Editorial

Trauma research: A new era

This randomized controlled pilot study compared a cognitive-behavioral therapy (Seeking Safety; SS) plus treatment-as-usual (TAU) to TAU-alone in 49 incarcerated women with substance use disorder (SUD) and posttraumatic stress disorder (PTSD; full or subthreshold). Seeking Safety consisted of a voluntary group treatment during incarceration and individual treatment after prison release. TAU was required in the prison and comprised 180 to 240 hours of individual and group treatment over 6 to 8 weeks. Assessments occurred at intake, 12 weeks after intake, and 3 and 6 months after release from prison. There were no significant differences between conditions on all key domains (PTSD, SUD, psychopathology, and legal problems); but both conditions showed significant improvements from intake to later time points on all of these outcomes across time. Secondary analyses at follow-up found trends for SS participants improving on clinician-rated PTSD symptoms and TAU participants worsening on self-reported PTSD symptoms. Also, SS demonstrated continued improvement on psychopathology at 3 and 6 months, whereas TAU did not. However, alcohol use improved more for TAU during follow-up. Satisfaction with SS was high, and a greater number of SS sessions was associated with greater improvement on PTSD and drug use. Six months after release from prison, 53% of the women in both conditions reported a remission in PTSD. Study limitations include lack of assessment of SS outcomes at end of group treatment; lack of blind assessment; omission of the SS case management component; and possible contamination between the two conditions. The complex needs of this population are discussed.

The history of trauma research is a relatively short one, dating back to the introduction of post-traumatic stress disorder (PTSD) into the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Whilst the introduction of PTSD has provided a major impetus for the scientific investigations of post-traumatic conditions in a variety of samples, fewer epidemiological studies have been conducted in the general population for both adults and children. Large differences in the lifetime prevalence rates reported for adult exposure to traumatic events (3.9–89.6%) as well as for PTSD (1.0–11.2%) have been observed owing to variations in the design, sampling strategies, and method of diagnostic assessments used. Despite these differences, however, several consistent findings have emerged, although it remains unclear to what extent the outcome of population-based surveys conducted predominantly in the USA can be generalized to other countries. Similarly, disasters occur in a wide variety of settings and circumstances, thereby introducing a number of methodological challenges that may deviate substantially from those commonly used in traditional epidemiological studies. Systematic reviews of the disaster literature based on meta-analyses have sought to address these limitations. A similar approach has been applied to the identification of vulnerability factors for PTSD in trauma-exposed adults to establish why considerable individual differences exist. Such knowledge is imperative to inform the selective use of interventions. We still await a better understanding of why some individuals display positive changes after trauma, given evidence of resilience in the face of even the most severe stressor.

For centuries, reports of severe emotional reactions to various adversities have been recorded. Historically, however, military combat has been the richest source of information about how individuals react to particularly disturbing events. On the other hand, over the last 20 years, much greater (and very welcome) attention has been paid to civilian trauma, not just those catastrophic events that capture the attention of the media but also those disturbing events of everyday life such as criminal assault and road, industrial and domestic accidents. This contribution identifies key epidemiological findings regarding the prevalence and incidence of post-traumatic disorders following many different kinds of military and civilian trauma. It also acknowledges that there is an urgent need for a wider range of epidemiological data, particularly from the UK. This contribution also emphasizes the complexity of the aetiology of post-traumatic disorders and identifies key factors which increase the likelihood of an individual developing such a condition. Two key emphases in this contribution are: (i) that not all those individuals exposed, even to the most disturbing events, will necessarily develop a post-traumatic disorder; and (ii) that post-traumatic stress disorder (PTSD) per se is relatively uncommon except in the context of comorbidity. This contribution describes the epidemiology of post-traumatic conditions (with a particular emphasis on PTSD) and the relevant vulnerability factors to their development.

Aims: To identify the prevalence of post-traumatic psychological symptoms after maxillofacial trauma and prognostic factors related to poor outcome.

Methods: Thirty-nine patients were assessed within 10 days of injury and 24 again 4–6 weeks later using five standardised self-report measures on each occasion and a short structured interview at the time of initial contact.

Results: Specific post-traumatic psychological symptoms were present at initial assessment in 21 patients (54%), with 9 (41%) meeting diagnostic criteria for post-traumatic stress disorder at review 4–6 weeks later. Other psychiatric problems, such as anxiety and depression, were identified by the General Health Questionnaire and the Hospital Anxiety and Depression Scale. Characteristics associated with poorer outcome included: a previous history of psychological distress; fear of the unknown, and female sex.

Conclusion: These findings highlight the adverse psychological effect of maxillofacial trauma both immediately after the event and 4–6 weeks after injury. Proper assessment of injured patients must include psychological aspects and further research is needed to identify the most appropriate response.

We provide an overview of the current understanding of posttraumatic psychological problems, such as posttraumatic stress disorder, and the implications for maxillofacial surgeons and allied professionals. Posttraumatic stress disorder is not confined to combat veterans; it is common after all traumatic events—including maxillofacial injury—and can become chronic unless recognized and treated. The neurobiologic underpinnings of and the known vulnerability factors for posttraumatic stress disorder are increasingly understood, assisting the nursing and surgical staff in their assessments. Both psychological and pharmacologic treatments have been shown to have efficacy; nevertheless, intervention by mental health professionals will not be required by all. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:515-20)

In this paper the experiences of the chronically ill are examined to explore the impact of post-traumatic stress disorder (PTSD), accumulated burden of adversity and trauma spectrum disorder on subsequent illness and coping behaviors. Individuals experiencing chronic diseases have been studied with regard to depression, anxiety and a variety of coping maladaptions, but negligible attention has been given to the PTSD potential of chronic disease over the life course. Yet, growing evidence suggests that the traumatogenic potential of chronic diseases, some sudden and unexpected onsets, and the traumatogenic changes in life circumstance, may produce maladaptive illness coping over the life course. More importantly, attention needs to focus on the additive effect of co-morbid life events and the traumatic potential of invasive medical therapies. Consideration of PTSD and a continuum of cumulative adversity provide a more complex and fully drawn understanding of the circumstances surrounding chronic illness coping and reasons for maladaptive coping following invasive therapies and changes in the disease trajectory. The pathophysiology that produces a chronic diseases does not begin at symptom onset, and the psychosocial strategies to cope with a chronic illness, whether efficacious or maladaptive, also do not begin at symptom onset, but develops over the life course.