Lifetime Legacy of War: Trauma ‘Under the Skin’ Is Underappreciated
Authors: Delaney Glass, BS, et al.
Abstract: People living in war may experience deteriorating health via weathering (wear and tear) from long-term exposures to psychosocial and environmental stressors, say the authors. Weathering embodied in somatic health complaints may illuminate the effects of war on health.
Their analyses focus on northern Vietnamese adults who were in their teens and early twenties during the height of the American War in Vietnam (1965-75).
Using data from the Vietnamese Health and Aging Study (VHAS), they investigate whether wartime stress exposures occurring during adolescence and early adulthood affect weathering in late adulthood. VHAS is a cross-sectional study wherein investigators surveyed 2,447 adults aged 60+ in four districts of northern and central Vietnam in 2018. These same individuals ranged in age from seven to 52 in 1965, with most having been in adolescence or early adulthood at the peak of the war. The sample used for this study were participants in the first VHAS wave in 2018.
The authors report that older Vietnamese adults exposed to high-intensity provincial bombing suffer more numerous somatic health complaints. And greater health complaints emerge among older adults whose most intense bombing exposures were at younger ages of adolescence (< age 15) as compared to those whose peak exposures were in older ages (19-25). “Our findings suggest that age of exposure to armed conflict is a critical determinant of weathering across the life course.”
The authors point to earlier research showing that events experienced or witnessed posing threats to one’s life or injury may induce extremes of fear and psychological overwhelm. “Experiencing early life adversity in the form of unexpected family death, deprivation, and threat has been associated with accelerated biological aging and worse overall health. Adversities via wartime exposures in childhood and adolescence have been associated with varied effects on physical growth, like stunting and elevated subjective age relative to chronological age.
“Traumatic war exposures and displacement have been robustly linked to development of conditions such as PTSD, depression, and anxiety. These exposures may also ‘get under the skin’ or become ‘embodied’ and contribute to somatic health complaints that are not explained by physical comorbidities, also known as somatization or somatic distress. Somatoform pain is pronounced in populations displaced by war and violence, often occurring alongside posttraumatic stress symptoms. Some research suggests individuals exposed to armed conflict will present with psychosomatic symptoms that may be highly correlated with other psychological outcomes.”
Importance: The authors remind us that every war has an afterlife: socially, economically, psychologically, and in terms of health. While each war is distinct, they are consistent in that they create an ‘environment’ with a cluster of stressors imposed upon populations that may become ‘embodied.’ Childhood adversity directly impacts young adult health, and may have indirect yet potent impacts on late life health. It is plausible that weathering in the context of war is detectable as a direct, embodied effect on health shortly after an armed conflict experience, but may manifest indirectly as somatic health complaints later in life.
However, “the many possible pathways and mechanisms through which war may ‘get under the skin’ and impact human health may be underappreciated and warrant far more attention. While research on somatic health complaints includes understanding relationships between somatic distress and traumatic exposures, our study is the first to unite developmental perspectives on adolescence, impacts of traumatic war exposures (namely aerial bombing), and somatization in a theoretical context of weathering.”
Availability: Published in the Journal of Psychosomatic Research.
How Interdisciplinary Teams Conceptualize Shared Decision-Making
Authors: Erick Cheung, MD, et al.
Abstract: The authors assess the prevalence and predictors of Shared Decision Making (SDM) in an adult, inpatient psychiatric setting.
SDM is a communication model in which clinicians identify areas of clinical concern and potential treatment options, and collaborate with the patient who provides their preferences and values to jointly guide treatment decisions. It is designed to reduce power and information asymmetry, enhance two-way engagement, and increase patient satisfaction by aligning treatment with patient values, and is recognized as a quality standard. Benefits of SDM include greater adherence to treatment, reduced costs and stigma, and better health and recovery.
Psychiatry is reported to have been slower than other medical fields to adopt SDM, with reasons ranging from paternalism among psychiatrists, patients’ cognitive capacity, time constraints, and doubts about benefits. Yet, studies of inpatients with schizophrenia or serious mental illness suggest that patients prefer SDM for communication, and that involvement in decisions is feasible for patients with schizophrenia, without taking up much physician time.
The authors’ project began after an inpatient psychiatric quality improvement (QI) team noted that post-discharge patient satisfaction was associated with patients “being included in their care,” a measure of SDM. While the QI team proposed a goal of enhancing SDM as a patient outcome, their initial step was to understand the landscape of SDM for psychiatric inpatients and their clinical team members.
Their study was also designed to show how interdisciplinary teams conceptualize SDM, and ultimately to assess how adult inpatients and interdisciplinary clinician teams compare in their rating of SDM, and explore factors that may enhance or interfere with SDM.
Diagnostic agreement/disagreement was found to be a key predictor of SDM for patients and clinicians; presence of psychosis was not. SDM was rated higher by clinicians than patients.
Importance: This QI initiative adds to the literature on SDM for adult psychiatric inpatients and interdisciplinary teams. Ratings of SDM by patients and clinicians were significantly lower for patients with diagnostic disagreement, informing opportunities to enhance inpatient care. Neither clinicians nor patients identified psychosis as a significant factor impacting SDM in this survey, challenging assumptions that clinicians may hold.
Availability: Published in General Hospital Psychiatry.
Prevalence of Bullying Among Adolescents Across Europe
Authors: Mehedi Hasan, MD, et al.
Abstract: The authors explore geographical variations in the prevalence of traditional and cyberbullying and their individual and additive role on adolescents’ psychological and somatic health issues.
Overall, the prevalence of traditional bullying among adolescents in the study was 26.9%, ranging from 8.8% in Armenia to 49.7% in Latvia. Cyberbullying was 15.8%, ranging from 5.8% in Greece to 38.3% in Greenland. One in 10 (8.4%) adolescents reported experiencing both forms of bullying, with the prevalence ranging from 2.5% (Greece) to 21% (Greenland).
Meta-analytic estimates suggest a significant role of both traditional and cyberbullying in poor somatic and psychological health issues. The additive effect of both forms of bullying is more prominent on psychological health issues than on somatic health issues, but associations vary across countries.
Importance: The prevalence of traditional and cyberbullying vary significantly across European countries while their individual and additive links with an increased risk of poor psychological and somatic health issues remain common in most countries. “To ensure both forms of bullying are prevented,” say the authors, “a multifaceted approach and particular attention to mental health issues in bullying victims are needed in countries with high prevalence of bullying.”
Availability: Pre-publication in the Journal of Psychosomatic Research.
Changes in Brain Connectivity Linked to Aggressive Behavior in Schizophrenia
Authors: Alexandra Fortier, PhD, et al.
Abstract: This study investigates the association between past-reported violent/aggressive behaviors and the functional connectivity of three brain regions (the DLPFC, the dACC, and the anterior insula)—involved in emotion regulation and response inhibition—during an emotional (i.e., angry) response inhibition task in patients with schizophrenia.
Forty-four male patients with schizophrenia and 22 healthy male controls performed an emotional go/no-go task using angry and neutral faces during a functional magnetic resonance imaging session. Generalized psycho-physiological interaction was conducted to explore task-based functional connectivity and a negative binomial regression was used to evaluate the relationship between neural alterations and violent/aggressive behaviors.
During emotion-related response inhibition, patients with schizophrenia displayed altered connectivity between the anterior insula and amygdala, the DLPFC and lateral orbitofrontal cortex, as well as the anterior insula and the dACC when compared to healthy individuals. The latter was negatively associated with aggressive behaviors in participants with schizophrenia.
“Our results highlight alterations in functional connectivity in brain regions involved in cognitive control and emotion processing which are associated with aggressive behaviors in schizophrenia,” say the authors.
Importance: Schizophrenia affects 0.34 to 0.85% of the US population. Although most individuals diagnosed are not violent nor aggressive, studies report two to five times higher odds of exhibiting violent behaviors or committing violent crimes in schizophrenia when compared to the general population.
In addition to the impact on victims, violent and aggressive behaviors are self-detrimental as they lead to the stigmatization of patients, increase the probability of incarceration, and hinder patients’ ability to secure stable employment.
Moreover, violent and aggressive behaviors contribute to lengthier hospitalizations, which in turn increase the costs of care. Given the psychosocial and economic consequences of violent and aggressive behaviors in schizophrenia, increasing efforts have been dedicated towards understanding the neural mechanisms underpinning violent behaviors in this population. None hitherto have investigated functional connectivity during a response inhibition task in this patient population.
Availability: Psychiatry Research: Neuroimaging.
Elderly with Long-Term Loneliness ‘May be High-Risk Group for Dementia’
Authors: Yanzhi Li, PhD, et al.
Abstract: Some lonely older adults might have transient loneliness, followed by full remission; others might have persistent loneliness. Such different courses might differ in predicting the risk of dementia, but most previous studies assessed short-term loneliness at a single time point, ignoring the long-term changes of loneliness. This study explores the association between eight-year trajectories of late-life loneliness and dementia.
Five distinct loneliness trajectories were identified: long-term low, persistently decreasing, persistently increasing, long-term moderate, and long-term high. Long-term high loneliness has the strongest correlation with dementia.
“The elderly show distinct patterns of loneliness over time, which cannot be captured by a single assessment of loneliness,” say the authors. “The elderly with long-term loneliness and persistently increasing loneliness might be the high-risk group for dementia. Further studies are needed to determine whether reducing loneliness can prevent dementia.”
Importance: With aging of the global population, dementia has become a growing public health problem worldwide, with enormous social and economic implications. In 2019, 57.4 million people worldwide had dementia, and this figure is estimated to be approximately 152.8 million by 2050. The global annual cost of dementia was $1 trillion in 2018 and is expected to double by 2030.
Availability: Pre-publication in the Journal of Geriatric Psychiatry.
Need to Differentiate True Suicidal Intention from a Desire to Hasten Death
Authors: Eduardo Andres Calagua-Bedoya, MD, et al.
Abstract: Psychiatric comorbidities are common among patients approaching end-of-life, often necessitating involvement of C-L psychiatrists. This team presents the case of a patient with advanced metastatic prostate cancer with a complicated hospital course who made suicidal remarks and requested a hastened death. Experts in C-L Psychiatry, palliative care and psycho oncology describe helpful diagnostic and therapeutic strategies for these cases. Key learning points are the differential diagnoses in EOL patients endorsing suicidal ideation, the psychiatric management of oncological and palliative care patients, the implementation of a safe discharge plan, and the role of the C-L psychiatrist in hospice care.
Co-author Carrie Ernst, MD, says the patient presented with a ‘frustrated’ mood, irritable affect, hopelessness about the potential for any symptomatic improvement, and strong desire to die. The desire for death included both a request for assistance from his health care providers to end his life and then a statement that he would find a way to end his own life upon discharge to home.
Co-author Philip Bialer, MD, FACLP, discusses current available treatments for patients approaching end-of-life: “Symptom management is the key. Ensuring maximum pain relief without over-sedating the patient to allow them to continue to interact with their family is crucial.”
Importance: The authors add: “The terminally ill patient can suffer from a variety of psychiatric conditions such as depression or delirium, but when suicide ideation is present, it is not always due to a major psychiatric illness. When evaluating these patients, it is important to differentiate true suicidal intention from a desire to hasten death, which can be secondary to demoralization, loss of autonomy, frustration or poor quality of life.”
Availability: Pre-publication in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).
You must be logged in to view this page
Please login below or register as a new user
Not an ACLP member? View Journal contents and abstracts here.