An Enduring Somatic Threat Model of Posttraumatic Stress Disorder Due to Acute Life-Threatening Medical Events

Posttraumatic stress disorder (PTSD) occurs in 12–25% of survivors of acute life-threatening medical events such as heart attack, stroke, and cancer, and is associated with recurrence of cardiac events and mortality in heart attack survivors. This article reviews the current state of knowledge about PTSD after such events, and proposes an Enduring Somatic Threat (EST) model of PTSD due to acute life-threatening medical events to address underappreciated differences between PTSD due to past, discrete/external traumatic events (such as combat) and PTSD due to acute manifestations of chronic disease that are enduring/internal in nature (such as heart attack and stroke). The differences include the external versus internal/somatic source of the threat, the past versus present/future temporal focus of threatening cognitions, the different types and consequences of avoidance behavior, and the different character and consequences of hyperarousal. Although important differences between the two types of PTSD exist, the EST model proposes that the underlying fear of mortality maintains PTSD symptoms due to both discrete/external and ongoing/somatic events. Finally, this article offers a research agenda for testing the EST model, with a particular focus on areas that may improve cardiovascular prognosis and health behaviors in survivors of heart attack and stroke

Trauma and PTSD symptoms: Does spiritual struggle mediate the link?

Because exposure to potentially traumatic events is common (Kessler, Sonnega, Bromet, & Hughes, 1995), the mechanisms through which posttraumatic stress disorder (PTSD) symptoms develop is a critical area of investigation (Ozer, Best, Lipsey, & Weiss, 2003). Among the mechanisms that may predict PTSD symptoms is spiritual struggle, a set of negative religious cognitions related to understanding or responding to stressful events. Although prominent theories emphasize cognitive factors in the development and maintenance of PTSD symptoms, they have not explicitly addressed spiritual struggle. The present prospective study tested the role of spiritual struggle in the development and maintenance of PTSD symptoms following trauma. We assessed exposure to trauma and nontrauma events during the first year of college, spiritual struggle due to the most stressful event, and PTSD symptoms resulting from the index event. Spiritual struggle partially mediated the relationship between trauma and PTSD symptoms. We found interesting that some individual subscales of spiritual struggle (specifically, Punishing God Reappraisal, Reappraisal of God's Powers, and Spiritual Discontent) partially mediated the relationship between trauma and PTSD symptoms; however, reappraisal of the event to evil forces did not relate to PTSD symptoms. These results suggest that spiritual struggle is an important cognitive mechanism for many trauma victims and may have relevance for cognitive therapy for PTSD

Measuring Beliefs about Suffering: Development of the Views of Suffering Scale

Efforts to measure religion have intensified and many specific dimensions have been identified. However, although belief is a core dimension of all world religions, little attention has been given to assessment of religious beliefs. In particular, one essential set of religious beliefs, those concerning the reasons for human suffering, has remained virtually unexamined in spite of the potential clinical relevance of these beliefs. To fill the need for a measure of people’s beliefs about suffering, we developed the Views of Suffering Scale (VOSS). Analyses identified factors related to traditional Christian teachings, unorthodox theistic beliefs, karma, and randomness. Internal consistency and test-retest reliability for VOSS subscale scores were good (α’s and r’s ≥ .70). Comparisons to measures of related constructs suggest that the VOSS scores demonstrate good convergent validity. One subscale score was modestly correlated with social desirability related to image management, and seven were positively correlated to self-deceptive enhancement. These preliminary studies suggest that the VOSS differentiates religious perspectives on suffering among a sample of US university students, though more research is needed to confirm its utility in diverse populations. The VOSS provides a valid way to measure individuals’ beliefs about suffering, allowing for inquiry into the factors that lead to various beliefs about suffering and the roles of these beliefs in adjusting to stressful life events

PTSD as meaning violation: Testing a cognitive worldview perspective

The cognitive perspective on posttraumatic stress disorder (PTSD) has been successful in explaining many PTSD-related phenomena and in developing effective treatments, yet some of its basic assumptions remain surprisingly underexamined. The present study tested 2 of these assumptions: (1) situational appraisals of the event as violating global meaning (i.e., beliefs and goals) is related to PTSD symptomatology, and (2) the effect of situational appraisals of violation on PTSD symptomatology is mediated by global meaning (i.e., views of self and world). We tested these assumptions in a cross-sectional study of 130 college students who had experienced a Diagnostic and Statistical Manual of Mental Disorders (4th ed., American Psychiatric Association, 1994) level trauma. Structural equation modeling showed that appraisals of the extent to which the trauma violated one's beliefs and goals related fairly strongly to PTSD. In addition, the effects of appraisals of belief and goal violations on PTSD symptoms were fully mediated through negative global beliefs about both the self and the world. These findings support the cognitive worldview perspective, highlighting the importance of the meaning individuals assign to traumatic events, particularly the role of meaning violation

Self-Esteem and the Acute Effect of Anxiety on Ambulatory Blood Pressure

Objectives: Recent research suggests that self-esteem may be associated with improved parasympathetic nervous system functioning. This study tested whether high self-esteem is associated with decreased ambulatory systolic blood pressure (ASBP) reactivity to anxiety in healthy adults during the waking hours of a normal day. Methods: Each of 858 participants completed a short version of the Rosenberg Self-Esteem Scale and then wore an ABP monitor that took two blood pressure readings per hour for 24 hours. Immediately after each blood pressure reading, participants completed an electronic diary report that included an anxiety rating on a 100-point visual analog scale. Using multilevel models, we assessed the association of momentary anxiety, high trait self-esteem, and their interaction on momentary ASBP, with adjustment for age, sex, race, ethnicity, and body mass index. Sensitivity analyses were conducted examining psychological factors associated with self-esteem: sense of mastery, optimism, social support, and depressive symptoms. Results: On average, a 1-point increase in cube root–transformed anxiety was associated with a 0.80-mm Hg (standard error = 0.09, p < .001) increase in ASBP, and the interaction of high self-esteem and momentary anxiety was significant, such that this effect was 0.48 (standard error = 0.20, p = .015) less in individuals with high self-esteem compared with all others. Results for self-esteem remained significant when adjusting for sex and psychological factors. Conclusions: Momentary increases in anxiety are associated with acute increases in ASBP, and high self-esteem buffers the effect of momentary anxiety on blood pressure. Thus, high self-esteem may confer cardiovascular benefit by reducing the acute effects of anxiety on systolic blood pressure

Depression and Doctor-Patient Communication in the Emergency Department

OBJECTIVE: Depression may adversely affect health outcomes by influencing doctor-patient communication. We aimed to determine the association between depressive symptoms and doctor-patient communication among patients presenting to the emergency department (ED) with a suspected acute coronary syndrome (ACS). METHOD: We enrolled a consecutive sample of 500 patients evaluated for ACS symptoms from the ED of an urban medical center. Depressive symptoms (8-item Patient Health Questionnaire, PHQ-8) and doctor-patient communication in the ED (Interpersonal Processes of Care) were assessed during hospitalization. Logistic regression was used to determine the association between depressive symptoms and doctor-patient communication, adjusting for age, sex, race, ethnicity, education, language, health insurance status and comorbidities. RESULTS: Compared to nondepressed patients, depressed patients (PHQ-8≥10) were more likely (P<.05) to report suboptimal communication on five of seven communication domains: clarity, elicitation of concerns, explanations, patient-centered decision making and discrimination. A greater proportion of depressed versus nondepressed patients reported suboptimal overall communication (39.8% versus 22.9%, P<.001). In adjusted analyses, depressed patients remained more likely to report suboptimal doctor-patient communication (adjusted odds ratio 2.42, 95% confidence interval 1.52-3.87; P<.001). CONCLUSIONS: Depressed patients with ACS symptoms reported less optimal doctor-patient communication in the ED than nondepressed patients. Research is needed to determine whether subjectively rated differences in communication are accompanied by observable differences

The association of posttraumatic stress disorder and quality of life during the first year after acute coronary syndrome

Acute coronary syndrome [ACS, including unstable angina (UA) or myocardial infarction (MI)] events can be psychologically traumatic experiences for patients given their unpredictable, sudden onset and life-threatening nature [1]. Although posttraumatic stress disorder (PTSD) is commonly associated with index events of war or assault, PTSD is also associated with life-threatening illness and in particular ACS with approximately 12% of patients developing PTSD [1] and [2]. PTSD due to ACS has a multitude of consequences, including increased risk of ACS recurrence and mortality [3] and [4] in addition to PTSD itself being a debilitating psychiatric condition. Sufferers of PTSD are burdened by symptoms that include re-experiencing the traumatic event via intrusive thoughts, flashbacks, or nightmares; avoiding reminders of the index event; persistent negative alterations in cognition and mood; or physiologic hyperarousal. As such, ACS-induced PTSD is likely associated with substantial detriment in quality of life (QOL). However, few studies have measured this association, and no study has investigated it among a general ACS population or longitudinally. Rather, prior studies were composed of ACS patients only in intensive care units (ICUs) or among armed-services veterans [5], [6] and [7] or are notable for limitations such as cross-sectional designs [5] and [7]

Posttraumatic Stress Disorder and Cardiovascular Disease

Posttraumatic stress disorder (PTSD) is an anxiety disorder initiated by exposure to a traumatic event and characterized by intrusive thoughts about the event, attempts to avoid reminders of the event, and physiological hyperarousal. In a number of large prospective observational studies, PTSD has been associated with incident cardiovascular disease (CVD) and mortality. Also, in recent years, a number of studies have shown that cardiovascular events can themselves cause PTSD in more than 1 in 8 patients with acute coronary syndrome. Further, a few small studies suggest that PTSD secondary to an acute CVD event then places patients at increased risk for subsequent CVD events and mortality. In this article, we review the evidence for a link between PTSD and CVD, and discuss potential mechanisms for that association as well as future directions for research

The association of short sleep after acute coronary syndrome with recurrent cardiac events and mortality

Although most patients survive an acute coronary syndrome (ACS; myocardial infarction [MI] or unstable angina [UA]), within 5 years 22% will be re-hospitalized and more than 1 in 3 will die [1]. Thus, identifying modifiable risk factors for ACS recurrence and mortality is critical

Perceived clinician-patient communication in the emergency department and subsequent post-traumatic stress symptoms in patients evaluated for acute coronary syndrome

Objectives: Evaluation for a potentially life-threatening cardiac event in the emergency department (ED) is a stressful experience that can result in symptoms of post-traumatic stress disorder, which are associated with increased risk of morbidity and mortality in patients. No study has tested whether good clinician–patient communication in the ED is associated with better psychological outcomes in these individuals and whether it can mitigate other risk factors for post-traumatic stress symptoms (PSS) such as perception of life threat and vulnerability in the ED. Methods: Data were analysed from 474 participants in the Reactions to Acute Care and Hospitalization (REACH) study, an observational cohort study of ED predictors of medical and psychological outcomes after evaluation for suspected acute coronary syndrome. Participants were recruited from November 2013 to January 2015 at a single-site academic medical centre (New York-Presbyterian-Columbia University Medical Center). Participants reported threat perceptions in the ED and provided information on their perceptions of clinician–patient communication using the Interpersonal Process of Care Survey. PSS were assessed using the Acute Stress Disorder Scale during follow-up. Results: 474 subjects were enrolled in the study. Median length of follow-up was 3 days after ED presentation, range 0–30 days, 80% within 8 days. Perceptions of good clinician–patient communication in the ED were associated with lower PSS, whereas increased threat perception was associated with higher PSS. A significant interaction between clinician–patient communication and threat perception on PSS suggested that patients with higher threat perception benefited most from good clinician–patient communication. Conclusion: Our study found an association between good clinician–patient communication in the ED during evaluation of potentially life-threatening cardiac events and decreased subsequent post-traumatic stress reactions. This association is particularly marked for patients who perceive the greatest degree of life threat and vulnerability during evaluation