Core Predictors Of Chronic Dysfunction In The Acute Phase

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Generally speaking, researchers have failed to demonstrate that the severity of intrusive, avoidance and hyperarousal symptoms within several days following a traumatic event is associated with the later development of PTSD. However, greater symptom severity from 1 to 2 weeks post-trauma and onwards has been positively associated with subsequent symptom severity [7]. On the other hand, it is fairly certain that persons with low symptom levels in the immediate aftermath of a traumatic event are not at risk for the development of subsequent PTSD. These findings are consistent with the idea that PTSD as a psychopathologic process reflects a failure of recovery.

Numerous studies have found a relationship between peri-traumatic dissociation and the subsequent development of PTSD (e.g., 5,8-10). One recent meta-analysis reported that peri-traumatic dissociation was the single best predictor (r = 0.35) of subsequent PTSD development among trauma-exposed individuals [11]. However, this association has not been a consistent finding [12-15] and, when present, has often been attributed to the effects of covariate interactions [16,17]. Prospective studies have also failed to identify peri-traumatic dissociation as a reliable predictor of chronic PTSD (e.g., 15-18). One important methodologic consideration is the distinction between true peri-traumatic dissociation, that is dissociative symptoms occurring during or immediately following the trauma, and the subsequent experience of depersonalization or derealization, occurring in the first weeks after exposure. The latter are required for a diagnosis of acute stress disorder (ASD), but have not been shown to predict PTSD any more than does the emergence of PTSD symptoms in the acute aftermath of trauma, i.e., re-experiencing, avoidance and arousal symptoms. Further, studies of dissociation in the aftermath of trauma have generally not accounted for compromised intellectual function, which in itself is a risk factor for PTSD, and is linked with dissociation [19]. Indeed, McNally [19] recently concluded that it remains undetermined whether dissociation in the aftermath of trauma predicts chronic PTSD over and above the development of other acute PTSD symptoms.

Closely related to dissociation is the potentially important role of panic during and after trauma exposure. There is evidence that panic attacks occur in 53-90% of trauma survivors during the traumatic experience [20]. Further, the majority of people with ASD report peri-traumatic and posttraumatic panic attacks [21]. Galea et al. [1] found peri-traumatic panic to be the best predictor of PTSD in the post September 11 survey of 1,008 residents living south of 110th Street in Manhattan. This observation is consistent with the results of a study of 747 police officers in which panic reactions during exposure were highly predictive of post-September 11 symptom development [22].

In attempting to formulate a psychological explanation as to why symptoms such as peri-traumatic dissociation or panic might be particularly predictive of PTSD, McNally [19] suggested that such symptoms can promote catastrophic interpretations of the trauma, and/or constitute a somatic experience that gives rise to the erroneous idea that the symptoms are harbingers of more serious problems. Indeed, some investigators have demonstrated the power of negatively appraising any aspect of the event in the peri-traumatic period to predict long-term pathology. For example, having a negative perception of other people's responses (e.g., ''I feel that other people are ashamed of me now''), is associated with the development of PTSD above that predicted by initial symptom levels [23]. Similarly, catastrophic attributions of responsibility for the trauma in the acute posttrauma phase have been shown to predict PTSD [24,25].

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