Mark D. Rusch

Psychopathology and Resilience Following Traumatic Injury: A Latent Growth Mixture Model Analysis

OBJECTIVE To investigate trajectories of PTSD and depression following traumatic injury using latent class growth curve modeling. METHOD A longitudinal study of 330 injured trauma survivors was conducted and participants were assessed during hospitalization, and at 1, 3, and 6 months follow-up. Acute Stress Disorder (ASD) was assessed during hospitalization using the Acute Stress Disorder Interview (ASD-I), PTSD was measured at all follow-up with the Post-Traumatic Stress Diagnostic Scale (PDS) and depression was measured at hospitalization with the (BSI) and at follow-up with the Center for Epidemiologic Studies Depression Scale (CESDS). Covariates were explored, including coping self-efficacy, anger, education level, and mechanism of injury. RESULTS Four latent classes were identified for PTSD and Depression symptoms: chronic distress, delayed distress, recovered, and resilience. When compared to the resilient group, individuals with chronic distress were more likely to have been assaulted, had higher levels of anger, and had less coping self-efficacy. The delayed distress group had lower education levels, higher levels of coping self-efficacy, and higher levels of anger. Individuals in the recovered group had fewer years of education, and higher levels of anger. CONCLUSION The majority of the injured trauma sample demonstrated resiliency, with those exhibiting distress doing so as a delayed, chronic, or recovered trajectory. Coping self efficacy, education, assaultive trauma type, and anger were important covariates of depression and PTSD trajectories. These results are similar to studies of individuals who experienced a major health threat and with survivors from the World Trade Center attacks in the U.S.

What is "treatment as usual" for nonepileptic seizures?

OBJECTIVE A recent NINDS/NIMH/AES-sponsored international NES Treatment Workshop identified a lack of knowledge in the field regarding standard of care in the management of patients with psychological nonepileptic seizures (NES). METHODS We administered a survey to AES clinicians to determine actual postdiagnostic instructions given to patients and referral practices, or NES treatment as usual. RESULTS The majority of respondents were epileptologists, followed by neurologists, neuropsychologists, and nurses, evenly dispersed across the United States. Almost all respondents reported discussing the diagnosis of NES with the patients. Sixty-nine percent of neurologists continued to follow the patient after NES diagnosis. Treatment referrals were most commonly made to psychiatrists and psychologists. Antiepileptic drugs were tapered by 83% of the respondents, and 47% prescribed psychotropic medications if comorbid diagnoses were made. CONCLUSION This is the first known national survey that summarizes national practices and the range of care, or treatment as usual, offered to patients with NES.

Psychological Treatment of Nonepileptic Events.

Nonepileptic events (NEEs) occur with and without true seizure disorders and vary greatly in clinical presentation. They are often associated with significant psychopathology. This paper proposes six categories of NEE patients based on psychosocial history, NEE etiology, and mechanisms of and response to psychotherapy. A series of 26 adult NEE patients were grouped according to six symptom patterns: (a) acute anxiety/panic, (b) impaired affect regulation and interpersonal skills, (c) somatization/conversion, (d) depression, (e) posttraumatic stress disorder, and (f) reinforced behavior pattern. Classification was made on the basis of the specific psychotherapeutic interventions found most effective with each patient group.

psychological Adjustment in Children after Traumatic Disfiguring Injuries: A 12-month Follow-up

&NA; The psychological adjustment of 57 children (age range, 3 to 12 years) who sustained mutilating traumatic injuries to the face or upper or lower extremities was assessed over a 12‐month interval. The injuries had occurred as a result of boating, lawn mower, or home accidents or dog bites. Within 5 days of the traumatic event, 98 percent of the children were symptomatic for posttraumatic stress disorder, depression, or anxiety. One month after the injury, 82 percent were symptomatic. Symptom frequency had declined by the time of the 3‐month and 6‐month evaluations, but 44 percent of the children continued to report symptoms at 12‐month follow‐up visits, and 21 percent met the diagnostic criteria for posttraumatic stress disorder. Typical symptoms included flashbacks, fear of re‐injury, mood disorders, body‐image changes secondary to disfigurement, sleep disturbances, and anxiety. These findings support the importance of psychological evaluation and treatment of children who suffer mutilating injuries that require the attention of plastic surgeons. (Plast. Reconstr. Surg. 106: 1451, 2000.)

When prolonged exposure fails: Adding an imagery-based cognitive restructuring component in the treatment of industrial accident victims suffering from PTSD

Prolonged exposure (PE) is a widely promulgated treatment modality for PTSD. While successful with many subjects, PE also has a significant failure rate (i.e., dropouts, nonimprovement, symptom exacerbation). To date, outcome research has not examined why PE at times appears to be the treatment of choice for PTSD and why it sometimes needs to be combined with cognitive restructuring interventions to be effective. This study presents a detailed cognitive-behavioral analysis of two industrial victims suffering from PTSD who failed to benefit from PE alone, but who subsequently made a quick and lasting recovery when an imagery-based, cognitive restructuring component was added to their exposure treatment. A comparative analysis is presented of the theoretical underpinnings and treatment components of the behavioral and cognitive treatments used with the subjects in this study—PE and imagery rescripting and reprocessing therapy (IRRT). PE is a behavioral treatment based upon theories of classical conditioning that relies on exposure, habituation, desensitization, and extinction to facilitate emotional processing of fear. By contrast, IRRT is cognitive therapy applied in the context of imagery modification. In IRRT, exposure is employed not for habituation, but for activating the trauma memory so that the distressing cognitions (i.e., the trauma-related images and beliefs) can be identified, challenged, modified, and processed.

Imagery rescripting for recurrent, distressing images

Intrusive images are a familiar aspect of daily experience that, when persistent and unwanted, may cause emotional distress. In many cases, images accompany disturbing and repetitive thoughts and ruminations. In others, images are the primary mental experience. This article describes the use of a therapy procedure—imagery rescripting (IR)—in the treatment of distressing intrusive images that occur spontaneously but are not memories of actual events or experiences (i.e., flashbacks, intrusive memories). Eleven individuals who reported recent onset of such images, and who did not benefit from brief treatment with imaginal exposure, subsequently improved significantly with one trial of IR. Subjective Units of Discomfort (SUDS) data and two case studies are presented. Results support the use of IR in the treatment of repetitive, distressing images that persisted despite previous personal efforts (distraction, reasoning) and clinical intervention with imaginal exposure.

Psychological response to trauma.

Severe traumatic injuries to the hands, extremities, and face can produce significant psychological reactions. Adjustment problems are more pronounced when the injuries result in disfigurement and significant loss of function. Long after the traumatic event, persistent fear, depression, avoidance, and body image changes result in substantial impairment in personal, social, and occupational functioning.

Comparing standard medical care for nonepileptic seizures in Chile and the United States

OBJECTIVE We sought to compare the diagnostic and treatment practices for psychogenic nonepileptic seizures (PNES) in the United States (US) to Chile. METHODS A survey on the diagnostic and treatment practices for PNES was administered to practicing clinicians in Chile. Results from 96 Chilean respondents were compared to results from 307 US clinicians. Type I error (alpha) was set to 0.005 for multiple comparisons. RESULTS DIAGNOSIS The diagnosis of PNES is made by inpatient video-EEG/LTM in 89% of the US respondents compared to 25% of the Chilean respondents (p<0.0001). The diagnosis of PNES is made by history and exam alone at twice the rate in Chile (38%) than in the US (16%; p<0.0001). TREATMENT A higher proportion of the Chilean respondents (65%) endorsed psychopharmacotherapy as potentially beneficial compared to the US respondents (31%; p<0.0001). DISCUSSION This cross-cultural multi-site survey reveals some differences in PNES evaluation and management between neurologists and other clinicians in the US and in Chile. Access to video EEG may improve PNES diagnosis and treatment.

Psychological impact of traumatic injuries: what the surgeon can do.

&NA; In their treatment of accident and assault victims, plastic surgeons have unique opportunities to identify and refer patients with posttraumatic stress symptoms. This article describes brief assessments that surgeons or their clinic staff can use to evaluate traumatically injured adults and children for trauma‐related psychological symptoms. An immediate postinjury evaluation (within 10 days of the trauma) consists of 11 questions to determine the presence of the following risk factors for posttrauma maladjustment: panic during or immediately after the trauma, reexperiencing symptoms, avoidance, sleep disturbance, injury from an assault, previous trauma and psychiatric history, and blaming someone else for the injury. The seven follow‐up interview questions assess reexperiencing symptoms, avoidance, trauma‐related phobias, depression, irritability, and increased substance use, all of which, if present, suggest psychological impairment. Questions recommended for the evaluation of younger children assess changes in play and recreational activity, sleep disturbance, night terror, aggression, irritability, avoidance, emergence of new fears, and loss of recently acquired developmental skills. The assessments require less than 2 minutes and are easily integrated into the hospital or clinic examinations of these patients. (Plast. Reconstr. Surg. 109: 18, 2002.)

Reasons for Failed Weight Loss Surgery

bariatric surgery offers an opportunity for effective, long-term weight loss where conventional methods have failed. Restrictive surgical procedures include vertical banded gastroplasty, sleeve gastrectomy, and lap band. The Roux-en-Y gastric bypass (RYGBP) offers a combination restrictive/malabsorptive approach. Malabsorptive procedures include biliopancreatic diversion with and without duodenal switch. All procedures result in substantial weight loss within 12 to 18 months following surgery. Although patients regain weight, the majority maintain lower weights over follow-up intervals of more than 7 years, with improvements in medical comorbidities, energy, mobility, quality of life, and emotional functioning. Unfortunately, subgroups of patients fail to benefit, largely due to postsurgical behavioral factors. The consequences range from insufficient weight loss to potentially lifethreatening medical complications (Table 1).