Mariana Cadrobbi Pupo

The accuracy of the Clinician-Administered PTSD Scale (CAPS) to identify PTSD cases in victims of urban violence

As a consequence of the increasing urban violence in Brazil, many cases of posttraumatic stress disorder (PTSD) are now seen in the community and clinical settings. The main aim of this article is to assess the psychometric properties of the Clinician-Administered PTSD Scale (CAPS) to study factors related to the etiology, prognosis, and efficacy of interventions of PTSD in civilian populations. PTSD outpatients from a program of victims of violence and subjects identified in an epidemiological survey conducted in the city of Sao Paulo completed a battery of validated instruments and the CAPS. Instrument reliability and validity were measured. The comparison between the CAPS scores and the Structured Clinical Interview for DSM IV (SCID) interview resulted in the following validity coefficients: sensitivity=90%, specificity=95%, and misclassification rate=7.1%. The area under the receiver operating characteristic (ROC) curve was 0.97. There was a positive correlation between CAPS scores with Beck Depression Inventory (BDI; 0.70) and Beck Anxiety Inventory (BAI; 0.76) scores. The Kappa coefficients were all higher than 0.63 for all CAPS items. The internal consistency for all CAPS items resulted in a Cronbachs alpha coefficient of 0.97. The CAPS showed to be both an accurate and a reliable research instrument to identify PTSD cases in a civilian population.

Efficacy of interpersonal therapy-group format adapted to post-traumatic stress disorder: an open-label add-on trial

Background: Post‐traumatic stress disorder (PTSD) is a highly prevalent condition, yet available treatments demonstrate only modest efficacy. Exposure therapies, considered by many to be the “gold‐standard” therapy for PTSD, are poorly tolerated by many patients and show high attrition. We evaluated interpersonal therapy, in a group format, adapted to PTSD (IPT‐G PTSD), as an adjunctive treatment for patients who failed to respond to conventional psychopharmacological treatment. Methods: Research participants included 40 patients who sought treatment through a program on violence in the department of psychiatry of Federal University of São Paulo (UNIFESP). They had received conventional psychopharmacological treatment for at least 12 weeks and failed to have an adequate clinical response. After signing an informed consent, approved earlier by the UNIFESP Ethics Review Board, they received a semi‐structured diagnostic interview (SCID‐I), administered by a trained mental health worker, to confirm the presence of a PTSD diagnosis according to DSM‐IV criteria. Other instruments were administered, and patients completed out self‐report instruments at baseline, and endpoint to evaluate clinical outcomes. Results: Thirty‐three patients completed the trial, but all had at least one second outcome evaluation. There were significant improvements on all measures, with large effect sizes. Conclusions: IPT‐G PTSD was effective not only in decreasing symptoms of PTSD, but also in decreasing symptoms of anxiety and depression. It led to significant improvements in social adjustment and quality of life. It was well tolerated and there were few dropouts. Our results are very preliminary; they need further confirmation through randomized controlled clinical trials. Depression and Anxiety, 2010.

Attentional and executive functions are differentially affected by post-traumatic stress disorder and trauma

BACKGROUND Among the neurocognitive impairments observed in patients with Post-traumatic Stress Disorder (PTSD), attentional and executive dysfunctions appear to correlate with negative effects on education, work, daily life activities, and social relations, as well as the re-experiencing, avoidance, and hyperarousal symptoms of PTSD. However, there is no consensus regarding which aspects of attentional and executive functions are impaired in PTSD patients. METHODS Attentional and executive functions were assessed using the digit span (WAIS-III) and spatial span (WMS-III) tests under forward and backward recall conditions, the Stroop Test, and the Wisconsin Card Sorting Test (WCST). Our sample was composed of victims of urban violence who developed PTSD (PTSD+) (n = 81), victims of urban violence who did not develop PTSD (PTSD-) (n = 70), and healthy controls not exposed to trauma (HC) (n = 50). RESULTS The PTSD+ group had poorer performance on the spatial span forward subtest (p = 0.023; eta(2) = 0.038) and poorer execution time (p = 0.023; eta(2) = 0.042) and accuracy (p = 0.019; eta(2) = 0.044) on the Stroop Test compared to HC. CONCLUSIONS These data suggest that there are few differences between the PTSD+ and HC groups, which are restricted to less complex measures of attentional and executive functional processes (short term capacity, selective attention, processing speed, and inhibitory control) and are related to visual stimuli. Therefore, cognitive impairments directly correlated with the manifestation of PTSD.

Early Trauma Inventory (ETI): cross-cultural adaptation and internal consistency

Early life stress is a strong predictor of future psychopathology during adulthood. The Early Trauma Inventory (ETI) was developed to detect the presence and impact of traumatic experiences that occurred up to 18 years of age. The ETI was translated and cross-culturally adapted and had its consistency evaluated. Victims of violence that met the inclusion and exclusion criteria were submitted to SCID-I and ETI. Ninety-one patients with post-traumatic stress disorder (PTSD) were included. Cronbachs alpha in the different domains varied from 0.595 to 0.793, and the total score was 0.878. Except for emotional abuse, most of the various domains displayed inter-item correlation rates of 0.51 to 0.99. The adapted version was useful for clinical and research purposes and showed good internal consistency and inter-item correlation. The ETI is a valid instrument with good consistency for evaluating history of childhood and adolescent trauma in adults.

Reduction of anterior cingulate in adults with urban violence- related PTSD

BACKGROUND To evaluate differences in limbic structure volume of subjects exposed to urban violence during adulthood, between those who developed posttraumatic stress disorder (with PTSD) and resilient matched controls (without PTSD). METHODS Limbic volumetric measures of 32 subjects with PTSD and 32 subjects without PTSD who underwent brain MRI were analyzed in an epidemiological study in the city of Sao Paulo. The hippocampus, amygdala, cingulate, and parahipocampal gyri volumes were estimated using FreeSurfer software. We also investigated the association between limbic volumetric measurements, symptom´s severity, and early life stress history (measure by Early Trauma Inventory - ETI). RESULTS Subjects with PTSD presented reduced volume of the right rostral part of the anterior cingulate, compared to subjects without PTSD, after controlling for intracranial volume, ETI, and depressive symptoms. Subjects with PTSD presented larger bilateral hippocampus and right amygdala, but secondary to the higher ETI. In PTSD group there was a positive correlation between ETI with bilateral hippocampus, bilateral amygdala, and left parahippocampus. LIMITATIONS First, the cross-sectional study design precludes causal interpretation of limbic structure reduction in PTSD, consequence of PTSD, or other life events. Finally, since the sample size was not sufficiently large, we could not observe whether or not limbic structure volume could be related to the type of trauma. CONCLUSIONS The present study provides evidence of a reduced anterior cingulate volume in subjects with PTSD than in resilient subjects exposed to urban violence. Enlargement of hippocampus and amygdala volume was observed in subjects with PTSD, however secondary to early trauma experience.

Relationship between structural abnormalities in the cerebellum and dementia, posttraumatic stress disorder and bipolar disorder

New evidence suggests that the cerebellum has structural and functional abnormalities in psychiatric disorders. Objective In this research, the goal was to measure the volume of the cerebellum and its subregions in individuals with psychiatric disorders and to relate these findings to their symptoms. Methods Patients with different degrees of cognitive impairment (Epidemiology of the Elderly - UNIFESP) and patients with post-traumatic stress disorder (PTSD) from population studies were analyzed. Also, patients with bipolar disorder from an outpatient clinic (Center for the Study of Mood and Anxiety Disorders, Universidade Federal da Bahia) were recruited for this study. All subjects underwent a 1.5T structural magnetic resonance scan. Volumetric measures and symptom measurements, by psychometric scales, were performed and compared between patients and controls. Results The cerebellum volume was reduced in patients with cognitive impairment without dementia and with dementia, in patients with PTSD, and in patients with bipolar disorder compared to controls. In dementia and PTSD, the left cerebellar hemisphere and vermis volume were reduced. In bipolar disorder, volumes of both hemispheres and the vermis were reduced. In the first two studies, these cerebellar volumetric reductions correlated with symptoms of the disease. Conclusion The exact nature of cerebellar involvement in mental processes is still not fully understood. However, abnormalities in cerebellar structure and its functions have been reported in some of these diseases. Future studies with larger samples are needed to clarify these findings and investigate whether they are important for treatment and prognosis.

Health-related quality of life in posttraumatic stress disorder: 4 years follow-up study of individuals exposed to urban violence

Evidence suggests that Posttraumatic Stress Disorder (PTSD) is associated with substantially reduced Health-related quality of life (HRQoL). This study aimed to explore the impact of PTSD symptoms in HRQoL and its predictors in individuals exposed to urban violence. We follow-up a cohort of 267 individuals exposed to urban violence, derived from an epidemiological survey and clinical cases from an outpatient program of victims of violence, with and without PTSD, by assessing symptoms and other measures at two intervals, approximately 4 years apart. PTSD symptom severity was associated with poorer quality of life at baseline and at follow-up. Higher levels of depression and anxiety, new trauma experiences, more traumas in childhood and more PTSD arousal symptoms were all predictors of lower HRQoL over time. Results strongly suggest the need to assess HRQoL in addition to symptoms in order to assess the true severity of PTSD. These results have implications for the functional recovery in the treatment of PTSD.

Long-term follow-up of attentional and executive functions of PTSD patients.

Scientific evidence showed significant correlations between symptoms of posttraumatic stress disorder (PTSD) and deficits in cognitive processing. Understanding how these deficits correlate with symptoms of PTSD in prospective studies can provide arguments to improve explanatory models of pathological mechanisms of this disorder. Our objective was to prospectively evaluate adult victims of urban violence suffering from PTSD, considering its impact on attention, executive functions, and the factors associated with these changes. We reapplied a battery of neuropsychological tests on a cohort of 43 patients with PTSD due to urban violence. We also reapplied the Clinician Administered PTSD Scale (CAPS) and the Beck Depression Inventory (BDI-I) scales. We administered a battery of neuropsychological tests: Wechsler Adult Intelligence Scale (WAIS-III) Digit Span, Wechsler’s Memory Scale—Revised (WMS-III), Spatial Span, Stroop, and Wisconsin Card Sort Test (WCST). Patients showed a clinical improvement evidenced by a statistically significant decrease in CAPS and BDI scores at follow-up. Regarding neuropsychological testing, significant differences were found at follow ups such as a reduced number of perseverative errors in WCST (p = .004) and an increase in the span of the backward digit subtest (p = .007). These changes are directly associated with education level (p = .030), and PTSD symptoms (p = .005). Patients on average showed an improvement in PTSD and depression symptoms at reevaluation. The data showed an improvement in cognitive performance of executive functions such as working memory and cognitive flexibility over the years. These enhancements are significant for patients with more years of study, and for those that have recovered clinically, showing fewer symptoms of depression PTSD.