Jonathan R. T. Davidson

Post-traumatic stress disorder in the community: an epidemiological study

Post-traumatic stress disorder (PTSD) was studied in the Piedmont region of North Carolina. Among 2985 subjects, the lifetime and six month prevalence figures for PTSD were 1.30 and 0.44% respectively. In comparison to non-PTSD subjects, those with PTSD had significantly greater job instability, family history of psychiatric illness, parental poverty, child abuse, and separation or divorce of parents prior to age 10. PTSD was associated with greater psychiatric comorbidity and attempted suicide, increased frequency of bronchial asthma, hypertension, peptic ulcer and with impaired social support. Differences were noted between chronic and acute PTSD on a number of measures, with chronic PTSD being accompanied by more frequent social phobia, reduced social support and greater avoidance symptoms.

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.

Evidence-based guidelines for the pharmacological treatment of anxiety disorders: Recommendations from the British Association for Psychopharmacology.

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

The epidemiology of social phobia: findings from the Duke Epidemiological Catchment Area Study

Social phobia was studied in a North Carolina community, using DSM-III criteria. Two kinds of comparison were made: social phobia v. non-social phobia, and comorbid social phobia v. non-comorbid social phobia. Six-month and lifetime prevalence rates were 2.7 and 3.8% respectively. Social phobia had an early onset, lasted a long time and rarely recovered. Predictors of good outcome recovery in a logistic regression analysis were onset of phobia after age 11, absence of psychiatric comorbidity and greater education. The disorder was often missed in medical consultation. Increased rates of psychiatric comorbidity existed, especially for other anxiety disorders and for schizophrenia/schizophreniform disorder. There was increased risk of neurological disorder. Social phobia was also associated with an increased rate of suicide attempts, antisocial behaviour and impaired school performance during adolescence, impaired medical health, increased health-seeking behaviour, poor employment performance, reduced social interaction and impaired social support. Comorbidity accounted for some, but not all observed differences.

Treatment of social phobia with gabapentin: A placebo-controlled study

A randomized, double-blind, placebo-controlled, parallel-group study was conducted to evaluate the efficacy and safety of gabapentin in relieving the symptoms of social phobia. Sixty-nine patients were randomly assigned to receive double-blind treatment with either gabapentin (dosed flexibly between 900 and 3,600 mg daily in three divided doses) or placebo for 14 weeks. A significant reduction (p < 0.05) in the symptoms of social phobia was observed among patients on gabapentin compared with those on placebo as evaluated by clinician- and patient-rated scales. Results were similar for the intent-to-treat and week-2 completer populations. Adverse events were consistent with the known side effect profile of gabapentin. Dizziness (p = 0.05), dry mouth (p = 0.05), somnolence, nausea, flatulence, and decreased libido occurred at a higher frequency among patients receiving gabapentin than among those receiving placebo. No serious adverse events or deaths were reported. On the basis of these limited data, it seems that gabapentin offers a favorable risk-benefit ratio for the treatment of patients with social phobia. Further studies are required to confirm this effect and to determine whether a dose-response relationship exists.

Treatment of Social Phobia With Clonazepam and Placebo

Clonazepam and placebo were administered in a double-blind pilot study to 75 outpatients with social phobia. The mean maximum dose of clonazepam was 2.4 mg/day at endpoint (range, 0.5 to 3 mg). Treatment was continued for up to 10 weeks. The results of an intent-to-treat analysis indicated superior effects of clonazepam on most measures. Response rates for clonazepam and placebo were 78.3 and 20.0%. Drug effects were apparent on performance and generalized social anxiety, on fear and phobic avoidance, on interpersonal sensitivity, on fears of negative evaluation, and on disability measures. Significant differences were evident by week 1, 2, or 6, depending upon the rating scale used. Clonazepam was well tolerated in general, although unsteadiness and dizziness were more severe and persistent than was the case for placebo subjects.

Spirituality, Resilience, and Anger in Survivors of Violent Trauma: A Community Survey

This study evaluates the relationship between spirituality, resilience, anger and health status, and posttraumatic symptom severity in trauma survivors. A community sample (N = 1,200) completed an online survey that included measures of resilience, spirituality (general beliefs and reincarnation), anger, forgiveness, and hatred. In survivors of violent trauma (n = 648), these measures were evaluated with respect to their relationship to physical and mental health, trauma-related distress, and posttraumatic symptom severity. Using multivariate regression models, general spiritual beliefs and anger emerged in association with each outcome, whereas resilience was associated with health status and posttraumatic symptom severity only. Forgiveness, hatred, and beliefs in reincarnation were not associated with outcome. The importance of these findings to treating trauma survivors is discussed.

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.

Diagnostic issues in posttraumatic stress disorder: considerations for the DSM-IV.

Four issues of key interest with regard to posttraumatic stress disorder in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are discussed. These include: (a) how to define the stressor criterion, especially, whether or not the victims response ought to be included and whether low-magnitude traumas qualify etiologically; (b) the cohesiveness of the syndrome and the validity of items across stressor groups; (c) the position of posttraumatic stress disorder within DSM-IV; and (d) comorbidity with other illnesses.