response to aversive pictures (Garrett and Maddock, 2001), and in human adaptations of animal paradigms of conditioned fear (LaBar et al., 1995 Morris et al., 1998 Whalen et al., 1998), to aversive auditory, olfactory and gustatory stimuli (Zald, 2003), and to exposure to procaine and inhalation of CO2 (Ketter et al., 1996 Brannan et al., 2001). These combined findings suggest a general role for the amygdala in the automatic, preconscious early detection of threat and danger in the environment, and possibly in triggering the experience of fear anxiety. Interestingly, amygdalar responses to fearful faces are increased in childhood and adolescence (Killgore et al., 2001) and in childhood anxiety and in posttraumatic stress disorder (PTSD) patients (Thomas et al., 2001 Hull, 2002).

Broader theoretical considerations of autobiographical remembering

Rice (chapter 10) reviews the role of memory perspective (i.e., field, one's original viewpoint, or observer, a third-party viewpoint) and imagery in autobiographical memory retrieval. One of the important questions that she addresses is how visual imagery, most particularly perspective-based imagery, may be a determinative factor in the autobiographical memory retrieval process. Whether visual imagery or perspective per se have a causal role or not, her review reminds us of the complexity of information contained in an autobiographical memory, and the potential complexity of the retrieval processes that need to construct and bring this information to mind. Apart from this main issue, Rice also reviews how abnormal remembering in clinical syndromes (e.g., PTSD or social phobia) appears to distort visual perspective, as individuals with certain disorders tend to recall memories surrounding their condition from a third-party viewpoint. The last main section contains three chapters which...

Further Developmental Considerations

From yet another perspective, a developmental point of view considers the question of how the developmental stage of an individual affects the individual's perceptions. Throughout life, but perhaps most noticeably in childhood, thinking and perception change with the development of changing biological capacities as well as with accumulated experience. Psychoanalytic understanding of unconscious mental processes always takes these matters into account. In particular, when the attempt is made clinically to infer early developmental influences, they are formulated in accord with the mental functioning of the child. An additional problematic discovery of psychoanalytic investigation has been the recognition that experiences at one phase of development may be reinterpreted or understood differently at a later time. This can give rise to the deferred action (Nachtrdglichkeit) of a repressed memory. Traumatic events of childhood can assume significance in adolescence or adulthood through...

Psychological Consequences Of Human Trafficking And Prostitution

A nine-country study of prostitution found that 68 of women, men, and transgendered people in prostitution had post-traumatic stress disorder (PTSD), a prevalence that is comparable to that among battered or raped women seeking help and survivors of state-sponsored torture.1 Across widely varying cultures on five continents the traumatic consequences of prostitution were similar whether prostitution was legal, tolerated, or illegal. Hossain and colleagues24 interviewed 204 trafficked girls and women in seven European countries and found that 77 met criteria for PTSD with high comorbidity rates for depression and anxiety.

Primary Anxiety Disorders

Several subtypes of anxiety disorders are seen in the medical setting (see Figure 7-1). We describe the following DSM-IV-TR anxiety disorders (American Psychiatric Association 2000) as primary to the extent that they are not specifically a psychological or physical reaction to a physical illness or substance (see left-hand column of Figure 7-1). Separation anxiety disorder involves inappropriate and excessive anxiety concerning separation from caregivers and or home and is particularly common in younger children admitted to the hospital. Generalized anxiety disorder presents with a pattern of excessive anxiety and worry for 6 months or longer that is associated with symptoms of restlessness, fatigue, difficulty with concentration, irritability, muscle tension, and sleep disturbance and may also be heightened during the stress of an inpatient admission. Obsessive-compulsive disorder in the physically ill child may include obsessive preoccupation or fears about physical illness and or...

Medical Traumatic Stress

Pediatric illnesses, injuries, and treatments may be experienced as traumatic events by patients and family members (Stuber and Shemesh 2006). Although often not reaching criteria for a diagnosis of acute stress disorder or PTSD, key symptoms of these disorders particularly reexperiencing, physiological arousal, and avoidance are common across illness groups and across the course of the illness (Kazak et al. 2006). The National Child Traumatic Stress Network (2009) defines pediatric medical traumatic stress as a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences. Research on traumatic stress in pediatric illness has increased markedly over the past decade across multiple illness and injury samples. Based on meta-analyses, the prevalence of medical traumatic stress is estimated to be 19 for injured children and 12 for ill children (Kahana et al. 2006)....

Traumatic Brain Injury and Postconcussive Syndrome

In a separate study examining the impact of mild, moderate, and severe childhood traumatic brain injury, Barker-Collo (2007) reported rates of emotional behavioral symptoms that were within normal limits across groups, with the moderate traumatic brain injury group having the highest levels of somatic and anxious-depressed symptoms. Although these symptoms may be transient, some patients develop more sustained symptoms. Notably, adult patients with traumatic brain injury have been found to have an increased risk of symptoms of acute stress disorder and subsequent PTSD (Harvey and Bryant 2000). Even when cerebral concussion does not result in any irreversible anatomic lesions, it may be followed with periods of retrograde amnesia. A small proportion of individuals may develop a constellation of symptoms postconcussion, including anxiety, impairment of sleep and appetite, irritability, light-headedness, headaches, and poor concentration (Goldberg and Posner 2000). Recent research...

Psychiatric Diagnosis in Litigation

The legal system is rarely concerned with the imperfect fit between diagnosis and legal concerns. Attorneys and judges usually focus on the presence or absence of the diagnosis. Courts and attorneys may require psychiatrists to provide DSM diagnoses or insist that they do so. This, in turn, may lead psychiatrists to give undue importance to diagnosis in forensic evaluations and to miss the essential assessment of impairment in function. Even when a diagnosis is appropriate and accurate, the categorical nature of DSM's nosology is such that necessary dimensional information may be overlooked or misinterpreted. These issues will be addressed by examining the use of the diagnosis of subthreshold posttraumatic stress syndrome (PTSD). Although discussed only in the context of personal injury litigation, the imperfect fit of categorical DSM diagnosis applies across the spectrum of civil and criminal litigation.

Implications for Forensic Psychiatry

DSM-IV relies on a system of diagnosis that establishes categorical boundaries, using both inclusion and exclusion criteria. The categorical nature of DSM diagnoses can create problems for psychiatrists providing assessments in litigation. This categorical diagnostic model does not accommodate dimensional posttraumatic stress spectrum syndromes such as the subthreshold PTSD diagnosed in Ms. J's case (Kinzie and Goetz 1996). Mental conditions such as subthreshold PTSD, which exhibit symptoms that fall outside the DSM-IV diagnostic criteria, are thereby excluded. A dimensional system of diagnosis avoids categorical boundaries, permitting stress spectrum syndromes to be recognized along with associated impairments (Maser and Patterson 2002). Lawyers, judges, and juries much prefer categorical diagnoses because of their seeming clarity. In litigation, decisions must be made at the time of trial. The assessment of an individual over time that occurs in clinical settings is a luxury not...

The Dark Side Develops

Tim, an Iraq veteran who lost both legs in a roadside ambush where most of his buddies died, has been taking drugs for years. He's been diagnosed with Post-traumatic Stress Disorder (PTSD) and uses several drugs, including alcohol, to help him relax and sleep. He is distressed that he has gradually needed more and more drugs to get to sleep, even for a short time. This has added to his troubles because of the increasing cost, and searching for drugs seems to dominate his activities. He is beginning to worry that he is addicted.

Studies of Cerebral Metabolism and Blood Flow in Anxiety Disorders

Relatively few imaging studies have investigated specific phobias. Most have employed PET imaging. While one study failed to demonstrate changes in rCBF (Mountz et al., 1989), results from others suggested activation of anterior-paralimbic regions (Rauch et al., 1995a) and sensory cortex (Fredrikson et al., 1995 Wik et al., 1993) corresponding to stimulus inflow associated with a symptomatic state. Although such results are consistent with a hypersensitive system for assessment of or response to specific threat-related cues, they do not provide clear anatomic substrates for the pathophysiology of specific phobia. Whereas one SPECT study of patients with social phobia and healthy control subjects found no significant between-group difference during resting conditions (Stein and Leslie, 1996), more recent cognitive activation neuroimaging studies revealed exaggerated respon-sivity of medial temporal lobe structures to human face stimuli (Birbaumer et al.,...

What Psychosocial Interventions Are Appropriate For Patients Whose Epilepsy Has Not Been Confirmed

Nonepileptic events may coexist with seizures in many patients with epilepsy. The clinician needs to explain carefully to patients the difference between epileptic and nonepileptic events. If patients are told that they are not having real seizures, they may feel angry, distrustful, or invalidated. But the events are real regardless of the cause and must be addressed. Some patients will be relieved to learn that they may not have epilepsy. Others may be confused or disappointed that there is no medical reason that can be identified for the events. Many patients who have nonepileptic events may also have been abused physically, mentally, or sexually in the past. Or they may have experienced a traumatic event or loss. Exploring these traumatic events with patients in a psychotherapeutic setting may provide emotional relief and may reduce the frequency of the nonepileptic events.

Monoamine Reuptake Inhibitors

Is produced rapidly in humans, with peak plasma levels of up to 3 times those of bupropion and a half-life of 24 hr. Therefore, orally administered bupropion is likely to lead to significant NE reuptake inhibition and relatively less DA reuptake inhibition. Bupropion increases locomotor activity and causes stereotyped behaviors in laboratory animals. In humans, it can cause restlessness, insomnia, anorexia, and psychosis. Bupropion is structurally related to phenylethylamines and unrelated to the TCAs, SSRIs, or MAOIs. It has no significant potency at binding to any known neurotransmitter receptors. Clinical studies have demonstrated that bupropion is effective in the treatment of major depressive episodes (Depression Guideline Panel, 1993). While early studies suggested that bupropion might be less likely to cause hypomania or mania in bipolar patients, subsequent studies suggested that it can cause mania and psychosis in bipolar patients, especially those with high pretreatment...

Temperament Adaptation and Resilience

Between 1939 and 1942, one of America's leading universities recruited 268 of its healthiest and most promising undergraduates to participate in a longitudinal study. The originators of the program, which came to be known as the Grant Study, felt that medical research was too heavily weighted in the direction of disease, and their intent was to chart the ways in which a group of promising individuals coped with their lives over the course of many years. Nearly 40 years later, George E. Vaillant, director of the study, reviewed the Grant Study men in the classic text, Adaptation to Life (Vaillant, 1977). He concluded that mental health exists as a continuum, like intelligence, not just as the absence of psychiatric symptoms, and that adaptation to life means continued growth. In fact, isolated traumatic events rarely seem to mould individual lives. What truly impinges upon health is the continued interaction between ones choice of adaptive mechanisms and ones sustained relationships...

Acute stress disorder

Acute stress disorder (ASD) is the development of anxiety and dissociation as well as other symptoms of a stress reaction that occur within the first four weeks following an extreme traumatic stressor (APA, 2000). As for a diagnosis of PTSD, the condition consists of dissociative, reexperiencing, avoidant, and arousal symptoms. The main difference between ASD and PTSD is that for the diagnosis of ASD three dissociative symptoms must be present, and that the symptoms occur one month after the exposure to the traumatic stressor. major goal of the task force responsible for developing this diagnosis for the DSM-IV-TR was to identify individuals in the posttrauma phase who would be likely to subsequently develop PTSD (Bryant & Harvey, 2000). To satisfy the criteria for the diagnosis of ASD, the individual must display acute dissociation (emotional numbing, derealization, depersonalization, reduced awareness of surroundings, dissociative amnesia), reexperiencing phenomena (intrusive...

Sociology and the Study of Race and Mental Health

Sociology provides some of the theoretical underpinnings on which race and mental health research is constructed. In turn, the sociology of mental health contributes to the discipline by providing theoretical refinements and empirical evidence about how race is linked to psychological and emotional states such as through traumatic events, discrimination, and treatment biases. This reciprocity between the sociology of mental health and the larger body of sociological work is evidenced in some of the common frameworks we outline below that have been used, over time, to study race and mental health. Our review also serves as a reminder that current studies on mental health are influenced by the social and political realities that frame discussions and conversations about race. Past debates have usually reinforced, often unintentionally, the social positions of racial groups rather than contesting the inequities found among racial groups. Support for one theoretical frame over another...

Suggested Readings

The concept of compensation for psychiatric damages, mental damages, or psychic trauma, as it is called in various settings, has evolved over time. Railway spines and brains (Weisaeth 2002) led physicians to explore the interplay of physical injury and nervous symptoms (Harrington 2003). The connection between physical injury and psychological symptoms reemerged in the World War I phenomenon of shell shock, and it evolved throughout the twentieth century history of warfare through the internecine neurasthenia, World War Il's psychoneuroses, and finally to the post-Vietnam era posttraumatic stress disorder. With the publication of DSM-IV, the concept of physical injury, or even the threat of physical injury causing psychic damage was expanded from the battlefield and broadened to include a wide range of potentially traumatic experiences.

Department of Veterans Affairs Disability Examinations

Department of Veterans Affairs provides comprehensive guidelines for disability examinations. Physicians employed or contracted by the Veterans Health Administration perform the examinations, which are then used to evaluate disability by the Veterans Benefits Administration. As of 2009, 57 separate worksheets describing disability examinations were available. Many of the separate exams can be and some must be performed by psychiatrists, including those entitled Eating Disorders, Mental Disorders, and Initial and Review Examinations for PTSD (U.S. Department of Veterans Affairs 2009).

Treatment for Child Victims

Efforts should be made to normalize and optimize the child's functioning as much as possible. Psychotherapy is indicated unless the victim is an infant or preverbal toddler. Victims of illness falsification may deny it have intense anger at the medical team, abuser, or other collusive family members have residual sick-role beliefs and behavior and or have posttraumatic stress disorder (especially in medical settings), self-esteem problems, difficulty defining family relationships, and immense grief (Ayoub 2006 Bools et al. 1993 Bursch 1999). The psychological impact of MBP victimization appears to be significant and chronic. Ongoing problems with social interaction, attention and concentration, oppositional disorders, patterns of reality distortion, poor self-esteem, and attachment difficulties with adults and peers are documented in the literature (Libow 1995). Although children can present as socially skilled and superficially well adjusted, they often struggle with the basic...

Evolution of secondary anxiety disorders following TBI

While the presence of psychiatric disorder is major determinant of outcome following TBI (Mooney & Speed, 1997), predicting which individual will go on to have an uncomplicated recovery and which will never recover remains a significant diagnostic dilemma. Certainly the evolution from the ASD to PTSD follows a reasonably predictable course, but ultimately which individual will develop and sustain the diagnosis of posttraumatic anxiety and the PCS is less predictable.

The Persisting Effects of Early Traumas and Adversities

Childhood abuse neglect also is associated with mental health problems during adulthood (e.g., Horwitz, Widom, McLaughlin, & White, 2001 Kessler & Magee, 1994). Childhood sexual assault is an especially potent harbinger of mental health problems, usually PTSD and or depression, both immediately after the assault and throughout adulthood (e.g., Roberts, O'Connor, Dunn, & Golding, 2004 Winfield, George, Swartz, & Blazer, 1990 Yama, Tovey, & Forgas, 1993). Indeed, even if children are not victims of abuse or assault, witnessing such aggression has persisting effects on adult mental health (e.g., Kessler & Magee, 1994 Shaw & Krause, 2002 - the latter demonstrates that effects persist 70 years after witnessing the violence). Adult Traumas. Traumas experienced after childhood also can be potent risk factors for mental health problems both immediately after the trauma and many years later. The most frequently studied adult trauma is combat exposure during war. By now, veterans of three major...

Disability and Specific Mental Disorders

Posttraumatic stress disorder, which is the subject of much litigation involving disability claims, is known to produce chronic and long-lasting symptoms. It may be quite disabling for people who do certain types of work, particularly if the trauma occurred in a work-like setting. However, there are few objective data to support chronic total disability from post-traumatic stress disorder (Drukteinis 2002).

Fracture etiology factor of risk

Vertebral bodies sustain fractures under two different mechanical environments repetitive loading that fatigues the cancellous bone and leads to the accumulation of microfractures, or single traumatic events may overload the vertebral body and lead to fracture 58 . To understand the etiology of vertebral fracture, information about the loads imposed onto the vertebral body and the load-bearing capacity of the vertebrae at the time of risk need to be quantified. This concept has been defined as the factor of risk, and represents the ratio of the load applied to the bone over the load necessary to cause a fracture 42 . The load

Coping Adaptation and Traumatic Stress

The traumatic stress that accompanies critical care hospitalization is also associated with acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) symptomatology. The rates of both diagnoses and subthreshold symptoms are at least comparable to those observed in children hospitalized on general medical wards (e.g., Rennick et al. 2002), although some studies have found higher rates of disorder and symptomatology in PICU patients. For example, Rees et al. (2004) found clinically significant symptoms of PTSD, including irritability and persistent avoidance of reminders of the admission, in 21 of PICU patients 7 months after discharge, but none of the comparison group of patients hospitalized on a general medical ward evidenced symptoms that reached diagnostic threshold. In a follow-up study in India, Muranjan et al. (2008) found that 43 of PICU patients, compared with only 6.7 of children hospitalized on a general pediatric ward, reported intrusive thoughts (including...

Assessment of Disability

Psychiatrists should not rely on interviews and mental status examinations alone to determine degree of impairment. Although limited, studies exploring the association among psychiatric disorders, symptoms, and impairments are available and provide the bases for reasoned mental health opinions regarding employment-related work issues such as impairment or need for accommodations (Gold and Shuman 2009). For example, PTSD and depression at 3 months after injury in the workplace significantly increase the risk of disability at 12 months post-injury (O'Donnell et al. 2009).

Concerns Regarding Parents and Families

A growing body of literature has documented ASD and PTSD symptomatology in parents of critically ill children. Balluffi et al. (2004) found that 32 of parents of children in a PICU met diagnostic criteria for ASD, and 21 met criteria for PTSD upon follow-up. Recent results from a study in the Netherlands (Bronner et al. 2008a) indicated that more than three-quarters of parents of PICU-hospi-talized children evidenced persistent subthreshold PTSD symptomatology. ASD and PTSD symptoms have been extensively documented in parents of infants requiring NICU hospitalization (e.g., Hol-ditch-Davis et al. 2003 Lefkowitz et al. 2008 Shaw et al. 2006), and evidence indicates that parents' traumatic experiences related to their infants' NICU hospitalization may have both short-term and persistent effects on later behaviors, such as infant sleeping and eating (Pierrehumbert et al. 2003), and attachment and family functioning (Mayes 2003). Diagnostic rates of ASD and PTSD are higher among parents...

Phenomenology and nosology of secondary affective disorders

The DSM-IV-TR (APA, 2000) diagnoses affective disorders following brain injury primarily by their associated syndromic presentation (i.e., major depression, dysthy-mia, or bipolar disorder) or as a consequence of their association with a particular medical illness (i.e., secondary to the organic disorder such as 293.83 Mood Disorder Due to a General Medical Condition) with the predominant symptom type indicated by subtypes, such as with depressive features, with major depressive-like episode, with manic features or with mixed features. The general medical condition is specified by an Axis III diagnosis (e.g., 850.9 Concussion or 851.80 Contusion, cerebral). The differential diagnosis of this condition could include the following conditions adjustment disorder with depressed mood, emotional lability, apathy and posttraumatic stress disorder (Robinson & Jorge, 1994, 2005).

Complexity of Adaptation

Once people develop PTSD, the recurrent unbidden reliving of the trauma in visual images, emotional states, or in nightmares produces a recurrent reliving of states of terror. In contrast to the actual trauma, which had a beginning, middle, and end, the symptoms of PTSD take on a timeless character. The traumatic intrusions themselves are horrifying They interfere with getting over the past, while distracting the individual from attending to the present. The unpredictable exposure to unbidden feelings, physical experiences, images, or other imprints of the traumatic event leads to a variety of (usually maladaptive) avoidance maneuvers, ranging from avoidance of people or actions that serve as reminders to drug and alcohol abuse and emotional withdrawal from friends or activities that used to be potential sources of solace. Problems with attention and concentration keep them from being engaged with their surroundings with zest and energy. Uncomplicated activities like reading,...

Conditional Responses to Specific Stimuli

Most PTSD sufferers have heightened physiological arousal in response to sounds, images, and thoughts related to specific traumatic incidents, while others have decreased arousal. Initial research on acute trauma victims found that people with PTSD, but not controls, respond to reminders with significant increases in heart rate, skin conductance, and blood pressure (Pitman et al., 1987). The elevated sympathetic responses to reminders of traumatic experiences that happened years, and sometimes decades, ago illustrate the intensity and timelessness with which these trauma imprints continue to affect current experience (Pitman et al., 1987). Post and his colleagues (1992) have shown that life events play a critical role in the first episodes of major affective disorders but become less pertinent in precipitating subsequent occurrences. This capacity of triggers with diminishing strength to produce the same response over time is called kindling. About one third of chronically traumatized...

Long Term Family Adjustment

The stress of a child's cancer diagnosis and treatment leaves some parents feeling helpless, extremely fearful, or horrified, thus setting the stage for symptoms of acute stress and or posttraumatic stress symptoms (Pai and Kazak 2006). Children whose parents are distressed are more likely to be distressed themselves (Robinson et al. 2007) however, parents appear to be at significantly higher risk for posttraumatic stress symptoms than their children (Kazak et al. 2004). A study of 214 parents of pediatric oncology patients found that 33 of the parents reported symptoms consistent with acute stress disorder at 1 week postdiagnosis, and half of those reported symptoms of posttraumatic stress disorder at 4 months postdiagnosis. Mothers were more likely to report symptoms than fathers (Poder et al. 2008). Another study of 201 parents using a different measure to assess acute and posttraumatic stress found that 51 of the mothers and 40 of the fathers reported symptoms meeting DSM-IV-TR...

Loss of Arousal Regulation

Elementary self-regulation involves an interconnected collection of neural patterns that maintain bodily processes and that represent, moment by moment, the state of the organism (Damasio, 1999). The immediate response to a traumatic experience involves dysregulation of arousal, with (a) exaggerated startle response, (b) over- or under-aroused physiological and emotional responses, (c) difficulty falling or staying asleep, and (d) dysregulation of eating, with lack of attention to needs for food and liquid. In people who develop PTSD, this pattern of disordered arousal persists. Once people develop PTSD, they suffer from a fundamental dysregulation at the brain stem level (Sahar et al., 2001). The regulatory processes of the brainstem involve the reticular activating system, the origin of the sympathetic nervous system, as well as two branches of the parasympathetic system, innervated by the vagus nerve the dorsal vagal system and the ventral vagus (Porges et al., 1996). Activation of...

Therapeutic Interventions

Verbalize the powerlessness 1. and unmanageability that result from PTSD and addictive behavior. (1) 2. Describe the traumatic events 2. and the resultant feelings and thoughts, in the past and the present. (2) 3. Complete psychological testing 3. or objective questionnaires for assessing PTSD. (3) Administer to the client psychological instruments designed to objectively assess PTSD (e.g., Trauma Symptom Inventory TSI , PTSD Symptom Scale-Self-Report PSS-SR ) give the client feedback regarding the results of the assessment. 4. List times that PTSD symptoms led to addictive behavior. 5. List the ways in which a 12-step recovery program can assist in recovery from PTSD and addictive behavior. (5) 4. Assign the client to list times when symptoms of Posttraumatic Stress Disorder led to addictive behavior. 25. Discuss with family members the connection between PTSD and addictive behavior. 18. Complete a re-administration of objective tests of PTSD as 27. Assess the outcome of treatment by...

Lessons From Neuroimaging Symptom Provocation Studies

Explore the pathogenesis and pathophysiology of PTSD. Structural abnormalities in PTSD found with MRI include nonspecific white matter lesions and decreased hip-pocampal volume. These abnormalities may reflect pretrauma vulnerability to develop PTSD or they may be a consequence of traumatic exposure, PTSD, and or PTSD sequelae. Rauch, van der Kolk, and colleagues conducted the first PET scan study of patients with PTSD (Rauch et al., 1996). When PTSD subjects were exposed to vivid, detailed narratives of their own traumatic experiences, they demonstrated increased metabolic activity only in the right hemisphere, specifically, in the areas that are most associated with emotional appraisal the amygdala, insula, and the medial temporal lobe. During exposure to their traumatic scripts, there was a significant decrease in activation of the left inferior frontal area Broca's area, which is responsible for motor speech. Most neuroimaging studies have found activation of the cingulate cortex...

In generally anxious participants

However, the surprising finding is that of an absence of explicit memory biases in generally anxious participants for threat-related material. This contrasts markedly with the state of affairs in depression (see Chapter 7) and in other anxiety disorders such as PTSD and panic states (see the relevant sections in this chapter). We propose that there are two reasons which may help to explain this profile of results in generally anxious participants. The first is methodological, in that many of the studies that have investigated memory for threat in generally anxious individuals have not chosen words that are specific to the person's exact domain of concern. In contrast, in such research with more circumscribed anxiety states such as panic the stimuli have meshed much more closely with the preoccupations of the participants. It is possible therefore that mnemonic biases are a function of generally anxious states but that they have yet to be properly tested for. However, it seems unlikely...

Role of the Anterior Cingulate Cortex ACC

Every activation study of PTSD subjects finds involvement of the cingulate. However, in some studies there is increased (Bremner, 1999b, 1999a Shin et al., 2001 Lanius et al., 2001) and in others decreased (Sachinvala, 2000) activations. The very process of activating emotion in the unfamiliar context of a laboratory environment might activate the anterior cingulate, including exposure to the stressful laboratory environment itself. Carter et al. (1999) have suggested that ACC activation results in a call for further processing by other brain circuits to address the conflict that has been detected. In most people, automatic mechanisms of emotion regulation are likely invoked to dampen strong emotion that may be activated in the laboratory. The PTSD neuroimaging studies suggest that many traumatized subjects are less capable of activating the ACC in response to emotionally arousing stimuli. In our treatment outcome study of PTSD (Levin et al., 1999), we found increased ACC activation...

Implications For Treatment

For over a century it has been understood that traumatic experiences can leave indelible emotional memories. Contemporary studies of how the amygdala is activated by extreme experiences dovetail with the laboratory observation that emotional memory may be forever (LeDoux et al., 1991). The accumulated body of research suggests that patients with PTSD suffer from impaired cortical control over subcortical areas responsible for learning, habituation, and stimulus discrimination. Hence, current thinking is that indelible subcortical emotional responses are held in check to varying degrees by cortical and hippocampal activity, and that delayed onset PTSD is the expression of subcortically mediated emotional responses that escape cortical, and possibly hip-pocampal, inhibitory control (van der Kolk and van der Hart, 1991 Pitman et al., 1990 Shalev et al., 1992). The early neuroimaging studies of PTSD showed that, during exposure to a traumatic script, there was decreased Broca's area...

Phase Oriented Treatment

Flooding and exposure are by no means harmless treatment techniques Exposure to information consistent with a traumatic memory can be expected to strengthen anxiety (i.e., sensitize and thereby aggravating PTSD symptomatology). Excessive arousal may make the PTSD patient worse by interfering with the acquisition of new information. When that occurs, the traumatic memories will not be corrected, but merely confirmed Instead of promoting habituation, it may accidentally foster sensitization.

Lifetime Accumulation of Stress and Disadvantage

In particular, studies focusing on specific types of events, such as violence exposures (Macmillan, 2001) reveal the traumatic nature of some stress exposures in the lives of the disadvantaged, and document the role of severe stress in curtailed education. Macmillan and Hagan (2004), for example, have examined the impact of an adolescent victimization on young adult socioeconomic attainment and found reductions in educational advancement that are mediated through the impact of violence on self perceptions of efficacy. In addition, experiencing victimization during adolescence is not a random event. Young people growing up in poverty have an elevated risk of experiencing violence, among other traumatic events including homelessness (McLoyd, 1998). Thus, events during adolescence which are severe and traumatic play an important role in our understanding of cumulative stress processes and the role of stratification in mental health processes linking generations.

Effects Of Sexual Assault

Researchers have identified a myriad of psychological effects of sexual assault on women. Burgess and Holmstrom's classic study18 first described rape trauma syndrome in sexual assault survivors, and more recent studies have documented numerous psychological consequences of rape (e.g., depression, anxiety, sexual problems) including PTSD.19-21 An alarming 17 to 65 of women with a lifetime history of sexual assault develop PTSD.22 Many (13 -51 ) meet diagnostic criteria for depression.22-24 An overwhelming majority of sexual assault victims develop fear and or anxiety (73 -82 )25 and 12 to 40 experience generalized anxiety.26-27 Approximately 13 to 49 of survivors become dependent on alcohol, whereas 28 to 61 may use other illicit substances.2,28 Further, it is not uncommon for victims to experience suicidal ideation (23 -44 )29 and 2 to 19 may attempt suicide.30 It is also important to note that some research has shown that multiple perpetrator rape incidents may be more serious and...

Risk factors for the development of eating disorders

Many athletes report that they developed eating disorders as a result of traumatic events, such as the loss or change of a coach, injury, illness or overtraining 108,120,124 . An injury can curtail the athlete's exercise and training habits. As a result, the athlete may gain weight owing to less energy expenditure, which in some cases may develop into an irrational fear of further weight gain. Then the athlete may begin to diet to compensate for the lack of exercise 116 .

Phobias And Obsessions

We have concentrated in this chapter on panic, generalised anxiety, and PTSD in order to illustrate several ways in which fear can become disordered. Two further traditional categories of so-called anxiety disorders phobias and obsessions can also be derived from fear. However, we propose that some phobias and obsessions can perhaps be more usefully derived from the basic emotion of disgust and there may be little or no role for fear responses in these cases. Consequently, we talk briefly about fear-derived phobias and obsessions here and continue the discussion in Chapter 9 on disgust.

Experimental Case Studies

Posttraumatic Stress Disorder Several examples reveal how difficult it can be to make the diagnosis of PTSD unless the physician looks for the problem. A young man suffered a cervical SCI when he injured his neck in a surf board accident. Six months later, he walked well and had only mild weakness in his hands and lower extremities, along with variably unpleasant tingling sensations in the legs. He had not returned to work, however. Exercise caused him to feel weak. He admitted to outbursts of anger and difficulty with concentration. Oddly, he would spend several days in bed every week, saying that his body felt tired after he tried to exert himself by taking a walk. He had stopped swimming, which had been a favored activity before the accident. On questioning, he recalled terrible nightmares in the first 2 months after his injury, a time when he was regaining control of his leg and arm movements. He described his accident with a very flat affect. He was driven off his surfboard by a...

Other Mental Disorders

Recent work has extended historical accounts of traumatic or abusive childhoods in eminent creatives and posited a connection with post traumatic stress disorder (PTSD). Linkages with substance and alcohol abuse have already been mentioned, and there is a rich anecdotal literature on associations between alcoholism and the use and abuse of other substances and creative functioning. However, a more recent and popular stream of literature has focused on the documented ill effects of addiction on creativity, creative individuals, and those around them, and on the role of recovery from substance abuse in tapping personal creativity and also recovering from traumatic events. As noted, over time and the course of study in this area, focus has shifted from characteristics of personality disorder to those of schizophrenia and then mood disorders. The question of which specific mental health diagnoses or which symptoms may be most associated with creativity is complicated by several things....

In Neuronal Transmission and in Multiple Behaviors

A variety of experimental animal paradigms exist for in vivo assessment of behavioral functions (98). The startle reflex (defined as the animal's response latency following stimulation elicited by an auditory stimulus) can be inhibited by a preceding stimulus (defined as prepulse inhibition) (99,100). The isolation-induced aggression paradigm assesses the animal's response to an intruding animal and reflects the level of hostility (98). The data derived can be extrapolated to human pathophysiology for example, deficits in prepulse inhibition (PPI) have been observed in patients suffering from schizophrenia (101), and PPI deficiency in rats can be corrected by antipsychotic treatment (102). Therefore, these experimental paradigms can be employed collectively to assess animal behavior. Compared to control animals, a -AR-- mice are hyperreactive to loud noises (i.e., display enhanced startle response) and display a deficit in PPI, whereas opposite findings were identified in a2C-AR+ +OE...

Financial Incentive and Malingering

Individuals who are seeking some form of compensation are commonly believed to be more likely to exaggerate symptoms. Four studies published by different authors in recent times have attempted to evaluate this belief. Frueh and colleagues (1997) found that veterans seeking compensation for PTSD, compared with non-compensation-seeking veterans, endorsed dramatically higher levels of psychopathology across psychometric measures and produced sharply elevated fake-bad validity indices despite controlling for factors such as income and clinician ratings of illness severity. Study authors concluded that their study identified a clear association between symptom overreporting and PTSD compensation-seeking status. Binder and Rohling (1996) evaluated the impact of financial incentives on disability, symptoms, and objective findings after closed-head injury. They found more abnormality and disability in evaluees with financial incentives, despite less severe injuries. Paniak and colleagues...

Malingering Assessment

Resnick (2003) has provided guidelines for the evaluation of malingering in PTSD. These guidelines, although specifically written for the evaluation of PTSD, serve as a framework for designing guidelines for the assessment of malingering in general. In the following discussion, we review useful techniques in the assessment of malingering. We also suggest guidelines derived from Resnick, as well as from our own experience, for the assessment of malingering across the spectrum of psychiatric disorders.

Neural Substrates of AM Retrieval

Consistent with these findings, physiological research in the study of trauma and PTSD suggests that the three major brain regions involved in trauma-related memory disturbances are the amygdala, the medial prefrontal cortex, and the hippocampus (for a review, see Shin, Rauch, & Pitman, 2006). There is evidence that, whereas the amygdala is highly responsive to trauma-related memories, activation in the medial PFC, including the ACC and medial frontal gyrus, is largely decreased in PTSD. This pattern of amygdala hyperactivation and PFC deactivation may be associated to typical memory disturbances in PTSD with intrusions of highly emotional memories and the inability to recall other aspects of the trauma, possibly because of ineffective retrieval inhibition of involuntary memory intrusions.

Lesion location and mechanism of the abnormal illness behaviour following TBI

This is not to gainsay the fact that even relatively naive individuals with relatively little motivation can manufacture convincing evidence of psychiatric disorder at least on self-report measures. As noted in the discussion of PTSD in chapter 4, Lees-Haley and Dunn (1994) found that 99 of untutored undergraduates could achieve a performance satisfying DSM-IV criteria for PTSD on a symptom checklist. Burges and McMillan (2001) noted a similar level of endorsement and observed that 94 of their sample of 136 night class college students could satisfy the criteria of PTSD after being read a vignette. Clearly it is possible for relatively untrained individuals with little or no knowledge of PTSD to fake responses on symptom checklists sufficient to achieve the diagnosis. It is anybody's guess how convincing a highly motivated individual facing a large financial settlement or the avoidance of prison or military duty might be capable of appearing. Dissociative disorders are characterized...

Treatment Adherence

Several individual and family characteristics have been linked to nonadherence in solid organ transplant populations. Individual factors, aside from age (specifically, adolescence), include poor self-esteem, communication and social skills deficits, poor acceptance of diagnosis, and psychiatric conditions such as depression and anxiety (Wolff et al. 1998). Medication side effects have been found to be associated with poor adherence (Kugler et al. 2007). In a study of 112 renal transplant patients, nonadherence was related to having a comorbid psychiatric illness, and psychiatric illness was a predictor for graft loss, emphasizing the importance of psychological treatment (Shaw et al. 2003). PTSD specifically has been strongly linked to nonadherence (Shemesh et al. 2000), and once PTSD symptoms were treated, adherence improved. In a study by Maikranz et al. (2007), depression has been found to be related to nonadherence. In this study, hope and uncertainty were linked to depression and...

Treatment Of Anxiety In Clinical Practice Symptoms of Anxiety

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994) includes eight major types of anxiety disorders, most of which have been summarized in previous chapters, including PTSD (Chapter 11), panic attacks (Chapter 12), obsessive-compulsive disorders (Chapter 13), and various acute stress reactions (Chapter 4). Here we will be primarily concerned with generalized anxiety disorders, but the coverage is also relevant for specific phobias, including social phobias and agoraphobia. The most common clinical symptom of all these disorders is excessive worry and sustained feelings of mental anguish. Among the common symptoms of generalized anxiety there are a variety of psychological disturbances, such as uncontrollable apprehensive expectations, jumpiness, and a tendency for excessive vigilance and fidgeting. The accompanying autonomic symptoms commonly include gastrointestinal irritability, diarrhea, and frequent urination, as well...

The Social Context of Recollection

A more elaborative style engage in reminiscing conversations more fully, and by the end of the preschool years are able to independently provide more detailed and coherent narratives of their personal past than are children of parents with a less elaborative style (Bauer & Burch, 2004 Farrant & Reese, 2000 Fivush, 1991 Flannagan, Baker-Ward, & Graham, 1995 Haden, 1998 Harley & Reese, 1999 Hudson, 1990 Peterson, Jesso, & McCabe, 1999 Peterson & McCabe, 1992 Reese, Haden, & Fivush, 1993 Welch-Ross, 1997). These relations are observed for the typical events of everyday life, as well as for emotionally salient and traumatic events, such as recollection of a devastating tornado (Bauer, Burch, Van Abbema, & Ackil, 2007) and trips to the emergency room (Sales, Fivush, & Peterson, 2003).

The Development of Recollection

N., Lukowski, A. F., Rademacher, J., Van Abbema, D. L., & Ackil, J. K. (2005). Working together to make sense of the past Mothers' and children's use of internal states language in conversations about traumatic and non-traumatic events. Journal of Cognition and Development, 6, 463-488.

Subcortical FEAR System and Feelings of Anxiety

Until demonstrated otherwise, a reasonable working hypothesis is that the whole FEAR circuit is necessary for a fully elaborated anxiety response. It is important to reemphasize that such core emotional circuits can be sensitized by repeated activation with ESB or stressful life experiences (Adamec and Young, 2000). Once such limbic permeabilities are established (Maren, 1999), as may occur most dramatically in PTSD (van der Kolk, 1987), there are no robust ways to reverse them (Davidson, 1997), even though certain experimental agents (e.g., cholecystokinin receptor blockade) can provide prophylaxis against trauma effects in an animal model (Adamec and Young, 2000). We can also anticipate that rich social contact and sincere support after trauma might do the same (Ruis et al., 1999).

Varieties of Anxiety Systems in the Brain

Many anxiety-related disorders may actually be constituted of mixtures of several emotions. The sustained mood changes that accompany PTSD often include mixtures of anxiety and anger. PTSD symptoms can often be ameliorated with antiseizure medications, for instance, carbamazepine, a GABA facilitator that does not consistently benefit either anticipatory anxiety or panic attacks (Charney et al., 1993). Likewise, carbamazepine can block kindling the seizure potentiation induced via once-a-day application of an ESB burst to seizure-prone areas of the temporal lobe such as hippocampus and amygdala, which has yielded an animal model for PTSD (Adamec and Young, 2000). Kindled animals often exhibit chronic emotional changes, including increased fearfulness, irritability, and at times heightened sexuality. In sum, it presently seems likely that brain systems that mediate generalized anxiety disorders and panic attacks, separation anxiety, and posttraumatic stress disorders can be neurally...

Psychosocial Adjustment

Two studies (a pilot and a follow-up) conducted in the United Kingdom found that after meningo-coccal infection, children displayed an increase in psychiatric problems as compared with their premorbid functioning (Judge et al. 2002 Shears et al. 2005). In the pilot study, Judge et al. (2002) followed 29 children (14 boys and 15 girls), ranging from 2 years to 15.9 years (mean age, 5.7), for 1 year after hospitalization in the pediatric intensive care unit. About two-thirds of the children (16 of the 29 children) had symptoms of posttraumatic stress disorder (PTSD), including nightmares and hyperarousal associated with thoughts and associations of their illness triggering vivid and distressing memories. Ten percent of those children met the full diagnostic criteria for PTSD (Judge et al. 2002). Shears et al. (2005) conducted a follow-up study of 60 children, ranging in age from 3 to 16 years, who were assessed for psychiatric problems after a hospital stay (either pediatric intensive...

Pollution Emotional and Cognitive Responses

Mous Exxon Valdez oil spill that took place in Valdez, Alaska, in 1989.18 In the course of studying thirteen Alaskan communities, they found a clear dose-response relationship on a number of social and mental health variables. As exposure to the oil and the disruptive cleanup procedures increased, there were declines in traditional social relations with family, friends, neighbors, and work mates. Problems such as drinking, substance abuse, and domestic violence became more common. After the spill, there was a greater frequency of depression, posttraumatic stress disorder, and generalized anxiety disorder. Alaskan natives and women were especially prone to psychiatric disorders in the postspill period.

Florestan and Eusebius Literature or Music

Two traumatic events contributed to Schumann's first serious depression at age fifteen, the death of his sister followed by that of his father. Schumann's sister, Emilie, 14 years older than Robert, suffered from a chronic skin disease as well as from emotional problems. It is believed that she either drowned herself or jumped from a window. This seems to have precipitated in Robert an inescapable longing to throw

Special considerations

Raphael (1992) further proposed some patterns that could occur over time with various risks for pathology. She stated that a post-traumatic reaction (PTR) could evolve into a disorder (PTSD), and that pathological grief could develop if the issues involved with the crisis are overlooked or avoided. As previously mentioned, there are risks that individuals can become fixated to the trauma. There remains personal vulnerability well past the traumatic experience, and often there is a failure of needed support to help work through the multiple issues involved. As with other types of losses, once the event has occurred, initial support has been offered, and some time has passed, most people external to the loss do not perceive any additional problems or need for support. Moreover, just as every loss has secondary losses, trauma includes secondary or symbolic losses and secondary traumatic reactions, especially when it becomes drawn out in legal processes.

Sleep Disorders of Parkinson s Disease

As REM sleep density and REM dreams and nightmares are significant predictors of suicidal ideation in depressed individuals (Agargun et al., 1998 McNamara, 2008). REM-related indices of persons with posttraumatic stress disorder (PTSD) predict severity of PTSD (Germain & Nielsen, 2003). Indeed incorporation of trauma-related memories into REM dreams is one of the Diagnostic and Statistical Manual of Mental Disorders' 4th edition (DSM-IV American Psychiatric Association, 2000) criteria for the disorder.

Prevalence Of Psychological Changes In Neurological Patients

Psychological function can be altered in diverse ways after brain damage or disease. Here we will focus on several studies that discuss the incidence of such psychological changes. Psychiatric changes are common after focal brain disease and brain injury. For example, a number of studies have investigated the consequences of traumatic brain injury, where depression appears to be the most prevalent psychiatric outcome. Recent studies have estimated that clinical depression affects a majority of traumatic brain injury sufferers in the period immediately after their brain injury (e.g., Deb et al., 2000 Silver et al., 1991 see Hales and Yudofsky, 1997, for review). At 12 months postinjury clinical depression was still prevalent in some 20 percent of patients (Deb et al., 2000 Fedoroff et al., 1992), frequently persisting beyond 24 months (Rao and Lyketsos, 2000). Similarly, anxiety disorders, including posttraumatic stress disorder and obsessive-compulsive disorder, are common after...

Conclusions and Discussion

The goal of this chapter was to provide and review an information processing perspective on involuntary recall after psychological trauma. Historically, the acknowledgment of PTSD as a psychiatric disorder has not been straightforward, partly due to political and social factors. However, even before this, PTSD related theory and experimental research has been innovative, especially when we consider that this chapter has only addressed the very specific topic of intrusive image-based trauma memories. As we have seen, an influential current perspective on involuntary recall in PTSD comes from an information processing tradition. We discussed two important information processing theories, namely the dual representation theory by Brewin and colleagues (1996,1989,2001) and the cognitive model of PTSD by Ehlers and Clark (2000). Although they differ on several aspects, both theories converge on the idea that a shift in balance between perceptual and conceptual processing lies at the heart...

Neuropsychological Findings

A large body of work compared PTSD patients with trauma-exposed and normal healthy controls on a wide range of neuropsychological measures employing emotionally neutral stimulus material. These measures often reflect a variety of memory tests, including initial learning encoding, short-delay recall (SDR), long-delay recall (LDR), retention (LDR minus SDR), cued recall, and recognition. A recent meta-analysis showed that PTSD-related cognitive impairments mainly occur in the verbal domain, and that visuospatial abilities are relatively intact (Brewin, Kleiner, Vasterling, & Field, 2007 see also Johnsen & Asbjornsen, 2008). The meta-analysis further showed that, by and large, this verbal deficit was reflected by problems with the immediate recall of target information. According to Brewin et al. (2007), impairments in immediate, but not delayed, memory imply dysfunction of attention and or strategic processing, impacting the initial registration of information. This idea of PTSD-related...

Executive Control as a Premorbid Vulnerability Factor

The next question that arises is whether cognitive impairments in PTSD are a consequence of the toxic effects of the exposure to a traumatic event, or may predate the trauma experience and PTSD onset. In the latter case, the cognitive impairments would represent a vulnerability factor that might explain individual differences in trauma response resulting in either natural recovery or in persistent symptomatology and eventually, PTSD (see Vasterling & Brailey, 2005). The idea that premorbid individual differences in cognitive ability may set people at risk for developing PTSD after trauma was investigated in several studies. These studies used different approaches. For example, Macklin et al. (1998) used archival military records to obtain measures of pre-trauma functioning. The results showed that lower pre-combat intelligence increased the risk of PTSD after combat exposure (see also Pitman, Orr, Lowenhagen, & Macklin, 1991 Koenen, Moffitt, Poulton, Martin, & Caspi, 2007 Breslau,...

Executive control as a multicomponent construct

A further division of the inhibition component of executive functioning may be of particular importance for present purposes. This involves the distinction between inhibition at the response level and inhibition at the cognitive level. Friedman and Miyake (2004) found that performance on tasks requiring the stopping or preventing of prepotent responses (e.g., the Stroop, stop-signal and antisaccade tasks see also Miyake et al., 2000) represented a different latent variable (response inhibition) than measures of resistance to proactive interference (resistance to PI indexed by list-learning paradigms). Response inhibition may be involved in preventing the natural but socially inappropriate tendency to say something embarrassing about a colleague's new purple dress. As an example of resistance to PI, consider the first weeks after purchasing a new mobile phone. During this time, it would be difficult to access the new number in long-term memory because the extensively used old number...

Interference Control and Intrusive Memories

How, then, might an executive ability such as resistance to PI contribute to either natural recovery or the development of psychopathology after trauma Consider someone who was injured in a major traffic accident involving actual death and injury of several people. In the aftermath of this event, this person may frequently experience stressful intrusive memories in the form of visual images of specific moments during the accident. For example, the person may suddenly experience a mental image of being stuck in the car with no possibility of getting out, realizing that he would probably die. In order to pick up everyday life again (e.g., preparing for an upcoming exam, resuming work as a financial controller), it would be increasingly helpful to ignore these stressful intrusions. Resistance to PI would enhance goal-directed behavior and focusing on tasks at hand. To the extent that that is successful, it would also allow for achieving gradual control over intrusions. By contrast, when...

Executive Control May Help Disengagement of Attention from Stressful Trauma Reminders

In general, clinical theories of PTSD (e.g., Ehlers & Clark, 2000) assume that intrusive re-experiencing reflects a direct retrieval process. That is, in contrast to an effortful strategic search for the specifics of an event (i.e., intentional retrieval), direct retrieval is automatic and cue-driven. It arises when a retrieval cue maps directly onto the content of a specific representation in long-term memory. Thus, in the context of PTSD, reminders that match the specific circumstances of a traumatic event (e.g., the color of a car, the smell of a rapist's breath) would trigger involuntary reliving (Ehlers & Clark, 2000). However, several accounts of PTSD (see Dalgleish, 2004) suggest that traumatic intrusions are not only triggered by cues that are unambiguously related to the traumatic event. Seemingly unimportant cues in the environment may also obtain intrusion-triggering power. Ehlers and colleagues (Ehlers, Michael, Chen, Payne, & Shan, 2006 Ehlers & Clark, 2000) argued that...

Interpretation or Meaning of the Stressor

Whether a crisis is precipitated by an external life event or an internal psychological thought or feeling, each person interprets or adds meaning to the acute precipitant. For some people, like Melinda in Case Study 1, a local violent crime precipitated a major emotional crisis and a recurrence of her PTSD symptoms. When listening for the precipitant of a crisis, it is important to understand the meaning of even minor stressors in the context of a patient's life. The robbery in Melinda's community had a personalized meaning to her that reawakened old wounds and PTSD symptoms, fueling a major emotional crisis. The following sequence of events, filtered through the lens of Melinda's select past personal experiences, created this current crisis. On learning of a local robbery, Melinda perceived a threat to her home and safety. This precipitant inundated her with traumatic memories of the hurricane and its aftereffects, which destroyed her home and her relationship. She felt anxious,...

Further Theoretical Considerations

We started this chapter by noting that apparently many people who are exposed to a traumatic stressor are able to overcome the emotional turmoil that may arise in the aftermath of such an event. We proposed that (part of) their resilience may be due to efficient executive functioning. That is, by focusing more and more on daily tasks as time progresses and thus preventing unwanted stressful memories from occupying working memory resources, people may gradually gain control over traumatic intrusions. Alternatively, relatively inefficient executive functioning may constitute a pre-trauma vulnerability factor that is responsible for the maintenance of intrusive memories, and ultimately, may contribute to the development of PTSD. Recently, Levy and Anderson (2008) advanced a similar proposal. This proposal is based on the memory inhibition theory that Anderson and colleagues have been developing for the past 15 years (see Anderson, 2005 Anderson, Bjork, & Bjork, 1994 Anderson & Green,...

Conclusion and Future Directions

All in all, we propose that deficient executive control constitutes a vulnerability factor that is expressed as an inability to disengage attention from perceptual trauma reminders in the post-trauma environment. As such, it may be responsible for the maintenance of intrusive memories that naturally arise in the aftermath of trauma and, ultimately, contribute to the development of PTSD. As this suggestion is based mainly on analogue studies, an interesting avenue for future research would be to test whether a premorbid deficit in executive control predicts intrusive memories after real-life traumatic events. For example, prospective studies of soldiers tested before and after deployment to a war zone might establish whether poor resistance to PI is a vulnerability factor for persistent intrusive memories. This may add knowledge to earlier prospective investigations (e.g., Parslow & Jorm, 2007 Gilbertson et al., 2006) which explored PTSD-related deficits in larger test batteries...

Other Trauma Treatments

Patients in an acute crisis or with disaster-related trauma may or may not require treatment. Crisis treatment is often necessary if the patient is suicidal or at risk for violence, has an acute medical emergency, or has a major psychiatric disorder (psychosis, PTSD, bipolar disorder, depression, overwhelming anxiety). All treatment is best when it is offered voluntarily or upon patient request. Exposure-based cognitive-behavioral therapy (CBT) is recommended for patients with PTSD (Bradley et al., 2005). CBT includes reexposure to past trauma through imagined, in vivo, directed therapeutic, written, verbal, or taped narrative. In addition, psychoeducation, breathing and relaxation training, and homework are often included (APA, 2004 Benedek et al., 2009 NICE, 2005).

Medications for Symptoms of Psychiatric Disorders

Thus far, no known interventions have prevented PTSD. For the primary treatment of PTSD, medications include selective serotonin reuptake inhibitors (SSRIs), prazosin, propranolol, and antiepileptics. PTSD symptoms, including reexperiencing the trauma, avoidance, numbing, and hyper-arousal, are effectively treated with SSRIs, including sertra-line, paroxetine, venlafaxine, and fluoxetine (APA, 2004 Benedek et al., 2009 Stein et al., 2006). A distinction between non-combat-related and combat-related PSTD is warranted when considering pharmacologic therapy (Benedek et al., 2009). Non-combat-related PTSD includes civilian trauma, childhood or adult sexual assault, IPV, interpersonal trauma, or trauma caused by a motor vehicle crash. For non-combat-related PTSD, sertraline, parox-etine, fluoxetine, and venlafaxine are effective in short-term trials. These SSRIs either can be a primary form of treatment, if the patient does not want exposure-based CBT, or can be combined with CBT no...

Putting it all together

It is difficult to contend that there is a direct and proportionate increase in the level of psychopathology and behavioural disturbance in those individuals who have more severe as compared to less severe injuries. For example, van Reekum et al. (2000), surveyed the incidence of major depression, bipolar affective disorder, generalized anxiety disorder, obsessive compulsive disorder, panic disorder, posttraumatic stress disorder, schizophrenia, substance abuse, and personality disorder subsequent to TBI and noted that the support for the association was mixed at best and, in the case of PTSD, there was compelling evidence for a reverse gradient (i.e., increased risk of PTSD with milder TBI) (p. 324). This is a similar conclusion to the one noted in chapter 4.

Alishia D Williams and Michelle L Moulds

Recent research has demonstrated that intrusive memories of negative autobiographical events represent an overlapping cognitive feature of depression and posttraumatic stress disorder (PTSD APA, 1994). Clearly, the content of intrusive memories in depression and PTSD is necessarily distinctive - in PTSD, the triggering event (and thus the content of the intrusions) must be traumatic (i.e., life threatening). Nonetheless, the intrusiveness of the memories in both conditions speaks to the possibility that common cognitive processes underpin their persistence in both disorders. This overlap challenges traditional notions of the dichotomy categorical division between mood and anxiety disorder symptomatology, and is in accordance with a transdiagnostic approach that underscores the utility of investigating shared clinical features across different disorders (Harvey, Watkins, Mansell, & Shafran, 2004). Understanding the role of intrusive memories will have significant potential implications...

Neurobiology and Genetics

Genetic epidemiologic studies have clearly documented that anxiety disorders aggregate in families and that this familial link primarily results from genetic factors (Smoller and Faraone, 2008). First-degree relatives of probands with the major anxiety disorders (panic disorder, social anxiety disorder, specific phobias, OCD) have a fourfold to sixfold increased risk of the index disorders compared to relatives of unaffected probands (Hettema et al., 2001). Genetic studies of GAD suggest that a common genetic susceptibility may apply to clusters of anxiety disorders and other comorbid disorders (Norrholm and Ressler, 2009). An overlap of genes may play a role in the development of multiple psychiatric conditions, including anxiety and depression.