William Berger

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.

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.

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.

Serum brain-derived neurotrophic factor predicts responses to escitalopram in chronic posttraumatic stress disorder.

INTRODUCTION Some studies have found that antidepressants increase serum brain-derived neurotrophic factor (BDNF) levels in patients with major depression and the expression of BDNF mRNA in limbic structures of rats. OBJECTIVES This study addressed whether the SSRI escitalopram increases serum BDNF levels in subjects with PTSD and whether BDNF levels are associated with treatment response. METHODS Medically healthy male subjects (N=16) with chronic PTSD completed a 12 week open-label trial of flexible dose (5-20 mg/day) escitalopram monotherapy. BDNF levels were obtained at baseline, and at weeks 4, 8 and 12. RESULTS PTSD symptoms significantly declined over the course of the 12 week escitalopram treatment. Despite a substantial improvement in PTSD symptoms, there was virtually no change in BDNF levels over time. Nevertheless, mean BDNF levels across the trial were strongly correlated with the slope of PTSD symptoms over the 12 weeks (r=0.58, p=0.018). Lower mean BDNF was associated with a greater decrease in PTSD symptoms over the course of the trial. CONCLUSIONS PTSD subjects with low BDNF levels demonstrated the largest treatment response from an agent with putative neurotrophic effects.

The impact of posttraumatic symptoms and comorbid mental disorders on the health-related quality of life in treatment-seeking PTSD patients

BACKGROUND There is a dearth of literature dealing with the impact of the severity of posttraumatic symptoms and of comorbid mental disorders on the health-related quality of life (HRQOL) of victims of civilian violence with a primary diagnosis of PTSD. OBJECTIVES To investigate the influence of the severity of posttraumatic symptoms and of presence of comorbid mental disorders on the HRQOL of treatment-seeking outpatients with PTSD. METHODS A sample of 65 PTSD patients was recruited in a specialized outpatient clinic. The volunteers had the diagnoses of PTSD and of comorbid mental disorders established with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). The severity of posttraumatic, depression and anxiety symptoms was measured with the PCL-C, BDI and BAI, respectively. HRQOL was assessed by means of the SF-36, a 36-item self-administered scale that measures eight domains of quality of life: vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, and mental health. Multiple linear regression models were fitted to investigate the relationship between the severity of posttraumatic, mood, and anxiety symptoms; the presence of specific current comorbid disorders and of psychotic symptoms, and the number of current comorbid conditions for each of the eight domains of HRQOL, after adjusting for the effect of sociodemographic characteristics. RESULTS The severity of PTSD symptoms predicted worse HRQOL in all eight domains of SF-36, even after controlling for the severity of depression and anxiety symptoms, the presence of panic disorder, OCD, specific and social phobia, psychotic symptoms, and the number of comorbid disorders. The strongest negative association between PTSD symptoms severity and HRQOL was found in the Social Functioning domain. Although the inclusion of the depressive symptoms in the models led to a reduction of the magnitude of the negative association between the severity of PTSD symptoms and the HRQOL domain scores, the former still accounted for most of the explained variance of the latter. CONCLUSIONS We found that even in the presence of comorbid mental disorders, the severity of posttraumatic symptoms remained the strongest predictor for impaired HRQOL in PTSD outpatients. Our results suggest that improvement of HRQOL should be considered a therapeutic objective and an essential outcome measure in the treatment of PTSD.

Confirmatory factor analysis of posttraumatic stress symptoms in Brazilian primary care patients: an examination of seven alternative models.

The DSM-IV-TR postulates that PTSD symptoms are organized into 3 clusters. This assumption has been challenged by growing number of factor analytical studies, which tend to favor 4-factor, first-order models. Our objective was to investigate whether the clusters of PTSD symptoms identified in North American and European studies could be replicated in a Brazilian sample composed of 805 primary care patients living in hillside slums. Volunteers were asked to fill out the Brazilian version of the Posttraumatic Stress Disorder Checklist-Civilian Version and a confirmatory factor analysis of this scale was conducted with the software LISREL 8.80. Seven models were tested and a 4-factor, first-order solution including an emotional numbing cluster was found to provide the best fit. Although PTSD has been characterized by some critics as a Western culture-specific disorder lacking universal validity, our results seem to uphold the cross-cultural validity of the 4-factor, first-order model.

Transtorno de estresse pós-traumático como acidente de trabalho em um bancário: relato de um caso

Este artigo relata o caso de um gerente de banco atendido por uma equipe multidisciplinar atraves de anamnese psiquiatrica e ocupacional e aplicacao de entrevista psiquiatrica semi-estruturada (SCID) para transtorno de estresse pos-traumatico (TEPT). O objetivo do artigo e exemplificar, com um caso clinico, as relacoes entre o TEPT e eventos traumaticos ocorridos no trabalho, demonstrando que o TEPT pode ser uma consequencia de acidente de trabalho bancario. A visao do TEPT como doenca ocupacional e um conceito novo e relevante devido aos indices elevados de violencia no Brasil. O reconhecimento do TEPT no contexto do trabalho bancario e importante para orientar servicos de saude, administradores e profissionais de recursos humanos na prevencao de TEPT (treinamento adequado, suporte psicologico, emissao de Comunicacao de Acidente de Trabalho, intervencoes na organizacao do trabalho), visando a melhoria da qualidade de vida.

Adaptação transcultural para o português do instrumento Peritraumatic Dissociative Experiences Questionnaire, Versão Auto-Aplicativa

INTRODUCCION: El articulo presenta la adaptacion transcultural al portugues del instrumento Peritraumatic Dissociative Experiences Questionnaire, Self-Report Version (PDEQ-SRV), para rastrear y cuantificar los fenomenos disociativos peritraumaticos. METODOS: Se hicieron dos traducciones y sus respectivas re-traducciones, evaluacion de la equivalencia semantica, elaboracion de la version sintesis, pre-test en el publico-objetivo y realizacion de la version final. RESULTADOS: Se observo un alto grado de equivalencia semantica entre el instrumento original y los dos pares de traducciones/re-traducciones, desde la perspectiva de los significados referencial y general. El pre-test en el publico-objetivo condujo a pocas modificaciones que confirmaron la realizacion de los criterios de equivalencia semantica. DISCUSION: El trabajo permite la primera adaptacion para el contexto brasileno de un instrumento especifico para identificacion y cuantificacion de sintomas disociativos peritraumaticos.BACKGROUND: This paper presents the cross-cultural adaptation to Brazilian Portuguese of the Peritraumatic Dissociative Experiences Questionnaire, Self-Report Version (PDEQ-SRV), aimed at the screening and quantification of peritraumatic dissociative phenomena. METHODS: Two translations and their respective back-translations were carried out, followed by semantic equivalence evaluation, preparation of the synthesis version, pre-testing in the target population, and definition of the final version. RESULTS: A high level of semantic equivalence was observed between the original instrument and the two pairs of translations/back-translations in terms of the referential and general meanings. The pre-testing stage in the target population led to few alterations aiming at fulfilling semantic equivalence criteria. DISCUSSION: This study presents the first adaptation to the Brazilian context of an instrument specifically designed to detect and quantify peritraumatic dissociative symptoms.

Comorbid depressive symptoms in treatment-seeking PTSD outpatients affect multiple domains of quality of life.

PURPOSE No study has examined the impact of the comorbid Axis I conditions on the quality of life (QoL) of patients with a primary diagnosis of PTSD. Our goal was to investigate the influence of comorbid disorders on the QoL of treatment-seeking outpatients with PTSD. METHODS The diagnoses of PTSD and of the comorbid disorders were established using the SCID-I. The 54 volunteers also completed the Posttraumatic Stress Disorder Checklist - Civilian Version, the BDI, the BAI, the Trauma History Questionnaire, and a socio-demographic questionnaire. Quality of life was assessed by means of the WHOQOL-BREF, a 26-item self-administered scale that measures four domains of QoL: psychological, physical, social, and environmental. Multiple linear regression models were fitted to investigate the relationship between the severity of post-traumatic, mood, and anxiety symptoms; the presence of specific current comorbid disorders and of psychotic symptoms, the number of current comorbid conditions, and a history of child abuse for each of the four domains of QoL, after adjusting for the effect of socio-demographic characteristics. RESULTS The severity of PTSD symptoms impacted negatively on the psychological and physical domains. The severity of depressive symptoms correlated negatively with QoL in all domains, independently of sex, age, occupation, and marital status. The psychotic symptoms impacted negatively on the environmental domain. A history of child abuse was negatively associated with the psychological and the social domains. CONCLUSIONS The severity of comorbid depressive symptoms is one of the most important factors in the determination of the QoL in patients with PTSD.