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Delirium is one of the most common behavioral manifestations of acute brain dysfunction in the intensive care unit (ICU) and is a strong predictor of worse outcome. Routine monitoring for delirium is recommended for all ICU patients using validated tools. In delirious patients, a search for all reversible precipitants is the first line of action and pharmacologic treatment should be considered when all causes have been ruled out, and it is not contraindicated. Long-term morbidity has significant consequences for survivors of critical illness and for their caregivers. ICU patients may develop posttraumatic stress disorder related to their critical illness experience.
Published by Elsevier Inc.
INTRODUCTION - Hereditary hemorrhagic telangiectasia (HHT) is characterized by frequent severe bleeding, particularly epistaxis, and life-threatening complications including stroke, brain abscess and heart failure. The psychological impact of HHT is not known. We conducted this cross sectional study to determine the prevalence of depression and post-traumatic stress disorder (PTSD) related to HHT.
METHODS - A survey tool comprising demographic and clinical information and two validated self-administered questionnaires, the PTSD checklist for DSM-5 (PCL-5) and Beck Depression Inventory-II (BDI-II), was distributed to individuals with HHT. Associations with clinical and demographic variables with depression and PTSD were evaluated in a logistic regression model.
RESULTS - A total of 222 individuals responded to the survey. Of these, 185 completed either the BDI II or PCL-5 and were included in the analysis. Median age was 54years and 142 (76.8%) were female. An existing diagnosis of depression, anxiety disorder and PTSD was present in 81 (43.8%), 59 (31.9%) and 16(8.6%) respondents, respectively. BDI-II scores>13 indicating at least mild depressive symptoms were present in 142 (88.7%) patients and 52 (28.1%) patients had a positive screen for PTSD (PCL-5 score≥38). On multivariable analysis, depression [OR 2.17 (95% CI 1.045-4.489), p=0.038], anxiety disorder [OR 2.232 (95% CI 1.066-4.676), p=0.033], and being unemployed [OR 2.234 (95% CI 1.46-4.714), p=0.019) were associated with PTSD.
CONCLUSION - We report a high prevalence of depressive and PTSD symptoms in individuals with HHT. While selection bias may lead to overestimation of prevalence in this study, our results are concerning and clinicians should remain vigilant for signs of psychological distress and consider screening for these disorders.
Copyright © 2017 Elsevier Ltd. All rights reserved.
INTRODUCTION - Survivors of thrombotic thrombocytopenic purpura (TTP) have high rates of chronic morbidities including neurocognitive complications and depression. There is limited information regarding the psychological consequences of TTP. We conducted this cross sectional study to estimate the prevalence of symptoms of PTSD and depression in survivors of TTP.
METHODS - An online survey tool comprising demographic and clinical information and two validated self-administered questionnaires, the PTSD checklist for DSM-5 (PCL-5) and Beck Depression Inventory-II (BDI-II), was distributed to individuals with TTP. Multivariable regression was used to identify clinical and demographic associations of depression and PTSD.
RESULTS - A total of 236 individuals completed either the BDI II or PCL-5 and were included in the analysis. Median age was 44years and 87.3% were female. Median time from diagnosis was 80months. BDI-II scores >13 indicating at least mild depressive symptoms were present in 80.8% individuals (15.8%, 28.2%, and 36.8% with mild, moderate and severe symptoms, respectively) and 35.1% had a positive screen for PTSD (PCL-5 score≥38). A previous diagnosis of depression [OR 3.65 (95% CI 1.26-10.57); p=0.017] and unemployment attributed to TTP [OR 5.86 (95% CI 1.26-27.09); p=0.024] were associated with depression. Younger age (p=0.017), a pre-existing anxiety disorder [OR 3.57 (95% CI 1.76-7.25), p<0.001], and unemployment attributable to TTP [OR 6.42 (95% CI 2.75-415.00), p<0.001] were associated with PTSD.
CONCLUSION - We report a high prevalence of PTSD and depression in TTP survivors. These results are concerning and indicate a need for further investigation to better define this association and its consequences.
Copyright © 2017 Elsevier Ltd. All rights reserved.
OBJECTIVES - (1) To examine differences in patient-reported outcomes, neuropsychological tests, and thalamic functional connectivity (FC) between patients with mild traumatic brain injury (mTBI) and individuals without mTBI and (2) to determine longitudinal associations between changes in these measures.
DESIGN - Prospective observational case-control study.
SETTING - Academic medical center.
PARTICIPANTS - A sample (N=24) of 13 patients with mTBI (mean age, 39.3±14.0y; 4 women [31%]) and 11 age- and sex-matched controls without mTBI (mean age, 37.6±13.3y; 4 women [36%]).
INTERVENTIONS - Not applicable.
MAIN OUTCOME MEASURES - Resting state FC (3T magnetic resonance imaging scanner) was examined between the thalamus and the default mode network, dorsal attention network, and frontoparietal control network. Patient-reported outcomes included pain (Brief Pain Inventory), depressive symptoms (Patient Health Questionnaire-9), posttraumatic stress disorder ([PTSD] Checklist - Civilian Version), and postconcussive symptoms (Rivermead Post-Concussion Symptoms Questionnaire). Neuropsychological tests included the Delis-Kaplan Executive Function System Tower test, Trails B, and Hotel Task. Assessments occurred at 6 weeks and 4 months after hospitalization in patients with mTBI and at a single visit for controls.
RESULTS - Student t tests found increased pain, depressive symptoms, PTSD symptoms, and postconcussive symptoms; decreased performance on Trails B; increased FC between the thalamus and the default mode network; and decreased FC between the thalamus and the dorsal attention network and between the thalamus and the frontoparietal control network in patients with mTBI as compared with controls. The Spearman correlation coefficient indicated that increased FC between the thalamus and the dorsal attention network from baseline to 4 months was associated with decreased pain and postconcussive symptoms (corrected P<.05).
CONCLUSIONS - Findings suggest that alterations in thalamic FC occur after mTBI, and improvements in pain and postconcussive symptoms are correlated with normalization of thalamic FC over time.
Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
RATIONALE - The incidence and risk factors of post-traumatic stress disorder (PTSD) related to the intensive care unit (ICU) experience have not been reported in a mixed veteran and civilian cohort.
OBJECTIVES - To describe the incidence and risk factors for ICU-related PTSD in veterans and civilians.
METHODS - This is a prospective, observational, multicenter cohort enrolling adult survivors of critical illness after respiratory failure and/or shock from three Veterans Affairs and one civilian hospital. After classifying those with/without preexisting PTSD (i.e., PTSD before hospitalization), we then assessed all subjects for ICU-related PTSD at 3 and 12 months post hospitalization.
MEASUREMENTS AND MAIN RESULTS - Of 255 survivors, 181 and 160 subjects were assessed for ICU-related PTSD at 3- and 12-month follow-up, respectively. A high probability of ICU-related PTSD was found in up to 10% of patients at either follow-up time point, whether assessed by PTSD Checklist Event-Specific Version (score ≥ 50) or item mapping using the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). In the multivariable regression, preexisting PTSD was independently associated with ICU-related PTSD at both 3 and 12 months (P < 0.001), as was preexisting depression (P < 0.03), but veteran status was not a consistent independent risk factor for ICU-related PTSD (3-month P = 0.01, 12-month P = 0.48).
CONCLUSIONS - This study found around 1 in 10 ICU survivors experienced ICU-related PTSD (i.e., PTSD anchored to their critical illness) in the year after hospitalization. Preexisting PTSD and depression were strongly associated with ICU-related PTSD.
Hyperarousal and sleep disturbances are common, debilitating symptoms of post-traumatic stress disorder (PTSD). PTSD patients also exhibit abnormalities in quantitative electroencephalography (qEEG) power spectra during wake as well as rapid eye movement (REM) and non-REM (NREM) sleep. Selective serotonin reuptake inhibitors (SSRIs), the first-line pharmacological treatment for PTSD, provide modest remediation of the hyperarousal symptoms in PTSD patients, but have little to no effect on the sleep-wake architecture deficits. Development of novel therapeutics for these sleep-wake architecture deficits is limited by a lack of relevant animal models. Thus, the present study investigated whether single prolonged stress (SPS), a rodent model of traumatic stress, induces PTSD-like sleep-wake and qEEG spectral power abnormalities that correlate with changes in central serotonin (5-HT) and neuropeptide Y (NPY) signaling in rats. Rats were implanted with telemetric recording devices to continuously measure EEG before and after SPS treatment. A second cohort of rats was used to measure SPS-induced changes in plasma corticosterone, 5-HT utilization, and NPY expression in brain regions that comprise the neural fear circuitry. SPS caused sustained dysregulation of NREM and REM sleep, accompanied by state-dependent alterations in qEEG power spectra indicative of cortical hyperarousal. These changes corresponded with acute induction of the corticosterone receptor co-chaperone FK506-binding protein 51 and delayed reductions in 5-HT utilization and NPY expression in the amygdala. SPS represents a preclinical model of PTSD-related sleep-wake and qEEG disturbances with underlying alterations in neurotransmitter systems known to modulate both sleep-wake architecture and the neural fear circuitry.
OBJECTIVES - To determine whether delirium during the hospital stay predicted health-related quality of life (HRQOL) at 1 year after injury in trauma intensive care unit (ICU) survivors without intracranial hemorrhage, and to examine the association between depressive and posttraumatic stress disorder (PTSD) symptoms and each of the HRQOL domains at 1-year follow-up.
DESIGN - Prognostic cohort with a 1-year follow-up.
SETTING - Level 1 trauma ICU.
PARTICIPANTS - Adult patients without intracranial hemorrhage (N=173) admitted to a level 1 trauma ICU.
INTERVENTIONS - Not applicable.
MAIN OUTCOME MEASURES - HRQOL was measured with the Medical Outcomes Study 36-Item Short-Form Health Survey at 1 year after traumatic injury.
RESULTS - Average delirium duration ± SD was .51±1.1 days. Hierarchical multivariable linear regression analyses did not find a statistical relationship between delirium and HRQOL at 1-year follow-up. However, increased levels of depressive symptoms at 1 year were statistically associated with poorer functioning in all physical and mental health HRQOL domains, whereas PTSD at 1 year was statistically associated with all HRQOL domains except role-physical (P<.05).
CONCLUSIONS - There was no statistical association between delirium during the hospital stay and HRQOL at 1 year, which may be due to the short time spent in delirium by our study population. Depressive symptoms demonstrated a stronger relationship with mental and physical HRQOL domains at 1 year than PTSD, indicating their own unique pathway after trauma. Findings lend support for the separate assessment and management of depression and PTSD. Additional research on the duration and subtypes of delirium is needed within the trauma ICU population, as the effects are not widely known.
Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
BACKGROUND - Critical illness is associated with cognitive impairment, but mental health and functional disabilities in survivors of intensive care are inadequately characterised. We aimed to assess associations of age and duration of delirium with mental health and functional disabilities in this group.
METHODS - In this prospective, multicentre cohort study, we enrolled patients with respiratory failure or shock who were undergoing treatment in medical or surgical ICUs in Nashville, TN, USA. We obtained data for baseline demographics and in-hospital variables, and assessed survivors at 3 months and 12 months with measures of depression (Beck Depression Inventory II), post-traumatic stress disorder (PTSD, Post-Traumatic Stress Disorder Checklist-Event Specific Version), and functional disability (activities of daily living scales, Pfeffer Functional Activities Questionnaire, and Katz Activities of Daily Living Scale). We used linear and proportional odds logistic regression to assess the independent associations between age and duration of delirium with mental health and functional disabilities. This study is registered with ClinicalTrials.gov, number NCT00392795.
FINDINGS - We enrolled 821 patients with a median age of 61 years (IQR 51-71), assessing 448 patients at 3 months and 382 patients at 12 months after discharge. At 3 months, 149 (37%) of 406 patients with available data reported at least mild depression, as did 116 (33%) of 347 patients at 12 months; this depression was mainly due to somatic rather than cognitive-affective symptoms. Depressive symptoms were common even among individuals without a history of depression (as reported by a proxy), occurring in 76 (30%) of 255 patients with data at 3 months and 62 (29%) of 217 individuals at 12 months. Only 7% of patients (27 of 415 at 3 months and 24 of 361 at 12 months) had symptoms consistent with post-traumatic distress disorder. Disabilities in basic activities of daily living (ADL) were present in 139 (32%) of 428 patients at 3 months and 102 (27%) of 374 at 12 months, as were disabilities in instrumental ADL in 108 (26%) of 422 individuals at 3 months and 87 (23%) of 372 at 12 months. Mental health and functional difficulties were prevalent in patients of all ages. Although old age was frequently associated with mental health problems and functional disabilities, we observed no consistent association between the presence of delirium and these outcomes.
INTERPRETATION - Poor mental health and functional disability is common in patients treated in intensive-care units. Depression is five times more common than is post-traumatic distress disorder after critical illness and is driven by somatic symptoms, suggesting approaches targeting physical rather than cognitive causes could benefit patients leaving critical care.
FUNDING - National Institutes of Health AG027472 and the Geriatric Research, Education and Clinical Center (GRECC), Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System.
Copyright © 2014 Elsevier Ltd. All rights reserved.
Relatively few targets of sexual harassment cope with the psychological sequelae of their experiences by engaging in litigation. Those who do are often subjected to forensic examination to evaluate their history of psychological distress or disorder and to determine whether such a condition could be reasonably attributed to the alleged harassment, as opposed to some other cause. An unbiased approach to such examinations is critical to all parties, as well as to the profession itself. This study investigates the relationship between the clinical and restructured clinical scales of the Minnesota Multiphasic Personality Inventory-2, the Trauma Symptom Inventory subscales, the Crime-Related Posttraumatic Stress Disorder (CR-PTSD) scale, and an American Psychiatric Association diagnosis (APA, Diagnostic and statistical manual of mental disorders; DSM-IV-TR; 4th ed., text rev., 2000, Washington, DC, Author) of PTSD in a sample of sexual harassment plaintiffs. All measures performed well independently, but together provided improved predictive accuracy, suggesting that the use of multiple validated measures as well as structured diagnostic interviews may help us better understand litigants' experiences and reduce bias in evaluations.
PsycINFO Database Record (c) 2013 APA, all rights reserved
Although an attentional bias for threat-relevant cues has been theorized in posttraumatic stress disorder (PTSD), to date empirical demonstration of this phenomenon has been at best inconsistent. Furthermore, the nature of this bias in PTSD has not been clearly delineated. In the present study, veterans with PTSD (n = 20), trauma-exposed veterans without PTSD (n = 16), and healthy nonveteran controls (n = 22) completed an emotional attentional blink task that measures the extent to which emotional stimuli capture and hold attention. Participants searched for a target embedded within a series of rapidly presented images. Critically, a combat-related, disgust, positive, or neutral distracter image appeared 200 ms, 400 ms, 600 ms, or 800 ms before the target. Impaired target detection was observed among veterans with PTSD relative to both veterans without PTSD and healthy nonveteran controls after only combat-related threat distracters when presented 200 ms, 400 ms, or 600 ms before the target, indicating increased attentional capture by cues of war and difficulty disengaging from such cues for an extended period. Veterans without PTSD and healthy nonveteran controls did not significantly differ from each other in target detection accuracy after combat-related threat distracters. These data support the presence of an attentional bias toward combat related stimuli in PTSD that should be a focus of treatment efforts.
© 2013 American Psychological Association