Postcards from the Id

Early Psychological Intervention Does Not Prevent Onset Of PTSD

This article reviews new research that indicates efforts to reduce the later development of Post Traumatic Stress Disorder (PTSD) following a traumatic event are ineffective in that goal.  The researchers examined data where, following a traumatic event, all individuals who were involved were provided some form of therapeutic intervention.  The efforts did not reduce the number of PTSD cases that developed later; in fact, the researchers noted the early efforts may have led to an increase in reported symptoms.  From the article:

PTSD is a condition that affects people who undergo extremely stressful experiences, such as earthquakes, violent crimes and military combat. They may suffer long-lasting psychological difficulties as a result. Experts have been trying to develop effective treatments to prevent PTSD from developing for 25 years, but there is little evidence that those used routinely offer any benefit.

The review encompassed people of all risk levels. Researchers looked at data from eleven studies involving a total of 941 people exposed to traumatic events. These studies offered interventions, which included cognitive behavioural therapy and individual and group counselling, to people whether or not they were experiencing symptoms of PTSD. None of these was effective at preventing PTSD. Patients given the treatments were more likely to report symptoms of PTSD after three to six months than patients who were not.

The study was quick to point out that all individuals were included in the study, not just those already reporting some level of symptomatology; that may account for the non-significant findings.  However, the article also notes how efforts toward finding an “early prevention” type of intervention have been going on for a long time, without any major breakthroughs thus far.  I’d have to imagine the military has been looking at this as well, for obvious reasons, and I suppose they haven’t been able to come up with a prevention intervention either.

My own experience with this, both as a psychologist in general and my participation on my facility’s crisis support team, is that this research confirms what we already know up until now.  I know there was a big push for critical incident stress debriefing as a primary form of this type of preventive intervention, but the research on debriefing is similar to that found above - no definitive help, and possibly harmful to some.

My brief take on the role mental health professionals and others can play in the immediate aftermath of a traumatic incident is simple - follow Maslow’s Hierarchy of Needs, normalize the individual’s response to the event, and help prepare the individual for needed help later by simply observing what might happen, and offering to facilitate needed services att any point in the future.  At this time, there is nothing one can “do” to prevent the onset of PTSD, so don’t try.  Help by addressing more immediate concerns (even getting someone a bottle of water, cup of coffee, etc.), being there for the individual, reducing their worry about other issues (i.e. helping out with child care arrangements, etc.).  This is the stuff that matters early on.  Later, if issues emerge, we can treat it.

Childhood Predictors of Adolescent Depression

Here’s an interesting article summing up recent research into the precursors of adolescent depression. For boys, it’s primarily anxiety, but with girls, it’s anxiety as well as antisocial behavior. Surprisingly, early depression did not predict later depression as much as these other warning signs. From the article:

"Anti-social behavior has typically been viewed as a big problem among boys, so it tends to be ignored among girls. Boys with early anti-social behavior typically go on to show more anti-social behavior while girls may turn inward with symptoms, morphing into other mental health problems such as depression eating disorders, anxiety and suicidal behavior during adolescence ," said James Mazza, a UW professor of educational psychology and lead author of the new study. He is currently serving as the past president of the American Association of Suicidology.

"When all the risk factors were analyzed, anti-social behavior and anxiety were the most predictive of later depression. It just may be that they are more prevalent in the early elementary school years than depression." He noted that depression and anxiety share a number of symptoms.

A couple of quick observations. First, it is a general trend that women display high incidences of “inward” mental health difficulties (e.g. depression, anxiety) while men tend to have higher incidences of “outward” mental health diagnoses (i.e. antisocial personality disorder). Interesting how the antisocial stuff continues to develop in boys, but with the girls, the focus shifts once adolescence is reached.

Also, this research again confirms the link between early anxiety and later depression, which I wrote about here. Again, if you are a parent or professional, please do not discount anxiety in kids: anxious kids grow up to be depressed adults, which is not a good thing. Nip these types of problems early, when the symptoms are more manageable, and a whole lot of discomfort and misery can be avoided.

What is also interesting about this study is that it demonstrates that children have some insight into their moods - the authors indicated the kids were able to successfully communicate their difficulties with the help of questionnaires. This is a good thing, insofar as we don’t have to rely solely on the observations of parents, teachers, and others. What this also means is that we need to take kids seriously - obviously, an over-reaction to the occasional stressor is one thing, but if a child is communicating regular discomfort with worry, it is worth it to examine it further.

Panic Attacks and Their Relationship to Heart Difficulties

I came across this interesting article today, which discusses recent research finding with respect to Panic Disorder (a mental health diagnosis) and its relationship to heart attacks and other coronary difficulties. The research suggests that there is a small increase in the future likelihood of a heart attack in those individuals who have had a panic attack prior to the age of 50. Conversely, those same individuals are less likely to die as a result of heart problems than the population at large. From the article:

Dr Walters and her colleagues looked at primary care medical records for 57,615 adults diagnosed with panic attacks/disorder and 347,039 adults who did not have the condition. They found that those aged under 50 were more than a third (38%) as likely to have a heart attack and nearly half (44%) as likely to develop heart disease subsequently than people who had not been diagnosed with the condition. For people aged over 50 there was a slightly increased risk of heart disease (11%).

However, when the researchers looked at deaths amongst adults diagnosed with panic attacks/disorder, they found that for all ages the risk of death from heart disease was reduced by about a quarter (24%) compared with the normal population.

The article is fairly well detailed, and offers some speculation about the possible reasons for these associations. What I find interesting about this is the ongoing complexity of the relationship between panic and heart problems. Simplistically, they are separate issues, at least in terms of etiology. However, their symptoms often mirror each other: many individuals who are subsequently diagnosed with a panic disorder are first seen at an emergency room, simply because the symptoms often feel like a heart attack.

On the other hand, this research may suggest there is some sort of additional relationship between the two. Back in the day when I was doing much more treatment, I would discuss panic attacks as part of my stress management groups. I would note that on the one hand, if one is having a panic attack, they are not experience a severe, acute physical problem (though the symptoms are severe, acute, and extremely uncomfortable). On the other hand, I would also note that chronic stress, anxious responses to that stress, and in particular panic-like responses are also not very good for one’s long-term health. In addition, the lifestyles often adopted by those with significant cases of panic disorder are not conducive to a healthy, balanced lifestyle. People will often restrict their activities as a result of panic, to include things like exercise - restrictions that would then negatively impact one’s health.

I think a couple of things come out of this article that are important considerations for anyone dealing with panic, either as a clinician or a client (or the family member of a person with panic). First, get treatment for it. Regardless of what the actual link is, obviously getting panic under control is an all-around good thing. Secondly, don’t consider only one half of the dynamic. Doctors, consider the need to refer for therapy. Therapists, refer the client for a physical. While the gap between the medical and mental health fields is shrinking, it is still prevalent,and I have no trouble acknowledging that mental health professionals often forget to consider the medical aspects of certain issues during the course of their treatment of a client, particularly when the issue is not being addressed by medication. If you or a person you know suffers from panic - visit both! One’s condition may not be either/or - it may be a combination of both mental health and medical issues. And even if the etiology is medical, a mental health consultation may help point you in the right direction regarding future changes to your lifestyle, changes to address the condition.

Anxiety May Stave Off Criminality Until Adulthood (at least for some)

According to this research, childhood issues associated with anxiety, including nervousness and social withdrawal, may prevent a certain subgroup of teens from acting criminally, at least until adulthood.  Once adulthood is reached, however, the effect appears to wear off.  From the article:

The authors found that being nervous and withdrawn shielded boys against committing criminal acts during adolescence, but, after the age of 21, it no longer held them back. Compared with early onset offenders, late onset criminals were more nervous, had fewer friends from ages 8 to 10, and were less likely to have had sexual intercourse by the age of 18. Compared with nonoffenders, those who turned to crime later in life were more anxious at school from ages 12 to14 and very neurotic by age 16.

I haven't read the actual research, just the article, but this makes some intuitive sense, if we broadly consider two different antisocial categories based on psychopathy (despite psychopathy being a continuous rather than discrete variable).  Individuals loading high on psychopathy will generally experience relatively little anxiety, both generally as well as specifically towards potential consequences.  This is in comparison to individuals who may have a predisposition towards antisocial behavior, but for reasons other than psychopathy.  The anxiety the non-psychopathic adolescents experience appears strong enough to prevent acting out, at least until they reach adulthood.

From an intervention perspective, the article's suggestion that certain efforts may be effective in preventinglate-onset antisocial behavior in this group, if we can address soem of the underlying factors prior to adulthood.  I'd certainly give this much more credence with this subgroup than with the psychopathic subgroup, who (at best) it can be argued require a whole different set of interventions that (as of now) haven't been shown to be statistically effective. 

New Study Finds Both Therapy and Zoloft Effective in the Treatment of Childhood Anxiety

Good news from the world of mental health research. According to this article, a new study has found both cognitive-behavioral therapy (CBT) and Zoloft to be effective in the treatment of childhood anxiety disorders (when compared to a control group that was simply administered a placebo), and that a combination of the two treatments proved to be even more effective. From the article:

The children had been diagnosed with a range of moderate to severe disorders, including separation anxiety, generalized anxiety and social phobia. Some of the children also had more than one disorder, including other anxiety disorders, attention deficit hyperactivity disorder and behavior problems.

Walkup and colleagues found that:

81 per cent of the children in the combined treatment group improved.

This compared with 60 per cent of the children in the CBT only group and 55 per cent Zoloft only group.

In the placebo group, 24 per cent of the children improved.

Children taking Zoloft showed no more side effects that children taking placebo and few children withdrew because of side effects.

No child attempted suicide, a rare side effect that can sometimes accompany use of antidepressants in children.

The article offers a brief description of both CBT and Zoloft, including their mechanism for facilitating improvement. What I appreciate about this particular article is that it noticed the effectiveness of CBT independent of any medication:

The findings reflect other studies that showed Zoloft and other SSRIs were effective treatments for childhood anxiety disorders. But the authors said this study also adds more evidence that high quality CBT, with or without medication, is an effective treatment for childhood anxiety disorders.

Continuing to identify the effectiveness of properly conducted therapy is paramount in helping the general population overcome any concerns or stigma they may have about the process. In addition, not all individuals respond to psychopharmacological treatment; documenting effective alternative treatments will give clients choices when it comes to dealing with these issues.

As I noted in an earlier post, anxiety is not only an important treatment issue in its own right, it is significantly associated with later development of depression. In short, “anxious kids often become depressed adults.” Learning to counteract the cognitive and behavioral patterns that lead to, and maintain, a state of anxiety would be the best preventative method towards reducing depression in adults. The article indicates that this research is continuing, which is also very good news. If you are interested in seeing the actual research article, follow the initial link, and click through at the bottom of that page.

Article Addresses Current Research into the Development of Anxiety and Depression

Here is a fairly comprehensive article that reviews some current research into the development of anxiety and depression disorders in teenagers. The researchers note anxiety and depression are often comorbid, and that anxiety usually (but not always) develops first). They also discuss the role neuroticism plays as a precursor to an anxiety disorder. The article is a bit confusing here, as they describe neuroticism in a manner that sounds an awful lot like anxiety. However, what they appear to be describing is neuroticism as a personality style that leads to individuals to experience negative feelings in excess of what the situations demands, which in turn leads to the development of anxiety, described more as an Axis I disorder. In the study, individuals were shown green and red cards; the green cards were “safe,” while the red cards signified “danger,” and were accompanied by mild shocks (following a build up to the shocks). Individuals high on neuroticism responded with a more generalized fear response, while low-neuroticism individuals exhibited fear only as the shock approached. The thinking is that individuals with high levels of neuroticism tend to generalize their anxious responses over time, to situations that don’t pull for it, or at least don’t have adverse responses consistent with the level of fear experienced. From the article:

"This is interpreted as neuroticism leading to enhanced anxiety under conditions associated with aversive events but in which negative events themselves are very unlikely," Craske said. "It may represent a failure to distinguish conditions that are safe from conditions in which threatening events are very likely to occur. By translation, these findings suggest that persons with high neuroticism would respond with appropriate fear to actual threatening events, but with additional unnecessary anxiety to surrounding conditions. This type of responding may explain why neuroticism contributes to the development of pervasive anxiety."

The article also reviews another study examining the potential for anxiety in children ages 7-12. From the article:

Craske and her colleagues measured physiological responses to a cue that was associated with — or "conditioned" to — a brief, loud noise. They then measured how fast these responses disappeared or extinguished when the cue was presented without the loud noise. They found an increase in sweat gland activity during the conditioning phase in anxiety-disordered children, and less extinction of this response in the at-risk children to cues that signaled the loud noise and also cues that did not signal the loud noise.

These findings suggest that anxiety and risk for anxiety in children are associated with "elevated excitatory responding to 'threat' cues and impaired inhibition of responses to 'safe' cues," according to Craske. The latter finding parallels the findings of unnecessary anxiety to conditions surrounding threatening events in adolescents high in neuroticism.

Interesting stuff, and extremely relevant. Research like this will continue to help treatment providers focus on the cognitions and behaviors that play a role in reinforcing these maladaptive responses to environmental cues. I won’t go into detail on my take on anxiety and depression again, but here is a link to a post I wrote some time ago related to these issues.

Anxiety and Insomnia Increase Risk Of Diabetes in Men

According to this research, men who experience psychological distress (including anxiety and insomnia) part significantly greater risk for developing Type 2 diabetes. Anxiety and depression have already been implicated in the development of heart disease, and were suspected of playing a role on the development of diabetes as well. From the article:

The men were tested for diabetes eight to ten years later and it was found that the men with the highest levels of psychological distress were 2.2 times more likely to develop Type 2 diabetes than those with the lowest levels. Altogether 103 men developed Type 2 diabetes.

Interestingly, women were not found to be at greater risk. In addition, the mechanism for this association will require further research. However, one important point to take away from this article is the ongoing documentation that one’s mental health functioning is significantly related to one’s overall functioning. This includes the observation of the impact of insomnia, which I’ve discussed previously as a simple barometer for assessing one’s overall level of functioning. In other words, if your sleeping well your doing well, and vice versa. I continue to expect that as research like this comes out, there will be an increased priority on addressing issues such as insomnia. Hopefully, the general public will also increase its willingness to address such issues, and not simply through the use of sleeping medication, but by actually addressing the problem. Not only will people function better, their health will improve.

PTSD And Its Impact on Depression and Pain

This is a brief article discussing the role of PTSD in the treatment of pain associated with the experience of trauma. According to the researchers, PTSD and depression are significantly correlated, and both increase the individual's perception of being disabled as a result of their pain. The authors suggest treatment providers place increased focus on treating PTSD for individuals who have experienced these types of events, particularly if the treatment of the pain by itself has been unsuccessful. Obviously, this would make a great deal of sense, given that individuals experiencing depression tend to have negative expectations for the outcomes of most future situations. It would seem reasonable to expect that individuals experiencing depression along with chronic pain would perceive themselves negatively, and experienced pessimism towards any intervention. The PTSD would reinforce this in a number of ways, including reinforcing the pessimism with an additional sense of a lack of self efficacy, making the trust between the individual and their treatment provider less stable, and inhibiting many otherwise healthy behaviors that could contribute to the reduction of pain (such as exercising outdoors). All in all, this article would seem to be another endorsement of the idea that clinicians need to approach an individual’s difficulties with an appreciation for all of the various issues that are present, and consider how certain symptoms (left undressed) may interfere with the treatment of other symptoms.

Brain Scans Assess Impact of Obsessive-Compulsive Disorder

According to this research, researchers have uncovered evidence that individuals with obsessive-compulsive disorder(OCD), as well as their family members, may experience understimulation in the part of the brain responsible for discontinuing habitual behavior. The article notes that OCD is currently diagnosed via clinical interview, and generally after the disorder is already prevalent. Research along these lines will hopefully allow for an earlier assessment of the issue, as well as some sort of intervention that would either prevents OCD, or at least reduce its severity. The article also briefly touches on the nature of OCD, and describes in more detail the nature of the clinical findings. From the article:

Dr Chamberlain, who led the study, explains, "Impaired function in brain areas controlling flexible behaviour probably predisposes people to developing the compulsive rigid symptoms that are characteristic of OCD. This study shows that these brain changes run in families and represent a candidate vulnerability factor. The current diagnosis of OCD is subjective and improved understanding of the underlying causes of OCD could lead to more accurate diagnosis and improved clinical treatments.

OCD can be a fairly debilitating mental health issue, and unfortunately one in which otherwise healthy individuals will attempt to conceal to shame or embarrassment. Treatments have been improving, both therapeutically and pharmacologically, but there is still much work to be done. Incidentally, a very good book to read if one is interested in learning more about this disorder is entitled The Boy Who Couldn’t Stop Washing. Written for the lay person, it is a fascinating exploration of OCD, with multiple examples. In addition, it gives the reader and idea of just how difficult living with OCD can be. I haven’t read it in a while, so I don’t know if it might be a bit dated at this point (in terms of the science), but the stories should still be relevant. Definitely worth reading.

PTSD May Contribute to Heart Disease, Early Death

This article reviews new research suggesting that those suffering from PTSD may be up to two times more likely to die from heart disease than others. In addition, the more serious the PTSD, the more one is at risk. From the article:

PTSD causes the body to release stress hormones, which leads to the inflammation and damage to the arteries and cardiovascular system damage. Stress hormones also tend to reduce the amount of inflammation-reducing cortisol in the body--though researchers aren't sure why.

"Increased levels of stress hormones and less cortisol from PTSD are a bad combination," Dr. Boscarino explained. "Basically, PTSD just cooks your arteries in this situation."

The researchers examined over 4000 Vietnam veterans. They found the association between PTSD and heart disease by examining Vietnam veterans who were diagnosed with PTSD verses those who had not been. The researchers also noted. The more generalized association between PTSD and negative health indicators:

Dr. Boscarino previously found that people with PTSD had dramatically higher rates of chronic health problems such as psoriasis, arthritis and other inflammatory diseases.

"The science is conclusively showing that if you suffer psychological trauma, it's going to take a toll on your physical health," Dr. Boscarino said. "Getting counseling today is critical to avoiding a related problem tomorrow."

I was very much encouraged to read that last paragraph. In particular, effective therapy for PTSD will include teaching the client how to both reducing and manage the physiological response to their trauma history. This will include building skills that aid the client in reducing physical symptoms as they arise, as well as reduce the frequency and intensity of physical arousal in response to triggers. As noted above, it is the increased levels of stress hormones that has been implicated in the development of the chronic health problems. It would appear that effective treatment of PTSD, including the addressing of the physical symptoms that characterize this disorder, what helped to reduce the likelihood of developing such health problems.