Digital archive of theses discussed at the University of Pisa


Thesis etd-11152016-110340

Thesis type
Tesi di specializzazione (5 anni)
Thesis title
PTSD and post-traumatic stress spectrum in parents of pediatric patients with epilepsy:gender differences and correlations with mood spectrum and adult autism subthreshold spectrum
Course of study
relatore Prof.ssa Dell'Osso, Liliana
correlatore Dott.ssa Carmassi, Claudia
  • parents
  • epilepsy
  • AdAS
  • PTSD
Graduation session start date
Release date
Post-traumatic stress disorder (PTSD) has acquired greater importance in the frame of psychiatric disorders through the last decades, with epidemiological studies proving a significant prevalence of the disease in the general population. Kessler et al reported PTSD rates as high as 6.8%, according to DSM-IV criteria, in the US National Comorbidity Survey Replication (NCS-R) study, confirming more than double rates among women (9.7%) with respect to men (3.6%) (Kessler et al., 2005).
Diagnostic criteria for PTSD have undergone several changes across the different editions of the Diagnostic and statistical Manual of Mental Disorders (DSM) with an important impact on the prevalence of the disorder. To date, epidemiological data are not yet available on PTSD prevalence rates according to the current DSM-5 criteria, but estimates have been reported in specific samples, such as natural disasters survivors (Carmassi et al., 2014).
In the Diagnostic and Statistical Manual of Mental Disorders (DSM), the criterion A for PTSD diagnosis went through a complete revision in the passage between DSM-IV-TR (APA, 2000) to DSM-5 (APA, 2013); on one hand, it no longer includes the subjective reaction to the trauma while on the other, was more emphasized the importance of traumatic events occurred to close one’s with the split of the criterion A in the subcriteria A2, A3, A4 which made explicit indirect exposure to the event. In this regard, the A2 criterion is that the person has attended as a witness the event that affected someone else, the A3 criterion is that the person has become aware of an event that happened to a close relative or a friend and A4 criterion instead contemplates that the person has suffered extreme or repeated exposure to distressing details of an event (eg first responders who have collected human remains). In fact, emerged in the last decades that the illness of close relative, in particular a child, can be one of the events with the highest emotional and destabilizing impact from a psychological point of view (Barakat et al., 1997; Kazak & Barakat, 1997; Landolt et al., 1998).
Subsequent revisions to the last edition of the Manual, have gradually allowed the inclusion of one’s child disease among the numbered events as traumatic. In particular, while the DSM-IV reported within the criterion A, a threatening disease in one’s child among the events experienced by others, the DSM-5 further changes the classification of this particular type of event and specifies that the event must be a medical catastrophe concerning one’s child, with the example of a rather peculiar condition that put lives at risk. It is therefore clear that in the transition between the old and the new Manual such criterion has been reformulated and threatening illness is replaced with medical catastrophe; the first case mainly highlights the objective seriousness nature of the disease for the health of the child, while the current statement highlights the need for the event to be violent or accidental with an evident attention on the urgency and abruptness of the perceived threat. Neither specifiers, despite the evolution, refer to chronic aspects of one’s child as potentially traumatic event.
Despite the above definition, the actual literature on PTSD among parents and caregivers of pediatric patients focuses on severe medical conditions often characterized by a chronic course, such as cancer or type 1 diabetes (Bruce et al., 2006; Horsch et al., 2012). There is only one previous study which specifically investigated PTSD among 77 mothers and 3 fathers of children with epilepsy and found a PTSD rate of 31.5% (according to the criteria DSM-IV-TR) (Iseri et al., 2006).
Nevertheless, epilepsy, thanks to its unique characteristics, is one of the traumatic events that may underlie the development of PTSD. First, referring to the criterion A2, a seizure of a child is an episode in which the parent in the majority of the cases is obliged to assist due to the close relationship between parents and children in the pediatric age. The epileptic seizure, especially the tonic-clonic one, is a sudden traumatic event which the caregiver assists helpless. Although the DSM-5 states that the traumatic event must be a medical catastrophe by referring to events that endangers the life of the child, seizures may fall under this definition; in fact, a seizure put parents faced with a critical situation in which they often fail to understand what is going on and they are confronted with a situation in which their own child in most cases loses consciousness.
Several authors have investigated the psychological impact of seizures in a son and emerged a state of intense fear and helplessness (Mu, 2005; Rodenburg et al., 2005). Especially tonic-clonic seizures that present particular features (such as convulsions, tongue biting, relaxation of the sphincters), suggest an event that puts in danger of life without any certainty about its duration and that have a great impact on caregivers, especially when seizures are frequent (Shatla et al., 2011). In light of this, for these features of acute and critical, we assume that epilepsy of a child fits the definition of medical catastrophe, required by the DSM-5.
At the same time, however, epilepsy is a very complex disease, as it is based on dual characteristics of acute and chronic: in addition to the aspect of the seizures as acute traumatic event, the chronic course of the disease leads to the concept of "dose" of trauma as a risk factor for PTSD.
In fact, particularly in cases that are refractory to therapy, parents, although aware of the diagnosis, have to interface repeatedly with the event "seizure" which, although losing the element of surprise remains highly emotional. Further, the state of continuous alarm and apprehension with which a parent must face together with the unpredictability of the disease leads constantly to fear both for the safety of the child and for the repercussions on the whole family. Several studies have evaluated the weight of the component of the frequency of seizures, especially for the forms refractory to therapy, experiencing overall worse outcomes and worse quality of life than responsive forms, both in patients and their families (Leidy et al., 1999; Moran et al., 2004; DP McLaughlin et al., 2008).
This element of repetitiveness, as already mentioned, introduce the concept of relationship between "dose" of the trauma and development of PTSD, whose relevance as a pre-traumatic risk factor has already been highlighted in the literature (Mollica et al., 1998; Dell’Osso et al., 2013) and of which the epileptic disease represents a paradigm. The concept of repetition has also been well highlighted in the DSM-5 criteria where it is underlined, in the specifier A4, the importance of extreme or repeated exposure to distressing details of an event.
In the regard of the above considerations, the main aim of the present study was to evaluate the impact of post-traumatic stress symptoms in parents of epileptic children with particular attention on gender differences and correlation between stress symptoms and socio-demographic characteristics concerning parents and children as well as children clinical variables, such as type of epilepsy and type of seizures.
Consistent with literature which suggests that psychiatric comorbidity represents one of the main risk factors for the development of PTSD ( Otto et al., 2004; Pollack et al., 2006;Dell'Osso, Da Pozzo, et al., 2010; Dell'Osso, Stratta, et al., 2014, Dell'Osso 2016) the second aim was to explore the presence of any correlation between symptoms of Post-Traumatic Stress Spectrum and both Mood and Adult Autism Subthreshold spectrums symptoms.
Results showed, according to DSM-5, a 10.4% of PTSD diagnosis and 37.3% of partial forms in the total sample; the frequency of the partial forms is perfectly in line with the data emerged in previous studies on parents of children with acute or chronic diseases.
Both demographic characteristics of the study sample and clinical features of children's disease didn’t demonstrate any impact on stress symptomatology.
Significant gender differences emerged in all symptoms clusters except avoidance, evidencing mothers to be more prone to develop post-traumatic symptomatology. On the contrary, noteworthy correlations between post-traumatic stress symptoms and both mood and adult autism subthreshold spectrums, emerged only in the subgroup of the fathers. In particular, our data highlighted a relationship between lifetime manic symptoms and PTSD. The correlations observed between traumatic spectrum and mood spectrum were consistent with previous studies in literature that showed the importance of mood symptoms, particularly manic/hypomanic, in the developing of PTSD and Post-Traumatic Stress Spectrum (Dell’Osso, Carmassi, Rucci, et al., 2009; Dell’Osso, Da Pozzo, et al., 2010; Dell’Osso, Stratta, et al., 2014). At the same time, correlations between the scores of TALS-SR and ADAS Spectrum domains revealed similar results with several statistically significant correlations, still among the subgroup of fathers. In particular, numerous correlations moderate to good, emerged between Domain II of TALS-SR (reactions to the events of loss) and Domain III ( non verbal communication), Domain VI (restricted interests and ruminations) and ADAS Spectrum total score; finally, we found a strong correlation between the total score of TALS-SR and Domain VI (restricted interests and ruminations) of the ADAS Spectrum. Ruminations seem in fact to be a nuclear element; in this regard has been speculated as emerging ruminations involving interpersonal problems, conflicts and traumas, may represent a trasversal symptom that involves major depression and PTSD to ASD, and that can trigger suicidal behaviors (Kato et al., 2013; Cloitre et al., 2014; Takara & Kondo, 2014). These results indicate how peculiar psychopathological characteristics could lead to greater vulnerability to the effects of trauma, as suggested by recent studies (Dell’Osso et al., 2015, Dell’Osso et al., 2016).
Interpretation of our results should keep in mind some important limitations of the study. The most important one, is represented by the limited sample size and the non-homogeneity in the gender distribution of the sample that may impact on the generalizability of our results. Second, the use of a structured clinical interview to detect PTSD symptoms may have determined feelings of shame on respondents expressing their symptoms. Third, is the lack of information on the duration of the epileptic illness in the child and, thus, on the time occurred since the first seizure observed by the parent since without knowing the number of seizures a child has recently experienced, it is unclear if continued seizures and witnessing of these seizures influences or maintains PTSD symptoms. Finally, children psychosocial comorbidities in particular behavioural problems, which are demonstrated to be one of the recognized cause of parental stress (Rodenburg et al., 2007) were not collected because parenting stress wasn’t our target; nevertheless it would be interesting to see if behavioral problems have an impact on PTSD, both full and partial, rates.
Despite the above limitations, this is the first study with the larger sample size to detect epilepsy-related post-traumatic symptoms in caregivers of pediatric patients according to DSM-5 and the relevance of the results suggests the need for further studies on this risk population.