Jean C. Beckham

Assessment of a new self-rating scale for post-traumatic stress disorder

BACKGROUND In post-traumatic stress disorder (PTSD) there is a need for self-rating scales that are sensitive to treatment effects and have been tested in a broad range of trauma survivors. Separate measures of frequency and severity may also provide an advantage. METHODS Three hundred and fifty-three men and women completed the Davidson Trauma Scale (DTS), a 17-item scale measuring each DSM-IV symptom of PTSD on 5-point frequency and severity scales. These subjects comprised war veterans, survivors of rape or hurricane and a mixed trauma group participating in a clinical trial. Other scales were included as validity checks as follows: Global ratings, SCL-90-R, Eysenck Scale, Impact of Event Scale and Structured Clinical Interview for DSM-III-R. RESULTS The scale demonstrated good test-retest reliability (r = 0.86), internal consistency (r = 0.99). One main factor emerged for severity and a smaller one for intrusion. In PTSD diagnosed subjects, and the factor structure more closely resembled the traditional grouping of symptoms. Concurrent validity was obtained against the SCID, with a diagnostic accuracy of 83% at a DTS score of 40. Good convergent and divergent validity was obtained. The DTS showed predictive validity against response to treatment, as well as being sensitive to treatment effects. CONCLUSIONS The DTS showed good reliability and validity, and offers promised as a scale which is particularly suited to assessing symptom severity, treatment outcome and in screening for the likely diagnosis of PTSD.

Pain coping skills training in the management of osteoarthritic knee pain: A comparative study

The purpose of this study was to determine whether a cognitive-behavioral intervention designed to improve pain coping skills could reduce pain, physical disability, psychological disability, and pain behavior in osteoarthritic knee pain patients. Patients in this study were older adults (mean age=64 years) having persistent pain (mean duration=12 years), who were diagnosed as having osteoarthritis of the knee on the basis of medical evaluation and x-rays. Patients were randomly assigned to one of three conditions: pain coping skills training, arthritis education, or a standard care control condition. Patients in the pain coping skills training condition (n=32) attended 10 weekly group sessions training them to recognize and reduce irrational cognitions and to use attention diversion and changes in activity patterns to control and decrease pain. Arthritis education subjects (n=36) attended 10 weekly group sessions providing them with detailed information on osteoarthritis. Standard care control subjects (n=31) continued with their routine care. Measures of coping strategies, pain, psychological disability, physical disability, medication use, and pain behavior were collected from all subjects before and after treatment. Results indicated that patients receiving pain coping skills training had significantly lower levels of pain and psychological disability post-treatment than patients receiving arthritis education or standard care. Correlational analyses revealed that patients in the pain coping skills training group who reported increases in the perceived effectiveness of their coping strategies were more likely to have lower levels of physical disability post-treatment. Taken together, these findings indicate that pain coping skills training can reduce pain and psychological disability in osteoarthritis patients. Future studies should examine whether behavioral rehearsal or spouse training can strengthen the effects of pain coping skills training in order to reduce physical disability and pain behavior as well as pain and psychological disability.

Chronic posttraumatic stress disorder and chronic pain in Vietnam combat veterans

A study was conducted to investigate chronic pain patterns in Vietnam veterans with posttraumatic stress disorder (PTSD). Combat veterans with PTSD completed standardized PTSD severity, pain, somatization, and depression measures. Of 129 consecutive out-patient combat veterans with PTSD, 80% reported chronic pain. In descending order were limb pain (83%), back pain (77%), torso pain (50%), and headache pain (32%). Compared to PTSD combat veterans without chronic pain, PTSD veterans who reported chronic pain reported significantly higher somatization as measured by the Minnesota Multiphasic Inventory 2 hypochondriasis and hysteria subscales. In the sample of 103 combat veterans with PTSD and chronic pain, MMPI 2 hypochondriasis scores and B PTSD symptoms (reexperiencing symptoms) were significantly related to pain disability, overall pain index, and current pain level MMPI 2 hypochondriasis and depression scores were also significantly related to percent body pain. These results are discussed in the context of current conceptualizations of PTSD.

A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder

BACKGROUND The anticonvulsant, lamotrigine, may be useful for symptom management in PTSD. METHODS Subjects enrolled in a 12-week double-blind evaluation of lamotrigine and placebo. Patients were randomized 2:1 to either lamotrigine or placebo. Lamotrigine was initiated at 25 mg/day and slowly titrated every 1 to 2 weeks over 8 weeks to a maximum dosage of 500 mg/day if tolerated. RESULTS Fifteen subjects entered treatment, fourteen of whom returned for subsequent visits. Of 10 patients who received lamotrigine, 5 (50%) responded according to the DGRP, compared to 1 of 4 (25%) who received placebo. Lamotrigine patients showed improvement on reexperiencing and avoidance/numbing symptoms compared to placebo patients. Treatments were generally well tolerated. CONCLUSIONS Lamotrigine may be effective as a primary psychopharmacologic treatment in both combat and civilian PTSD and could also be considered as an adjunct to antidepressant therapy used in the treatment of PTSD. These promising results warrant further large sample double-blind, placebo-controlled trials.

Post-traumatic stress disorder and smoking: a systematic review.

We conducted a systematic review of what is known about the relationship between post-traumatic stress disorder (PTSD) and smoking to guide research on underlying mechanisms and to facilitate the development of evidence-based tobacco treatments for this population of smokers. We searched Medline, PsychINFO, and the Cochrane Central Register of Controlled Trials and identified 45 studies for review that presented primary data on PTSD and smoking. Smoking rates were high among clinical samples with PTSD (40%-86%) as well as nonclinical populations with PTSD (34%-61%). Most studies showed a positive relationship between PTSD and smoking and nicotine dependence, with odds ratios ranging between 2.04 and 4.52. Findings also suggest that PTSD, rather than trauma exposure itself, is more influential for increasing risk of smoking. A small but growing literature has examined psychological factors related to smoking initiation and maintenance and the overlapping neurobiology of PTSD and nicotine dependence. Observational studies indicate that smokers with PTSD have lower quit rates than do smokers without PTSD. Yet a few tobacco cessation treatment trials in smokers with PTSD have achieved quit rates comparable with controlled trials of smokers without mental disorders. In conclusion, the evidence points to a causal relationship between PTSD and smoking that may be bidirectional. Specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. Intervention studies that test behavioral and pharmacological interventions designed specifically for use in patients with PTSD are needed to reduce morbidity and mortality in this population.

Prevalence and correlates of heavy smoking in Vietnam veterans with chronic posttraumatic stress disorder.

A study was conducted to investigate smoking patterns in 445 Vietnam veterans with and without posttraumatic stress disorder (PTSD). Combat veterans with PTSD reported similar occurrence of smoking (53%) compared to combat veterans without PTSD (45%). For those who smoked, combat veterans with PTSD reported a significantly higher rate of heavy smoking (> or = 25 cigarettes daily): 28% of combat veterans without PTSD were heavy smokers and 48% of combat veterans with PTSD were heavy smokers. PTSD diagnosis and heavy smoking status were independently and differentially related to motives for smoking. In combat veterans with PTSD, heavy smoking status was positively related to total health complaints, lifetime health complaints, health complaints in the past year, negative health behaviors, total PTSD symptoms, DSM-IV C cluster (avoidance and numbing) and D cluster (hyperarousal) PTSD symptoms. Heavy smoking status was also associated with fewer positive health behaviors.

Caregiver burden and psychological distress in partners of veterans with chronic posttraumatic stress disorder

Caregiver burden and psychological distress were examined in a sample of 71 partners of Vietnam War combat veterans. Partners of patients (n = 51) diagnosed with posttraumatic stress disorder (PTSD) experienced more caregiver burden and had poorer psychological adjustment than did partners of veterans without PTSD (n = 20). Among PTSD caregivers, patient PTSD symptom severity and level of interpersonal violence were associated with increased caregiver burden. When accounting for patient PTSD symptom severity, hostility, presence of major depression, level of interpersonal violence, and health complaints, only PTSD severity was uniquely associated with caregiver burden. Caregiver sociodemographic factors including age, race, education, and the availability of social support, did not moderate the relationship between PTSD symptom severity and caregiver burden. Caregiver burden was strongly related to spouse psychological adjustment.

Integrating Tobacco Cessation Into Mental Health Care for Posttraumatic Stress Disorder: A Randomized Controlled Trial

CONTEXT Most smokers with mental illness do not receive tobacco cessation treatment. OBJECTIVE To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates. DESIGN, SETTING, AND PATIENTS A randomized controlled trial of 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009. INTERVENTION Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment. MAIN OUTCOME MEASURES Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status. RESULTS Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time. CONCLUSION Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00118534.

Posttraumatic Stress Disorder, Cardiovascular, and Metabolic Disease: A Review of the Evidence

BackgroundPosttraumatic stress disorder (PTSD) is a significant risk factor for cardiovascular and metabolic disease.PurposeThe purpose of the current review is to evaluate the evidence suggesting that PTSD increases cardiovascular and metabolic risk factors, and to identify possible biomarkers and psychosocial characteristics and behavioral variables that are associated with these outcomes.MethodsA systematic literature search in the period of 2002–2009 for PTSD, cardiovascular disease, and metabolic disease was conducted.ResultsThe literature search yielded 78 studies on PTSD and cardiovascular/metabolic disease and biomarkers.ConclusionsAlthough the available literature suggests an association of PTSD with cardiovascular disease and biomarkers, further research must consider potential confounds, incorporate longitudinal designs, and conduct careful PTSD assessments in diverse samples to address gaps in the research literature. Research on metabolic disease and biomarkers suggests an association with PTSD, but has not progressed as far as the cardiovascular research.

Caregiver burden in partners of Vietnam war veterans with posttraumatic stress disorder

Caregiver burden in 58 partners of Vietnam veterans with posttraumatic stress disorder (PTSD) was examined. The relationship between patient PTSD severity and caregiver burden, as well as the effect of several caregiver and patient variables on caregiver psychological status, was evaluated twice, an average of 8 months apart. Patient symptom severity was positively correlated with caregiver burden. Time 1 cross-sectional analysis indicated that greater caregiver burden was associated with greater caregiver psychological distress, dysphoria, and anxiety. Patient symptom severity also contributed to caregiver psychological distress; financial stress contributed to caregiver dysphoria and trait anxiety. Time 2 cross-sectional analyses essentially replicated the Time 1 findings. A third set of analyses examining change scores indicated that changes in caregiver burden for individuals in the sample positively predicted individual changes in caregiver psychological distress, dysphoria, and state anxiety.