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Background: The prolonged stress experience caused by the COVID-19 pandemic and two earthquakes led to increased alcohol and psychoactive substance use (PSU) accompanied by a decrease in mental wellbeing and quality of life (QoL) in the Croatian population. Our aim was to determine the relationship between alcohol and PSU and mental health outcomes including anxiety and depression, and QoL. Methods: A cross-sectional online survey conducted from September 30 to October 27, 2021, included 1,118 Croatian adults (220 men and 898 women; mean age, 35.1 ± 12.3 years) recruited through non-probabilistic convenience sampling. The survey consisted of a self-reported questionnaire on PSU, the CAGE Alcohol Questionnaire, the Hospital Anxiety Depression Scale, and the World Health Organization Quality of Life (WHOQoL)-BREF. Structural equation modeling was used to evaluate the association between PSU, problematic alcohol use (PAU), mental health outcomes, and QoL. Results: The model demonstrated a good fit and indicated that PSU increase, PAU, and anxiety and depression symptoms significantly explained all QoL domains (p < 0.001 for all). Both PSU increase and PAU during prolonged stress were directly associated with decreased QoL. These relationships were also indirectly mediated through increased anxiety and depression symptoms. Conclusion: These results showed the need to direct public health interventions and treatment interventions during and after long-term stress (pandemics and earthquakes) to reduce the negative impact on substance use and QoL by reducing depression and anxiety, which ultimately may contribute to better wellbeing and rapid recovery of individuals affected by prolonged stress.

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Background: During the COVID-19 pandemic and concomitant earthquakes in Croatia in 2020, increased Internet use (IU) and Internet-based addictive behaviors were associated with decreasing mental well-being. We determined the changes in IU, problematic IU (PIU), and problematic specific Internet activities in young adults during the prolonged stress caused by the pandemic and earthquakes, age differences in PIU and differences in perceived source of stress (pandemic or earthquakes), and association between PIU and increase in specific Internet activities and stress, anxiety, and depression symptoms in young adults. Methods: A cross-sectional online survey conducted from September 30, 2021 to October 17, 2021 included 353 young adults aged 22.6 ± 2.1 years, 382 early adults aged 32.1 ± 4.4 years, and 371 middle-aged adults aged 49.0 ± 6.5 years. Data on sociodemographic characteristics, stressors (without perceived stressors, only pandemic-related stressor, only earthquake-related stressor, and both pandemic and earthquake-related stressors), PIU and IU were collected with a self-report questionnaire. The Impact of Event Scale and the Hospital Anxiety Depression Scale were used to evaluate mental symptoms. PIU and problematic specific Internet activities were assessed using Tao et al.'s criteria. Data were anaylzed with paired-sample Wilcoxon test, McNemar's and Pearson's chi-square tests, and structural equation modeling. Results: In 17% of young adults, we found increased PIU (OR = 5.15, 95% CI [2.82, 10.18]), problematic social media use (OR = 2.77, 95% CI [1.56, 5.14]), and uncontrolled online shopping (OR = 5.75, 95% CI [1.97, 22.87]) (p < 0.001 for all). PIU and problematic social media use were more common among young adults (60.8%), as well as problematic online gaming (25.9%). Problematic social media use was more frequent among young adults reporting pandemic stress than among those without perceived stress (69.9% vs. 43.2%). Increased online gaming predicted more severe avoidance symptoms (p = 0.041), increased social media use predicted more severe depression symptoms (p = 0.017), increased online shopping predicted more severe intrusion (p = 0.013) and anxiety symptoms (p = 0.001). PIU predicted more severe intrusion (p = 0.008), avoidance (p = 0.01), anxiety (p < 0.001), and depression (p = 0.012) symptoms. Conclusion: Different effects of the pandemic and earthquakes on IU could reflect a different effect of various stressors on Internet behavior of young adults. Type of problematic Internet behavior may predict for the type of mental health problem.

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ABSTRACT: In a cross-sectional study, we measured the impact of the first three COVID-19 pandemic waves and two earthquakes, occurring during the same period in Croatia, on the quality of life (QoL) of the general adult population. An online survey consisting of sociodemographic questions, questions related to COVID-19 and earthquake stressors, the World Health Organization Quality of Life (WHOQoL)-BREF scale, Impact of Event Scale, and Patient Health Questionnaire 4 was completed by 220 men and 898 women (mean age, 35.1 ± 12.3 years). In a series of regressions, we examined the association among five blocks of predictors and six dependent QoL variables, four domain scores, and two global scores. Both WHOQoL-BREF global and domain scores after the prolonged stress were significantly predicted by anxiety, depression, stress symptoms, and sociodemographic characteristics. COVID-19-related stressors predicted significantly physical and psychological health, social relationships, and environmental QoL, whereas earthquake-related stressors predicted health satisfaction, physical and psychological health, and environmental QoL.

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In 2020, Croatia was hit by the COVID-19 pandemic and two earthquakes. As previous research showed that Internet use (IU) increased during the COVID-19 pandemic, we carried out an online survey to determine the levels of problematic Internet use (PIU) and problematic specific Internet activities before and during the prolonged stress caused by the COVID-19 pandemic as well as earthquakes. We also determined the correlation between the PIU and specific Internet activities and anxiety, depression, and stress symptoms. According to the responses of 1,118 participants from all Croatian regions, PIU increased by 14.1 percent (odds ratio [OR] 6.2), problematic social media use by 12.6 percent (OR 4.8), and uncontrolled online shopping by 5.3 percent (OR 5.8) in comparison with presurvey period. The PIU increase was significantly higher in participants reporting only pandemic-related stress than in those reporting both pandemic- and earthquake-related stress. Problematic social media use increased in those reporting only pandemic-related stress and both pandemic- and earthquake-related stress. The strongest correlation between PIU and problematic social media use and anxiety, depression, intrusion, and avoidance symptoms was found among those reporting both pandemic- and earthquake-related stress. The correlation between psychiatric measures and PIU and problematic specific Internet activities varied depending on the source of experienced or perceived stress. Our findings show the relationship between the problematic stress-related Internet behaviors, different types of stressors, and their impact on the overall PIU and problematic specific Internet activities in situations of prolonged stress.

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Background: Increased prevalence and severity of both substance and behavioral addictions are among the most harmful consequences of the COVID-19 outbreak.Objective: To determine the sociodemographic characteristics, COVID-19-related stressors, and stress, anxiety, and depression symptoms that may predict the use and changes in the use of psychoactive substances (PS) during the first three COVID-19 waves in Croatia.Methods: The cross-sectional online survey included 1,118 adult participants (220 men and 898 women; mean age: 35.1 [SD = 12.3] years; age range: 18-78) from general adult population. Sociodemographic data were collected, and ad-hoc developed questionnaires on COVID-19-related stressors, PS use before and during the pandemic, CAGE Alcohol Questionnaire, Impact of Event Scale, and Hospital Anxiety Depression Scale were applied.Results: The PS use increased in 31% of participants. The use of tobacco, caffeine, alcohol, cannabinoids, and anxiolytics showed the greatest increase in the last year (tobacco 7.1%; caffeine 5.8%; alcohol 6.4%; cannabinoids 2.5%; and anxiolytics 3.9%). Alcohol consumption during the pandemic increased in 16.8% of participants who consumed alcohol before the pandemic, with 4.5% of them reporting problematic alcohol use (PAU). The tested model demonstrated relatively good model-data fit and significantly predicted 11.8% increase in the use of PS and 9.8% of PAU.Conclusion: Being married or in a relationship and severe anxiety and depression symptoms predicted increased use of PS and PAU, while higher education level and ever being diagnosed with COVID-19 predicted only increased use of PS.

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PURPOSE OF REVIEW: The COVID-19 outbreak profoundly influenced human lives on different levels. This narrative review aims to present recent data relating to the COVID-19 pandemic and internet use and internet-based addictive behaviours [problematic Internet use (PIU), Internet addiction, Internet gaming disorder, problem gambling or gambling disorder, social media addiction including smartphone use disorder, problematic pornography use, and compulsive buying]. RECENT FINDINGS: During the COVID-19 pandemic, the prevalence of Internet use and Internet-based addictive behaviours increased in all age groups. The COVID-19 pandemic and related containment measures were been associated with increased levels of stress, anxiety, and depression in the general population, especially among children and adolescents, which are the vulnerable groups for the development of mental disorders during the crisis. Furthermore, the fear resulting from the disease, the 'lockdown' measures, high levels of uncertainty regarding the future, and financial insecurity increased levels of loneliness, PIU, and Internet addiction. SUMMARY: Longitudinal researches focused on the negative impacts of Internet use in prolonged stress situations on mental health, vulnerable groups, and quality of life (QoL) are needed to help clinicians and policymakers to reduce adverse consequences. Prevention programs for Internet use and Internet-based addictive behaviours must be customized to meet the needs of children, adolescents, and adults. Also, treatment programs must be tailored to the needs of patients with different Internet-based addictions.

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INTRODUCTION: Sociodemographic factors can sometimes be more contributory in relation to war-related stress-induced disorder treatment and compensation-seeking than health-related factors. However, their impact is often overlooked. This study explores a relationship between sociodemographic factors and diagnoses of combat-related stress-induced disorders in combat compensation seekers for delayed-onset PTSD (DOPTSD). MATERIALS AND METHODS: Between June 2002 and August 2004, at the Regional Centre for Psychotrauma Zagreb, University Hospital Dubrava, the expert team evaluated subjects to diagnose DOPTSD and other comorbid illnesses. The study included 831 war veterans who experienced combat stress during the 1991-1995 Croatian war. They were subjects of psychiatric treatments before applying for compensation. The researchers derived results from data collected during the expert evaluation for compensation seeking, which included a structured diagnostic procedure. The diagnostic procedure included structured clinical interviews that also provided sociodemographic (age, sex, education, employment, marital status, number of children, and place of residence) and other data (heredity, medical history of physical and mental disorders, history of social functioning, combat-related and post-traumatic experiences, symptoms, their duration, intensity, and treatment). After the interview, the Clinical Global Impression Scale, the Clinician-Administrated PTSD Scale, and the Mississippi Scale for Combat-Related PTSD were applied. Final diagnoses of a lifetime or current PTSD and stress-related disorders according to the ICD-10 were established after fulfilling psychiatric and psychometric criteria. Multiple logistic regression determined independent contributions of sociodemographic characteristics (e.g., age, gender, education, employment and marital status, and parental status), war (duty duration and physical disabilities from combat injuries), and post-war experiences (outpatient treatment duration and the number of hospitalizations) in predicting compensation eligibility. RESULTS: Better-educated combat compensation seekers were 2.23 times more likely to have eligible psychiatric diagnoses. Furthermore, married veterans were 2.22 times more likely to have eligible diagnoses than single compensation seekers. Likewise, hospitalization status was a risk factor concerning post-war experiences for eligible psychiatric diagnoses. CONCLUSION: Marriage and higher education are accounted for longer DOPTSD in the group of combat compensation seekers with diagnoses eligible for compensation as a protective factor. A higher number of hospitalizations was also predictive because of more severe PTSD symptomatology as a risk factor. Higher education, marriage, and the higher number of the hospitalizations contributing to war-related DOPTSD diagnoses eligible for compensation.

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This study sought to assess the agreement between commonly used measures of shame- and guilt-proneness, the Test of Self-Conscious Affect-3 (TOSCA-3), representing scenario measures, and the Personal Feelings Questionnaire-2 (PFQ-2), representing checklist measures. To overcome the limitations of the widely used correlation analysis, the 2 measures were compared by the Bland-Altman method. We administered both measures at once to the same sample of 138 graduate students (67.39% were female; median age = 27 years). A randomly selected sample of 46 students repeated the procedure 8 weeks later. We tested how well our data fit the hypothesized measurement models, analyzed internal consistency of measures, evaluated their repeatability, and analyzed the agreement between them. To account for the different ranges, both measures' scores were expressed as the percentages of their maxima. The observed data fit the proposed models well. Both measures showed good internal consistency and repeatability. In the shame domain, TOSCA-3 exceeded PFQ-2 scores by 22.32% on average (49.81, -5.13%; 95% limits of agreement), and even more in the guilt domain, by 38.4% (67.75, 8.20%). Our results question the often-assumed congruence of the shame domains assessed by scenario and checklist measures.

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A vast number of veterans with posttraumatic stress disorder (PTSD) have chronic somatic comorbidities. However, their relationship with quality of life (QoL) has received little attention. We aimed to compare QoL of veterans with similar intensity of PTSD but different number of chronic somatic disorders. Of 129 veterans, 78% had at least one somatic disorder, and they reported lower QoL across all domains than veterans without somatic comorbidities. The greatest effect size was observed on social relationship (d = 0.65), it was notable on environment (d = 0.4) and psychological health (d = 0.38), and it was not relevant on physical health (d = 0.05). There was a negative correlation between the number of somatic disorders and scores on psychological health (rs = -0.217, p = 0.014), social relationships (rs = -0.248, p = 0.005), and environment (rs = -0.279, p = 0.001). The QoL of war veterans decreases significantly with the number of comorbid somatic conditions, particularly on the nonphysical domains of QoL.

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AIM: To determine the differences between aggressive and non-aggressive alcoholics in sociodemographic and clinical characteristics and ego strength. METHODS: This cross-sectional study included 111 aggressive and 123 non-aggressive male alcoholics aged between 25 and 60 years who were admitted to the Department for Alcoholism, University Psychiatric Hospital Vrapce, Zagreb, Croatia, from January to December 2016. All participants met the diagnostic criteria for alcohol dependence according to the Croatian Mini International Neuropsychiatric Interview (MINI), 4th revised edition of Diagnostic and Statistical Manual of Mental Disorders, and the International Classification of Diseases. Participants were clinically assessed by an experienced psychiatrist using a clinical interview, MINI, Questionnaire from the Brown-Goodwin Lifetime History of Aggression, and Ego Identity Scale (EIS) according to Erikson. A clinical psychologist performed cognitive function measurements. EIS scores were analyzed using one-way analysis of variance. RESULTS: In comparison with non-aggressive alcoholics, aggressive alcoholics were more often divorced, unemployed, hospitalized, and first treated for alcoholism at an earlier age (P<0.05 for all). They more frequently experienced depression (42.4% vs 19.4%, P=0.013) and attempted suicide (34.7% vs 6.2%, P=0.003), achieved a lower level of maturity at the second stage of psychosocial development related to shame and doubt (14.0±4.1 vs 17.4±3.7, P=0.013) and at the fourth stage related to inferiority (13.1±6.8 vs 18.1±9.3, P=0.011), and had lower total EIS score (75.8±20.4 vs 85.2±21.5, P<0.012) than non-aggressive alcoholics. CONCLUSION: Aggressive alcoholics had weaker ego-strength than non-aggressive alcoholics, experienced more depressive reactions and suicide attempts, and showed poorer psychosocial functioning. Oxford Centre for Evidence-based Medicine level of evidence: 3*.

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The paper outlines the difference between the so-called normal (common) lying and pathological lying. Pathological lying is an intriguing topic, still lacking any strong professional consensus, clear etiology, treatment options and prognoses. The paper explores some possible psychological mechanisms of pathological lying, reviews biological factors in pathological lying, and considers forensic significance of normal and pathological lying. The relationship between pathological lying and mental disorders is also discussed. The authors suggest that lying should be considered as a heterogenic and multidimensional behavioral pattern. The paper highlights how important it is to assess the patient's control over lying, the function of lying, insight into and awareness of lying, as well as the effect of lying on everyday functioning.

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Delusions are often recognized as key to the concept of psychosis. What is delusion is one of the basic questions of psychopathology. The common denominator of definitions of delusions is the divergence between the strong conviction in the delusional belief and superior evidences to the contrary which are continually ignored. An implicit, sustainably unspoken assumption is that the person with delusional belief has cognitive capacities to process the (counter-)arguments relevant to their delusion. However, individual's cognitive capacities are not being emphasized when delusions are evaluated. Moreover, the impact of cognitive decline on formation of delusions is neglected, both in theory and practice. We elaborate that cognitive deficits may facilitate, oppose, or mimic delusions. We focus on the last, which can lead to diagnosing as delusion what could be explained by cognitive decline and better called pseudo-delusion. The risk is significant when cognition is impaired, as in demented people; an issue which has not yet been debated. True delusions are incompatible with person's cognitive capacities, i.e., if we take into account person's cognitive status, we still cannot understand how the person holds the strange belief with an extraordinary conviction. Pseudo-delusions would be beliefs, thoughts or judgments that at first seem delusional (they are false, subculturally atypical beliefs that are strongly maintained in the face of counterargument), but lose the essence of delusions after we take cognitive impairment into account. Pseudo-delusions could actually be explained or understood by person's cognitive impairments, they "fit into" them. The reported reality-based contents of delusions in the elderly, poor response to antipsychotics and lack of association with early or family history of psychiatric disorders could in part be accounted for by the bias of misdiagnosing the cognitive impairment as the delusion. Not recognizing that the cognitive impairment underlies formation of pseudo-delusions and misdiagnosing it as delusions may lead to focusing on antipsychotic treatment, instead on treatment of the underlying cognitive deficit.

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BACKGROUND: Posttraumatic stress disorder (PTSD) has a great impact on a patient's quality of life (QoL). People in long-term contact with a person suffering from PTSD, such as family members, may also consequently develop various emotional problems. METHODS: We investigated whether chronic combat PTSD is related to lower QoL of veterans' wives. The study included 164 veterans with PTSD, 281 PTSD veterans' wives, 115 healthy non-veterans' wives and 223 men without PTSD. All participants were assessed for psychiatric morbidity (Mini International Neuropsychiatric Interview) and measures of QoL (World Health Organization Quality of Life Questionnaire - short form). In veterans, the symptoms were evaluated using Clinician Administered PTSD Scale (CAPS). RESULTS: The pattern of differences between the study groups was similar across all QoL domains. Men without PTSD had the highest scores, followed by women who were not married to PTSD patients (significantly different across all four QoL domains). PTSD veterans' wives tended to had lower scores than either of these groups. Significant differences between PTSD veterans' wives and women who were not married to PTSD patients were observed in three (out of four) QoL domains: psychological health, Z = 2.907, P = 0.022; social relationships, Z = 3.285, P = 0.006; and environmental domain, Z = 5.317, P < 0.001. The lowest scores were recorded in PTSD veterans (significantly lower than PTSD veterans' wives in every domain except environmental). The wives who reported to be ill at the time tended to have lower scores across all four domains (P < 0.05) (low to moderate correlation; physical health, ρ = -0.56; psychological health, ρ = -0.42; social relationships, ρ = -0.30; environmental, ρ = -0.33), as well as those who sometimes in their lives they sought professional help due to having problems with their husband (P < 0.05) (very low to low correlation; physical health, ρ = -0.37; psychological health, ρ = -0.38; social relationships, ρ = -0.30; environmental, ρ = -0.15). CONCLUSION: Our results indicate the negative impact of husband's chronic PTSD on overall QoL, psychological health, social relations, and environmental area of QoL of veteran's wives. Assessment of QoL may be important during the intervention and planning of specific treatment and rehabilitation programs for the families of war veterans.

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Lamotrigine is an antiepileptic drug with broad spectrum of actions, also approved for the treatment of bipolar disorder. Growing number of reports document the antiaggressive effect of lamotrigine in various psychiatric diseases. However, there has been only 1 study in the literature investigating the role of lamotrigine in posttraumatic stress disorder (PTSD), but its antiaggressive aspect was not observed. Although aggression is commonly associated with PTSD, there is paucity of data considering its management. We report a case of a patient with treatment-resistant PTSD, whose aggressive outbursts dominated his clinical picture and which were greatly improved after introducing lamotrigine in therapy. Our case suggests that lamotrigine may be useful in treating aggression and aggression-related symptoms in PTSD.

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BACKGROUND: Previous work has shown that inhibition of fear is impaired in posttraumatic stress disorder (PTSD) resulting from both civilian and combat trauma. The purpose of the present study was to investigate the inhibition of learned fear in traumatized individuals diagnosed with either acute stress disorder (ASD) or PTSD. This is the first study to use a conditioned inhibition paradigm with traumatized individuals within a month of trauma exposure. We hypothesized that impaired fear inhibition would be evident in PTSD, but not ASD. METHOD: Using established translational, psychophysiological methods including fear-potentiated startle, and skin conductance, we examined fear acquisition, stimulus discrimination, and the transfer of learned safety in a Croatian population with ASD or PTSD. This cross-sectional study included three age-matched groups: healthy nontrauma controls (n = 27), a group with chronic PTSD (10 or more years since trauma exposure, n = 24), and a group with ASD (30 days or less since trauma exposure, n = 27). RESULTS: The presence of trauma-related psychopathology, whether acute or chronic, was associated with an impaired ability to transfer learned safety based on fear-potentiated startle measures, while healthy control subjects showed significant fear inhibition in the presence of the safety cue compared to the danger cue, F(1,26) = 12.64, P = .001. CONCLUSIONS: These data expand our previously observed findings of PTSD-associated fear inhibition deficits by demonstrating that trauma-related impairments in safety learning are evident within 30 days of trauma exposure.

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OBJECTIVES: Psychotic symptoms frequently occur in veterans with combat-related posttraumatic stress disorder (PTSD). Brain-derived neurotrophic factor (BDNF) plays a major role in neurodevelopment, neuro-regeneration, neurotransmission, learning, regulation of mood and stress responses. The Met allele of the functional polymorphism, BDNF Val66Met, is associated with psychotic disorders. This study intended to assess whether the Met allele is overrepresented in unrelated Caucasian male veterans with psychotic PTSD compared to veteran controls. METHODS: The BDNF Val66Met variants were genotyped in 576 veterans: 206 veterans without PTSD and 370 veterans with PTSD subdivided into groups with or without psychotic features. RESULTS: Veterans with psychotic PTSD were more frequently carriers of one or two Met alleles of the BDNF Val66Met polymorphism than veterans with PTSD without psychotic features and veterans without PTSD. CONCLUSIONS: The study shows that veterans with psychotic PTSD carried more Met alleles of the BDNF Val66Met than non-psychotic veterans with PTSD or veterans without PTSD. The results might add further support to the hypothesis that psychotic PTSD is a more severe subtype of PTSD.

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The aim of this study is to prospectively examine electromyographic (EMG) responses in patients diagnosed with acute stress disorder (ASD) after experiencing a traffic accident or violent attack, within one month after the traumatic event and six months later. Half of the participants met criteria for posttraumatic stress disorder (PTSD) after six months. Psychophysiological parameters can provide a better clarification between ASD and PTSD patients. Heightened startle magnitude in the immediate aftermath of trauma may be a good predictor of PTSD; moreover, a lack of startle habituation appears to be a more stable marker of PTSD, which persists for six months after trauma exposure.

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An association between traumatic stress and cardiovascular disease (CVD) is supported by various epidemiological studies. Platelet activation and binding of activated platelets to leukocytes contributes to the pathophysiology of CVD. Evidence of hyperactive sympathetic nervous system, altered expression of platelet α(2)-adrenoreceptors (α(2)AR), and altered platelet adenylate cyclase activity in patients with posttraumatic stress disorder (PTSD) suggest that platelet reactivity in PTSD may be altered as well. We tested whether platelet reactivity to increasing doses of adenosine-diphosphate (ADP), epinephrine (EPI), or their combination differs between war veterans with PTSD (n=15) and healthy controls (n=12). For this purpose, citrated whole blood was incubated with increasing concentrations of ADP (0.1, 1, 10 µM), EPI alone (10 nM, 100 nM, 1000 nM), or EPI (10 nM, 100 nM, 1000 nM) in combination with 0.1 µM ADP. A subset of samples was also incubated with 10 µM yohimbine (YOH), α(2)AR antagonist, to distinguish receptor-specific effects. Platelet CD62P expression and formation of platelet-leukocyte aggregates (PLA) [platelet-monocyte (P-Mo), -lymphocyte (P-Ly), and -neutrophil (P-Ne) aggregates] were measured using three-color flow cytometry. Platelet reactivity was higher in war veterans with PTSD when compared to controls, as determined by greater CD62P expression and formation of PLA in response to ADP alone or in combination with EPI. Platelet reactivity also correlated with the severity of PTSD symptoms. Preliminary experiments with YOH indicate that stress-associated EPI elevations may contribute to platelet activation through a α(2)AR-dependent mechanism. The enhanced platelet reactivity observed in our study may be the underlying mechanism contributing to the development of CVD in PTSD patients.

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