abstract: Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD) are highly prevalent illnesses that can result in profound impairment. While many patients with these disorders present in primary care, research suggests that physicians under-detect and suboptimally manage MDD and PTSD in their patients. The development of more effective training interventions to aid primary care providers in diagnosing mental health disorders is of the utmost importance. This research focuses on evaluating computer-based training tools (Avatars) for training family physicians to better diagnose MDD and PTSD. Three interventions are compared: a "choice" avatar simulation training program, a "fixed" avatar simulation training program, and a text-based training program for training physicians to improve their diagnostic interviewing skills in detecting and diagnosing MDD and PTSD. Two one-way ANCOVAs were used to analyze the differences between the groups on diagnostic accuracy while controlling for mental health experience. In order to assess specifically how prior mental health experience affected diagnostic accuracy the covariate of prior mental health experience was then used as an independent variable and simple main effects and pairwise comparisons were evaluated. Results indicated that for the MDD case both avatar treatment groups significantly outperformed the text-based treatment in diagnostic accuracy regardless of prior mental health experience. For the PTSD case those receiving the fixed avatar simulation training more accurately diagnosed PTSD than the text-based training group and the choice-avatar training group regardless of prior mental health experience. Confidence ratings indicated that the majority of participants were very confident with their diagnoses for both cases. Discussion focused on the utility of avatar technology in medical education. The findings in this study indicate that avatar technology aided the participants in diagnosing MDD and PTSD better than traditional text-based methods employed to train PCPs to diagnose. Regardless of experience level the fixed avatar group outperformed the other groups for both cases. Avatar technology used in diagnostic training can be user-friendly and cost-effective. It can also have a world-wide reach. Additional educational benefit could be provided by using automated text analysis to provide physicians with feedback based on the extent to which their case diagnostic summaries cover relevant content. In conclusion, avatar technology can offer robust training that could be potentially transferred to real environment performance. / Dissertation/Thesis / Ph.D. Counseling Psychology 2012

The current study employed an exploratory approach to examine how specific sets of variables map onto a theoretical framework of posttraumatic growth (Schaefer & Moos, 1998). Specifically, the predictive capacity of belief in ultimate justice, optimism, and supportive relationships on outcomes of posttraumatic growth (PTG) and distress were examined, as mediated by supportive spirituality, meaning making, and problem solving. Secondarily, the factor structure and internal consistency of the English translation of the Belief in Immanent and Ultimate Justice Scale (BIUJS; Maes, 1998a, 1998b) was tested, which had yet to be used in the United States or with sexual assault survivors specifically. Archival data of 217 female survivors of sexual assault who completed an online survey as part of the author’s thesis were analyzed through structural equation modeling (SEM). The BIUJS, when applied specifically to sexual assault survivors, is best represented by a three-factor solution. The model hypothesized according to Schaefer and Moos’ (1998) theoretical framework was not supported by SEM results, and an alternate model emerged from analyses is presented to explain how worldview and appraisal/coping are related to posttraumatic growth and distress for sexual assault survivors. Survivors’ worldview (i.e., supportive spirituality, belief in ultimate justice, and belief in an immanently just world) indirectly predicted levels of PTG and distress. The relation between worldview and outcomes was significantly mediated by appraisal and coping (i.e., presence of meaning, optimism, supportive relationships, and problem solving). The current study adds to the literature and provides important directions for researchers and clinicians by demonstrating the important roles of worldview and appraisal/coping in facilitating growth, as well as the essential role of distress in healing.

abstract: This study examined four research questions investigating relationships among the experience of trauma, identity development, distress, and positive change. There were 908 participants in the study, ranging in age from 18 to 24 which is known as the period of emerging adulthood. Participants completed an online survey regarding their exposure to trauma and reactions to these experiences. The first research question examined the experience of trauma for the sample. The second question examined group differences among the participant's identity status, gender, and posttraumatic stress disorder (PTSD) diagnostic status on the hypothesized variables. In general, comparisons among the four identity status groups found participants who experienced greater identity exploration (diffused and moratorium) experienced more distress, whereas the identity status groups that reported greater identity commitments (foreclosed and achieved) were associated with positive change. Similar findings were found for PTSD diagnostic status indicating more distress and identity exploration for participants with the diagnosis and more positive change and identity commitments for participants without the diagnosis. Female participants were found to experience more PTS symptoms, centrality of the trauma event, and positive growth than males. Examination of the relationships between trauma severity and posttraumatic growth revealed an inverted U-shaped relationship (quadratic) that was a significant improvement from the linear model. An S-shaped relationship (cubic) was found for the relationship between trauma exposure and posttraumatic growth. Regression analyses found the centrality of the trauma event to one's identity predicted identity distress above and beyond the experience of trauma. In addition, identity distress and the centrality of the trauma contributed to the variance for identity exploration, while only identity distress contributed to identity commitments. Finally, identity development significantly predicted positive change above and beyond, identity distress, centrality of the trauma event, and the experience of trauma. Collectively, these results found both distress and growth to be related to the experience of trauma. Distress within one's identity can contribute to difficulties in the psychosocial stage of identity development among emerging adults. However, the resolution of identity exploration towards commitments to goals, roles, and beliefs, can help trauma survivors experience resilience and growth after stressful experiences. / Dissertation/Thesis / Ph.D. Counseling Psychology 2013

This diploma thesis focuses on posttraumatic stress disorder and the related psychosomatic conditions looking into the diversity of somatic responses to stress factors or a traumatic event. In the opening part, trauma processing mechanism is described as well as clinical changes in the brain after an unprocessed traumatic event. The following chapters describe therapy options in case of an existing posttraumatic stress disorder, accepting the traumatic event as part of a closed personal history and creating an added value in the form of higher resistance. The closing theoretic part deals with psychosomatic medicine. The practical part inquires into knowledge of students of the teaching and medical study programmes regarding posttraumatic stress disorder and compares the individual groups. The survey results discover surprising gaps in the professional knowledge of future physicians and teachers. By comparing the related data, a recommendation is being made that students' knowledge has to be broadened in this respect. KEY WORDS psychic traumatic, posttraumatic stress disorder, psychosomatic medicine

This dissertation consists of two studies designed to broaden our understanding of the impact of complex trauma on symptom profiles and outcomes of children in the child welfare system through the lenses of gender, development, and placement permanency. Data for both were obtained using the Child and Adolescent Strengths and Needs Comprehensive Assessment tool (CANS; Lyons, Gawron, & Kisiel, 2005) for youth ages 6 -17 years involved in the child welfare system. In Study 1, I examined symptom profiles of 3,446 youth to determine the ability of gender, age, ethnicity, trauma type, and other adversity variables to predict the following CANS domains: posttraumatic stress symptoms (PTSS), emotional/ behavioral needs, risk behaviors, life domain functioning, and child strengths. Findings supported the hypothesis that males and females would exhibit a similar number and severity of PTSS subsequent to exposure to maltreatment, including complex trauma. Unique gender-specific developmental profiles of trauma exposure and symptomatology emerged. I concluded that the complex and dynamic interactions among gender, age, trauma experience, and psychosocial functioning are more complicated than can be elucidated in main effect or two-way interactions. It is therefore recommended that trauma researchers disaggregate analyses by gender in trauma research because the dynamics of trauma are different for males and females. In Study 2, I employed survival analyses to examine the ability of child characteristics, complex trauma exposure, and placement-related variables to predict placement disruption in a sample of 4,822 youth at high-risk for placement disruption. Older age, female gender, higher levels of externalizing behavior, and more prior placements increased risk for placement disruption, whereas longer time in care and type of out-of-home placement decreased risk for placement disruption in the sample. It is recommended that placement stability be directly targeted for those at higher risk through provision of intensive support to youth and their foster caregivers. Caseworkers should receive training about those subgroups most at-risk for placement disruption. Externalizing behavior and attachment, but not PTSS, mediated the relation between complex trauma and placement disruption. Intervention for youth with a history of complex trauma should focus on both attachment and externalizing behaviors.

This study examined, via a meta-analysis, the relations among stressors, social support, and stress reactions. Unexpectedly, small to medium negative, but robust effect sizes were found for the stressors-social support relation. As expected the stressor-stress reaction relation was positive, and the social support-stress reaction relation was negative. Both relations had small to medium effect sizes that ranged from weak to very robust. The direct effect of social support on the stressor-stress reaction was generally supported, whereas the suppressor and mediating models were not supported. Furthermore, the findings were inconclusive for the moderator effect of social support. Non-interpersonal traumas appear different in the stressor-social support and social support-stress reaction relations compared to other trauma types. These findings have important clinical implications.

Posttraumatic growth, defined as positive psychological changes in the aftermath of adversity and suffering, is a relatively recent focus in psychological research. The addition of this concept to the literature has provided a new, more resiliency-based framework through which to view survivors of various forms of trauma. Despite estimates that over half of all sexual assaults are not reported to the authorities, current crime statistics indicate that 1 in 4 women are sexually assaulted in their lifetime (Campbell & Wasco, 2005). Given the large percentage of the population that is impacted by sexual assault, it is essential that professionals better understand the factors that influence the successful healing and growth that can occur post-trauma. The purpose of this study was to further expand the literature on posttraumatic growth in sexual assault survivors by considering this phenomenon through the lens of attachment theory. Specifically, this study tested a proposed model of the inter-relationships among subjective and objective perceptions of threat during the sexual assault, adult romantic attachment, and posttraumatic growth. It was hypothesized that adult romantic attachment and parent-child attachment would mediate the relationship between subjective, or perceived threat, defined as the victim's perception of life threat, and objective threat, defined as the severity of the sexually aggressive act perpetrated on the victim, and posttraumatic growth. Finally, it was hypothesized that subjective threat appraisal would better predict posttraumatic growth than objective threat appraisal. Contrary to hypotheses, results of the study indicated that adult romantic attachment and parent-child attachment did not mediate the relationship between subjective and objective threat appraisal and posttraumatic growth. Thus, both path analytic models were not viable. However, exploratory analysis indicated that both subjective and objective threat appraisal were directly related to posttraumatic growth, with subjective perceived threat appraisal accounting for more of the variance.

Submitted by Fabio Sobreira Campos da Costa (fabio.sobreira@ufpe.br) on 2017-07-25T12:32:10Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Angelo-tese doutorado.pdf: 2038180 bytes, checksum: be401d99f221bbdf4a8d892feb579538 (MD5) / Made available in DSpace on 2017-07-25T12:32:10Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) Angelo-tese doutorado.pdf: 2038180 bytes, checksum: be401d99f221bbdf4a8d892feb579538 (MD5) Previous issue date: 2016-11-24 / Introdução: A incidência de hidrocefalia pós craniectomia descompressiva(CD) em pacientes com traumatismo cranioencefálico(TCE) é entre 0-45% segundo a literatura. A hidrocefalia traz prejuízos ao prognóstico neurológico e demanda reconhecimento clínico precoce. Existem diversas variáveis radiológicas e clínicas descritas com associação ao risco de hidrocefalia. Para estudar a influência desses fatores conduzimos um estudo retrospectivo, observacional em um centro terciário de atendimento a pacientes com TCE com foco principal na análise do volume de herniação transcraniana (VHTC) após CD. Métodos: selecionamos 50 pacientes que realizaram CD para TCE entre janeiro de 2014 e janeiro de 2015. Hidrocefalia foi reconhecida e definida na presença de critérios radiológicos de Gudeman, indicação de derivação ventricular, e na mensuração do Índice de Evans modificado maior que 33%. Analisamos as seguintes variáveis: Idade, Sexo, Escala de Coma de Glasgow à admissão, reatividade pupilar, índice de Zunkeller, presença de higroma, VHCE, diâmetro da craniectomia e distância da craniectomia em relação à linha média. Regressão logística foi utilizada definindo o desfecho com ou sem hidrocefalia como medida de análise. Resultados: 17 pacientes desenvolveram hidrocefalia (34%). VHCE após CD (p<0.001), Higroma subdural (p<0.001) ), Escala de coma de Glasgow abaixo de 6( p=0.015), sinais de herniação uncal(p=0.042) e maior valor no índice de Zumkeller(p=0.04) foram associados com o desenvolvimento de hidrocefalia pós-CD. Regressão logística demonstrou que entre essas variáveis as que foram consideradas como fatores de risco independente são o VHTC (OR 11.08; 95%IC 2.10,58.4; p=0.004) e a presença de higroma (OR 49.59; 95%IC 4.1,459;p=0.002). Conclusões: Observamos uma forte associação entre a severidade do TCE, o volume de herniação cerebral transcraniana e presença de higroma subdural com o desenvolvimento de hidrocefalia. Pacientes com esses achados devem ser acompanhados rigorosamente visando evitar prejuízo clínico. / In patients undergoing decompressive craniectomy(DC) for traumatic brain injury(TBI) there has been reported an incidence of hydrocephalus between 0-45%. Hydrocephalus affects long term survival and needs a prompt and correct diagnosis. There are several radiological and clinical features described in association with development of hydrocephalus. For study the influence of these factors we conducted a retrospective observational single-center cohort study in a tertiary care center with special attention to the transcalvarial brain herniation volume(TCH) after DC. Methods: We selected 50 patients that underwent DC after closed head injury between january 2014 and January 2015. Hydrocephalus was defined as a modified frontal horn index greater than 33%, Gudeman CT scan criteria or insertion of ventriculoperitoneal Shunt. Variables we analyzed were: age, post-resuscitation Glasgow Coma Scale (GCS) score, pupil reactivity, Zunkeller index, presence of hygroma, TCH volume, craniectomy diameter and distance of craniectomy from midline. Logistic regression was used with hydrocephalus as the primary outcome measure. Results: 17 patients developed hydrocephalus(34%). TCH volume after decompression ( p<0.001), subdural hygroma ( p ), lower admission Glasgow Coma Scale score ( p=0.015), unilateral pupil reactivity(p=0.042) and higher Zumkeller index(p=0.044) were significant risk factors for hydrocephalus after decompressive craniectomy. Logistic regression analysis showed that factors independently associated with the development of hydrocephalus was the TCH volume (odds ratio 11.08; 95%CI 2.10, 58.4; p = 0.0046), and presence of hygroma (odds ratio 49.59; 95%IC 4.1, 459; p=0.002). Conclusions: There is a clear association between severity of TBI, TCH volume and subdural hygroma with the development of hydrocephalus. Clinicians should follow closely patients with those findings in order to avoid late deterioration.

Huntington disease (HD) is a genetically transmitted fatal neurodegenerative condition that currently has no cure. The symptoms of HD are manifested as cognitive declines, neuropsychiatric disturbances, and motor dysfunction. An autosomal dominant genetic defect is responsible for the onset of HD, which means that the children of an affected parent have a 50% chance of inheriting the disease. Predictive genetic testing for HD has been available since 1993, and a positive test result means that a person will develop HD with 100% certainty. People who have the HD-gene expansion, but have not yet manifested unequivocal motor signs, are said to be in the prodromal phase of HD. A number of studies have examined concerns about the utility of genetic testing and its negative psychological consequences for gene-expanded and non-expanded individuals (e.g., traumatization, suicidal ideation). Although research has understandably focused on the potential for distress, there has been some evidence suggesting that individuals may actually experience psychological growth related to a receiving a genetic test result (e.g., improved relationships, pursuing new opportunities). The aim of the present study was to understand the relationship between genetic testing, prodromal HD symptoms, and posttraumatic growth (PTG). Participants were recruited through the multinational PREDICT-HD study (Jane Paulsen, PI) and they completed the Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) to assess permanent positive psychological change as a result of learning about their HD-gene status. The Symbol Digit Modalities Test (Smith, 1991), Unified Huntington's Disease Rating Scale Motor Exam (Huntington's Study Group, 1996), and the SCl-90-R Depression subscale (Derogatis, 1994) were also completed. A total of 82 gene-expanded patients and 37 non-expanded patients took part in this study. Results revealed that gene-expanded and non-expanded individuals reported experiencing PTG, particularly in their appreciation for life and ability to relate to others. Gene-expanded and non-expanded participants did not differ in the amount of growth they reported, which indicated that the outcome of genetic testing was not related to how much growth people experienced. Age and gender were associated with PTG, with younger participants and women reporting the most growth. The amount of time elapsed since genetic testing, estimated proximity to a diagnosis of HD, and the clinical characteristics of prodromal HD were not related to PTG. In conclusion, people experience positive psychological change as result of genetic testing for HD. The findings of this study have important implications for future research and for mental health professionals assisting people through the genetic counseling process.

Prior research has pointed to an association between a history of traumatic events and premenstrual syndrome (PMS) in women. The objective of this study was to further investigate the relationship between trauma and PMS among female veterans, a population with high rates of sexual and physical abuse, as well as combat-related exposures. We conducted a case-control study of 502 women veterans under the age of 52 who were associated with the Iowa City Veterans Affairs Medical Center. Trauma history, gynecological health, mental health (including posttraumatic stress disorder), and other variables were obtained through telephone interview. Cases were women who had moderate to severe PMS as defined by validated criteria and controls were women without PMS. The prevalence of PMS was 14.3%. Thirty-three percent of subjects reported a completed sexual assault, 29% a combat-related trauma, and 86% a non-combat related trauma. Factors significantly associated with PMS (p<0.05) in the univariate analysis were: attempted, completed, and number of rapes during a woman's lifetime; rape before age 18; rape during military service; childhood sexual abuse; and number of non-combat related traumas. Childhood physical abuse and combat-related trauma were not associated with PMS in univariate analyses. In our final multivariate model, lifetime completed sexual assault was associated with PMS (odds ratio =2.42, 95% confidence interval = 1.33-4.40). Findings from this study among female veterans indicate that a history of trauma, particularly sexual trauma, is associated with moderate to severe PMS. Further study is warranted to confirm temporal relationships and causal mechanisms.