Bonnie L. Green

Trauma and health : physical health consequences of exposure to extreme stress

A Context for Understanding the Physical Health Consequences of Exposure to Extreme Stress Trauma, PTSD, and Health Status Costs and Health Care Utilization Associated With Traumatic Experiences Depression, Trauma, and Cardiovascular Health Coping and Health: A Comparison of the Stress and Trauma Literatures Psychoneuroimmunology and Trauma PTSD, Allostatic Load, and Medical Illness Somatization Trauma, PTSD, and Health Risk Behaviors Understanding Relationships Among Trauma, PTSD, and Health Outcomes

Intimate Partner Violence, PTSD, and Adverse Health Outcomes

The high prevalence of adverse health outcomes related to intimate partner violence (IPV) is well documented. Yet we know little about the pathways that lead to adverse health outcomes. Research concerning the psychological, biological, neurological, behavioral, and physiological alterations following exposure to IPV—many of which are associated with posttraumatic stress disorder (PTSD)—represents a promising area of empirical discovery. New technologies and interdisciplinary collaborative efforts are required to integrate diverse methodologies and to apply new findings to improving the health and well being of those affected by IPV. This article focuses on victimization by IPV and addresses the most important research findings in the last 20 years (health and mental health burden of IPV), the most important research issue for the next decade (pathways between IPV and adverse health outcomes), and the most promising methodological innovation for the study of IPV (integrated, interdisciplinary, biobehavioral methodology).

Posttraumatic stress disorder. Toward DSM-IV.

This report raises conceptual issues about the validity of the posttraumatic stress disorder diagnosis as described in DSM-III. The helpfulness of DSM-III is acknowledged, but gaps in that classification are noted. These are organized into three areas: the etiology of the disorder, its natural history, and diagnostic specificity. Suggestions are made for conceptualizing these issues and for research that needs to be undertaken to help resolve them. The authors urge more theoretical and empirical attention to these important issues in the upcoming years, so that later diagnostic descriptions and understandings will be more precise.

Trauma History as a Predictor of Psychologic Symptoms in Women With Breast Cancer

PURPOSEnTo identify predictors of psychiatric problems in women with early-stage breast cancer.nnnPATIENTS AND METHODSnOne hundred sixty women with early-stage breast cancer were recruited from three treatment centers. They filled out self-report questionnaires, including a medical history and demographic survey, the Trauma History Questionnaire, Life Event Questionnaire, Brief Symptom Inventory, Beck Depression Inventory, and Duke-UNC Functional Social Support Questionnaire, and were evaluated using the Structured Clinical Interview for DSM-III-R.nnnRESULTSnHierarchical regression analyses indicated that four of five variable sets made a significant incremental contribution to outcome prediction, with 35% to 37% of the variance explained. Outcomes were predicted by demographic variables, trauma history variables, precancer psychiatric diagnosis, recent life events, and perceived social support. Cancer treatment variables did not predict outcome.nnnCONCLUSIONnThe findings highlight the important roles of trauma history and recent life events in adjustment to cancer and have implications for screening and treatment.

Assessing levels of psychological impairment following disaster: consideration of actual and methodological dimensions.

It is noted that research on the psychological effects of disaster, particularly with regard to rates of impairment, has turned up confusing and sometimes contradictory results. Two sets of dimensions salient to such investigations are noted: those which are aspects of disasters per se and affect actual rates of impairment (“true scores”) and those which could be expected to affect estimates of impairment rates (“error variance”) following disaster. Dimensions of disasters per se suggested by others are reviewed, and an additional dimension is proposed. Four methodological dimensions affecting reported impairment rates are described (sampling of subjects, level of data, case identification, and time of follow-up). Studies of long term psychological effects of disaster where some estimate of impairment was given are reviewed in order to demonstrate the noncomparability of findings from study to study due to methodological differences.

Multiple diagnosis in posttraumatic stress disorder. The role of war stressors.

Prior studies have shown that posttraumatic stress disorder (PTSD) in Vietnam veterans is associated with various aspects of war stressors and that other diagnoses often co-occur with PTSD in this population. The present report examines the prediction of other diagnoses, in combination with PTSD, from a variety of war stressor experiences in a broad sample of veterans recruited from clinical and nonclinical sources. The results show that PTSD with panic disorder is better explained by war stressors than other diagnostic combinations and that high-risk assignments and exposure to grotesque deaths were more salient than other stressor experiences in accounting for different diagnostic combinations. Implications of the findings for PTSDs placement in the DSM-III-R and for psychological and pharmacological treatments were discussed.

One-Year Outcomes of a Randomized Clinical Trial Treating Depression in Low-Income Minority Women

This study examines 1-year depressive symptom and functional outcomes of 267 predominantly lowincome, young minority women randomly assigned to antidepressant medication, group or individual cognitive- behavioral therapy (CBT), or community referral. Seventy-six percent assigned to medications received 9 or more weeks of guideline-concordant doses of medications; 36% assigned to psychotherapy received 6 or more CBT sessions. Intent-to-treat, repeated measures analyses revealed that medication (p=.001) and CBT (p=.02) were superior to community referral in lowering depressive symptoms across 1-year follow-up. At Month 12, 50.9% assigned to antidepressants, 56.9% assigned to CBT, and 37.1% assigned to community referral were no longer clinically depressed. These findings suggest that both antidepressant medications and CBT result in clinically significant decreases in depression for low-income minority women.

Mental Health Effects of Adolescent Trauma Exposure in a Female College Sample: Exploring Differential Outcomes Based on Experiences of Unique Trauma Types and Dimensions

Abstract Most studies on the psychological impact of trauma exposure focus on the response to a single type of trauma, with little or no attention paid to the contribution of prior traumatic experiences. The goal of this study was to disentangle some of the confounding effects of multiple trauma exposures by exploring the unique contribution to mental health outcomes made by specific types and dimensions of trauma. This report compares the psychological outcomes of college women who experienced different types of trauma during adolescence, including traumatic bereavement, sexual assault, and physical assault. Young women who had experienced a single event of one of these types were compared with peers who had experienced multiple single events, ongoing sexual and/or physical abuse, as well as those who had experienced no trauma. Results, based on structured clinical interviews, and self-report measures showed that there were some significant differences in mental health outcomes based on trauma type. However, trauma exposure versus no exposure and the cumulative effects of exposure versus one-time experiences played the key roles in differentiating the groups.

The need for mental health services research focusing on poor young women

Despite the fact that the relationship between poverty and increased risk for a broad spectrum of mental disorders has been documented for several decades, very little is known about providing mental health treatments to poor individuals. In this paper, we emphasize the importance of developing, and empirically evaluating, sensitive and appropriate interventions for poor young women who suffer from common mental disorders. WHO ARE THE US POOR?: In the US, nearly 14% of individuals live in poverty, and another 20% in near poverty. The poor are disproportionally women and children such that 63% of female-headed households are poor. Young women and ethnic minorities are over-represented among the poor also, with 55% of those living below the poverty level being minorities. NEEDS AND BARRIERS TO CARE AMONG POOR, YOUNG WOMEN: The poor have more mental disorders than those with more resources. Further, women are twice as likely as men to have a mood or anxiety disorder, including major depression and post-traumatic stress disorder (PTSD), with younger women at higher risk than older women. Research alos indicates that poor women have high exposure to traumatic events and cumulative adversity that is directly related to their mental health. This history may serve, in part, as a barrier to seeking mental health care. Other barriers in this population include lack of insurance, lack of access to primary care where mental disorders might be detected, practical problems like lack of childcare or transportation, and the inflexibility of low-income service jobs. Religious beliefs and attitudes about mental health treatment may play a role as well. Recent policy changes in the US have contributed to the vulnerability of this group as eligibility for welfare programs has reduced, and time limits have decreasd. Services for immigrants are also severely limited, and managed care strategies for those in the public sector may be confusing. IMPORTANT, UNANSWERED QUESTION: More needs to be learned about the mental health status and needs of poor women, along with the impact of loss of public support on their physical and mental health. Access to mental health care within a managed care setting also needs to be addressed, and care taken to understand the particular needs of poor populations that will actually make these services accessible to them. Insufficient attention has thus far been paid to the cost implications of providing these services to the poor. While providing treatment is associated with significant costs, the costs of not providing care, especially the effects of depression on offspring, should not be overlooked. CHALLENGES TO EXAMINING MENTAL HEALTH IN POOR WOMEN: A number of suggestions were made for addressing practical and methodological challenges to providing mental health services. These include placing services for these individuals within their familiar medical settings, which requires close working relationships between psychiatric and medical personnel within these settings. Outreach is a necessary part of getting poor women into treatment, and should be a routine part of helping women become engaged with caregivers. Providing culturally sensitive treatments is an important focus too, through developing knowledge about the culturally based customs and expectations of target groups. Measurement issues need to be attended to, as most research instruments have been developed on middle class populations, and have not been examined for their psychometric properties and norms in less advantaged groups. Careful translation techniques are also required. Finally, working with institutions sponsoring research to educate them about special problems and challenges with these groups will help improve the quality and efficiency of the work accomplished.

Disorders of Extreme Stress (DESNOS) Symptoms Are Associated With Type and Severity of Interpersonal Trauma Exposure in a Sample of Healthy Young Women

Childhood abuse and other developmentally adverse interpersonal traumas may put young adults at risk not only for posttraumatic stress disorder (PTSD) but also for impairment in affective, cognitive, biological, and relational self-regulation (“disorders of extreme stress not otherwise specified”; DESNOS). Structured clinical interviews with 345 sophomore college women, most of whom (84%) had experienced at least one traumatic event, indicated that the DESNOS syndrome was rare (1% prevalence), but DESNOS symptoms were reported by a majority of respondents. Controlling for PTSD and other anxiety or affective disorders, DESNOS symptom severity was associated with a history of single-incident interpersonal trauma and with more severe interpersonal trauma in a dose-response manner. Noninterpersonal trauma was associated with elevated prevalence of PTSD and dissociation but not with DESNOS severity. Study findings indicate that persistent posttraumatic problems with self-regulation warrant attention, even in relatively healthy young adult populations.