Functional impairment in Posttraumatic Stress Disorder: A systematic review and meta-analysis

(1) Background: This scoping review identifies subjective cognitive decline (SCD) indicators in ADLs and instrumental activities of daily living (IADLs) in older adults with depressive symptoms using the WHO International Classification of Functioning, Disability, and Health (ICF). (2) Methods: We searched Medline via Ebscohost, Pubmed, and PsycINFO for articles published on activities of daily living (ADL) indicators of SCD in older adults with depressive symptoms, published in English language journals from January 2011 to November 2021. Following the flow diagram, 2032 titles and abstracts were screened for relevance based on the Population, Concept, and Context inclusion and exclusion criteria. (3) Results: Eight articles provided evidence about the ADL indicators of SCD in older adults with depressive symptoms. The analysis yielded indicators based on low and high cognitively demanding tasks assessed on five different scales. Framed on the ICF categorization and coding system, the SCD-ADL indicators are personal care, mobility, and general tasks and demands; SCD-IADL indicators are mobility, general tasks and demands, learning and applying knowledge, domestic life, communication, major life areas, and community, social, and civic life. (4) Conclusion: Highly cognitively demanding activities present more difficulties for individuals with SCD, making IADLs a stronger predictor of SCD than ADLs.

BackgroundThe number of older people with unmet care and support needs is increasing substantially due to the challenges facing the formal and informal care system in the United Kingdom. Addressing these unmet needs is becoming one of the urgent public health priorities. In order to develop effective solutions to address some of these needs, it is important first to understand the care and support needs of older people.MethodsA scoping review was conducted, using the Arksey and O’Malley original and enhanced framework, to understand the care and support needs of older people, focusing on those living at home with chronic conditions in the UK. The search was conducted using five electronic data bases, grey literature and reference list checks. The WHO International Classification of Functioning, Disability and Health (ICF) framework was used to analyse and categorise the literature findings.ResultsForty studies were included in the final analysis- 32 from academic literature and 8 from grey literature. The review highlighted that older adults faced a range of physical, social and psychological challenges due to living with chronic conditions and required care and support in three main areas: 1) social activities and relationships; 2) psychological health; and 3) activities related to mobility, self-care and domestic life. The review also highlighted that many older people demonstrated a desire to cope with their illness and maintain independence, however, environmental factors interfered with these efforts including: 1) lack of professional advice on self-care strategies; 2) poor communication and coordination of services; and 3) lack of information on services such as care pathways. A gap in the knowledge was also identified about the care and support needs of two groups within the older population: 1) older workers; and 2) older carers.ConclusionsThe review highlighted that older people living with chronic conditions have unmet care needs related to their physical and psychological health, social life, as well as the environment in which they live and interact. Findings of this review also emphasized the importance of developing care models and support services based around the needs of older people.

Post-traumatic stress disorder (PTSD) is becoming increasingly common among military personnel who have participated in combat operations, posing a significant challenge to their normal social functioning. Without effective rehabilitation programs, maladaptive behaviors can become habitual, hindering social integration. Therefore, it is crucial to start the mental recovery process as early as possible. This work evaluated the validity of the diagnostic approaches recommended by the Research Domain Criteria (RDoC) project in evaluating the PTSD severity. We used the RDoC and International Classification of Functioning, Disability, and Health (ICF) domains to evaluate PTSD-associated functional impairment. The work reviewed the syndromic heterogeneity of PTSD, the challenges of differential diagnosis, and the impact of etiological factors on the clinical presentation. We identified three main categories of functional impairment: stress-related behaviors, interpersonal interactions, and cognitive abilities. Diagnostic approaches and research paradigms were proposed to assess and standardize these categories. The RDoC and ICF concepts provide a new perspective on the pathogenesis of PTSD and development of personalized management strategies. It appears promising to enhance specialized diagnostic approaches for this patient population, considering their cultural and mental background.

Epidemiology and risk factors for sleep disturbances in children and youth with cerebral palsy: An ICF-based approach

Stroke-associated impairments display a wide variety of clinical signs and symptoms. Therefore, a multidisciplinary team with different experts working closely together is necessary for effective stroke rehabilitation.In rehabilitation of stroke patients, a holistic view on functioning and disability is necessary to establish an individualized and comprehensive treatment program. The WHO International Classification of Functioning, Disability and Health (ICF) provides a common language to describe individual functioning in a given context suitable for a shared documentation system.Goal setting has become a central component of effective communication and decision-making in rehabilitation practice, both as part of the process and as a person-centred outcome measure for stroke rehabilitation. Nevertheless, agreed standards on goal setting and evaluation still need to be defined.Here, we highlight some aspects with relevance for multidisciplinary team building and coordination and for using the ICF in the context of stroke rehabilitation; how to describe individual levels of functioning and disability and to set treatment goals as well as to identify barriers and facilitators to individual functioning and health.KeywordsTeam approachShared documentationICFGoal settingGoal attainment scalingStroke care pathwaysBiopsychosocialClinical reasoningFunctioningDisabilityStroke rehabilitation

Background: The International Trauma Questionnaire (ITQ) is a self-report assessment focused on the core features of Post-Traumatic Stress Disorder (PTSD) and complex Post-Traumatic Stress Disorder (CPTSD). It is consistent with the organizing principles of the 11th revision to the WHO's International Classification of Diseases (ICD-11). Since the 1990s, the number of North Korean defectors (NKD) entering South Korea to escape human rights violations has been increasing rapidly, with 33,815 NKD settled by 2021. The South Korean government faces an important challenge in supporting NKD to successfully adapt and settle in South Korean society. NKD experience various traumatic events during the process of defecting and repatriation. Therefore, it is essential to understand the psychological disorders of NKD, especially PTSD and CPTSD. Objective: This study aimed to test the validity of the ITQ assessment and explore the differences in symptoms and quality of life between PTSD and CPTSD. Method: The study sample comprised 503 trauma-exposed NKD. Confirmatory factor analysis (CFA) and latent class analysis (LCA) were used to evaluate the validity of ITQ. One-way analysis of variances and post-hoc analyses revealed the difference in the Depression and Somatic Symptoms Scale (DSSS) and WHOQOL-BREF results among PTSD and CPTSD symptom LCA classes. Results: The CFA and LCA results supported the ICD-11 conceptualization of PTSD and CPTSD in NKD. The CFA results confirmed that both the first- and second-order models were statistically fit, but for community-dwelling NKD the first-order model had better model fit than the second-order model. The LCA findings revealed a four-class model with ‘PTSD’, ‘CPTSD’, ‘DSO’, and ‘low symptom’ classes. Compared to the PTSD class, CPTSD class had higher levels of depression and somatic symptoms and a lower quality of life. Conclusion: This study provided evidence that ITQ is a valid tool to assess PTSD or CPTSD in community-dwelling NKD.

Background: Besides the measurement of symptoms, information on functioning and disability in daily routines expands the description of impairments in patients with anxiety disorders. Therefore, the measurement of activities and participation, as theoretically included in the International Classification of Functioning, Disability and Health (ICF) is of increasing importance. The objective of this study is to give an overview over the implementation of the concept ‘activities and participation’ in outcome measurements of patients with anxiety disorders. Methods: Based on a literature review in PubMed and PsycInfo databases and including 200 papers, this study analyses 65 outcome instruments used in randomized controlled trials in anxiety disorders according to their content related to the ICF domain of ‘Activities and participation’. Results: Instruments used in trials evaluating outcome in patients with anxiety disorder only partially address activities and participation. Over all 65 instruments, the chapters on ‘Interpersonal interactions and relationships’ and ‘Mobility’ were most frequently included in measurements. Conclusions: The identification of relevant ICF categories (core sets) according to activities and participation and especially interpersonal interactions and relationships as well as mobility, can be a basis for describing functioning and evaluating treatment in anxiety disorders, helping to improve outcome assessment in clinical practice.

Posttraumatic stress disorder (PTSD) has been associated with executive or attentional dysfunction and problems in emotion processing. However, it is unclear whether these two domains of dysfunction are related to common or distinct neurophysiological substrates. To examine the hypothesis that greater neuropsychological impairment in PTSD relates to greater disruption in prefrontal-subcortical networks during emotional anticipation. Case-control, cross-sectional study. General community and hospital and community psychiatric clinics. Volunteer sample of 37 women with PTSD related to intimate partner violence and 34 age-comparable healthy control women. We used functional magnetic resonance imaging (fMRI) to examine neural responses during anticipation of negative and positive emotional images. The Clinician-Administered PTSD Scale was used to characterize PTSD symptom severity. The Wechsler Adult Intelligence Scale, Third Edition, Digit Symbol Test, Delis-Kaplan Executive Function System Color-Word Interference Test, and Wisconsin Card Sorting Test were used to characterize neuropsychological performance. Women with PTSD performed worse on complex visuomotor processing speed (Digit Symbol Test) and executive function (Color-Word Interference Inhibition/Switching subtest) measures compared with control subjects. Posttraumatic stress disorder was associated with greater anterior insula and attenuated lateral prefrontal cortex (PFC) activation during emotional anticipation. Greater dorsolateral PFC activation (anticipation of negative images minus anticipation of positive images) was associated with lower PTSD symptom severity and better visuomotor processing speed and executive functioning. Greater medial PFC and amygdala activation related to slower visuomotor processing speed. During emotional anticipation, women with PTSD show exaggerated activation in the anterior insula, a region important for monitoring internal bodily state. Greater dorsolateral PFC response in PTSD patients during emotional anticipation may reflect engagement of cognitive control networks that are beneficial for emotional and cognitive functioning. Novel treatments could be aimed at strengthening the balance between cognitive control (dorsolateral PFC) and affective processing (medial PFC and amygdala) networks to improve overall functioning for PTSD patients.

Introduction There is growing evidence that Post Traumatic Stress Disorder (PTSD) increases the risk of dementia, and sleep impairment in PTSD may contribute to this link. Increased cerebrospinal fluid (CSF) norepinephrine (NE) is associated with glymphatic dysfunction and poor neurocognitive outcomes. To understand the role of sleep in mediating the increased risk of dementia in PTSD, we investigated whether sleep-specific symptoms of PTSD are related to CSF NE level and cognitive function. Methods We analyzed a prospective study of combat Veterans with repetitive blast mild traumatic brain injury (mTBI). All underwent CSF sampling and the PTSD and DSM checklist 5 for military (PCL-M), a 17-item self-report measure reflecting DSM-IV symptoms of PTSD. We derived a sum score of each symptom cluster; Questions 1-5: “Re-Experiencing”, 6-12: “Avoidance and Negative Cognition and Mood” and 13-17: “Hypervigilance”. Among the 17 items, questions 2 and 13 are sleep-related symptoms. We calculated correlations of the sum score of each category with CSF NE level with and without sleep-specific questions (2: nightmare and 13: sleep disruption) with CSF NE levels. Trails A (attention and visual motor function) and Trail B (executive function) tests were performed. Results A total of 49 mTBI participants were included. A sum score of symptoms related to re-experiencing (r=0.34, p=0.001) and hyperarousal (r=0.3, p=0.03) were weakly correlated with elevated CSF NE. Excluding the sleep-specific symptom questions from these two categories attenuated the correlation (re-experiencing r=0.31, p=0.03; hyperarousal r=0.2, p=0.1). The scores of sleep-specific symptoms were separately examined, the correlation with CSF NE was (nightmare r=0.37, p=0.0009; sleep impairment r= 0.35, p=0.001). The symptom cluster related to avoidance and negative cognition and mood was not associated with NE level (r=0.15, p=0.9). Elevated CSF NE was strongly associated with lower Trials B performance (r=0.34, p=0.001). Trails A performance was not associated. Conclusion PTSD-associated sleep symptoms of nightmares and sleep disruption are most strongly associated with CSF NE. CSF NE is associated with worsening executive function measured by Trails B. Sleep symptoms may be the driver of the poor neurocognitive outcomes in patients with PTSD. Traditional symptom clusters of PTSD may not accurately reflect the risk of cognitive function. Support (if any)

Memory function was studied in combat veterans with posttraumatic stress disorder (PTSD), combat veterans without PTSD, and noncombat veterans. The Vocabulary and Digit Span subtests of the WAIS and Logical Memory (LMS) and Verbal Paired Associates (VPAS) subtests of the Wechsler Memory Scale III were administered. Combat veterans with PTSD showed impaired memory on the LMS and VPAS compared to combat veterans without PTSD or noncombat veterans. Veterans with PTSD also showed lower WAIS Vocabulary subtest scores--but not digit span subtest scores--than combat veterans without PTSD or noncombat veterans. Medication status, co-morbid diagnosis, and age all failed to account for these memory differences, but when self-assessed depression--as measured by the Zung Self-Rating Depression Scale--or anxiety--as measured by the Spielberger State-Trait Anxiety Scale--was statistically removed, group differences on these memory measures were no longer significant. However, using a stepwise regression procedure, in which both anxiety and depression were employed to predict the LMS and VPAS scores, only the Zung scale reliably predicated performance. The present results, showing that PTSD is associated with general learning and memory impairments, is an important finding, but the specific effects of depression as a mediator of these deficits should be further studied.

A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD

Problems in communication serve as frequent markers of developmental delay and disability in childhood. Documentation of delayed or atypical receptive or expressive communication is one of the key diagnostic factors in the identification of children for intervention and support. This paper (1) reviews issues in classification and measurement of communication disabilities, (2) presents an overview of the development and publication of the WHO International Classification of Functioning, Disability and Health (ICF), and (3) identifies the implications of the ICF for children and youths with communication disabilities. As a conceptual framework, the ICF may be used productively to define the focus for different efforts to address children's language and communication difficulties. Impairments of a physical or mental nature can be covered in the Body Function and Body Structure components, complementing the information provided by the ICD-10 with descriptive documentation. The component of Activities, encompassing performance aspects of communication, lends itself to functional assessment and intervention in habilitation and education programs. The component of Participation provides an operational basis for policy initiatives focusing on social integration and community life. Finally, the Environmental Factors component serves as a framework for identifying the nature and extent of access and opportunity for individuals and populations.

The role of heightened arousal has been previously discussed as a contributor to neurocognitive impairment in posttraumatic stress disorder (PTSD). To investigate whether psychological effects (distraction, re-location of resources) elicited by the evocation of traumatic memories impact on subsequent cognitive performance in PTSD, two parallel versions of a working memory task were administered to 33 trauma-exposed participants (15 with and 18 without PTSD). Between first and second working memory assessment a trauma-related interview was conducted including the narration of the trauma. Levels of working memory impairment in PTSD patients remained unchanged. This study provides preliminary evidence that neurocognitive impairment is not secondary to psychological effects induced by the evocation of traumatic memories. Nevertheless, it is recommended that future PTSD research should devote more care to the order in which trauma-related and other dependent variables such as cognitive tests are presented to participants.

There is growing evidence to support sleep impairment as a core feature of posttraumatic stress disorder (PTSD). Sleep impairment in PTSD is associated with severe distress and poorer treatment outcomes. Therefore, specific attention to this symptom of PTSD is warranted and accurate assessment of sleep impairment is critical. The current study investigated the association between self-reported and objective assessment of sleep and sustained attention in women with PTSD. Study participants include 50 treatment-seeking, female, interpersonal violence survivors who have PTSD. Nocturnal sleep duration was measured with self-report sleep diaries and objective actigraphy assessment over the course of 7 nights. Sustained attention during daytime was measured by the Psychomotor Vigilance Task (PVT). Results indicated that self-reported nocturnal sleep duration, but not objective or global sleep quality measures, best predicted attentional deficits as indicated by lapses and inverse reaction time on the PVT. Daily sleep diaries predicted 19% and 14% of the variance in attentional lapses and inverse reaction time, respectively. In a sample of women with PTSD, self-reported nocturnal sleep duration predicted deficits in sustained attention. Conversely, sleep duration as measured by actigraphy and global sleep quality, did not predict sustained attention. Findings suggest that assessing sleep impairment on a daily basis may provide clinically relevant information in evaluating daytime symptoms and provide guidance in targeting this particularly troublesome symptom in the treatment of PTSD. Werner KB, Arditte Hall KA, Griffin MG, Galovski TE. Predicting attentional impairment in women with posttraumatic stress disorder using self-reported and objective measures of sleep. J Clin Sleep Med. 2019;15(9):1329-1336.

This study examines the effect of posttraumatic stress disorder (PTSD) on function and physical performance in older overweight military Veterans with comorbid conditions. This is a secondary data analysis of older Veterans (mean age = 62.9 yr) participating in a physical activity counseling trial. Study participants with PTSD (n = 67) and without PTSD (n = 235) were identified. Self-reported physical function (36-item Short Form Health Survey) and directly measured physical performance (mobility, aerobic endurance, strength) were assessed. Multivariate analyses of variance controlling for demographic factors and psychiatric disorders demonstrated significant physical impairment among those with PTSD. PTSD was negatively associated with self-reported physical function, functioning in daily activities, and general health (p < 0.01). Those with PTSD also performed significantly worse on tests of lower-limb function (p < 0.05). Despite being significantly younger, Veterans with PTSD had comparable scores on gait speed, aerobic endurance, grip strength, and bodily pain compared with Veterans without PTSD. This study provides preliminary data for the negative association between PTSD and physical function in older military Veterans. These data highlight the importance of ongoing monitoring of physical performance among returning Veterans with PTSD and intervening in older overweight Veterans with PTSD, whose physical performance scores are indicative of accelerated risk of premature functional aging.