Anke B. Witteveen

The role of executive function in posttraumatic stress disorder: A systematic review

BACKGROUNDnAlthough posttraumatic stress disorder (PTSD) has been associated with disturbances in verbal memory, studies examining executive functioning in PTSD show mixed results.nnnMETHODSnA systematic review and meta-analysis were performed to compare executive functioning in patients with current PTSD and controls without any psychiatric disorder. Standard mean differences (SMD) in executive functioning scores were calculated using random-effects models. Covariates were added to examine whether differences exist between subgroups.nnnRESULTSnAcross 18 studies, 1080 subjects were included. In comparison with 431 exposed controls and 227 healthy controls, 422 people with PTSD showed significantly impaired executive functioning. Subgroup analyses revealed more pronounced differences between PTSD patients and exposed controls than healthy controls. Male gender, higher age, war trauma, and higher severity of co-morbid depressive symptoms were related to poorer executive functioning in PTSD patients compared to exposed controls.nnnLIMITATIONSnDue to insufficient data and heterogeneity, not all subgroup differences or characteristics could be taken into account.nnnCONCLUSIONSnOverall, PTSD patients were found to show impaired executive functioning. Future research should further elucidate the subgroup effects and focus on clinical implications with regard to daily functioning and treatment outcome.

TENTS guidelines: development of post-disaster psychosocial care guidelines through a Delphi process

BACKGROUNDnHow best to plan and provide psychosocial care following disasters remains keenly debated.nnnAIMSnTo develop evidence-informed post-disaster psychosocial management guidelines.nnnMETHODnA three-round web-based Delphi process was conducted. One hundred and six experts rated the importance of statements generated from existing evidence using a one to nine scale. Participants reassessed their original scores in the light of others responses in the subsequent rounds.nnnRESULTSnA total of 80 (72%) of 111 statements achieved consensus for inclusion. The statement all responses should provide access to pharmacological assessment and management did not achieve consensus. The final guidelines recommend that every area has a multi-agency psychosocial care planning group, that responses provide general support, access to social, physical and psychological support and that specific mental health interventions are only provided if indicated by a comprehensive assessment. Trauma-focused cognitive-behavioural therapy (CBT) is recommended for acute stress disorder or acute post-traumatic stress disorder, with other treatments with an evidence base for chronic post-traumatic stress disorder being made available if trauma-focused CBT is not tolerated.nnnCONCLUSIONSnThe Delphi process allowed a consensus to be achieved in an area where there are limitations to the current evidence.

Differences between effects of psychological versus pharmacological treatments on functional and morphological brain alterations in anxiety disorders and major depressive disorder: A systematic review

The most prevalent mental disorders, anxiety and mood disorders, are associated with both functional and morphological brain changes that commonly involve the fear network including the (medial) prefrontal cortex, hippocampus and amygdala. Patients suffering from anxiety disorders and major depressive disorder often show excessive amygdala and reduced prefrontal cortex functioning. It is, however, still unclear whether these brain abnormalities disappear or diminish following effective treatment. This review aims to compare the effects of psychotherapy and pharmacotherapy on functional and morphological brain measures in these disorders. Sixty-three studies were included, 30 investigating psychotherapy effects and 33 investigating pharmacotherapy effects. Despite methodological differences, results suggest a functional normalization of the fear network. Pharmacotherapy particularly decreases over-activity of limbic structures (bottom-up effect) while psychotherapy tends to increase activity and recruitment of frontal areas (top-down effect), especially the anterior cingulate cortex. Additionally, pharmacotherapy, but not psychotherapy, has been associated with morphological changes, depending on the disorder. These findings suggest that both types of treatments normalize (functional) brain abnormalities each in specific ways.

A psychobiological rationale for oxytocin in the treatment of posttraumatic stress disorder.

Although cognitive-behavioral therapy (CBT) is an effective treatment for posttraumatic stress disorder (PTSD), many patients fail to attain remission with CBT. The authors propose augmentation of CBT with oxytocin in the treatment of PTSD. Oxytocin has a combination of pharmacologic effects that result in a sense of safety for the patient, which is a prerequisite to successful treatment of PTSD. We suggest a dual explanatory mechanism as to why oxytocin may be effective: through a reduction of fear response (decreasing amygdala activation, inhibiting fear response, and enhancing extinction learning) and through an increase of social interaction (activating social reward-related brain regions increasing engagement in the therapeutic alliance). Given that PTSD is marked by deficits in anxiety/stress regulation and in social functioning, and that oxytocin is implicated in both of these areas, oxytocin seems a likely candidate for treatment of patients with PTSD. Further clinical studies of the therapeutic value of oxytocin are indicated.

Long term health complaints following the Amsterdam Air Disaster in police officers and fire‐fighters

Background: On 4 October 1992, a cargo aircraft crashed into apartment buildings in Amsterdam, the Netherlands. Fire-fighters and police officers assisted with the rescue work. Objectives: To examine the long term health complaints in rescue workers exposed to a disaster. Methods: A historical cohort study was performed among police officers (nu200a=u200a834) and fire-fighters (nu200a=u200a334) who performed at least one disaster related task and reference groups of their non-exposed colleagues (nu200a=u200a634 and nu200a=u200a194, respectively). The main outcome measures included digestive, cardiovascular, musculoskeletal, nervous system, airway, skin, post-traumatic stress, fatigue, and general mental health complaints; haematological and biochemical laboratory values; and urinalysis outcomes. Results: Police officers and fire-fighters who were professionally exposed to a disaster reported more physical and mental health complaints, compared to the reference groups. No clinically relevant statistically significant differences in laboratory outcomes were found. Conclusions: This study is the first to examine long term health complaints in a large sample of rescue workers exposed to a disaster in comparison to reference groups of non-exposed colleagues. Findings show that even in the long term, and in the absence of laboratory abnormalities, rescue workers report more health complaints.

Executive function in posttraumatic stress disorder (PTSD) and the influence of comorbid depression.

BACKGROUNDnPosttraumatic stress disorder (PTSD) has been associated with neurocognitive deficits, such as impaired verbal memory and executive functioning. Less is known about executive function and the role of comorbid depression in PTSD. Recently, studies have shown that verbal memory impairments may be associated with comorbid depressive symptoms, but their role in executive function impairments is still unclear.nnnOBJECTIVEnTo examine several domains of executive functioning in PTSD and the potentially mediating role of comorbid depressive symptoms in the relationship between executive function and PTSD.nnnMETHODnExecutive functioning was assessed in 28 PTSD patients and 28 matched trauma-exposed controls. The Cambridge Neuropsychological Test Automated Battery (CANTAB) with subtests measuring response inhibition (SST), flexibility/set shifting (IED), planning/working memory (OTS) and spatial working memory (SWM) was administered in PTSD patients and trauma-exposed controls. Regression analyses were used to assess the predictive factor of PTSD symptoms (CAPS) and depressive symptoms (HADS-D) in relation to executive function when taking into account the type of trauma. Pearsons correlations were used to examine the association between PTSD symptom clusters (CAPS) and executive function. The mediating effects of depression and PTSD were assessed using regression coefficients and the Sobels test for mediation.nnnRESULTSnOur findings indicate that PTSD patients performed significantly worse on executive function than trauma-exposed controls in all domains assessed. PTSD symptoms contributed to executive functioning impairments (SST median correct, IED total errors, OTS latency to correct, SWM total errors and SWM strategy). Adding depressive symptoms to the model attenuated these effects. PTSD symptom clusters numbing and to a lesser extent avoidance were more frequently associated with worse executive function (i.e., IED total errors, OTS latency to correct and SWM total errors) than reexperiencing and hyperarousal. Depressive symptoms mediated the relation between PTSD and executive function on some executive function measures (IED total errors and OTS latency to correct), whereas PTSD did not mediate the relation between depression and executive function.nnnCONCLUSIONSnPTSD patients perform worse on executive function. The impairments seem to be mostly associated with the less specific PTSD symptom cluster of numbing. Depressive symptoms seem to mediate the relationship between PTSD and executive function. These findings may have clinical implications with regard to treatment indication and prognosis.

Associations of cortisol with posttraumatic stress symptoms and negative life events: a study of police officers and firefighters

Given the inconsistent associations of cortisol with posttraumatic stress disorder (PTSD), analysis of basal functioning of the hypothalamic-pituitary-adrenal (HPA) axis in subjects frequently exposed to trauma and critical incidents with a range of PTSD symptomatology, may be valuable. In an epidemiological sample of 1880 police officers and firefighters, associations of salivary cortisol with PTSD, negative life events (NLE) and exposure to a major air disaster more than 8 years earlier, was explored. Probable PTSD was unrelated to cortisol level while past (>8 years earlier) and more recently experienced NLE were associated with lower cortisol levels even after adjustment for confounders. Disaster exposure interacted significantly with PTSD symptoms on cortisol level. In the disaster-exposed subgroup, PTSD symptomclusters of intrusion and hyperarousal (in particular sleep disturbances), were associated with lower and higher cortisol levels, respectively. A final model using backward elimination strategy, retained time of saliva sampling, smoking, gender, and NLE>8 years earlier in the total sample, and additionally symptomclusters of intrusion and hyperarousal in the disaster-exposed subgroup. The final model explained 10% of the variance in cortisol. The findings are discussed in relation to literature on posttraumatic stress and basal functioning of the HPA-axis.

Psychological distress of rescue workers eight and one-half years after professional involvement in the Amsterdam air disaster

This study examined specific and general psychological distress 8.5 years following the 1992 cargo aircraft crash in Amsterdam. Participants included 334 occupationally exposed fire fighters and 834 occupationally exposed police officers compared with reference groups of 194 fire fighters and 634 police officers who were exposed to duty-related stressors other than the disaster. On the standardized instruments of psychological distress, exposed fire fighters reported more somatic complaints and fatigue, while exposed police officers reported higher psychological distress on all aspects. The degree and type of exposure at the disaster site and other background factors were associated with several outcomes of psychological distress levels of exposed rescue workers. The disasters’ aftermath of rumors about potential health consequences due to toxic exposure likely contributed to the long-lasting psychological distress of some of the rescue workers as well.

Epidemiological study air disaster in Amsterdam (ESADA): study design

BackgroundIn 1992, a cargo aircraft crashed into apartment buildings in Amsterdam, killing 43 victims and destroying 266 apartments. In the aftermath there were speculations about the cause of the crash, potential exposures to hazardous materials due to the disaster and the health consequences. Starting in 2000, the Epidemiological Study Air Disaster in Amsterdam (ESADA) aimed to assess the long-term health effects of occupational exposure to this disaster on professional assistance workers.Methods/DesignEpidemiological study among all the exposed professional fire-fighters and police officers who performed disaster-related task(s), and hangar workers who sorted the wreckage of the aircraft, as well as reference groups of their non-exposed colleagues who did not perform any disaster-related tasks. The study took place, on average, 8.5 years after the disaster. Questionnaires were used to assess details on occupational exposure to the disaster. Health measures comprised laboratory assessments in urine, blood and saliva, as well as self-reported current health measures, including health-related quality of life, and various physical and psychological symptoms.DiscussionIn this paper we describe and discuss the design of the ESADA. The ESADA will provide additional scientific knowledge on the long-term health effects of technological disasters on professional workers.

Dimensionality of the posttraumatic stress response among police officers and fire fighters: An evaluation of two self-report scales

Confirmatory factor analyses were done to assess the dimensionality of the stress response in a sample of police officers and fire fighters (n = 1,168) involved in the 1992 air disaster in Amsterdam. The confirmatory factor analyses were applied to the responses on two psychometrically different instruments, i.e., the Self-Rating Inventory for Posttraumatic Stress Disorder (SRIP) and the Impact of Event Scale (IES). The previously found distinction between (active) avoidance and numbing in samples highly affected by posttraumatic stress disorder appears to be applicable to the stress response of a less affected sample. For the SRIP, a five-factor structure (i.e., intrusion, avoidance, hyperarousal, emotional numbing and sleep disturbance) appeared to fit slightly better than the four-factor structures from previous findings. For the IES, our results replicated findings of a four-dimensional structure (i.e., intrusion, avoidance, numbing and sleep disturbance) underlying the posttraumatic stress response. The factors of the best-fitting structure of both instruments proved reliable. Due to the psychometric properties of the two instruments, the relationship between similar factors in both instruments was only low to moderate. Compared with the IES, factors of the SRIP were, however, less discriminative from other symptoms of psychopathology. Replication in different traumatized or community samples is recommended.