Anxiety Disorders: Steinberg AM

Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Friedman M, Gersons BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev AY, Solomon Z, Steinberg AM, Ursano RJ. · Summa-Kent State University, Center for the Treatment and Study of Traumatic Stress, Akron, OH 44310, USA. · Psychiatry. · Pubmed #18181708 No free full text.

Abstract: Given the devastation caused by disasters and mass violence, it is critical that intervention policy be based on the most updated research findings. However, to date, no evidence-based consensus has been reached supporting a clear set of recommendations for intervention during the immediate and the mid-term post mass trauma phases. Because it is unlikely that there will be evidence in the near or mid-term future from clinical trials that cover the diversity of disaster and mass violence circumstances, we assembled a worldwide panel of experts on the study and treatment of those exposed to disaster and mass violence to extrapolate from related fields of research, and to gain consensus on intervention principles. We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self- and community efficacy, 4) connectedness, and 5) hope.

Steinberg AM, Brymer MJ, Decker KB, Pynoos RS. · Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, CA 90064, USA. · Curr Psychiatry Rep. · Pubmed #15038911 No free full text.

Abstract: Over the past decade, the University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index has been one of the most widely used instruments for the assessment of traumatized children and adolescents. This paper reviews its development and modifications that have been made as the diagnostic criteria for post-traumatic stress disorder have evolved. The paper also provides a description of standard methods of administration, procedures for scoring, and psychometric properties. The Reaction Index has been extensively used across a variety of trauma types, age ranges, settings, and cultures. It has been broadly used across the US and around the world after major disasters and catastrophic violence as an integral component of public mental health response and recovery programs. The Reaction Index forms part of a battery that can be efficiently used to conduct needs assessment, surveillance, screening, clinical evaluation, and treatment outcome evaluation after mass casualty events.

Saltzman WR, Layne CM, Steinberg AM, Arslanagic B, Pynoos RS. · College of Education, California State University, Long Beach, CA, USA. · Child Adolesc Psychiatr Clin N Am. · Pubmed #12725014 No free full text.

Abstract: This article describes the public mental health approach used to develop and implement a school-based postwar trauma/grief intervention program for adolescents in Bosnia-Herzegovina. This approach includes development of multilateral partnerships with local and ministerial stakeholders, systematic assessment that yields a detailed understanding of the specific range and severity of trauma and loss experiences, current adversities and trauma reminders among the affected population, and a training program aimed at developing the capacities of local service providers and an indigenous support infrastructure so that the intervention program may be directed and sustained by people within the communities served. Concluding comments detail an expanded conceptual framework for public mental health interventions that may be appropriate for terrorist and mass-casualty events.

Pynoos RS, Steinberg AM, Piacentini JC. · Trauma Psychiatry Service, University of California at Los Angeles 90024, USA. · Biol Psychiatry. · Pubmed #10599482 No free full text.

Abstract: Empirical findings regarding childhood traumatic stress are placed within a developmental life-trajectory model that incorporates a tripartite etiology of posttrauma distress. This approach recognizes an intricate matrix of child-intrinsic factors, developmental maturation and experience, life events, and evolving family and social ecologies. Of central developmental importance in the field of traumatic stress is the ontogenesis of appraisal, emotional response, emotional and physiological regulation, and consideration of protective action with regard to danger. The complexity of traumatic situations and their aftermath suggests the relevance of multiple stress diatheses in understanding individual variability in proximal and distal effects. Neurobiological systems that subserve danger mature over childhood and adolescence. Neurophysiological and neurohormonal studies among traumatized children and adolescents suggest potential neurodevelopmental stage-related vulnerabilities within these systems. Advances in child development and traumatic stress provide tools for investigating proximal and distal interplay of psychopathology, disturbances in the acquisition and maintenance of developmental competencies, and life-trajectory outcomes. A developmental psychopathology model suggests different avenues by which dangerous circumstances, childhood traumatic experiences, and posttraumatic stress disorder (PTSD) can intersect with other anxiety disorders over the life span.

Layne CM, Saltzman WR, Poppleton L, Burlingame GM, Pasalić A, Duraković E, Musić M, Campara N, Dapo N, Arslanagić B, Steinberg AM, Pynoos RS. · UCLA National Center for Child Traumatic Stress, 11150 West Olympic Boulevard, Suite 650, Los Angeles, CA 90064, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #18664995 No free full text.

Abstract: OBJECTIVE: To evaluate the comparative effectiveness of a classroom-based psychoeducation and skills intervention (tier 1) and a school-based trauma- and grief-focused group treatment (tier 2) of a three-tiered mental health program for adolescents exposed to severe war-related trauma, traumatic bereavement, and postwar adversity. METHOD: A total of 127 war-exposed and predominantly ethnic Muslim secondary school students attending 10 schools in central Bosnia who reported severe symptoms of posttraumatic stress disorder (PTSD), depression, or maladaptive grief and significant impairment in school or relationships were randomly assigned to one of two experimental conditions. These included either an active-treatment comparison condition (tier 1), consisting of a classroom-based psychoeducation and skills intervention alone (n = 61, 66% girls, mean age 16.0 years, SD 1.13) or a treatment condition composed of both the classroom-based intervention and a 17-session manual-based group therapy intervention (tier 2), trauma and grief component therapy for adolescents (n = 66, 63% girls, mean age 15.9 years, SD 1.11). Both interventions were implemented throughout the school year. Distressed students who were excluded from the study due to acute risk for harm (n = 9) were referred for community-based mental health services (tier 3). RESULTS: Program effectiveness was measured via reductions in symptoms of PTSD, depression, and maladaptive grief assessed at pretreatment, posttreatment, and 4-month follow-up. Analysis of mean-level treatment effects showed significant pre- to posttreatment and posttreatment to 4-month follow-up reductions in PTSD and depression symptoms in both the treatment and comparison conditions. Significant pre- to posttreatment reductions in maladaptive grief reactions were found only in the treatment condition. Analyzed at the individual case level, the percentages of students in the treatment condition who reported significant (p <.05) pre- to posttreatment reductions in PTSD symptoms (58% at posttreatment, 81% at 4-month follow-up) compare favorably to those reported in controlled treatment efficacy trials, whereas the percentages who reported significant reductions in depression symptoms (23% at posttreatment, 61% at follow-up) are comparable to, or higher than, those found in community treatment settings. Lower but substantial percentages of significant symptom reduction were found for PTSD (33% at posttreatment, 48% at follow-up) and depression symptoms (13% at posttreatment; 47% at follow-up) in students in the comparison condition. The odds of significant symptom reduction were higher for PTSD symptoms at both posttreatment and 4-month follow-up and for maladaptive grief at posttreatment (no follow-up was conducted on maladaptive grief). Rates of significantly worsened cases were generally rare in both the treatment and comparison conditions. CONCLUSIONS: A three-tiered, integrative mental health program composed of schoolwide dissemination of psychoeducation and coping skills (tier 1), specialized trauma- and grief-focused intervention for severely traumatized and traumatically bereaved youths (tier 2), and referral of youths at acute risk for community-based mental health services (tier 3) constitutes an effective and efficient method for promoting adolescent recovery in postwar settings.

Brymer MJ, Steinberg AM, Sornborger J, Layne CM, Pynoos RS. · National Center for Child Traumatic Stress, University of California, Los Angeles, 11150 West Olympic Boulevard, Suite 650, Los Angeles, CA 90064, USA. · Child Adolesc Psychiatr Clin N Am. · Pubmed #18558316 No free full text.

Abstract: This article describes the exposure of refugees, and particularly refugee children, to trauma, loss, and severe hardship in their countries of origin, while fleeing to their host countries, and after arrival in the host country. It then discusses acute psychosocial interventions for traumatized children and families, in particular the "Psychological First Aid" and "Skills for Psychological Recovery" guidelines developed by the National Child Traumatic Stress Network and the National Center for Posttraumatic Stress Disorder. It concludes by discussing the need to establish an evidence base for the effectiveness of such interventions.

Goenjian AK, Walling D, Steinberg AM, Roussos A, Goenjian HA, Pynoos RS. · UCLA/Duke University National Center for Child Traumatic Stress, Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA 90064, USA. · J Affect Disord. · Pubmed #18547646 No free full text.

Abstract: OBJECTIVE: To compare depression and PTSD symptoms of parentally bereaved adolescents and a comparison group after a catastrophic natural disaster. METHOD: Six and a half years after the Spitak earthquake, 48 parentally bereaved adolescents and a comparison group of 44 subjects with no parental loss were evaluated using the Depression Self - Rating Scale (DSRS) and Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI). RESULTS: Orphans scored significantly higher on depression than those who lost a father (Mean DSRS scores: 20.2+/-3.3 vs. 16.6+/-5.2; p<0.001), who in turn scored significantly higher than those who lost a mother (Mean DSRS scores: 16.6+/-5.2 vs. 12.7+/-4.1; p<0.002). Depression scores for orphans fell above the cut-off for clinical depression, while those who lost a father scored slightly below. PTSD scores within each group fell in the moderate range of severity, with girls scoring higher than boys (Mean CPTSD-RI scores: 35.9+/-11.3 vs. 29.3+/-10.1; p<0.04). LIMITATION: As self-report instruments were used, responses may have been over- or under- reported. Participants belonged to the same ethnic group and therefore the results may not be generalizable to other populations. CONCLUSION: Loss of both parents and, to a lesser degree, loss of a father is a significant risk factor for depression, but not for PTSD. This study extends prior findings documenting post-disaster chronicity of depression and PTSD among bereaved adolescents, and underscores the need for post-disaster mental health and social programs, especially for those who suffer the loss of both parents.

Scrimin S, Axia G, Capello F, Moscardino U, Steinberg AM, Pynoos RS. · Department of Developmental and Social Psychology, University of Padova, Italy. · Psychiatry Res. · Pubmed #16515809 No free full text.

Abstract: This report describes symptoms of posttraumatic stress disorder (PTSD) among a group of Beslan's children (N=22) and their primary caregivers (N=20) 3 months after the children had been taken hostage in their school by a group of terrorists. Attention and memory were also measured. Children and their caretakers showed high levels of ongoing PTSD symptoms. Children also showed difficulties in sustaining attention and in short-term memory (digit span). These scores strongly indicate the need for appropriate interventions and ongoing monitoring of course of recovery.

Goenjian AK, Walling D, Steinberg AM, Karayan I, Najarian LM, Pynoos R. · UCLA/Duke University National Center for Child Traumatic Stress, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, USA. · Am J Psychiatry. · Pubmed #16330594 links to  free full text

Abstract: OBJECTIVE: This study evaluated 1) the natural course of posttraumatic stress and depressive reactions among untreated adolescents from two cities in an earthquake zone (Gumri and Spitak) and one at the periphery (Yerevan) who were differentially exposed to the 1988 Spitak earthquake in Armenia and 2) the effectiveness of brief trauma/grief-focused psychotherapy among adolescents from Gumri. METHOD: One hundred twenty-five adolescents were assessed with the Child Posttraumatic Stress Disorder Reaction Index (CPTSD-RI) and the Depression Self-Rating Scale (DSRS) at 1.5 and 5 years postearthquake. At 1.5 years, trauma/grief-focused group and individual psychotherapy was provided over 6 weeks to a group of students in Gumri. RESULTS: CPTSD-RI scores among untreated adolescents from Gumri and Spitak subsided significantly but mildly at follow-up, with scores from Spitak, the city at the epicenter, remaining above the cutoff for a diagnosis of PTSD. DSRS scores increased mildly in both earthquake cities but only significantly in Gumri. Among treated adolescents in Gumri, improvement in CPTSD-RI scores was three times that of the untreated Gumri comparison group. The treated group also tended to improve on their DSRS scores, whereas these scores worsened significantly among untreated subjects. CONCLUSIONS: Untreated adolescents exposed to severe trauma are at risk for chronic PTSD and depressive symptoms. Brief trauma/grief-focused psychotherapy is effective in reducing PTSD symptoms and halting the progression of depression. This study supports the implementation of mental health intervention programs in schools after disasters to reduce trauma-related psychopathology.

Roussos A, Goenjian AK, Steinberg AM, Sotiropoulou C, Kakaki M, Kabakos C, Karagianni S, Manouras V. · Attiki Child Psychiatric Hospital, Athens, Greece. · Am J Psychiatry. · Pubmed #15741470 links to  free full text

Abstract: OBJECTIVE: This study evaluated the severity of posttraumatic stress and depressive reactions among children and adolescents 3 months after the 1999 earthquake in Ano Liosia, Greece, and additionally assessed the relationship of these reactions to objective and subjective features of earthquake exposure, sex, school level, postearthquake difficulties, death of a family member, and thoughts of revenge. METHOD: This school-based study of 1,937 students was conducted in two differentially exposed cities (Ano Liosia, at the epicenter, and Dafni, 10 kilometers from the epicenter) with an earthquake exposure questionnaire, the UCLA Posttraumatic Stress Disorder (PTSD) Reaction Index, and the Depression Self-Rating Scale. RESULTS: Endorsement of earthquake-related exposure items between the two cities was congruent with the extent of earthquake impact in each city. Median PTSD Reaction Index scores were significantly higher in Ano Liosia. The estimated rates of PTSD and clinical depression for both cities combined were 4.5% and 13.9%, respectively. Depression, subjective and objective earthquake-related experiences, and difficulties at home accounted for 41% of the variance in severity of PTSD reactions. PTSD score was the single most powerful variable predicting depression (36% of the variance), with only sex making a small but significant additional contribution. CONCLUSIONS: This study demonstrated the feasibility of conducting large-scale school-based postdisaster mental health screening for planning intervention strategies. The present findings regarding PTSD and depression indicate the need to provide targeted specialized postdisaster mental health services to subgroups with significant levels of posttraumatic stress and depressive reactions after an earthquake of moderate intensity.

Dyb G, Holen A, Steinberg AM, Rodriguez N, Pynoos RS. · Department of Psychiatry and Behavioural Medicine, Faculty of Medicine, Norwegian University of Science and Technology, MTFS, NO-7489 Trondheim, Norway. · Child Abuse Negl. · Pubmed #12951142 No free full text.

Abstract: OBJECTIVE: This report describes the cascade of stressful events and secondary life changes experienced by parents in a case of alleged sexual abuse at a day care program. The study evaluated parents' Posttraumatic Stress Disorder (PTSD) symptoms and general psychological responses to the stressful events 4 years after the alleged abuse, and explored predictive factors of parental distress. METHODS: A total of 39 parents were interviewed about stressful events, life changes, and social support. Current distress reactions, psychological wellbeing, and locus of control were assessed with a battery of standardized measures. RESULTS: Hearing about the sexual abuse, testifying in court, hearing the verdict, and being exposed in media reports were all rated by the parents as distressing events. The majority of the parents experienced secondary life changes after the alleged sexual abuse. Four years after the alleged sexual abuse, one-third of the parents reported a high level of PTSD Intrusive symptoms and one-fourth reported a high level of PTSD Avoidance symptoms. There was a significant positive correlation between a measure of psychological wellbeing and PTSD. Secondary life changes and locus of control significantly predicted PTSD. CONCLUSION: This study demonstrates that the alleged sexual abuse of children in day care and the resulting events in the legal system and the media constitute significant and chronic stressors in the lives of the children's parents. These findings underscore the need to expand the focus of trauma-related sequelae from the child victim to their parents and family.

Goenjian AK, Pynoos RS, Steinberg AM, Endres D, Abraham K, Geffner ME, Fairbanks LA. · Department of Psychiatry and Biobehavioral Sciences, UCLA/Duke University National Center for Child Traumatic Stress, UCLA School of Medicine Los Angles, California 90064, USA. · J Trauma Stress. · Pubmed #12895013 No free full text.

Abstract: This study evaluated basal levels and responsiveness to exercise of plasma adrenocorticotropic hormone (ACTH), and serum thyroid stimulating hormone (TSH), growth hormone (GH) and cortisol among adolescents from two differentially exposed groups 6 1/2 years after the 1988 earthquake in Armenia. Severity of total PTSD and Category C and D symptoms were negatively correlated with baseline cortisol. Preexercise ACTH was significantly lower, and preexercise TSH higher, among adolescents with more exposure. Depressive symptoms were negatively correlated with baseline cortisol and positively with TSH. Mean GH, TSH, and cortisol levels in both groups fell within normal limits. The pre- to postexercise increase in GH, TSH, and cortisol suggests that exercise challenge may be useful in the field investigation of neurohormonal activity among traumatized individuals.

Goenjian AK, Molina L, Steinberg AM, Fairbanks LA, Alvarez ML, Goenjian HA, Pynoos RS. · Trauma Psychiatry Program, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, CA, USA. · Am J Psychiatry. · Pubmed #11329403 links to  free full text

Abstract: OBJECTIVE: This study determined the severity of posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch and the relationship of these reactions to objective and subjective features of hurricane exposure, death of a family member, forced relocation, and thoughts of revenge. METHOD: Six months after the hurricane, 158 adolescents from three differentially exposed cities were evaluated by using a hurricane exposure questionnaire, the Child Posttraumatic Stress Disorder Reaction Index, and the Depression Self-Rating SCALE: RESULTS: Severe levels of posttraumatic stress and depressive reactions were found among adolescents in the two most heavily affected cities. Severity of posttraumatic stress and depressive reactions and features of objective hurricane-related experiences followed a "dose-of-exposure" pattern that was congruent with the rates of death and destruction across cities. Level of impact (city), objective and subjective features, and thoughts of revenge accounted for 68% of the variance in severity of posttraumatic stress reaction. Severity of posttraumatic stress reaction, death of a family member, and sex accounted for 59% of the variance in severity of depression. CONCLUSIONS: After a category 5 hurricane, adolescents in heavily affected areas with extreme objective and subjective hurricane-related traumatic features of exposure experience severe and chronic posttraumatic stress and comorbid depressive reactions. The recovery of the severely affected Nicaraguan adolescents is vital to the social and economic recovery of a country ravaged by years of political violence and poverty. These findings strongly indicate the need to incorporate public mental health approaches, including systematic screening and trauma/grief-focused interventions, within a comprehensive disaster recovery program.

Goenjian AK, Steinberg AM, Najarian LM, Fairbanks LA, Tashjian M, Pynoos RS. · Trauma Psychiatry Program, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, USA. · Am J Psychiatry. · Pubmed #10831470 links to  free full text

Abstract: OBJECTIVE: The authors sought to assess the severity and longitudinal course of posttraumatic stress, anxiety, and depressive reactions among two groups of adults differentially exposed to severe and mild earthquake trauma and a third group exposed to severe violence. They also examined interrelationships among these reactions and predictors of outcome and compared posttraumatic stress disorder (PTSD) symptom category profile and course between those exposed to earthquake and those exposed to violence. METHOD: Seventy-eight non-treatment-seeking subjects were assessed with self-report instruments approximately 1.5 and 4.5 years after the 1988 Spitak earthquake in Armenia and the 1988 pogroms against Armenians in Azerbaijan. RESULTS: The two groups that had been exposed to severe trauma (earthquake or violence) had high initial and follow-up PTSD scores that did not remit over the 3-year interval. Overall, depressive symptoms subsided. Posttraumatic stress, anxiety, and depressive reactions were highly intercorrelated within and across both time intervals. No significant differences in PTSD severity, profile, or course were seen between subjects exposed to severe earthquake trauma versus those exposed to severe violence. CONCLUSIONS: After exposure to severe trauma, either an earthquake or violence, adults are at high risk of developing severe and chronic posttraumatic stress reactions that are associated with chronic anxiety and depressive reactions. Clinical evaluation and therapeutic intervention should include specific attention to these reactions. Early mental health intervention is recommended to prevent their chronicity.

Bystritsky A, Vapnik T, Maidment K, Pynoos RS, Steinberg AM. · UCLA Anxiety Disorders Program, USA. · Depress Anxiety. · Pubmed #10723635 No free full text.

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Goenjian A, Stilwell BM, Steinberg AM, Fairbanks LA, Galvin MR, Karayan I, Pynoos RS. · Department of Psychiatry and Biobehavioral Sciences, UCLA, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #10199108 No free full text.

Abstract: OBJECTIVES: To compare moral development and psychopathological interference with conscience functioning (PI) among adolescents exposed to different degrees of earthquake-related trauma and to investigate the relationship of moral development and PI to exposure to trauma, severity of posttraumatic stress disorder (PTSD) symptoms, postearthquake adversities, and extent of loss of nuclear family members. METHOD: Adolescents (N = 193) from 2 cities at different distances from the epicenter were evaluated. The Stilwell Structured Conscience Interview was used to assess moral development and PI. Structured self-report instruments were used to obtain ratings of severity of earthquake-related trauma, posttraumatic stress symptoms, and postearthquake adversities. RESULTS: Adolescents in the city near the epicenter manifested advanced moral development as compared with their counterparts in the less affected city. Concomitantly, they endorsed responses indicating PI. Levels of PI were significantly correlated with severity of PTSD symptoms. CONCLUSION: In the aftermath of a catastrophic natural disaster, children assume greater responsibilities and confront a multitude of morally challenging interpersonal situations which may result in an advancement of their moral development. Yet, at the same time, PTSD symptoms and negative schematizations of self and others may give rise to disturbances in conscience functioning. The findings suggest that therapeutic consideration should be given to assisting children in integrating the horror of their traumatic experiences and the harshness of posttrauma adversities into an adaptive schema of good and evil in themselves and the world.