Objective:
C-reactive protein (CRP), a marker of systemic inflammation, has been associated with psychiatric disorders including major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Some research suggests that exposure to trauma can trigger increased activity in the inflammatory system. Dissociation is associated with chronic trauma exposure and may be an important factor in understanding the risk for psychiatric outcomes associated with inflammation. The main objective of the current study was to understand how CRP was related to trauma, dissociation, PTSD and MDD in a sample of 55 traumatized African American women with type 2 diabetes mellitus recruited from an urban hospital.
Method:
High sensitivity CRP (hsCRP) was assayed through blood samples; psychiatric disorders were assessed with structured clinical interviews, dissociation was assessed with the Multiscale Dissociation Inventory, and exposure to trauma in childhood and adulthood was assessed with the Childhood Trauma Questionnaire and the Traumatic Events Inventory, respectively.
Results:
Correlational results showed a significant association between higher concentrations of hsCRP and child abuse (p<.05), overall dissociation severity (p<.001), and PTSD symptoms (p<.01). ANOVA results showed significantly higher levels of hsCRP in those with current MDD, current PTSD, and remitted PTSD. A hierarchical linear regression model demonstrated a significant association between dissociation symptoms and greater hsCRP levels independent of childhood abuse, PTSD, and MDD (R2Δ=0.11, p=.001) and independent of emotion dysregulation (p<.05)
Conclusion:
These findings suggest that dissociation symptoms among those with a history of trauma may be particularly associated with higher levels of inflammation.
Psychophysiological hallmarks of posttraumatic stress disorder (PTSD) include exaggerated fear responses, impaired inhibition and extinction of conditioned fear, and decreased discrimination between safety and fear cues. This increased fear load associated with PTSD can be a barrier to effective therapy thus indicating the need for new treatments to reduce fear expression in people with PTSD. One potential biological target for reducing fear expression in PTSD is the hypothalamic-pituitary-adrenal (HPA) axis, which is dysregulated in PTSD. Recent translational rodent studies and cross-sectional clinical studies have shown that dexamethasone administration and the resulting suppression of cortisol in individuals with PTSD leads to a decrease in the fear responses characteristic of PTSD. These data, taken together, suggest that dexamethasone may serve as a novel pharmacologic intervention for heightened fear responses in PTSD. We conducted a double-blind, placebo-controlled trial to test our hypothesis that dexamethasone administration and the concomitant suppression of HPA axis hyperactivity would attenuate fear expression and enhance fear extinction in individuals with PTSD. Study participants (n = 62) were recruited from Grady Memorial Hospital in Atlanta, GA. Participants were randomized to receive dexamethasone or placebo prior to fear conditioning and extinction, in a counterbalanced design (treatments separated by a week). Both PTSD- (n = 37) and PTSD+ (n = 25) participants showed significant startle increases in the presence of the danger signal during placebo and dexamethasone treatments (all p < 0.05). However, only PTSD- control participants showed decreases in fear-potentiated startle across extinction blocks during both conditions (p's ≤ 0.001), with PTSD+ participants showing deficits in fear extinction and safety discrimination in the placebo condition. Notably, extinction and discrimination deficits in PTSD+ subjects were markedly reversed with dexamethasone (p < 0.001). These data suggest that dexamethasone may serve as a pharmacological agent with which to facilitate fear extinction and discrimination in individuals with PTSD.
Positive and negative affect are both associated with health outcomes. Using validated measures, we examined associations between affect, self-reported measures of health, and objective measures of systemic inflammation in a cross-sectional sample of outpatient subjects recruited from an urban county hospital. Participants (n = 1055) recruited from the Grady Trauma Project in Atlanta, GA underwent standardized interviews including self-report measures of psychiatric symptoms and physical health. A subset (n = 246) consented to an assay of serum C-reactive protein (CRP). Regression models including positive affect as the predictor variable with covariates of age, gender, income, trauma load, depression and PTSD symptoms, were significantly associated with physical health domain scales of the Short Form-36 Health Survey (SF-36) of general health (R2 = 0.212; p < 0.001) and physical functioning (R2 = 0.154; p = 0.013). No association was observed using negative affect as the predictor variable. While greater serum CRP concentrations were associated with less positive affect (r = −0.137; p = 0.038), this relationship did not remain significant (p = 0.250) when controlling for demographic variables, body mass index, trauma load, and psychiatric symptoms. Future studies using larger samples or samples with more variance for CRP and positive and negative affect may be helpful in investigating the relationship between CRP and positive and negative affect. Our results support the hypothesis that positive affect contributes beneficially to physical health. Development of strategies to enhance positive affect in at-risk populations may be a meaningful way to improve their health.
Introduction: There is growing interest in delivering patient-centered care in all areas of medical practice, yet acquiring the requisite attitudes, skills, and behaviors simply by observing or participating in current systems of care that employ a medical or physician-centric model is challenging. Patient centeredness involves an understanding of patients' perspectives on their illness and treatment, the impact that health and illness have on the lives of patients, and the values and goals patients have for themselves, while also encouraging patients and health care professionals to engage in a shared decision-making model of health care. That model aspires to result in increased trust between providers and patients, as well as better patient outcomes. Methods: This 90-minute workshop utilizes three different approaches to help the learner develop patient-centered care and communication skills in a mental health setting: a video of a patient sharing her experience with the mental health system, a narrative model of appreciating patient experience (first-person memoir), and an exercise using patient-centered language in a medical record documentation. Results: This workshop was presented at the American Association of Psychiatric Directors of Residency Training (AADPRT) Annual Meeting in March 2016. Approximately 21 people attended. Feedback was received from 11 participants and demonstrated a high degree of agreement (4.5 out of 5) with the following statements: the speakers met the stated educational objectives; the content was educationally useful; the information in this presentation will inform my educational practices; the presentation advanced my knowledge of the subject. Discussion: While these three pedagogical exercises do not cover the entirety of the skills required for patient-centered care and communication, they do provide a useful starting point for hearing and appreciating the experience of the patient. Despite the focus on mental health settings and treatment, other medical specialties could derive useful ideas from this workshop format or adapt the materials to their own needs.
The COVID-19 pandemic has dramatically impacted almost every sector of American society and has transformed our lives in a matter of months. It has altered how we practice psychiatry and teach our trainees. Amid this crisis, psychiatry educators and academic leaders have faced numerous challenges, including prioritizing trainee protection and education and ensuring high-quality treatment for patients. The selections from the online topical collection “COVID-19 and Psychiatry Education” [1] printed in the December 2020 issue of Academic Psychiatry offer two educational case reports and various perspectives from medical students, residents, fellows, and faculty that explore the impact of the pandemic on training and education as well as on well-being. They help provide insight into how this pandemic has uniquely affected psychiatric education.
Objective
The purpose of the study was to assess demographic features, rates of trauma exposure, prevalence of post‐traumatic stress and depressive symptoms in a group of urban, low‐income, African‐American women with type 1 or type 2 diabetes mellitus.
Research Design and Methods
We conducted a survey of (n = 290) low‐income, African‐American women seeking care in the diabetes clinic of an urban hospital and collected data on the demographic characteristics, childhood and nonchildhood abuse trauma exposure, and the severity of post‐traumatic stress and depressive symptoms using the Post‐traumatic Stress Disorder (PTSD) Symptom Scale (PSS) and the Beck Depression Inventory (BDI). In a subset of women with type 2 diabetes (n = 96), we assessed haemoglobin A1c to examine the relationship between psychopathology and glycaemic control.
Results
Of the overall sample, 61.7% reported exposure to trauma in their lifetime, and 30.4% and 29.3% had current PTSD and MDD, respectively. Exposure to both childhood and nonchildhood abuse trauma was associated with an increased PTSD and depressive symptom severity (P's < .05). PTSD diagnosis, but not depression, was associated with increased haemoglobin A1c (P = .002).
Conclusions
These data document high levels of trauma exposure, PTSD and depressive symptoms in diabetic African‐American women treated in a specialty clinic of an urban hospital setting. Furthermore, these data indicate that the presence of PTSD is negatively associated with glycaemic control.
Background: The objective of this study is to investigate the association between childhood trauma and lipid profiles in adults from a highly traumatized population at-risk for cardiovascular disease.
Method: We recruited 452 participants, primarily African-American and of low socioeconomic status, from general medical clinics in a large urban hospital. We performed direct comparisons, univariate analysis of variance and regression analyses together and separated by sex, examining the associations of child abuse, body mass index, lipid lowering drug use, blood pressure, age, and substance use to HDL levels and HDL/LDL ratios.
Results: A history of moderate to severe levels of childhood trauma and abuse was associated with a significant decrease in HDL levels (P≤ .01) and HDL/LDL ratios (P≤ .001) relative to males with low levels of abuse. This relationship held when the status of lipid-lowering drugs was considered. When controlling for age, substance abuse, tobacco use, and adult trauma, the effects of childhood trauma remained significant. We found a significant child abuse by sex interaction on HDL/LDL ratios [F(1,369)=13.0, P≤. .0005] consistent with a differential effect of trauma on dyslipidemia in male but not female subjects.
Conclusions: Our data suggest that childhood trauma exposure, obtained with self-report measures, may contribute to increased risk of cardiovascular disease by way of stress-mediated alterations of lipid concentration and composition in male, but not female, subjects.
Background: As mental health services in outpatient medical clinics expand, psychiatrists must be trained to practice in these settings. Objectives: The Academy of Consultation-Liaison Psychiatry residency education subcommittee convened a writing group with the goal of summarizing the current evidence about outpatient consultation-liaison psychiatry (CLP) training and providing a framework for CLP educators who are interested in developing outpatient CLP rotations within their programs. Method: MEDLINE (via PubMed), Embase, and PsycINFO (via OVID) were reviewed each from inception to December 2019, for psychiatric CLP services in ambulatory settings that involved residents or fellows. The CLP education guidelines were reviewed for recommendations relevant to outpatient CLP. We also searched MedEd portal for published curriculums relevant to CLP. The group held 2 conferences to reach consensus about recommendations in setting up outpatient CLP rotations. Results: Seventeen articles, 3 Academy of Consultation-Liaison Psychiatry–supported guidelines, and 8 online didactic resources were identified as directly reporting on the organization and/or impact of an outpatient CLP rotation. These manuscripts indicated that residents found outpatient CLP rotations effective and relevant to their future careers. However, the literature provided few recommendations for establishing formal outpatient CLP training experiences. Conclusions: Outpatient CLP rotations offer multiple benefits for trainees, including exposure to specific clinical scenarios and therapeutic interventions applicable only in the outpatient setting, increased continuity of care, and the unique experience of providing liaison and education to non-mental health providers. The article outlines recommendations and examples for developing outpatient CLP rotations which CLP educators can incorporate in their programs.
The relationship of analgesic medication use with posttraumatic stress disorder (PTSD) diagnosis was investigated among a sample of 173 African Americans presenting for routine outpatient visits at an urban mental health center. Seventy-eight (43.5%) of the sample met DSM-IV PTSD criteria. Those with PTSD had significantly higher use of analgesic medication (both opiate and non-opiate), as compared with non-PTSD patients. PTSD symptoms, as measured by the Posttraumatic Symptom Scale, were significantly higher in subjects who were prescribed analgesics. The authors conclude that there may be a relationship between PTSD and use of pain medications warranting further examination of the endogenous opiate system in the pathophysiology of PTSD.
The current study investigated the relationship between trauma exposure and psychopathology in a sample of predominately African-American women of low socioeconomic status (SES). Women (N = 7430) were recruited from medical clinics at two large public hospitals in Atlanta, GA, from 2005 to 2017. Women were assessed for sociodemographics, life-course trauma burden, posttraumatic stress disorder (PTSD), and major depressive disorder (MDD) utilizing self-report and structured clinical interview assessments. The effects of trauma exposure on current and lifetime PTSD and MDD were examined. Ninety-one percent of women reported trauma exposure, 83% reported a monthly household income of less than $2000, and 41% reported a history of arrest. Regarding psychiatric diagnoses, 30.8% met the criteria for probable MDD, and 32.3% met the criteria for probable PTSD. History of childhood abuse and total lifetime trauma significantly increased PTSD and depressive symptoms with additional incremental trauma exposure. PTSD and depressive symptom scores (95% CI) increased from 5.5 (5.0–6.1) and 8.4 (7.9–9.0) in the no trauma group to 20.8 (20.1–21.5) and 20.4 (19.7–21.2), respectively, in those exposed to four or more types of trauma. These results show high rates of adult and childhood trauma exposure, PTSD, MDD, and an additive effect of lifetime trauma exposure on the development of PTSD and MDD in a sample of low SES African-American women. These findings bring light to the high psychiatric symptom burden in this population and call for increased availability of interventions to address symptoms as well as policies aimed at reducing trauma exposure across the lifespan.