Monday, 12 September 2011
PTSD Can Surface for Years After Initial Trauma, Post-9/11 Study Shows Pauline Anderson http://www.medscape.com/viewarticle/703572
May 29, 2009 — A new study that assessed New Yorkers exposed to the events of September 11, 2001 provides additional evidence that posttraumatic stress disorder (PTSD) can surface up to 2 years after the event in individuals with preexisting emotional or social problems.
The study, which offers unique insights into the effects on the population of the same traumatic event, found that possible contributing factors to PTSD include a history of depression, female sex, Latino ethnicity, and low self-esteem.
In addition to this delayed reaction, the response to the original traumatic event could be triggered by a subsequent stressful event, such as a job loss, said lead author, Joseph A. Boscarino, PhD, from the Geisinger Center for Health Research, in Danville, Pennsylvania.
"Doctors should be aware of these background factors and that there could be a triggering event that all of a sudden causes a person to lose his or her psychological resources and social support and could manifest in a full-blown PTSD reaction," Dr. Boscarino told Medscape Psychiatry.
"They might misdiagnose this symptom onset as depression or substance abuse, and it's not. If these patients don't get to psychotherapy or get to a mental-health professional, the diagnosis might be missed."
The study is published online March 7 in Social Psychiatry and Psychiatric Epidemiology.
Dr. Boscarino and colleagues interviewed a random sample of English- and Spanish-speaking adults who were living in New York City on the day of the World Trade Center (WTC) disaster. At baseline, they conducted 2368 diagnostic interviews by telephone about between October and December 2002. At 1-year follow-up, they interviewed 1681 of the original sample.
To meet PTSD criteria, subjects had to be exposed to a traumatic event and to have experienced intense feelings of fear, helplessness, or horror. In addition, they had to have suffered symptoms of avoidance, intrusive thoughts, and increased arousal for at least 1 month, and these symptoms had to have a negative impact on their functioning or caused significant distress.
The baseline and follow-up PTSD assessments covered the year prior to the date of the interview.
Delayed And Persistent Cases
Investigators classified resilient cases of PTSD as those that did not meet PTSD criteria at either baseline or follow-up and remitted PTSD cases as those that met criteria at baseline but not at follow-up. Delayed PTSD cases did not meet criteria at baseline but did at follow-up, and persistent PTSD cases met criteria at both baseline and follow-up.
Demographic variables included age, sex, marital status, and race. Stress variables included degree of exposure to the WTC disaster (low, moderate, high, or very high) and traumatic events experienced before or during the year after the WTC disaster. Psychosocial variables included social-support availability and self-esteem. Researchers also assessed respondents for lifetime depression, panic attack during the WTC disaster, handedness, and presence of attention-deficit disorder (ADD).
The study found that the majority of PTSD cases that occurred at baseline and follow-up appeared to be related to the WTC disaster and not to some other trauma — not surprising, considering the impact of this event.
Lifetime Trauma Significant
At baseline, there were significant associations between PTSD and being female (odds ratio [OR], 3.64), having depression before the WTC disaster (OR, 3.30), having been exposed to more lifetime traumas (OR, 1.33), having self-esteem (OR, 0.88), having social support (OR, 0.90), and having greater exposure to the WTC-disaster events (OR, 1.34).
At follow-up, the most important associations with PTSD were being Latino (OR,2.33), being mixed-handed (OR, 2.61), being an immigrant (OR, 1.95), having experienced recent negative life events (OR, 1.92), having been exposed to more lifetime traumas (OR, 1.19), and having self-esteem (OR, 0.77).
Compared with resilient cases, persistent PTSD — those cases present at baseline and at follow-up — were more likely to have a history of depression (RR, 4.08); be mixed-handed (relative risk [RR], 4.63), female (RR, 2.80), an immigrant (RR, 2.73), or Latino (RR, 2.54); having had greater negative life events (RR, 2.20), greater WTC-disaster exposure (RR, 1.70), or greater lifetime trauma exposure (RR, 1.40); and having self-esteem (RR, 0.75).
Being Latino seems to carry a special vulnerability to PTSD even after for socioeconomic status and language were controlled for, said Dr. Boscarino, adding that it is not clear why this is.
Ambidextrous Individuals More Vulnerable
The genetic predisposition to be able to use both hands interchangeably is another prominent risk factor for PTSD. "It means your brain is wired somewhat differently, and your right brain is dominant," said Dr. Boscarino. "When that occurs, it appears that you're more susceptible to emotional responses, and you have a greater, more intense fear response."
This study found that females were at risk for PTSD at baseline, although they tended to recover somewhat by the follow-up period, and other studies show that war veterans are more susceptible than civilians to posttraumatic stress, suggesting that female veterans might be at especially high risk for this disorder.
"From the studies I've seen, women soldiers who had domestic problems and then served overseas are more vulnerable to PTSD," said Dr. Boscarino. He added that the US government is working to address stress among female veterans.
Delayed onset of PTSD may help explain why some veterans with few initial symptoms remain vulnerable to PTSD over a relatively long period of time, said the Dr. Boscarino. Factors that might explain the delay could include underreporting of symptoms at an initial assessment or overreporting of symptoms at later assessments.
Loss of Coping Mechanism
The fact that PTSD symptoms can appear 2 years after a stressful event is important, since currently the definition of delayed-onset PTSD encompasses symptoms that surface only up to 6 months following an event, said Dr. Boscarino. He added that a "triggering" situation, such as a job loss, financial problem, or death in the family years after the initial event can cause individuals to lose their coping mechanisms.
"Delayed PTSD is not something that people make up; it is real, and there are risk factors that can predict it," said Dr. Boscarino.
Complicating delayed PTSD are matters related to disability and compensation. "The whole issue of delayed PTSD is still being worked out in medical sciences and in the courts," he said.
Information on the length of time from a trauma to symptom onset as well as information on past mental health and the presence of potential "triggering" events should be taken into consideration when making a diagnosis of PTSD, especially delayed PTSD, said Dr. Boscarino.
Study Missed the "Big Bump"
Since the study did not start until a year after 9/11, it missed "the big bump" in PTSD among New Yorkers just after the disaster, said David Spiegel, MD, from Stanford University School of Medicine, in California, when asked for a comment. At that time, residents of certain areas of the city had rates of PTSD of up to 20%, he said.
"Much of the acute PTSD came and went within 6 months, so this study is dealing with relatively late and chronic cases."
Still, the findings are important, said Dr. Spiegel. For one thing, they send an important message — that early social support can serve as a "buffer" to protect against posttraumatic stress. "People who don't have good social support are more likely to get PTSD."
The authors report no conflicts of interest.
Soc Psychiatry Psychiatr Epidemiol. Published online March 7, 2009. Abstract