Philippe Birmes

Peritraumatic dissociation, acute stress, and early posttraumatic stress disorder in victims of general crime.

Objective: To compare the relation between peritraumatic dissociation and acute stress and the early development of posttraumatic stress disorder (PTSD) in victims of general crime. Method: A total of 48 subjects were assessed within 24 hours of the trauma, using the Peritraumatic Dissociative Experiences Questionnaire Self-Report Version (PDEQ-SRV). They were followed longitudinally to assess acute stress (2 weeks after the assault,) using the Standford Acute Stress Reaction Questionnaire (SASRQ), and posttraumatic stress (at 5 weeks), using the Clinician-Administered PTSD Scale (CAPS) and the Impact of Event Scale (IES). Results: Among PTSD subjects mean PDEQ scores were significantly higher (mean 3, SD 0.9) than in those without PTSD (mean 2.3, SD 0.7) (t = 2.78, df 46, P = 0.007). Among PTSD subjects, mean SASRQ scores were significantly higher (mean 97.9, SD 29.2) than in those without PTSD (mean 54.8, SD 28.2) (t = 4.9, df 46, P = 0.00007). Conclusions: High levels of peritraumatic dissociation and acute stress following violent assault are risk factors for early PTSD. Identifying acute reexperiencing can help the clinician identify subjects at highest risk.

Peritraumatic reactions and posttraumatic stress symptoms in school-aged children victims of road traffic accident.

OBJECTIVE The purpose of this study is to investigate the power of self-reported peritraumatic distress and dissociation to predict the development of posttraumatic stress disorder (PTSD) symptoms in school-aged children. METHODS School-aged children aged 8 to 15 years admitted to an emergency department after a road traffic accident were enrolled (n=103). Participants were assessed with the child versions of the Peritraumatic Distress Inventory and the Peritraumatic Dissociative Experiences Questionnaire within 1 week. Posttraumatic stress disorder symptoms were then assessed at 5 weeks. RESULTS A significant association between peritraumatic variables and two measures of PTSD symptoms was demonstrated. However, in a multivariate analysis, peritraumatic distress was the only significant predictor of acute PTSD symptoms (beta=.33, p<.05). CONCLUSIONS As has been found in adults, peritraumatic distress is a robust predictor of who will develop PTSD symptoms among school-aged children.

Does reconsolidation occur in humans: a reply

Schiller and Phelps (2011) have provided a thoughtful and comprehensive review in the May issue of Frontiers in Behavioral Neurosciences entitled, “Does reconsolidation occur in humans?” This scholarly paper captures many of the challenges in translating the animal research on reconsolidation to humans. We agree with their main argument that there is little published evidence in humans that meets one important reconsolidation criterion, namely, that the memory-weakening treatment should be administered after the memory reactivation, so as not to influence the preceding memory retrieval process. However, it is unclear whether pre-reactivation propranolol significantly hampers memory retrieval. On the basis of this uncertainty, Schiller and Phelps go on to suggest that the memory impairing effects of pre-reactivation propranolol (e.g., Kindt et al., 2009; Brunet et al., 2011) must be explained by some process other than reconsolidation. Such a conclusion appears illogical, because if propranolol does not impair retrieval sufficiently to preclude reconsolidation, then blockade of memory reconsolidation remains a viable explanation for pre-reactivation propranolols memory-weakening action. Indeed, the ultimate evidence for successful memory retrieval is measured during reactivation (e.g., freezing behavior in rodent fear conditioning, GSR in human fear conditioning, etc.). Therefore, any impairment of retrieval should be detected. Moreover, as shown recently by Debiec et al. (2011) immediate post-retrieval beta-adrenergic receptor stimulation enhances reconsolidation of fear conditioning in the amygdala. In this scenario, administration of propranolol following memory retrieval (which results in arousal and noradrenergic stimulation) may be too late to be effective. So, a parsimonious explanation is that pre-reactivation propranolol did block reconsolidation to some extent in the above-mentioned studies. Pre-reactivation propranolol studies (and other studies with a similar design) ought to be pursued vigorously because, irrespective of how the memory impairing effect is obtained, they offer the prospect of a novel approach to treating mental disorders that have at their core an emotional, usually traumatic, memory. Although Schiller and Phelps acknowledge some of the challenges of blocking reconsolidation using pharmacological means in humans, it is important to note the reasons for this difficulty. In animals, reconsolidation (i.e., protein synthesis) is believed to begin 3–10 min after memory reactivation (Monfils et al., 2009). Most of it appears to take place within the first 2 h (Przybyslawski et al., 1999) and to be over by the sixth hour (Duvarci and Nader, 2004). Considering that oral propranolol takes about 90 min to reach its peak bioavailability in human blood (Marino, 1987); and considering that only a fraction of this drug will eventually cross the blood–brain barrier to be available to exert the necessary effect, protocols that use post-reactivation propranolol are vulnerable to yielding negative results because not enough protein synthesis will have been blocked by the time the drug reaches its full effect in the human brain. Since conducting our proof-of-concept study in posttraumatic stress disorder (PTSD; Brunet et al., 2008), which used post-reactivation propranolol, we have opted to use pre-reactivation propranolol in an attempt to develop what we hope will be a more potent therapeutic protocol (see Brunet et al., 2011). It is unfortunate that this type of protocol does not meet an important scientific criterion for studies that use it to be labeled as genuine “reconsolidation” studies, but this is the price to pay for conducting sound translational research in patients. Schiller et al. (2010) are to be commended for their efforts to devise a human protocol that circumvents the problems associated with pharmacological blockade of reconsolidation by incorporating new material into a destabilized old memory, rather than simply blocking its reconsolidation. However, they have yet to show that such an approach is sufficiently potent to help patients overcome their psychological symptoms stemming from a traumatic emotional memory.

Prevalence of post-traumatic stress disorder and depression in two groups of children one year after the January 2010 earthquake in Haiti

BACKGROUND More than 500 studies were conducted in Haiti following the January 12 of 2010 earthquake, yet few of them assessed mental health of the population. To our knowledge, none targeted the effectiveness of various methods used to treat survivors, whether adults or children METHOD Our study aimed to assess one year after the disaster, the effect of a specific psycho-social support offered to relocated children in Port-au-Prince compared with a control group. RESULTS The two groups were homogeneous in the intensity of the peritraumatic distress they experienced. We were unable to show a significant difference between both in the average scores for PTSD, nor for depression, nor in three out of the four sub-scales of the Child Behavior Check-List. In case children, 68% and 40.9%, respectively, and 50% and 20.5% of the control group, reported severe levels of the symptoms of PTSD and depression. These surprising results can be explained by the absence of equivalence in the two groups from a socio-demographic point of view and because subjects were not randomly selected in the recruitment process. CONCLUSION This study has not made it possible to indicate the effectiveness of a specific psycho-social support offered to children in the aftermath of the disaster. On the other hand, the sample illustrates the high prevalence (more than 50% for PTSD) of severe post-traumatic stress in this group of school-age children, one year after the earthquake. These results indicate that serious attention should be paid to the mental health aspects in reconstruction program for the country.

Effects of Propranolol, a β-noradrenergic Antagonist, on Memory Consolidation and Reconsolidation in Mice

Memory reconsolidation impairment using the β-noradrenergic receptor blocker propranolol is a promising novel treatment avenue for patients suffering from pathogenic memories, such as post-traumatic stress disorder (PTSD). However, in order to better inform targeted treatment development, the effects of this compound on memory need to be better characterized via translational research. We examined the effects of systemic propranolol administration in mice undergoing a wide range of behavioral tests to determine more specifically which aspects of the memory consolidation and reconsolidation are impaired by propranolol. We found that propranolol (10 mg/kg) affected memory consolidation in non-aversive tasks (object recognition and object location) but not in moderately (Morris water maze (MWM) to highly (passive avoidance, conditioned taste aversion) aversive tasks. Further, propranolol impaired memory reconsolidation in the most and in the least aversive tasks, but not in the moderately aversive task, suggesting its amnesic effect was not related to task aversion. Moreover, in aquatic object recognition and location tasks in which animals were forced to behave (contrary to the classic versions of the tasks); propranolol did not impair memory reconsolidation. Taken together our results suggest that the memory impairment observed after propranolol administration may result from a modification of the emotional valence of the memory rather than a disruption of the contextual component of the memory trace. This is relevant to the use of propranolol to block memory reconsolidation in individuals with PTSD, as such a treatment would not erase the traumatic memory but only reduce the emotional valence associated with this event.

Validation of the Peritraumatic Dissociative Experiences Questionnaire and Peritraumatic Distress Inventory in school-aged victims of road traffic accidents

BACKGROUND Although the reliable and valid Peritraumatic Distress Inventory (PDI-C) and Peritraumatic Dissociative Experiences Questionnaire (PDEQ) are useful for identifying adults at risk of developing acute and chronic posttraumatic stress disorder (PTSD), they have not been validated in school-aged children and their predictive values remain unknown in this population. This study aims to assess the psychometric properties of the children versions of these two measures (PDI-C and PDEQ-C) in a sample of French-speaking school-children. METHODS One-hundred and thirty-three consecutive victims of road traffic accidents, aged 8-15 years, were recruited into this longitudinal study via the emergency room. The peritraumatic reactions were assessed at baseline and PTSD symptoms were assessed 1 month later. RESULTS Cronbachs alpha coefficients were 0.8 and 0.77 for the PDI-C and PDEQ-C, respectively. The 1-month test-retest correlation coefficient (n=33) was 0.77 for both measures. The PDI-C demonstrated a two-factor structure while the PDEQ-C displayed a one-factor structure. As with adults, the two measures were intercorrelated (r=0.52) and correlated with subsequent PTSD symptoms and diagnosis (r=0.21-0.56; P<0.05). CONCLUSIONS The children versions of the PDI and PDEQ are reliable and valid in children.

Course of posttraumatic stress symptoms over the 5 years following an industrial disaster: A structural equation modeling study

The present study examined individual latent changes in posttraumatic stress disorder (PTSD) symptoms over a 60-month period after an industrial disaster. Participants were recruited from survivors of a factory explosion. Participants were assessed retrospectively for peritraumatic reactions and acute stress symptoms. Posttraumatic stress disorder symptoms were then assessed at 6, 15, and 60 months. Using structural equation modeling, the authors tested 3 hypotheses of individual latent change: stability of PTSD symptoms between 6, 15, and 60 months; change between 6 and 15 months; and change between 15 and 60 months. Only one model provided a good fit suggesting that PTSD symptoms evolved between 6 and 15 months after trauma exposure and remained stable at the individual level thereafter.

Peritraumatic distress predicts posttraumatic stress symptoms in older people

In a recent publication of the International Journal of Geriatric Psychiatry, Chung et al. (2009) found that 35% of older people were suffering from posttraumatic stress disorder (PTSD) after a fall. However, they found no predictive factors for the development of PTSD. We would like to report the preliminary results of a study carried out with the main objective of assessing the predictive power of peritraumatic reactions in older adults. Peritraumatic distress, a measure of the intensity of DSM-IV PTSD criteria A2, indexes ‘fear, helplessness, and horror’ as well as other reactions experienced during or immediately after trauma exposure while peritraumatic dissociation refers to alterations in the experience of time, place, and persons. Older adults were enrolled in the study from the emergency department (ED) of Toulouse and Bordeaux University Hospitals. The study was approved by the institutional ethical committee of the Toulouse University Hospital. Eligible adults (age >65 years, French speaking) were admitted to the ED after either a road traffic accident or a violent assault. Exclusion criteria comprised mental retardation, prior psychiatric disorder, Mini Mental State Examination score <28, or a life-threatening condition. During the recruitment period, 34 participants were enrolled in the study and were assessed within 1 week of ED admission. Twenty-five of these subjects (73.5%) completed a second assessment 1 month after admission. Peritraumatic reactions were assessed at baseline and PTSD symptoms at 1 month. The Peritraumatic Distress Inventory (PDI) was used to assess distress at the time of the traumatic event. The PDI is composed of 13 selfreport items scored on a 5-point scale, with higher total scores indicating increased distress (range: 0–52) (Brunet et al., 2001). Peritraumatic dissociation was assessed using the Peritraumatic Dissociative Experiences Questionnaire (PDEQ). The PDEQ is a 10-item self-report questionnaire, with each item scored on a 5point scale and higher total scores indicating increased dissociation (range: 10–50) (Birmes et al., 2005). The primary outcome measure was PTSD symptoms measured using the Clinician-Administered PTSD Scale (CAPS). The CAPS provides a total symptom severity score (range: 0–136) with higher scores indicating an increased level of PTSD symptoms (Blake et al., 1995). Clinical and sociodemographic data were collected from medical charts and are reported in Table 1. Five (20%) participants met the criteria for PTSD at 1 month. Pearson’s correlation analyses revealed that 1-month CAPS score was not significantly correlated with gender or age. It was, however, significantly associated with baseline PDI score (r1⁄4 0.60, p< 0.01) and PDEQ score (r1⁄4 0.41, p< 0.05). Multiple regression analysis was then performed to assess the ability of peritraumatic variables (PDI and PDEQ) to predict 1-month PTSD symptoms. Due to the small sample size, all other independent variables were excluded from the analysis. The model identified PDI score as the only significant peritraumatic predictor of 1-month PTSD symptoms (b1⁄4 0.78, p< 0.01) and predicted 32.2% of the total variance. Our results do not replicate those of Chung et al. (2009) concerning the association between PTSD symptoms and gender or age. This discrepancy might be explained by the small sample size. Nevertheless, the main original finding from this study is that peritraumatic distress is a significant predictor of acute PTSD symptoms 1 month after trauma in older adults. Similar to results in younger adults, increased distress at the time of a trauma predicts increased levels of PTSD symptoms in elderly subjects. Previous research has highlighted the association between peritraumatic dissociation and the development of PTSD symptoms in adults (Lensvelt-Mulders et al., 2008). Our study confirms these results but suggests that peritraumatic distress might be a better predictor than dissociation in older adults. There are several limitations to our study. The small sample size and low number of PTSD cases limited the analysis to symptoms only. Furthermore, assessing PTSD symptoms 1month posttraumamight be too early and the impact of peritraumatic distress and dissociation on long-term symptoms remains to be explored.

Traumatic Grief and Traumatic Stress in Survivors 12 Years after the Genocide in Rwanda

The relationship between exposure to traumatic events and traumatic grief and the role of mediating and moderating variables [peritraumatic distress, post traumatic stress disorder (PTSD) symptoms and symptoms of depression] were studied in survivors of the genocide of Batutsi in Rwanda in 1994. One hundred and two survivors (70 women, mean age 45 ± 7.53 years) participated in this retrospective study. All of them had lost a member of their family. The severity of traumatic exposure (Comprehensive Trauma Inventory), peritraumatic distress (Peritraumatic Distress Inventory), current PTSD symptoms (PTSD Checklist), depressive symptoms (Beck Depression Inventory) and traumatic grief symptoms (Inventory of Traumatic Grief) was evaluated. A hierarchical multiple regression analysis was then conducted to examine the relative contribution of each variable to the symptoms of traumatic grief. The severity of traumatic exposure was related to traumatic grief symptoms (B=0.06, R=0.6, R(2) =0.36 and ß=0.6, t=7.54, p=0.00). The Baron and Kenny procedure (1986) (including three separate regressions), along with the Sobel test, was used to test mediation effects. Peritraumatic distress and PTSD symptoms may be mediating variables between traumatic exposure and traumatic grief. Traumatic grief is a complex but assessable entity, where previous distress and suffering result from both psychological trauma and the loss of a loved one.

Borderline personality disorder and rTMS: A pilot trial

A randomized, controlled study was carried out to assess the effect of a series of 10 sessions of high-frequency rTMS to the right DLPFC in 10 Borderline Personality Disorder patients. Patients in the rTMS group showed improvements in anger, affective instability (Borderline Personality Disorder Severity Index) and planning (Tower Of London). Two smoking cessations were observed.