Mauro V. Mendlowicz

Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers

PurposeWe sought to estimate the pooled current prevalence of posttraumatic stress disorder (PTSD) among rescue workers and to determine the variables implicated in the heterogeneity observed among the prevalences of individual studies.MethodsA systematic review covering studies reporting on the PTSD prevalence in rescue teams was conducted following four sequential steps: (1) research in specialized online databases, (2) review of abstracts and selection of studies, (3) review of reference list, and (4) contact with authors and experts. Prevalence data from all studies were pooled using random effects model. Multivariate meta-regression models were fitted to identify variables related to the prevalences heterogeneity.ResultsA total of 28 studies, reporting on 40 samples with 20,424 rescuers, were selected. The worldwide pooled current prevalence was 10%. Meta-regression modeling in studies carried out in the Asian continent had, on average, higher estimated prevalences than those from Europe, but not higher than the North American estimates. Studies of ambulance personnel also showed higher estimated PTSD prevalence than studies with firefighters and police officers.ConclusionsRescue workers in general have a pooled current prevalence of PTSD that is much higher than that of the general population. Ambulance personnel and rescuers from Asia may be more susceptible to PTSD. These results indicate the need for improving pre-employment strategies to select the most resilient individuals for rescue work, to implement continuous preventive measures for personnel, and to promote educational campaigns about PTSD and its therapeutic possibilities.

Early- and late-onset obsessive-compulsive disorder in adult patients: an exploratory clinical and therapeutic study.

It has been suggested that early- and late-onset forms of obsessive-compulsive disorder (OCD) may stem from different neurobiological substrates manifesting themselves through particular phenotypic profiles. Our study aimed to assess the existence of clinical and therapeutic differences between adult patients with early- and late-onset OCD (EOCD and LOCD, respectively). Sixty-six patients with OCD were consecutively recruited among individuals seeking treatment in a university hospital clinic for anxiety and depressive disorders. Patients with EOCD (n=33) and LOCD (n=33) were compared and contrasted with regard to clinical and therapeutic characteristics using the two tailed t test for continuous variables and the Pearsons goodness of fit Chi-square test for categorical ones; Fishers exact test was employed when indicated. We found that, compared to their LOCD counterparts, adult patients with EOCD were characterized by (1) male gender predominance, (2) greater number of clinically significant obsessions and compulsions, (3) higher frequency of rituals repetition, (4) increased severity of obsessive-compulsive symptoms at baseline, and (5) greater number of required therapeutic trials during the follow-up. However, no significant differences between groups were noted in the final treatment outcome. Our results are consistent with previous studies suggesting that EOCD may represent a more severe subtype of this disorder.

Quality of life and symptom dimensions of patients with obsessive-compulsive disorder

The aim of this study was to evaluate the impact of different dimensions of obsessive-compulsive symptoms, of co-morbid anxious depressive symptoms, and of sociodemographic characteristics on the quality of life of patients with obsessive-compulsive disorder (OCD). We evaluated 53 patients with OCD and 53 age- and gender-matched individuals from the community with a sociodemographic questionnaire, the Structured Clinical Interview for the Diagnosis of Diagnostic and Statistical Manual of Mental Disorders, fourth Edition, (DSM-IV), the Short-Form Health Survey-36 (SF-36), the Saving Inventory-Revised, the Obsessive-Compulsive Inventory-Revised, the Beck Depression Inventory and the Beck Anxiety Inventory. A series of stepwise linear regression analyses were performed, having the SF-36 dimensions as the dependent variables and the sociodemographic and clinical features as the independent ones. Patients with OCD displayed significantly lower levels of quality of life in all dimensions measured by the SF-36, except bodily pain. A model that included depressive symptoms, hoarding and employment status predicted 62% of the variance of the social functioning dimension of the quality of life of patients with OCD. Washing symptoms explained 31% of the variance of limitation due to physical health problems. Further, a series of models that included depressive, but not obsessive-compulsive symptoms, explained the remaining SF-36 dimensions. The severity of depressive and anxiety symptoms seems, therefore, to be powerful determinants of the level of quality of life in patients with OCD.

Impulse control disorders in patients with obsessive-compulsive disorder.

Abstract  The purpose of the present paper was to identify the rate of prevalence of impulse control disorders (ICD) in patients with obsessive–compulsive disorder (OCD) and to compare patients with OCD with and without ICD with regard to sociodemographic, clinical and prognostic characteristics. Forty‐five patients with OCD were assessed by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (4th edn, DSM‐IV) plus additional modules for the assessment of ICD and examined using the Yale–Brown Obsessive–Compulsive Scale, the Clinical Global Impression, the Beck Depression Inventory, the Hamilton Depression Rating Scale, and the Global Assessment of Functioning. These patients were treated with serotonin re‐uptake inhibitors (SRI) and followed for a variable period of time. Individuals with ICD (here defined as including not only the impulse control disorders not elsewhere classified of the DSM‐IV, but also other disorders in which impulse control is a prominent feature such as alcohol and drug dependence, paraphilias and bulimia nervosa/binge eating disorder) were compared to those without ICD using the Mann–Whitney U‐test and the Pearsons goodness of fit χ2 test. Sixteen patients with OCD (35.5%) displayed comorbid ICD. Patients with ICD were characterized by a significantly earlier age at OCD onset (P = 0.04), a more insidious appearance of OCD symptoms (P = 0.04), a higher rate of comorbid anxiety disorders (P = 0.03), a greater number (P = 0.02) and severity of compulsive symptoms (P = 0.04), an increased rate of counting compulsions (P = 0.02), and a higher number of required SRI trials (P = 0.01). When OCD is found in association with ICD, the clinical picture is characterized by a greater severity of the obsessive–compulsive symptoms at presentation and by the requirement of a greater number of therapeutic attempts during follow up.

Does D-cycloserine enhance exposure therapy for anxiety disorders in humans? A meta-analysis.

The treatment of anxiety is on the edge of a new era of combinations of pharmacologic and psychosocial interventions. A new wave of translational research has focused on the use of pharmacological agents as psychotherapy adjuvants using neurobiological insights into the mechanism of the action of certain psychological treatments such as exposure therapy. Recently, d-cycloserine (DCS) an antibiotic used to treat tuberculosis has been applied to enhance exposure-based treatment for anxiety and has proved to be a promising, but as yet unproven intervention. The present study aimed to evaluate the efficacy of DCS in the enhancement of exposure therapy in anxiety disorders. A systematic review/meta-analysis was conducted. Electronic searches were conducted in the databases ISI-Web of Science, Pubmed and PsycINFO. We included only randomized, double-blind, placebo-controlled trials with humans, focusing on the role of DCS in enhancing the action of exposure therapy for anxiety disorders. We identified 328 references, 13 studies were included in our final sample: 4 on obsessive-compulsive disorder, 2 on panic disorder, 2 on social anxiety disorder, 2 on posttraumatic stress disorder, one on acrophobia, and 2 on snake phobia. The results of the present meta-analysis show that DCS enhances exposure therapy in the treatment of anxiety disorders (Cohen d =  −0.34; CI: −0.54 to −0.14), facilitating the specific process of extinction of fear. DCS seems to be effective when administered at a time close to the exposure therapy, at low doses and a limited number of times. DCS emerges as a potential new therapeutic approach for patients with refractory anxiety disorders that are unresponsive to the conventional treatments available. When administered correctly, DCS is a promising strategy for augmentation of CBT and could reduce health care costs, drop-out rates and bring faster relief to patients.

Posttraumatic stress disorder in parents of children with chronic illnesses: A meta-analysis.

OBJECTIVE To estimate PTSD prevalence in parents of children with chronic illnesses or undergoing invasive procedures, and its association with higher risk of PTSD among parents. METHODS Sixteen studies reporting prevalence of PTSD in parents of children with chronic illnesses were identified through a systematic review in Pubmed, Web of Science, Pilots and PsycINFO databases. MAIN OUTCOME MEASURES Pooled current PTSD prevalence was calculated for parents from these studies. Pooled PTSD prevalence ratios were obtained by comparing parents of children with chronic diseases with parents of healthy children. Meta-regression was used to identify variables that could account for the lack of homogeneity. RESULTS Pooled PTSD prevalence was 19.6% in mothers, 11.6% in fathers, and 22.8% in parents in general (p < .001). Pooled prevalence ratio for the four studies reporting on mothers and comparison healthy groups was 4.2 (p < .001). CONCLUSIONS The high prevalence of PTSD found in this population highlights the importance of promptly assessing and treating post-traumatic symptoms in parents of children with chronic diseases as a key step to prevent the negative consequences of PTSD and preserve their competency as caregivers.

Is tonic immobility the core sign among conventional peritraumatic signs and symptoms listed for PTSD

BACKGROUND Previous studies suggested the importance of peritraumatic reactions as predictors of PSTD symptoms severity. Despite mounting evidence that tonic immobility occurs under intense life threats its role as predictor of PTSD severity remains by and large understudied. The objective of this study was to investigate the role of peritraumatic reactions (tonic immobility, panic and dissociation) as predictors of PTSD symptoms severity. METHODS Participants were 32 victims of urban violence with PTSD diagnosed through the SCID-I. In order to evaluate PTSD symptoms at baseline, we used the Post-Traumatic Stress Disorder Checklist-Civilian Version. To assess peritraumatic reactions we employed the Physical Reactions Scale, the Peritraumatic Dissociative Experiences Questionnaire and Tonic Immobility questions. As confounding variables, we considered negative affect (measured by the Positive and Negative Affect Schedule-Trait Version), sex and time elapsed since trauma. RESULTS Tonic immobility was the only predictor of PTSD symptoms severity that kept the statistical significance after controlling for potential confounders. LIMITATIONS This study was based on a relatively small sample recruited in a tertiary clinic, a fact that may limit the generalizability of its findings. The retrospective design may have predisposed to recall bias. CONCLUSIONS Our study provides good reason to conduct more research on tonic immobility in PTSD with other samples and with different time frames in an attempt to replicate these stimulating results.

Is there tonic immobility in humans? Biological evidence from victims of traumatic stress.

Tonic immobility, characterized by profound motor inhibition, is elicited under inescapable threat in many species. To fully support the existence of tonic immobility in humans, our aim was to elicit this reaction in a laboratory setting and measure it objectively. To mimic exposure to life-threatening events in the lab, trauma-exposed participants with PTSD (n=18) and without PTSD (n=15) listened to the script of their autobiographical trauma. Posturography and electrocardiography were employed. Reports of script-induced immobility were associated with restricted area of body sway and were correlated with accelerated heart rate and diminished heart rate variability, implying that tonic immobility is preserved in humans as an involuntary defensive strategy. Immobility reports seemed more evident in PTSD, suggesting that, in some patients, tonic immobility may be elicited during re-experiencing episodes in daily life. This study provided a measure of tonic immobility, a peritraumatic reaction for which cumulative clinical evidence had linked to the severity of PTSD.

Psychiatric comorbidity in a Brazilian sample of patients with binge-eating disorder

We compared sociodemographic characteristics and psychiatric status in obese Brazilian patients who did (n=32) and did not (n=33) meet DSM-IV criteria for binge-eating disorder (BED). The samples mean age was 35.0 years (+/-10.5), with 92.3% of individuals being female and 41.5% having some higher education. Obese binge eaters (OBE) were significantly more likely than obese non-binge eaters to meet criteria for a current diagnosis of any axis I disorder, any mood disorder and any anxiety disorder. Specifically, OBE patients were characterized by significantly higher rates of current and lifetime histories of major depressive disorder. Similar to patients from developed countries, Brazilian patients with BED display increased rates of psychiatric comorbidity, particularly mood and anxiety disorders.

The impact of tonic immobility reaction on the prognosis of posttraumatic stress disorder

Tonic immobility is the last defense reaction to entrapment by a predator. In humans, peritraumatic tonic immobility was correlated with PTSD severity and poor response to treatment. This study compared the role of peritraumatic dissociation, panic physical symptoms and tonic immobility as predictors of response to standard pharmacotherapy for PTSD. Thirty-six PTSD patients underwent a naturalistic pharmacological treatment. The Posttraumatic Stress Disorder Checklist - Civilian Version (PCL-C) and the Clinical Global Impressions Severity of Illness item scores (CGI-S) were employed at baseline and endpoint to examine treatment outcome. Peritraumatic reactions were assessed using the Physical Reactions Subscale, the Peritraumatic Dissociative Experiences Questionnaire and four motor questions of the Tonic Immobility Scale. After controlling for confounders, tonic immobility was the best predictor of a poor response to treatment, either considering the PCL-C or the CGI-S scores. Tonic immobility seems to have a greater negative impact on PTSD prognosis than peritraumatic panic or dissociation. Additional translational and clinical research may inform about particular mechanisms underlying tonic immobility and open new avenues for prevention and treatment of PTSD.