Ulrich Schnyder

Reformulating PTSD for DSM-V : Life after Criterion A

The diagnosis of posttraumatic stress disorder has been criticized on numerous grounds, but principally for three reasons (a) the alleged pathologizing of normal events, (b) the inadequacy of Criterion A, and (c) symptom overlap with other disorders. The authors review these problems along with arguments why the diagnosis is nevertheless worth retaining in an amended form. A proposal for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is put forward that involves abolishing Criterion A, narrowing the B criteria to focus on the core phenomena of flashbacks and nightmares, and narrowing the C and D criteria to reduce overlap with other disorders. The potential advantages and disadvantages of this formulation are discussed.

Antonovsky's sense of coherence: trait or state?

Background: The aim of this study was first to analyze the stability of Antonovsky’s Sense of Coherence (SOC) as a measure of a person’s world view over time; secondly, to investigate its relationship with depression and anxiety. Methods: Data from two longitudinal studies were used: a study of severely injured accident victims (n = 96), and a study of patients suffering from rheumatoid arthritis (RA, n = 60). The 13 items short version of the SOC scale and measures of depression and anxiety (Symptom Checklist, Hospital Anxiety and Depression Scale) were administered repeatedly over 6–12 months in both studies. Results: In the sample of accident victims, a significant decrease in the SOC mean score was observed during the first half year after the accident. During the same time period, symptoms of anxiety and depression decreased significantly. In the second half year after the accident, SOC as well as measures of psychopathology remained stable. RA patients showed high stability of SOC and measures of anxiety and depression over time. In both samples, between-time correlations of SOC scores were high (r ≥ 0.70, p < 0.01), indicating a high test-retest stability of SOC. Furthermore, in both samples, significant negative correlations of a moderate to high degree (r = –0.28 to –0.73, p < 0.01) were found between SOC and measures of anxiety and depression. Conclusions: SOC can be seen as a relatively stable (trait) measure. However, traumatic events such as life-threatening accidents may change a person’s world view and thus their SOC, even if psychiatric symptoms abate. This suggests that SOC is not merely a proxy measure of psychopathology, but rather a partially independent, general measure of a person’s world view.

Posttraumatic disorders following injury: an empirical and methodological review

Although there has been a marked increase in research on psychological disorders following physical injury in recent years, there are many discrepancies between the reported findings. This paper reviews the prevalence outcomes of recent studies of the mental health sequelae of physical injury with a focus on posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and depression. The review critically outlines some of the methodological factors that may have contributed to these discrepancies. The phenomenological overlap between organic and psychogenic symptoms, the use of narcotic analgesia, the role of brain injury, the timing and content of assessments, and litigation are discussed in terms of their potential to confound findings with this population. Recommendations are proposed to clarify methodological approaches in this area. It is suggested that a clearer understanding of the psychological effects of physical injury will require the widespread adoption of more rigorous, standardized and transparent methodological procedures.

A randomized, controlled pilot study of MDMA (±3,4-Methylenedioxymethamphetamine)-assisted psychotherapy for treatment of resistant, chronic Post-Traumatic Stress Disorder (PTSD):

Psychiatrists and psychotherapists in the US (1970s to 1985) and Switzerland (1988–1993) used MDMA legally as a prescription drug, to enhance the effectiveness of psychotherapy. Early reports suggest that it is useful in treating trauma-related disorders. Recently, the first completed pilot study of MDMA-assisted psychotherapy for PTSD yielded encouraging results. Designed to test the safety and efficacy of MDMA-assisted psychotherapy in patients with treatment-resistant PTSD; our randomized, double-blind, active-placebo controlled trial enrolled 12 patients for treatment with either low-dose (25 mg, plus 12.5 mg supplemental dose) or full-dose MDMA (125 mg, plus 62.5 mg supplemental dose). MDMA was administered during three experimental sessions, interspersed with weekly non-drug-based psychotherapy sessions. Outcome measures used were the Clinician-Administered PTSD Scale (CAPS) and the Posttraumatic Diagnostic Scale (PDS). Patients were assessed at baseline, three weeks after the second and third MDMA session (end of treatment), and at the 2-month and 1-year follow-ups. We found that MDMA-assisted psychotherapy can be safely administered in a clinical setting. No drug-related serious adverse events occurred. We did not see statistically significant reductions in CAPS scores (p = 0.066), although there was clinically and statistically significant self-reported (PDS) improvement (p = 0.014). CAPS scores improved further at the 1-year follow-up. In addition, three MDMA sessions were more effective than two (p = 0.016).

German version of Clinician-Administered PTSD Scale

This study assessed the reliability of a German translation of the Clinician-Administered PTSD Scale (CAPS) by using data from 45 survivors of accidents who were hospitalized at the department of traumatology of a university hospital. Assessments were carried out 5 days (Time 1) and 6 months (Time 2) after the accident. Internal consistency proved to be comparable to that of the original English version: Cronbachs alpha was .88 at T1 and .92 at T2 for the CAPS total score. The CAPS correlated significantly with the validated German version of the Impact of Event Scale (IES) (T1: r = .56, T2: r = .78). The data suggest that the German version of the CAPS is a reliable instrument for the assessment of posttraumatic stress disorder symptomatology in accident victims. Further studies are necessary to validate further the questionnaire.

Sense of Coherence – A Mediator between Disability and Handicap?

Background: The aim of this study was first to analyze the associations between disability and handicap and Antonovsky’s concept of sense of coherence (SOC); secondly, to find out how the SOC concept could be integrated in the WHO model of impairments, disabilities, and handicaps (ICIDH). Methods: Data from two studies were used: one on patients with rheumatoid arthritis, one on severely injured accident victims. Objective measures of the illness or the injury were conceptualized as indicator variables for disability, whereas variables related to the patients’ subjective judgement were conceptualized as indicator variables for handicap. Correlations were calculated between both sets of variables and the SOC scale total score. Results: SOC showed no significant correlation with ‘disability variables’ (rheumatoid arthritis: HAQ, SF36 physical functioning; accidental injuries: ISS, GCS). However, significant correlations were found between SOC and all ‘handicap variables’ (rheumatoid arthritis: HAD, SF36 social functioning; accidental injuries: CAPS-2, IES, SCL-90-R depression subscale). Conclusions: SOC is related to the psychosocial effects of health problems. It may be understood as a mediator between disability and handicap. Prospective studies are needed to clarify whether the SOC scale can be used as an outcome predictor with regard to psychosocial adaptation, in acute as well as in chronic health problems.

Altered blood coagulation in patients with posttraumatic stress disorder

Objective: Posttraumatic stress disorder (PTSD) has been associated with an increased cardiovascular risk, though the pathophysiologic mechanisms involved are elusive. A hypercoagulable state before occurrence of coronary thrombosis contributes to atherosclerosis development. We investigated whether PTSD would be associated with increased coagulation activity. Methods: We measured resting plasma levels of clotting factor VII activity (FVII:C), FVIII:C, FXII:C, fibrinogen, and D-dimer in 14 otherwise healthy patients with PTSD and in 14 age- and gender-matched, trauma-exposed non-PTSD controls. Categorical and dimensional diagnoses of PTSD were made using the Clinician-Administered PTSD Scale (CAPS) interview. We also investigated to what extent the relationship between PTSD and coagulation measures would be confounded by demographics, cardiovascular risk factors, lifestyle variables, time since trauma, and mood. Results: Coagulation factor levels did not significantly differ between patients with a categorical diagnosis of PTSD and controls while controlling for covariates. In all subjects, FVIII:C was predicted by hyperarousal severity (&bgr; = 0.46, p = .014) independent of covariates and by overall PTSD symptom severity (&bgr; = 0.38, p = .045); the latter association was of borderline significance when separately controlling for gender, smoking, exercise, and anxiety (p values <.07). In patients, fibrinogen was predicted by hyperarousal severity (&bgr; = 0.70, p = .005) and by overall PTSD symptom severity (&bgr; = 0.61, p = .020), with mood partially affecting these associations. FVII:C, fibrinogen, and D-dimer showed no independent association with PTSD symptoms. Conclusions: PTSD may elicit hypercoagulability, even at subthreshold levels, offering one psychobiological pathway by which posttraumatic stress might contribute to atherosclerosis progression and clinical cardiovascular disease. BMI = body mass index; CAD = coronary artery disease; CAPS = Clinician-Administered PTSD Scale; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; FVII:C = clotting factor VII activity; FVIII:C = clotting factor VIII activity; FXII:C = clotting factor XII activity; MBP = mean arterial blood pressure; MI = myocardial infarction; PTSD = posttraumatic stress disorder; SNS = sympathetic nervous system; IL = interleukin; HADS = Hospital Anxiety and Depression Scale.

Does acute stress disorder predict post-traumatic stress disorder in traffic accident victims? Analysis of a self-report inventory

The objective of this study was to account for acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) morbidity in a self-report survey of traffic accident victims and to evaluate the relationship between ASD and PTSD in this sample, and furthermore, to find both a model of independent variables accounting for variance in ASD and PTSD symptom level. Ninety patients, treated at an emergency ward after traffic accidents, participated in this longitudinal self-report survey. ASD was assessed using the Acute Stress Disorder Scale (ASDS) and PTSD was assessed at 6-8 months follow-up using the Posttraumatic Diagnostic Scale (PDS). Twenty-five patients (28%) met the cutoff scores for ASDS. Fifteen patients (17%) fulfilled criteria for PTSD according to the PDS. ASD was only able to predict 50% of patients who later developed high levels of PTSD symptomatology. A model of three variables explained 35% of the variance in ASD symptom level. Two variables explained 40% of the variance in PTSD symptom level. In both regression models, dissatisfaction with social support was associated with a higher symptom level. The results from this study reflect already voiced problems with the ASD diagnosis. The lack of precision in predicting who will develop PTSD is pronounced in this study. The acute traumatic symptom level explains a large part of the variance in PTSD symptom level. However, other variables also seem to play an important role.Research evidence indicates that approximately 10 h a week is a sufficient intensity for short-term day treatment programmes for patients with personality disorders. In this article, we discuss which therapeutic components should be included in such a programme. Relevant research and clinical literature are reviewed. The fit between the therapeutic components and the programme as a whole is discussed according to: 1) scientific evidence of the effectiveness of the therapeutic components, 2) a sound theoretical rationale, 3) evidence of user satisfaction among patients, 4) clinical experiences of staff, 5) comprehensiveness and consistency, and 6) available therapeutic skills and resources. We advocate an 11-h treatment programme comprising small group psychotherapy, art group therapy, large group psychotherapy, cognitive group therapy, problem-solving group therapy and optional adjuncts (cognitive behavioural group therapy) for patients with additional anxiety and eating disorders.

Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study.

OBJECTIVE Motor vehicle accidents (MVA) and work-related injuries are two of the more common causes of chronic pain. Nevertheless, there is little evidence on predicting factors regarding the development of chronic pain following physical injury. METHODS The present study investigated temporal associations between accident-related factors, psychological factors [symptoms of posttraumatic stress disorder (PTSD), anxiety, depression, coping], and the development of chronic pain in a sample of individuals who had sustained severe accidental injuries (N=90). Assessments were performed within 1 month of the accident, and at 6, 12, and 36 months post trauma. RESULTS A total of 40 individuals (44%) reported accident-related pain 3 years after the accident. Individuals with chronic pain showed significantly more symptoms of PTSD, depression, and anxiety, more disability, and more days off work. Analysis of temporal associations between psychological variables and the development of chronic pain indicated that the separation of the pain from the nonpain group mostly occurred between 6 (T2) and 12 months (T3). Differences were much less pronounced at T1. CONCLUSION The prevalence of chronic pain in severely injured patients 3 years after the accident is considerably high. The development of chronic pain is more related to psychological factors, particularly PTSD symptoms, in the aftermath of the accident, as compared to sociodemographic and accident-related variables at the time of the accident. These findings may be helpful to elucidate the problems in predicting chronic pain conditions in injured subjects and to recognize the onset of a chronic pain condition more reliably.

Mutual influence of posttraumatic stress disorder symptoms and chronic pain among injured accident survivors: A longitudinal study

The relationship between acute stress disorder (ASD), posttraumatic stress disorder symptoms (PTSD), and chronic pain was investigated in a longitudinal study of injured accident victims (N = 323, 64.7% men). Assessments took place 5 days (T1), 6 (T2) months, and 12 (T3) months postaccident. Relations between pain and posttraumatic stress symptoms were tested by structural equation modeling. Subjects diagnosed with full or subsyndromal PTSD at T2 and at T3 (14 and 19%) reported significantly higher pain intensity. Cross-lagged panel analysis yielded a mutual maintenance of pain intensity and ASD or PTSD symptoms across T2. Across the second half year, PTSD symptoms impacted significantly on pain but not vice versa. Clinicians need to pay careful attention to PTSD symptoms in accident survivors suffering from chronic pain.