Chris R. Brewin

Meta-Analysis of Risk Factors for Posttraumatic Stress Disorder in Trauma-Exposed Adults

Meta-analyses were conducted on 14 separate risk factors for posttraumatic stress disorder (PTSD), and the moderating effects of various sample and study characteristics, including civilian/military status, were examined. Three categories of risk factor emerged: Factors such as gender, age at trauma, and race that predicted PTSD in some populations but not in others; factors such as education, previous trauma, and general childhood adversity that predicted PTSD more consistently but to a varying extent according to the populations studied and the methods used; and factors such as psychiatric history, reported childhood abuse, and family psychiatric history that had more uniform predictive effects. Individually, the effect size of all the risk factors was modest, but factors operating during or after the trauma, such as trauma severity, lack of social support, and additional life stress, had somewhat stronger effects than pretrauma factors.

Psychological theories of posttraumatic stress disorder.

We summarize recent research on the psychological processes implicated in posttraumatic stress disorder (PTSD) as an aid to evaluating theoretical models of the disorder. After describing a number of early approaches, including social-cognitive, conditioning, information-processing, and anxious apprehension models of PTSD, the article provides a comparative analysis and evaluation of three recent theories: Foa and Rothbaums [Foa, E. B. & Rothbaum, B. O. (1998). Treating the trauma of rape: cognitive behavioral therapy for PTSD. New York: Guilford Press] emotional processing theory; Brewin, Dalgleish, and Josephs [Psychological Review 103 (1996) 670] dual representation theory; Ehlers and Clarks [Behaviour Research and Therapy 38 (2000) 319] cognitive theory. We review empirical evidence relevant to each model and identify promising areas for further research.

Intrusive Images in Psychological Disorders: Characteristics, Neural Mechanisms, and Treatment Implications

Involuntary images and visual memories are prominent in many types of psychopathology. Patients with posttraumatic stress disorder, other anxiety disorders, depression, eating disorders, and psychosis frequently report repeated visual intrusions corresponding to a small number of real or imaginary events, usually extremely vivid, detailed, and with highly distressing content. Both memory and imagery appear to rely on common networks involving medial prefrontal regions, posterior regions in the medial and lateral parietal cortices, the lateral temporal cortex, and the medial temporal lobe. Evidence from cognitive psychology and neuroscience implies distinct neural bases to abstract, flexible, contextualized representations (C-reps) and to inflexible, sensory-bound representations (S-reps). We revise our previous dual representation theory of posttraumatic stress disorder to place it within a neural systems model of healthy memory and imagery. The revised model is used to explain how the different types of distressing visual intrusions associated with clinical disorders arise, in terms of the need for correct interaction between the neural systems supporting S-reps and C-reps via visuospatial working memory. Finally, we discuss the treatment implications of the new model and relate it to existing forms of psychological therapy.

A cognitive neuroscience account of posttraumatic stress disorder and its treatment

Recent research in the areas of animal conditioning, the neural systems underlying emotion and memory, and the effect of fear on these systems is reviewed. This evidence points to an important distinction between hippocampally-dependent and non-hippocampally-dependent forms of memory that are differentially affected by extreme stress. The cognitive science perspective is related to a recent model of posttraumatic stress disorder, dual representation theory, that also posits separate memory systems underlying vivid reexperiencing versus ordinary autobiographical memories of trauma. This view is compared with other accounts in the literature of traumatic memory processes in PTSD, and the contrasting implications for therapy are discussed.

Predicting PTSD symptoms in victims of violent crime: the role of shame, anger, and childhood abuse.

To examine the role of cognitive-affective appraisals and childhood abuse as predictors of crime-related posttraumatic stress disorder (PTSD) symptoms, 157 victims of violent crime were interviewed within 1 month post-crime and 6 months later. Measures within 1 month post-crime included previous physical and sexual abuse in childhood and responses to the current crime, including shame and anger with self and others. When all variables were considered together, shame and anger with others were the only independent predictors of PTSD symptoms at 1 month, and shame was the only independent predictor of PTSD symptoms at 6 months when 1-month symptoms were controlled. The results suggest that both shame and anger play an important role in the phenomenology of crime-related PTSD and that shame makes a contribution to the subsequent course of symptoms. The findings are also consistent with previous evidence for the role of shame as a mediator between childhood abuse and adult psychopathology.

Patient preferences and randomised clinical trials.

The child should be examined but not without the knowledge and agreement of a parent (or the order of a court). Mothers of pr?adolescent children should always be invited to be present, except in the most exceptional circumstances. Adolescent patients should be asked whether they wish a parent to be present. It is usually counterproductive to examine a resistant child, and if his or her cooperation cannot be obtained the examination should be deferred unless there are urgent medical reasons to proceed. The child should be examined as soon as optimal arrangements can be made. Few children require urgent examination. Repetitive examination is usually abusive and should be avoided. The examination should be conducted in absolute privacy and in an environment where the child can be comfortable?not behind screens in open wards or in police stations. There should be adequate equipment for any necessary diagnostic tests. Recording and photographic facilities are an advantage but their value is outweighed if they cause distress to the child or mean that another examination has to be conducted. Who should examine?

Considering PTSD for DSM‐5

This is a review of the relevant empirical literature concerning the DSM‐IV‐TR diagnostic criteria for PTSD. Most of this work has focused on Criteria A1 and A2, the two components of the A (Stressor) Criterion. With regard to A1, the review considers: (a) whether A1 is etiologically or temporally related to the PTSD symptoms; (b) whether it is possible to distinguish “traumatic” from “non‐traumatic” stressors; and (c) whether A1 should be eliminated from DSM‐5. Empirical literature regarding the utility of the A2 criterion indicates that there is little support for keeping the A2 criterion in DSM‐5. The B (reexperiencing), C (avoidance/numbing) and D (hyperarousal) criteria are also reviewed. Confirmatory factor analyses suggest that the latent structure of PTSD appears to consist of four distinct symptom clusters rather than the three‐cluster structure found in DSM‐IV. It has also been shown that in addition to the fear‐based symptoms emphasized in DSM‐IV, traumatic exposure is also followed by dysphoric, anhedonic symptoms, aggressive/externalizing symptoms, guilt/shame symptoms, dissociative symptoms, and negative appraisals about oneself and the world. A new set of diagnostic criteria is proposed for DSM‐5 that: (a) attempts to sharpen the A1 criterion; (b) eliminates the A2 criterion; (c) proposes four rather than three symptom clusters; and (d) expands the scope of the B–E criteria beyond a fear‐based context. The final sections of this review consider: (a) partial/subsyndromal PTSD; (b) disorders of extreme stress not otherwise specified (DESNOS)/complex PTSD; (c) cross‐ cultural factors; (d) developmental factors; and (e) subtypes of PTSD. Depression and Anxiety, 2011.

Brief screening instrument for post-traumatic stress disorder

BACKGROUND Brief screening instruments appear to be a viable way of detecting post-traumatic stress disorder (PTSD) but none has yet been adequately validated. AIMS To test and cross-validate a brief instrument that is simple to administer and score. METHOD Forty-one survivors of a rail crash were administered a questionnaire, followed by a structured clinical interview 1 week later. RESULTS Excellent prediction of a PTSD diagnosis was provided by respondents endorsing at least six re-experiencing or arousal symptoms, in any combination. The findings were replicated on data from a previous study of 157 crime victims. CONCLUSIONS Performance of the new measure was equivalent to agreement achieved between two full clinical interviews.

Autobiographical memory functioning in depression and reports of early abuse.

The authors investigated the memory functioning of depressed women patients with and without a reported history of child physical or sexual abuse using J. M. G. Williams and K. Broadbents (1986) Autobiographical Memory Test. Whereas latency to recall autobiographical memories was not related to reports of abuse, patients who reported childhood sexual abuse produced more overgeneral memories to positive and negative cues. In addition, patients reporting high levels of avoidance of spontaneous memories of childhood physical or sexual abuse in the past week retrieved more overgeneral memories to positive and negative cues.

Trauma films, information processing, and intrusive memory development

Three experiments indexed the effect of various concurrent tasks, while watching a traumatic film, on intrusive memory development. Hypotheses were based on the dual-representation theory of posttraumatic stress disorder (C. R. Brewin, T. Dalgleish, & S. Joseph, 1996). Nonclinical participants viewed a trauma film under various encoding conditions and recorded any spontaneous intrusive memories of the film over the following week in a diary. Changes in state dissociation, heart rate, and mood were also measured. As predicted, performing a visuospatial pattern tapping task at encoding significantly reduced the frequency of later intrusions, whereas a verbal distraction task increased them. Intrusive memories were largely unrelated to recall and recognition measures. Increases in dissociation and decreases in heart rate during the film were also associated with later intrusions.