Anxiety Disorders: Stuber ML

Shemesh E, Stuber ML. · Department of Psychiatry and Pediatrics, Mount Sinai School of Medicine, New York, NY 10029, USA. · CNS Spectr. · Pubmed #16520688 links to  free full text

Abstract: Can a medical illness or its treatment qualify as an emotionally traumatic event and can it cause posttraumatic stress disorder symptoms? If so, can the view of a medical illness as a traumatic experience enhance our ability to understand patients' adjustment to illness and their emotional reactions to it? Is it important to identify posttraumatic symptoms and try to address them in medically ill patients? These questions form the backbone for this review. Because many questions remain unanswered (or the answers are not definitive yet), we concisely summarize the issues and present our own view of the most pressing questions for further research.

Stuber ML, Shemesh E, Saxe GN. · Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 48-240A NPI, Los Angeles, CA 90095, USA. · Child Adolesc Psychiatr Clin N Am. · Pubmed #12725008 No free full text.

Abstract: Posttraumatic stress symptoms have been reported in response to various serious medical illnesses in adults and children. Not surprisingly, posttraumatic stress is probably more common in response to acute, life-threatening, events that are related to the illness. Emerging data suggest that children often experience life-saving medical procedures as traumatic, which puts caretakers and medical personnel in the role of perpetrators for the children. Trauma symptoms are also reported as common and severe in caregivers. Both of these issues have been previously poorly understood and should be addressed in assessment and treatment. As with other traumatic events, developmental considerations, the nature and severity of the event itself, social supports, and premorbid exposure to negative life events are also important issues to consider in developing appropriate interventions. The importance of developing prevention and treatment for PTSD in medically ill children and adults includes increased morbidity and mortality (e.g., nonadherence to medications) and psychiatric sequelae and decreased quality of life. Obstacles to systematic study of a psychiatric intervention for this group include difficulties assessing multidrug regimens and cognitive treatment effects in this group. The relative stability of social supports and the potential use of preventive measures make this an attractive population for intervention. Clinicians and researchers are encouraged to work together to develop and use uniform screening and assessment methods that will help to identify cases and facilitate the multicenter trials that are vital to increasing knowledge in this patient population.

Rourke MT, Stuber ML, Hobbie WL, Kazak AE. · Division of Oncology, Children's Hospital of Philadelphia, PA 19104-4399, USA. · J Pediatr Oncol Nurs. · Pubmed #10444940 No free full text.

Abstract: Little research has been done to explore how the psychological symptoms of child and adolescent cancer survivors change in the decades following successful treatment. This article examines these changes with a focus on the utility of a posttraumatic stress framework for understanding the long-term coping issues that individuals face as they mature and make transitions to young adulthood. First, the literature supporting the use of a posttraumatic stress framework in child and adolescent survivors is reviewed. Developmental contributions to changes and increases in posttraumatic symptomatology during young adulthood are then discussed and posttraumatic symptoms most often seen in this group are presented. Preliminary research with young adult survivors is also reviewed and discussed as support for a posttraumatic stress framework with this population. Ongoing research efforts aimed at elaborating on this framework are described. Finally, clinical implications for health care providers are explored, and guidelines for assessing the impact of posttraumatic stress on young adults' use of health care resources are offered.

Glover DA, Steele AC, Stuber ML, Fahey JL. · Division of Child and Adolescent Psychiatry, Department of Psychiatry and Biobehavioral Sciences, UCLA Neuropsychiatric Institute, Los Angeles, CA 90024-7159, USA. · Brain Behav Immun. · Pubmed #15797313 links to  free full text

Abstract: This study investigated circulating natural killer (NK), CD4+ and CD8+ cells in response to acute psychological challenge among mothers of child cancer survivors with and without posttraumatic stress symptoms (PTSS). Control mothers of healthy children (n=9) were compared to 17 cancer mothers with (PTSS: n=9) and without PTSS (No PTSS: n=7) under conditions of rest, after a generic stressor (MAT: mental arithmetic task) and a personalized stressor (script-driven trauma imagery), and after recovery from each stressor. Results indicate the PTSS group had higher percentage CD4+ and lower CD8+ levels than non-symptomatic women and blunted NK reactivity to generic challenge. Multiple regression analyses indicated PTSS effects were independent of self-reported distress. Contrary to expectations, cancer mothers without PTSS were not significantly different from controls on tonic or phasic immune outcomes. Also unlike predictions, reactivity to challenge was greatest to the non-social MAT stressor compared to the personalized challenge for all groups. Conclusions are constrained by study limitations (e.g., small sample size and potential phase order effects). Nonetheless, results are consistent with an emerging literature on PTSS-associated immune differences and further suggest these effects may be distinct from that associated with subjective distress more generally.

Stuber ML, Shemesh E. · Department of Psychiatry & Biobehavioral Sciences, University of California Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90024-1759, USA. · Child Adolesc Psychiatr Clin N Am. · Pubmed #16797441 No free full text.

Abstract: Symptoms of PTSD have been reported in response to a variety of life-threatening medical illnesses and injuries in adults and children. Emerging data suggest that children often experience medical treatment and hospitalization as traumatic, putting caregivers and medical personnel in the role of the unintended accomplice. Adequate pain control by pharmacologic and behavioral means; child and family psychological support using evidence-based CBT, dynamic psychotherapy, and other techniques; and meticulous attention to communication via a team-based approach are the cornerstones of pediatric palliative care in general and PTSD prevention and treatment in particular. Emerging evidence suggests that PTSD in life-limiting pediatric illness can be ameliorated, if not prevented, and treated when it occurs, contributing materially to the quality of life of a child and family. A landmark finding of PTSD research with medically ill children and their families is that parents are at least as symptomatic, or more, as their children, underlining the importance of a family-directed approach addressing every family mem-ber. Pediatric caregivers increasingly recognize their therapeutic role when curative therapy is no longer possible is as pivotal as in the setting of acute illness.

Stuber ML, Schneider S, Kassam-Adams N, Kazak AE, Saxe G. · Semel Institute for Neurosciences and Human Behavior, University of California, Los Angeles, Los Angeles, CA 90024-1759, USA. · CNS Spectr. · Pubmed #16520691 No free full text.

Abstract: Children and their parents who are exposed to medical life-threat due to illness or injury are at risk for developing symptoms of posttraumatic stress. However, the prevention, detection, and treatment needed are often not available in the acute care settings of the hospital. The National Child Traumatic Stress Network and the Substance Abuse and Mental Health Services Administration have created a set of materials for use by hospital health providers and families that is available for download free from the National Child Traumatic Stress Network website, www.nctsn.org.

Mintzer LL, Stuber ML, Seacord D, Castaneda M, Mesrkhani V, Glover D. · Division of Child and Adolescent Psychiatry, Department of Psychiatry and Biobehavioral Science, Neuropsychiatric Institute, University of California, Los Angeles, California, USA. · Pediatrics. · Pubmed #15930227 links to  free full text

Abstract: OBJECTIVE: Symptoms of posttraumatic stress disorder (PTSD) after life-threatening medical illness have been found to predict poor outcome in preliminary studies of adults and children. However, these symptoms are rarely recognized in general medical or pediatric settings. Here we report on the first large investigation to assess prevalence and correlates of self-reported symptoms of posttraumatic stress in a nonreferred sample of adolescent liver, heart, and kidney transplant recipients. METHODS: One hundred four adolescents, ages 12 to 20 years (mean: 15.7; SD: 2.1), completed and returned the University of California, Los Angeles, PTSD Index for the Diagnostic and Statistical Manual of Mental Disorders. All participants were at least 1 year post-initial transplant and were fluent speakers of English and/or Spanish. RESULTS: More than 16% of the adolescents met all symptom criteria for PTSD, and an additional 14.4% met 2 of 3 symptom-cluster criteria. Regression analysis indicated no effect of gender, ethnicity, age at interview, organ type, time since transplant, or age at transplant. CONCLUSIONS: As has been found with other life-threatening pediatric conditions, solid organ transplantation can precipitate symptoms of posttraumatic stress. Symptoms are not predicted by what would be considered objective factors increasing life threat, suggesting a greater salience of subjective appraisal of threat, as has been seen in studies of childhood cancer survivors.

Young GS, Mintzer LL, Seacord D, Castañeda M, Mesrkhani V, Stuber ML. · Neuropsychiatric Institute, University of California, Los Angeles, California 90024-1759, USA. · Pediatrics. · Pubmed #12777592 links to  free full text

Abstract: OBJECTIVE: To examine the incidence, severity, and factors related to posttraumatic stress disorder (PTSD) symptoms in parents of pediatric solid organ transplant recipients. METHOD: A total of 170 caregivers of pediatric transplant recipients completed self-report measures of psychological functioning between 10 and 38 months after their child's most recent transplant. Demographic data, child health variables, and ratings of medical attitudes and social functioning were also collected to help explain individual differences in psychological functioning. RESULTS: Although caregivers of pediatric transplant recipients did not report elevated levels of depression or anxiety, they did report elevated levels of PTSD symptoms. Multiple regression analyses revealed that PTSD symptoms were most strongly associated with parent reports of child health, family impact of the transplant, and attitudes toward medical caregivers. CONCLUSIONS: PTSD seems to be relatively common in parents of pediatric transplant recipients and may be largely the result of how parents perceive and interpret the transplant experience.

Meeske KA, Ruccione K, Globe DR, Stuber ML. · Long-Term Information, Follow-up and Evaluation (LIFE) Program, Childrens Center for Cancer and Blood Diseases, Childrens Hospital Los Angeles, USA. · Oncol Nurs Forum. · Pubmed #11338757 No free full text.

Abstract: PURPOSE/OBJECTIVES: To explore the relationship between posttraumatic stress disorder (PTSD) and quality of life (QOL)/psychological outcome in young adult survivors of childhood cancer. DESIGN: Cross-sectional, descriptive study. SETTING: A large comprehensive pediatric cancer center on the West Coast. SAMPLE: Fifty-one young adult survivors of childhood cancer, 18-37 years of age, disease free, and off treatment for an average of 11 years (range 2.8-26.7 years). METHODS: A structured clinical interview was used to establish a PTSD diagnosis. Self-report instruments were used to assess QOL (RAND SF-36) and psychological distress (Brief Symptom Inventory (BSI)). Survivors with and without PTSD were compared on the BSI and RAND SF-36. MAIN RESEARCH VARIABLES: PTSD status, QOL and psychological distress. FINDINGS: Eleven subjects (20%) met full criteria for PTSD. Significant group differences were found for 17 of the 18 outcome variables. Survivors with PTSD reported clinically significant levels of psychological distress, whereas symptom levels for those without PTSD fell well within population norms. On all domains, QOL scores were significantly lower for the PTSD group compared to the non-PTSD group. CONCLUSIONS: PTSD in survivors of childhood cancer is related to long-term outcome. PTSD is associated with a poorer QOL (physical and mental) and an increase in psychological distress. Data suggest that survivors with PTSD have significant functional limitations and psychological comorbidity. IMPLICATIONS FOR NURSING PRACTICE: Screening cancer survivors for PTSD will identify high-risk patients who need further evaluation and intervention.

Shemesh E, Lurie S, Stuber ML, Emre S, Patel Y, Vohra P, Aromando M, Shneider BL. · Department of Psychiatry, Division of Child and Adolescent Psychiatry, Mount Sinai Medical Center, New York, New York 10029, USA. · Pediatrics. · Pubmed #10654989 No free full text.

Abstract: BACKGROUND: Symptoms of posttraumatic stress disorder (PTSD) were described in survivors of life-threatening diseases, the trauma being the experiences associated with the disease or its treatment. Their prevalence in liver transplant recipients is unknown. Based on clinical observations, we hypothesize that a significant proportion of pediatric liver transplant recipients suffers from PTSD symptoms. We further hypothesize that nonadherence (noncompliance) to medical management may, in some cases, be associated with these symptoms. Traumatized patients, according to this hypothesis, will avoid taking their medications, because these serve as painful reminders of the disease. OBJECTIVES: To determine the prevalence of PTSD symptoms in a sample of pediatric liver transplant recipients. To determine whether symptoms of PTSD are associated with nonadherence in these patients. To describe the clinical presentation of PTSD and the management of severe nonadherence in patients who suffer from this disorder. METHODS: Nineteen pediatric liver transplant recipients and their caretakers were interviewed, using the UCLA Post Traumatic Stress Disorder Reaction Index (PTSRI). Data were obtained on a few demographic parameters and perception of disease threat. Adherence was evaluated by 2 methods: 1) a clinician panel (taking into account the clinical sequelae of severe nonadherence); and 2) computation of the standard deviations (SDs) of consecutive determinations of blood levels of Tacrolimus (a higher SD means higher variability between individual measures and is therefore an indicator of nonadherence). As an illustration of the general phenomenon, we describe 3 cases of liver transplant recipients who were nonadherent and who suffered from PTSD. RESULTS: Six of 19 patients had positive scores on all 3 components of the PTSRI (PTSD patients). Three of these, and none of the others, were considered significantly nonadherent by the panel. Therefore, nonadherence was significantly associated with the existence of symptoms from all 3 domains of PTSD (Fisher's exact test) in our sample. In particular, a high avoidance score on the PTSRI was highly correlated with panel-determined nonadherence. Further, SD of medication levels were significantly higher in PTSD patients, compared with the rest of our sample. No significant differences were found in perception of disease threat or demographic variables between PTSD patients and the rest of our sample. The 3 cases that we describe became adherent to their medications when symptoms of PTSD subsided during the course of therapy. CONCLUSIONS: Clinically significant nonadherence, determined by 2 different methods, was associated with the full spectrum of PTSD symptoms in this sample. It was especially associated with a high avoidance score, which suggests that avoidance of reminders of the disease (eg, medications) may be a mechanism of nonadherence. Screening for and management of these symptoms, therefore, may improve adherence. This novel concept may be applicable to other patient populations. However, more data are needed before any definite conclusions can be drawn.