Disasters are traumatic events that may result in a wide range of mental and physical health consequences. Post-traumatic stress disorder (PTSD) is probably the most commonly studied post-disaster psychiatric disorder. This review aimed to systematically assess the evidence about PTSD following exposure to disasters.

A systematic search was performed. Eligible studies for this review included reports based on the DSM criteria of PTSD symptoms. The time-frame for inclusion of reports in this review is from 1980 (when PTSD was first introduced in DSM-III) and February 2007 when the literature search for this examination was terminated.

We identified 284 reports of PTSD following disasters published in peer-reviewed journals since 1980. We categorized them according to the following classification: (1) human-made disasters (n=90), (2) technological disasters (n=65), and (3) natural disasters (n=116). Since some studies reported on findings from mixed samples (e.g. survivors of flooding and chemical contamination) we grouped these studies together (n=13).

The body of research conducted after disasters in the past three decades suggests that the burden of PTSD among persons exposed to disasters is substantial. Post-disaster PTSD is associated with a range of correlates including sociodemographic and background factors, event exposure characteristics, social support factors and personality traits. Relatively few studies have employed longitudinal assessments enabling documentation of the course of PTSD. Methodological limitations and future directions for research in this field are discussed.

The psychological aftermath of the Chernobyl accident is regarded as the largest public health problem unleashed by the accident to date. Yet the mental health of the clean-up workers, who faced the greatest radiation exposure and threat to life, has not been systematically evaluated. This study describes the long-term psychological effects of Chernobyl in a sample of clean-up workers in Ukraine.

The cohorts were 295 male clean-up workers sent to Chernobyl between 1986 and 1990 interviewed 18 years after the accident (71% participation rate) and 397 geographically matched controls interviewed as part of the Ukraine World Mental Health (WMS) Survey 16 years after the accident. The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) was administered. We examined group differences in common psychiatric disorders, suicide ideation and severe headaches, differential effects of disorder on days lost from work, and in the clean-up workers, the relationship of exposure severity to disorder and current trauma and somatic symptoms. Analyses were adjusted for age in 1986 and mental health prior to the accident.

Relatively more clean-up workers than controls experienced depression (18.0% v. 13.1%) and suicide ideation (9.2% v. 4.1%) after the accident. In the year preceding interview, the rates of depression (14.9% v. 7.1%), post-traumatic stress disorder (PTSD) (4.1% v. 1.0%) and headaches (69.2% v. 12.4%) were elevated. Affected workers lost more work days than affected controls. Exposure level was associated with current somatic and PTSD symptom severity.

Long-term mental health consequences of Chernobyl were observed in clean-up workers.

The cognitive and academic outcomes of infants exposed to radiation after the meltdown at Chornobyl have been intensely debated. Western-based investigations indicate that no adverse effects occurred, but local studies reported increased cognitive impairments in exposed compared with non-exposed children. Our initial study found that at age 11 years, school grades and neuropsychological performance were similar in 300 children evacuated to Kiev as infants or in utero compared with 300 classmate controls, yet more evacuee mothers believed that their children had memory problems. This study re-examined the children's performance and academic achievement at age 19 years.

In 2005–2006, we conducted an 8-year follow-up of the evacuees (n=265) and classmate controls (n=261) assessed in Kiev in 1997. Outcomes included university attendance, tests of intelligence, attention, and memory, and subjective appraisals of memory problems. Scores were standardized using a local population-based control group (n=327). Analyses were stratified by parental education.

Evacuees and classmates performed similarly and in the normal range on all tests, and no differential temporal changes were found. The results were comparable for the in utero subsample. The rates of university attendance and self-reported memory problems were also similar. Nevertheless, the evacuee mothers were almost three times as likely to report that their children had memory problems compared with controls.

Chornobyl did not influence the cognitive functioning of exposed infants although more evacuee mothers still believed that their offspring had memory problems. These lingering worries reflect a wider picture of persistent health concerns as a consequence of the accident.

Although symptoms such as fatigue, headache and pain in bones and muscles are common after disasters, risk factors for these symptoms among disaster survivors have rarely been studied. We examined predisposing, precipitating and perpetuating factors for these physical symptoms among survivors of a man-made disaster. In addition, we examined whether risk factors for physical symptoms differ between survivors and controls.

Survivors completed a questionnaire 3 weeks (n=1567), 18 months and 4 years after the disaster. Symptoms and risk factors were measured using validated questionnaires. A comparison group was included at waves 2 and 3 (n=821). Random coefficient analysis (RCA) was used to study risk factors for symptoms.

Female gender [beta (β)=1.0, 95% confidence interval (CI) 0.6–1.4], immigrant status (β=1.0, 95% CI 0.6–1.4) and pre-disaster psychological problems (β=0.8, 95% CI 0.1–1.4) were predisposing factors for symptoms. Although disaster-related factors were predictors, the relationship between symptoms and disaster-related factors was not very strong and the magnitude of this association was reduced when perpetuating factors were added. Intrusions and avoidance, depression, anxiety and sleeping problems were important perpetuating factors for physical symptoms among survivors and mediated the association between traumatic stress and physical symptoms. Risk factors for symptoms were comparable between survivors and controls.

The results indicate that health-care workers should be alert for physical symptoms among female survivors, immigrant survivors and individuals with a high level of psychological problems both before and after a disaster.

There is considerable interest in understanding further the factors that increase the risk of post-traumatic stress disorder (PTSD) for military personnel. This study aimed to investigate the relative contribution of demographic variables; childhood adversity; the nature of exposure to traumatic events during deployment; appraisal of these experiences; and home-coming experiences in relation to the prevalence of PTSD ‘caseness’ as measured by a score of ⩾50 on the PTSD Checklist (PCL) in UK Armed Forces personnel who have been deployed in Iraq since 2003.

Data were drawn from the first stage of a retrospective cohort study comparing UK military personnel who were deployed to the 2003 Iraq War with personnel serving in the UK Armed Forces on 31 March 2003 but who were not deployed to the initial phase of war fighting. Participants were randomly selected and invited to participate. The response rate was 61%. We have limited these analyses to 4762 regular service individuals who responded to the survey and who have been deployed in Iraq since 2003.

Post-traumatic stress symptoms were associated with lower rank, being unmarried, having low educational attainment and a history of childhood adversity. Exposure to potentially traumatizing events, in particular being deployed to a ‘forward’ area in close contact with the enemy, was associated with post-traumatic stress symptoms. Appraisals of the experience as involving threat to one's own life and a perception that work in theatre was above an individual's trade and experience were strongly associated with post-traumatic stress symptoms. Low morale and poor social support within the unit and non-receipt of a home-coming brief (psycho-education) were associated with greater risk of post-traumatic stress symptoms.

Personal appraisal of threat to life during the trauma emerged as the most important predictor of post-traumatic stress symptoms. These results also raise the possibility that there are important modifiable occupational factors such as unit morale, leadership, preparing combatants for their role in theatre which may influence an individual's risk of post-traumatic stress symptoms. Therefore interventions focused on systematic preparation of personnel for the extreme stress of combat may help to lessen the psychological impact of deployment.

Due to neuropsychological conceptualizations of orbitoprefrontal cortex (OFC) dysfunction underpinning impulsive aggression and the incidence of such behaviour in post-traumatic stress disorder (PTSD), this study aimed to explore olfactory identification (OI) ability in war veterans with PTSD as a probe of putative OFC dysfunction; and to explore the utility of OI ability in predicting aggressive and impulsive behavior in this clinical population.

Participants comprised 31 out-patient male war veterans with PTSD (mean=58.23 years, s.d.=2.56) recruited from a Melbourne Veterans Psychiatry Unit, and 31 healthy age- and gender-matched controls (mean=56.84 years, s.d.=7.24). All participants were assessed on clinical measures of PTSD, depression, anxiety, and alcohol misuse; olfactory identification; neurocognitive measures of dorsolateral prefrontal, lateral prefrontal and mesial temporal functioning; and self-report measures of aggression and impulsivity.

War veterans with PTSD exhibited significant OI deficits (OIDs) compared to controls, despite uncompromised performance on cognitive measures. OIDs remained after covaring for IQ, anxiety, depression and alcohol misuse, and were significant predictors of aggression and impulsivity.

This research contributes to emerging evidence of orbitoprefrontal dysfunction in the pathophysiology underlying PTSD. This is the first study to report OIDs as a predictor of aggression and impulsivity in this clinical population. It prompts further exploration of the potential diagnostic utility of OIDs in the assessment of PTSD. Such measures may help delineate the clinical complexity of PTSD, and support more targeted interventions for individuals with a greater susceptibility to aggressive and impulsive behaviors.

Identifying risk factors for the development of post-traumatic stress disorder (PTSD) is important for understanding and ultimately preventing the disorder. This study assessed pain shortly after traumatic injury (i.e. peritraumatic pain) as a risk factor for PTSD.

Participants (n=115) were patients admitted to a Level 1 Surgical Trauma Center. Admission to this service reflected a severe physical injury requiring specialized, emergent trauma care. Participants completed a pain questionnaire within 48 h of traumatic injury and a PTSD diagnostic module 4 and 8 months later.

Peritraumatic pain was associated with an increased risk of PTSD, even after controlling for a number of other significant risk factors other than acute stress disorder symptoms. An increase of 0.5 s.d. from the mean in a 0–10 pain rating scale 24–48 h after injury was associated with an increased odds of PTSD at 4 months by more than fivefold, and at 8 months by almost sevenfold. A single item regarding amount of pain at the time of hospital admission correctly classified 65% of participants.

If these findings are replicated in other samples, high levels of peritraumatic pain could be used to identify individuals at elevated risk for PTSD following traumatic injury.

Functional brain-imaging studies in post-traumatic stress disorder (PTSD) have suggested functional alterations in temporal and prefrontal cortical regions. Effects of psychotherapy on these brain regions have not yet been examined.

Twenty civilian PTSD out-patients and 15 traumatized control subjects were assessed at baseline using psychometric ratings. Cerebral blood flow was measured using trauma script-driven imagery during 99mtechnetium hexamethyl-propylene-amine-oxime single-photon emission computed tomography scanning. All 20 out-patients were randomly assigned to treatment or wait-list conditions. Treatment was brief eclectic psychotherapy (BEP) in 16 weekly individual sessions.

At baseline, greater activation was found in the right insula and right superior/middle frontal gyrus in the PTSD group than in the control group. PTSD patients treated with BEP significantly improved on all PTSD symptom clusters compared to those on the waiting list. After effective psychotherapy, lower activation was measured in the right middle frontal gyrus, compared to the PTSD patients on the waiting list. Treatment effects on PTSD symptoms correlated positively with activation in the left superior temporal gyrus, and superior/middle frontal gyrus.

BEP induced clinical recovery in PTSD patients, and appeared to modulate the functioning of specific PTSD-related sites in the prefrontal cortical regions.

Although cognitive behaviour therapy (CBT) is the treatment of choice for post-traumatic stress disorder (PTSD), approximately half of patients do not respond to CBT. No studies have investigated the capacity for neural responses during fear processing to predict treatment response in PTSD.

Functional magnetic resonance imaging (fMRI) responses of the brain were examined in individuals with PTSD (n=14). fMRI was examined in response to fearful and neutral facial expressions presented rapidly in a backwards masking paradigm adapted for a 1.5 T scanner. Patients then received eight sessions of CBT that comprised education, imaginal and in vivo exposure, and cognitive therapy. Treatment response was assessed 6 months after therapy completion.

Seven patients were treatment responders (defined as a reduction of 50% of pretreatment scores) and seven were non-responders. Poor improvement after treatment was associated with greater bilateral amygdala and ventral anterior cingulate activation in response to masked fearful faces.

Excessive fear responses in response to fear-eliciting stimuli may be a key factor in limiting responses to CBT for PTSD. This excessive amygdala response to fear may reflect difficulty in managing anxiety reactions elicited during CBT, and this factor may limit optimal response to therapy.

Measurement invariance of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) post-traumatic stress disorder (PTSD) criterion symptoms was tested by gender and trauma type, assaultive and non-assaultive.

Analysis was conducted using latent class analysis (LCA), based on findings that the three-class LCA model from Breslau et al. (Archives of General Psychiatry 2005, 62, 1343–1351) fits the data across the four groups best. The classes represent three levels of PTSD-related disturbance: no disturbance, intermediate disturbance and pervasive disturbance, with the last one approximating the DSM-IV PTSD diagnosis.

Analysis of measurement invariance showed that, with respect to gender, there was no evidence of differential symptom reporting within the same disturbance class. DSM-IV symptom indicators represent the latent structure of PTSD equally in males and females. We found that more female than male victims of assaultive violence experienced pervasive disturbance. In the absence of measurement variability associated with gender, the finding is likely to reflect a gender difference in susceptibility. The analysis of measurement invariance detected evidence of variability associated with trauma type. Victims of assaultive violence in the pervasive disturbance class report more severe distress (especially emotional numbing) than do victims of non-assaultive violence in the same class.

The finding of measurement bias associated with type of trauma raises questions about the applicability of a single definition for PTSD associated with assaultive violence and PTSD associated with traumatic events of lesser magnitude.

Hierarchical cumulative scales are common and informative in psychology. The General Health Questionnaire (GHQ) does not appear to have been subjected to an analysis that examines the hierarchical and cumulative nature of its items. We report an analysis of data from the 30-item GHQ (GHQ-30) as part of the Health and Lifestyle Survey (HALS).

Data from 6317 participants who completed the GHQ-30 as part of the HALS were analysed using the Mokken Scaling Procedure (MSP), which is a computer program that searches polychotomous data for hierarchical and cumulative scales on the basis of a range of diagnostic criteria.

A final scale consisting of nine items from the GHQ-30 was obtained that, according to the criteria for a Mokken scale, was a reliable and very strong scale. The least difficult item in the scale is ‘been (un)able to face up to your problems?’ and the most difficult item is ‘felt that life isn't worth living?'

Items from the GHQ-30 form a short hierarchical and cumulative scale. The majority of these items also appear in the GHQ-12. The nine-item GHQ shows better distribution properties than the GHQ-30 and compares very favourably with the GHQ-12.

While various conceptualizations of the link between childhood adversity and later depression have been offered, most have not accounted for the possibility that early adversity predicts continuing stress proximal to depression onset. Thus, the present study tested the possible mediating role of recent stress in the association between early adversity and depression in late adolescence.

Study questions were examined in a longitudinal community sample of 705 youth who were contemporaneously assessed for early adversity exposure prior to age 5 years, chronic and episodic stress at age 15 years, and major depression prior to age 15 years and between 15 and 20 years.

Total youth stress burden at age 15 years mediated the effect of early adversity on depression between ages 15 and 20 years, and none of the observed relationships were moderated by onset of depression prior to age 15 years.

These findings suggest that continued stress exposure proximal to depression onset largely accounts for the association between early adversity and depression in late adolescence. Intervention should thus focus on disrupting the continuity of stressful conditions across childhood and adolescence. Future studies of the neurobiological and psychosocial mechanisms of the link between early experiences and depression should explore whether the effects of early experiences are independent of continuing adversity proximal to depressive onset.

Patients with schizophrenia are at increased risk of being victims of violent and non-violent crimes. We have determined how the experience of crime and subjective feelings of safety differ between urban and rural residential areas.

We analysed data from the European Schizophrenia Cohort (EuroSC), a 2-year follow-up study of 1208 patients in the UK, France and Germany. Subjective safety and a history of victimhood were elicited with Lehman's Quality of Life Inventory. Regression models adjusted the effects of living environment for country, education, employment, financial situation, drug and alcohol abuse, criminal arrests and the level of schizophrenic symptoms.

Ten per cent of patients were victims of violent and 19% of non-violent crimes. There was no significant relationship between victim status and residential area. However, subjective safety was clearly worse in cities than in rural areas. Aspects of objective and subjective safety were related to different factors: being the victim of violence was most strongly associated with alcohol and drug abuse and with criminal arrests of the patients themselves, whereas impaired subjective safety was most strongly associated with poverty and victimhood experience.

Although urban living was not associated with increased objective threats to their security, patients did feel more threatened. Such stress and anxiety can be related to concepts of social capital, and may contribute unfavourably to the course of the illness, reflecting the putative role of appraisal in cognitive models of psychosis. Securing patients’ material needs may provide a way to improve subjective safety.

Mental health clinicians are frequently asked to assess the risks presented by patients making threats to kill, but there are almost no data to guide such an evaluation.

This data linkage study examined serious violence following making threats to kill and the potential role of mental disorder. A total of 613 individuals convicted of threats to kill had their prior contact with public mental health services established at the time of the index offence. The group's subsequent criminal convictions were established 10 years later using the police database. Death from suicidal or homicidal violence was also established.

Within 10 years, 44% of threateners were convicted of further violent offending, including 19 (3%) homicides. Those with histories of psychiatric contact (40%) had a higher rate (58%) of subsequent violence. The highest risks were in substance misusers, mentally disordered, young, and those without prior criminal convictions. Homicidal violence was most frequent among threateners with a schizophrenic illness. Sixteen threateners (2.6%) killed themselves, and three were murdered.

In contrast to the claims in the literature that threats are not predictive of subsequent violence, this study revealed high rates of assault and even homicide following threats to kill. The mentally disordered were over-represented among threat offenders and among those at high risk of subsequent violence. The mentally disordered threateners at highest risk of violence were young, substance abusing, but not necessarily with prior convictions. Those who threaten others were also found to be at greater risk of killing themselves or being killed.