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Background: Healthcare providers (HCPs) may be at elevated risk for moral injury due to increased exposure to potentially morally injurious events (PMIEs) throughout the COVID-19 pandemic. Identifying PMIEs experienced during the COVID-19 pandemic is a critical first step for understanding moral injury in HCPs. Accordingly, the purpose of the present study was to gain a deeper understanding of the work-related PMIEs experienced by HCPs in Canada during the pandemic. Methods: Canadian HCPs completed an online survey between February and December 2021 about mental health and functioning, including demographics and the Moral Injury Outcome Scale (MIOS). We conducted a qualitative thematic analysis of PMIEs described extemporaneously by HCPs in the open-text field of the MIOS. Results: One-hundred and twenty-four (N = 124) HCPs were included in analysis. Eight PMIE-related themes were identified, comprising patients dying alone; provision of futile care; professional opinion being ignored; witnessing patient harm; bullying, violence and divided opinions; resources and personal protective equipment; increased workload and decreased staffing; and conflicting values. Conclusions: Understanding broad categories of PMIES experienced by Canadian HCPs during the COVID-19 pandemic provides an opportunity to enhance cultural competency surrounding their experiences which will aid the development of targeted prevention and intervention approaches.

Collective research has identified a key electroencephalogram signature in patients with post-traumatic stress disorder, consisting of abnormally reduced alpha (8–12 Hz) rhythms. We conducted a 20-session, double-blind, randomized controlled trial of alpha desynchronizing neurofeedback in patients with post-traumatic stress disorder over 20 weeks. Our objective was to provide mechanistic evidence underlying potential clinical improvements by examining changes in aberrant post-traumatic stress disorder brain rhythms (namely, alpha oscillations) as a function of neurofeedback treatment. We randomly assigned participants with a primary diagnosis of post-traumatic stress disorder (n = 38) to either an experimental group (n = 20) or a sham-control group (n = 18). A multichannel electroencephalogram cap was used to record whole-scalp resting-state activity pre- and post-neurofeedback treatment, for both the experimental and sham-control post-traumatic stress disorder groups. We first observed significantly reduced relative alpha source power at baseline in patients with post-traumatic stress disorder as compared to an age/sex-matched group of neurotypical healthy controls (n = 32), primarily within regions of the anterior default mode network. Post-treatment, we found that only post-traumatic stress disorder patients in the experimental neurofeedback group demonstrated significant alpha resynchronization within areas that displayed abnormally low alpha power at baseline. In parallel, we observed significantly decreased post-traumatic stress disorder severity scores in the experimental neurofeedback group only, when comparing baseline to post-treatment (Cohen’s d = 0.77) and three-month follow-up scores (Cohen’s d = 0.75), with a remission rate of 60.0% at the three-month follow-up. Overall, our results indicate that neurofeedback training can rescue pathologically reduced alpha rhythmicity, a functional biomarker that has repeatedly been linked to symptoms of hyperarousal and cortical disinhibition in post-traumatic stress disorder. This randomized controlled trial provides long-term evidence suggesting that the ‘alpha rebound effect’ (i.e. homeostatic alpha resynchronization) occurs within key regions of the default mode network previously implicated in post-traumatic stress disorder.

Throughout the COVID-19 pandemic, healthcare workers (HCWs) have been exposed to highly stressful situations, including increased workloads and exposure to mortality, thus posing a risk for adverse psychological outcomes, including acute stress, moral injury, and depression or anxiety symptoms. Although several reports have sought to identify the types of coping strategies used by HCWs over the course of the pandemic (e.g., physical activity, religion/spirituality, meditation, and alcohol), it remains unclear which factors may influence HCWs’ choice of these coping strategies. Accordingly, using a qualitative approach, the purpose of the present study was to gain a deeper understanding of the factors influencing HCWs’ choice of coping strategies during the COVID-19 pandemic in Canada. Fifty-one HCWs participated in virtual, semi-structured interviews between February and June 2021. Interview transcripts were analysed through an inductive thematic approach, yielding two primary themes. First, HCWs described an ongoing shift in their approach to coping depending on their mental “bandwidth”, ranging from “quick fix” to more “intentional effort” strategies to engage in proactive strategies to improve mental health. Second, many HCWs identified various barriers to desired coping strategies during the pandemic, including the preponderance of pandemic- and other circumstantial-related barriers. The findings from this study offer a unique understanding of the factors influencing HCWs’ choice of coping strategies under novel and increased stress. This knowledge will be central to developing appropriate forms of support and resources to equip HCWs throughout and after the pandemic period, and in mitigating the potential adverse mental health impacts of this period of prolonged stress and potential trauma.

Background: The four-dimensional (‘4-D’) model has been proposed as a theoretical framework to understand and delineate trauma-related dissociative experiences, categorizing symptoms into trauma-related altered states of consciousness (TRASC) and normal waking consciousness (NWC), which occur along four dimensions: time, thought, body and emotion. Objective: The main aim of the present study was to evaluate the validity of this model in patients with post-traumatic stress disorder (PTSD), with and without comorbid dissociative disorders. Method: The predictions of the 4-D model were tested in 142 patients with PTSD, with (N = 46) and without (N = 96) comorbid dissociative disorders. Results: As predicted by the 4-D model, experiences of TRASC were less frequent and more specifically related to other measures of dissociation, dissociative disorder comorbidity and a history of childhood sexual abuse compared to experiences of NWC. The predicted lower intercorrelation of TRASC was not supported. Conclusion: The 4-D model represents a promising framework for understanding dissociation across trauma-related disorders.

The flocculus is a region of the vestibulocerebellum dedicated to the coordination of neck, head, and eye movements for optimal posture, balance, and orienting responses. Despite growing evidence of vestibular and oculomotor impairments in the aftermath of traumatic stress, little is known about the effects of chronic psychological trauma on vestibulocerebellar functioning. Here, we investigated alterations in functional connectivity of the flocculus at rest among individuals with post-traumatic stress disorder (PTSD) and its dissociative subtype (PTSD + DS) as compared to healthy controls. Forty-four healthy controls, 57 PTSD, and 32 PTSD + DS underwent 6-min resting-state MRI scans. Seed-based functional connectivity analyses using the right and left flocculi as seeds were performed. These analyses revealed that, as compared to controls, PTSD and PTSD + DS showed decreased resting-state functional connectivity of the left flocculus with cortical regions involved in bodily self-consciousness, including the temporo-parietal junction, the supramarginal and angular gyri, and the superior parietal lobule. Moreover, as compared to controls, the PTSD + DS group showed decreased functional connectivity of the left flocculus with the medial prefrontal cortex, the precuneus, and the mid/posterior cingulum, key regions of the default mode network. Critically, when comparing PTSD + DS to PTSD, we observed increased functional connectivity of the right flocculus with the right anterior hippocampus, a region affected frequently by early life trauma. Taken together, our findings point toward the crucial role of the flocculus in the neurocircuitry underlying a coherent and embodied self, which can be compromised in PTSD and PTSD + DS.

Individuals who engage in criminal behavior for which they are found not criminally responsible (NCR) may be at increased vulnerability to experience moral pain and, in extreme circumstances, moral injury after regaining insight into the consequences of their behavior. Yet, almost no research exists characterizing the nature, severity, or impact of moral pain in this population. Semi-structured interviews were conducted with nine forensic psychiatric patients and 21 of their care providers. Narratives were explored using thematic analysis. Findings demonstrate that NCR patients endorse symptoms consistent with moral injury, including feelings of guilt toward victims, shame for one’s behavior, and a loss of trust in one’s morality. Moral pain is a strong driver of behavior and must be understood as part of a constellation of factors influencing criminality, risk, and recovery. Future research must develop adequate tools to measure and characterize offense-related moral injury to understand its impact on this population.

This chapter summarizes the common neurobiological pathways underpinning the wide range of symptoms seen in trauma-related disorders and provides helpful language for psychoeducation that can instill hope in the brain’s capacity to heal. This chapter reviews the triune brain model and highlights the role of more primitive brain areas in carrying out automatic defensive responses to threat, as conceptualized in the defense cascade model. Particular attention is given to dissociative responses, including freezing and collapsing/playing dead. The authors highlight crucial brain areas such as the periaqueductal gray matter, which enacts these defenses in the body. The authors also discuss how sensory processing abnormalities in areas such as the vestibular system, the cerebellum, and the temporal lobe can explain psychotic-like and dissociative symptoms, which are frequently misinterpreted as psychosis or malingering. Finally, the chapter reviews intrinsic connectivity networks and difficulties with higher-order cognitive functions.

This module focuses on recognizing and interrupting patterns that increase the risk of doing things that are risky, unhealthy, or unsafe. It also offers things you can do to help yourself get and feel safer. As part of this work, you will learn why getting your healthy needs met safely is so important for your healing, and we will help you recognize what your healthy needs are and how to work toward meeting them. You will also learn how to recognize and manage challenging situations and how to notice and respond to early warning signs in order to break the cycle of unhealthy behavior and reduce trauma-related reactions.

The assessment of trauma-related disorders (TRD) and dissociative disorders (DD) is not widely taught. Accurate assessment of dissociative symptoms can be challenging without adequate training. Clinicians who have not been trained in assessing TRD may mistakenly attribute TRD and DD symptoms to psychosis, bipolar disorder, borderline personality disorder, or malingering. As a result, TRD and DD are frequently underdiagnosed and misdiagnosed, preventing these highly symptomatic individuals from receiving appropriate treatment. This chapter provides a practical overview of the assessment of trauma-related and dissociative symptoms, including self-report measures and structured assessment tools that can complement the clinical interview; the assessment of common comorbidities; methods of distinguishing TRD and DD from diagnoses with similar presentations; and potential alternative explanations for apparently dissociative experiences. The chapter also discusses the possible challenges and pitfalls of using “general” psychological assessment instruments that have not been validated with individuals with complex trauma histories.

Traumatized individuals often become triggered and overwhelmed without noticing they are ungrounded. They typically do not yet know how to safely self-regulate. When dysregulated, patients cannot integrate new information or work productively in therapy. Therefore, it is crucial that clinicians are skilled in detecting signs of dysregulation and know strategies to help patients get regulated. Repeatedly working on noticing dysregulation and practicing grounding in sessions teaches patients how to engage in therapy from within a grounded state; this is a crucial skill they can transfer to their daily lives. This chapter provides clinicians with the information and tools they need to do this work, including descriptions of signs of hyperarousal and hypoarousal, ways to teach patients how to get grounded and regulated, and instructive roleplays that provide the language and approaches that are useful for supporting patients’ management of dissociation, emotions, and somatic symptoms.

Challenges involving boundary management, the therapeutic frame, and interpersonal patterns repeatedly emerge in trauma treatment. These issues emerge out of the lessons that patients learned via abusive relationships about control and others’ unreliability and abusiveness. This chapter discusses methods for recognizing and resolving trauma-based interpersonal patterns such as boundary management, traumatic reenactments, mistrust of the therapist, and ruptures in the therapeutic relationships. The impact of insecure attachment on the therapeutic relationship is addressed, including patients’ difficulties tolerating therapists’ absences, overly frequent calls between sessions, and help rejection. Roleplays are presented with specific language and approaches that can guide clinicians in recognizing and discussing trauma-based relational difficulties. Although challenging, these “echoes of trauma” in the therapeutic relationship serve as powerful opportunities to resolve the interpersonal impact of victimization.

This chapter reviews research about treatment for trauma-related disorders (TRDs) and discusses the functions of risky, unhealthy behaviors in TRDs. Teaching patients four core skills that provide safer ways to meet these functions promotes stabilization: grounding, separating past from present, self-compassionate emotion regulation, and getting healthy needs met safely. The Finding Solid Ground educational program teaches these skills and was the foundation of the Treatment of Patients with Dissociative Disorders (TOP DD) Network study. Together, the TOP DD studies show that when individuals with TRDs are treated by clinicians who focus on dissociative and other trauma-based symptoms, patients’ safety improves, hospitalizations become less frequent, and treatment costs decrease. The TOP DD studies indicate that education about safety, emotion regulation, and symptom management, combined with individual therapy that addresses TRDs, is associated with a wide range of improvements for TRD individuals. Treatment focused on TRDs help highly dissociative individuals find solid ground in healing from trauma.

This chapter defines dissociation and trauma-related disorders (TRD), discusses the etiology of TRD, and describes the prevalence and complex symptom presentations of individuals who have experienced complex trauma. Despite being at least as prevalent as many other types of mental illness, complex TRDs are underrecognized. Consequently, most of these individuals do not receive treatment specifically targeting the dissociative symptoms that maintain them. Due to a variety of factors, including lack of training for professionals, misunderstandings about dissociation, and a shortage of trauma-trained therapists, individuals with TRD are “hidden in plain sight” despite typically seeking mental health treatment for years. Furthermore, the shortage of clinicians trained in assessing and treating TRD creates a barrier for obtaining treatment that is of meaningful help in stabilizing trauma-related reactions including dissociation. The costs of being underrecognized and undertreated are enormous for dissociative individuals, the health care system, and society.

Trying to keep us safer, our minds are often on alert for signs of danger. Unfortunately, because we notice similarities with past experiences far easier than differences, this means we can have significant difficulty noticing when situations are safer. In other words, we can have difficulty separating the past from the present. This module offers ways to help yourself notice when the present is safer than the past and be more aware of your current resources and options. It will also help you learn how to catch thinking mistakes that can make it difficult to separate past from present, imagery techniques that can help you separate the present from the past, and how to contain traumatic intrusions, all of which will help you see the “here and now” more clearly, making it easier to stay grounded, heal, and grow.

This chapter offers a framework for understanding and stabilizing risky, unhealthy, and unsafe behaviors. Topics discussed include the importance of approaching this work in a collaborative, trauma-informed way that emphasizes the patient’s autonomy; recognizing risky, unhealthy, and unsafe behaviors as attempts to self-regulate; and providing training and guidance regarding healthy ways to self-regulate as a foundation for changes in these patterns. The chapter also addresses the fears patients experience related to making these kinds of changes, and the importance of looking for the particular functions and the risks and benefits of specific behaviors, especially in relation to the patient’s goals for themselves. This chapter includes roleplays illustrating useful approaches and specific language to address common challenges encountered in working with individuals with trauma-related disorders, such as experiencing ongoing interpersonal violence, potentially risky choices, and ways to improve safety in relationships.

This chapter offers guidance on how to use the Finding Solid Ground Program Workbook’s information sheets and exercises in individual and group contexts. The Finding Solid Ground program provides complex trauma patients with a coherent, comprehensive approach to trauma treatment rooted in an understanding of the neurobiological impacts of trauma. The program’s structure and materials provide information in a sequence that introduces the most important foundational information and skills first and builds on these, session by session, in a manner (and at a pace) designed to be manageable. This approach reduces the likelihood of unintentionally overwhelming and dysregulating patients while trying to help them learn how to reduce dysregulation and increase adaptive strengths. This kind of approach is crucial in treating individuals with trauma-related disorders, addresses issues that are often misunderstood by clinicians, and can make a meaningful difference in patients’ initial and continued engagement in treatment.

This module offers ways to help yourself make progress toward getting and feeling safer. This module focuses on teaching you things you can do toward healing the impact of trauma, and steps you can expect along the way. As part of this, you will learn how to notice signs you might be having trauma-related thoughts, and how to manage them so that past experiences do not automatically make you feel bad. This module will also help you develop and use plans for managing intense emotions, noticing and managing trauma-based thoughts, and developing and using imagery techniques for when you’re feeling too much.

Grounding offers powerful help toward managing and reducing symptoms related to trauma, including feeling “too much” (feeling strong or overwhelming feelings or urges); feeling “too little” (feeling disconnected or numb); feeling confused or having a hard time thinking clearly; losing track of time or where you are; having a hard time noticing when things are safer; or feeling like the past is happening again. This module will help you learn and practice the two core grounding skills (orienting to and anchoring in the present). In addition, the module describes how to notice you are getting ungrounded and offers 101 ways to get and stay grounded so you can find the ways of grounding that work best for you. By doing this work, you can learn to prevent yourself from getting overwhelmed by developing healthy, healing-focused ways to manage when you start to feel too much or too little.

Over the course of this program, you’ve been learning how to help yourself heal from the effects of trauma, including learning healthy ways to manage trauma-related symptoms. You’ve also been learning how to have healthy relationships with your emotions and all of who you are—including increasing self-compassion, getting your healthy needs met safely, and giving yourself the care you need. This module will help you learn how to keep making progress toward feeling safer, including feeling safe while feeling your feelings, how to help yourself be OK with feeling good, and how to keep healing. It will also guide you in noticing and giving yourself credit for what you have been doing, identifying and addressing factors that may be keeping you from feeling safer and better, and recognizing the changes you’ve made. Finally, you can think about what you would like to revisit and practice more.

This chapter offers an introduction to understanding and working with people who have dissociative self-states (DSS). Toward this end, the chapter discusses similarities and differences between DSS and normative self-state functioning, the link between DSS and disorganized attachment, descriptions of DSS systems, relationships between DSS, and functions of DSS. The chapter then offers principles for working with persons with DSS and describes commonly encountered DSS types and strategies for working with them. In addition, this chapter includes examples of ways to respond to and work with patients presenting with specific, common challenges, such as working with self-states in relation to unsafe or risky behaviors; investigating the underlying concerns of patients who have self-states reluctant to make changes in their thinking and/or behavior; working with patients who cannot remember their behavior, experiences, or a previous session; and working with childlike self-states.

This module builds on all you’ve already done as part of this program and focuses on learning more ways to help yourself recognize, interrupt, and reduce things that get in the way of getting and feeling safer. Toward these ends, this module will help you learn about your “window of tolerance” and how to calm your alarm system. You will practice getting and feeling safer by staying within and slowly expanding your window of tolerance. It will also help you practice having safer experiences, doing things that help calm your alarm system, and reducing behaviors that get in the way of getting and feeling safer. You will also learn about reducing your exposure to unhealthy and retraumatizing experiences and ways to help yourself when your risk of doing unhealthy or unsafe things is increasing.

Trauma can dramatically change the range of emotions and physical sensations that feel comfortable or manageable. People who have experienced trauma often feel too much or too little emotion and body sensations. Traumatic experiences can lead people to believe that certain feelings are not OK—or that no emotions are OK. This can lead people to not want their emotions and body sensations and to be afraid of emotions and sensations. In addition, they may never have learned how to have a healthy relationship with their emotions, body sensations, or themselves as a person. At the same time, it is difficult to get and feel safer without a healthy relationship with your emotions, body, and all of who you are. This module will help you work toward manageably developing healthy relationships with these aspects of your experience. This will gradually help you get and feel safer.

You can heal, recover from trauma, and grow, and this workbook can guide you through this important, meaningful work, step by step, at a pace that feels safe for you. If you’ve experienced trauma, life may sometimes feel hopeless, full of feeling too much or too little. You may feel that the world is a terrifying and dangerous place. You may even feel like you don’t deserve anything positive, especially if you have been hurt by people you needed, loved, or relied on. To escape the pain, you may have been disconnecting from yourself and the world, including in risky or unsafe ways. In this workbook, the expert authors guide you step by step along the path of healing from trauma and offer specific exercises to practice daily that will help you feel safer and develop a grounded, worthy sense of self. This book includes the information sheets and exercises that are the foundation for the Finding Solid Ground program. The companion book, Finding Solid Ground: Overcoming Obstacles in Trauma Treatment, provides the theoretical, clinical, and research rationale for the program. This workbook breaks recovery into practical manageable steps that can be immediately implemented. Participation in the Finding Solid Ground program in the Treatment of Patients with Dissociative Disorder (TOP DD) Network study was associated with increased ability to manage emotions in healthy ways and reduced dissociation, posttraumatic stress symptoms, and self-injury. Join the international community of people who have used this program to find solid ground!

Even seasoned clinicians can feel deskilled when trying to help to highly traumatized and dissociative patients. Together, this book and its accompanying workbook for patients provide an evidence-informed, pragmatic, and compassionate approach to the stabilization and treatment of complex trauma and dissociation. These books will help clinicians immediately implement ways to assess and treat traumatized individuals with a comprehensive therapeutic program that includes session-by-session Information Sheets and Exercises developed through the process of synthesizing decades of clinical experience, the results of the Treatment of Patients with Dissociative Disorders (TOP DD) studies, and feedback from individuals living with trauma-related disorders. Traumatized individuals who participated in the program as part of the TOP DD Network study were better able to manage emotions in healthy ways and reduced their levels of dissociation, posttraumatic stress symptoms, and self-injury. This book provides guidance on how to use the program in individual and group contexts, as well as expert recommendations for assessing dissociation and clinical vignettes that focus on how to overcome common obstacles in trauma treatment. The companion workbook includes the patient-facing Information Sheets and Exercises that are the foundation for the Finding Solid Ground program. Together, these books present a coherent, comprehensive approach to trauma treatment that rests upon a clearly articulated understanding of the neurobiological impacts of trauma. Clinicians of all levels of experience will find these books inspiring, informative, and accessible.

LAY SUMMARY Moral injury (MI) refers to the distress experienced when people do, or do not, do something that goes against their morals or values. It can also occur when people perceive that their values have been betrayed. MI is associated with several mental health conditions, including posttraumatic stress disorder (PTSD), depression, and anxiety. A potential risk factor for MI may include difficulties with emotion regulation (ER). Difficulties with ER refers to the ability to manage emotions. It is associated with the same mental health conditions linked to MI, including PTSD. The purpose of this study was to examine whether difficulties with ER were associated with MI in a Canadian military personnel and Veteran sample. Participants completed several questionnaires assessing for MI, difficulties with ER, and other mental health symptoms, such as PTSD, while they were inpatients at a psychiatric hospital. It was found that MI and perceived betrayals were associated with symptoms of PTSD. Symptoms of PTSD, depression, and anxiety were also associated with one another. Difficulties with ER were also associated with symptoms of PTSD, depression, and anxiety but were not related to MI. The findings serve as a first step in examining potential risk factors of MI.

To explore care aide perceptions of caring for residents who aides perceived had past psychological trauma.Through cognitive interviews, we developed a definition of trauma for four survey questions about caring for residents with psychological trauma. We added these questions to our routine care aide survey in 91 care homes in Western Canada (September 2019 to February 2020). We asked if care aides perceived that they were caring for residents with trauma, how often, types of trauma experienced, and what indication led them to perceive a resident had experienced trauma. We analyzed data using content analysis (open-ended questions) and regression analyses (closed-ended questions).Three thousand seven hundred and sixty five care aides responded (70% response rate) to the survey, and 53% perceived caring for one or more residents with a history of psychological trauma in the previous 2 weeks. Within six categories of traumatic events, abuse (35%) and war exposure (26%) were most common. Most common indications of trauma reported by care aides (five categories) were reliving the experience or having intrusive symptoms (28%) and avoidant behaviors (24%). Care aides were more likely to report caring for a resident who they perceived had experienced past psychological trauma if they were younger, spoke English as their first language, self-reported experiencing more aggression from residents, or who worked in not-for-profit homes.This preliminary study supports the need for further study of care aides' perceptions and experiences of caring for residents with past trauma, and the effects of caring for these residents on quality of work life.

Objective: We investigate the potential therapeutic application of virtual reality (VR) technology as an aid to meditation practice among persons varying in posttraumatic stress disorder (PTSD) symptoms. Method: In this within-group mixed-methods study, 96 young adults practiced both VR- and non-VR-guided meditations and reported on their experience of positive affect (PA), negative affect (NA), other meditative experiences and perceived satisfaction-credibility of each meditation. Results: Participants reported more PA and greater perceived satisfaction-credibility following the VR as compared to non-VR-guided meditations primarily when the VR meditation was practiced first, before the non-VR meditation, as opposed to vice versa. The experience of NA during meditation practice was infrequent, although persons with increased PTSD symptoms reported increased distress during both VR and non-VR meditation. Conclusions: Further study of therapeutic applications of VR as an aid to meditation practice among people with PTSD symptoms is warranted. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objective Dissociative disorders (DDs) are associated with intensive, long-term treatment, suicidality, recurrent hospitalizations, and high rates of disability. However, little is known about the specifics of the economic burden associated with DDs. This worldwide, systematic review examines the results of studies in adults on direct and indirect costs associated with DDs. Method We searched 6 databases and the reference lists of articles. We also approached researchers to identify unpublished studies. No language restrictions were imposed. Results A total of 1,002 records met the search criteria, of which 29 papers were selected for full-text inspection. Ultimately, of these, we reviewed four empirical studies. We provide a narrative discussion of study findings. Our findings suggest that DDs are costly to society, and that there is a reduction in service utilization and associated costs over time with diagnosing of and specialized treatment for DDs. However, the overall quality of the economic evaluations was low; several types of DDs, comorbid conditions, and costs were not included; and men were underrepresented. Due to the heterogeneity among studies, we could not perform a meta-analysis. Conclusions Due to the heterogeneity and low quality of the identified economic evaluations, no firm conclusions about the economic burden of DDs alone can be drawn. Higher quality research, including a detailed description of the study design, population, and primary outcome measures used, utilizing appropriate clinical alternatives and including major comorbidities, is urgently needed to more rigorously assess the economic impact of DDs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Neurofeedback is emerging as a psychophysiological treatment where self-regulation is achieved through online feedback of neural states. Novel personalized medicine approaches are particularly important for the treatment of posttraumatic stress disorder (PTSD), as symptom presentation of the disorder, as well as responses to treatment, are highly heterogeneous. Learning to achieve control of specific neural substrates through neurofeedback has been shown to display therapeutic evidence in patients with a wide variety of psychiatric disorders, including PTSD. This article outlines the neural mechanisms underlying neurofeedback and examines converging evidence for the efficacy of neurofeedback as an adjunctive treatment for PTSD via both electroencephalography (EEG) and real-time functional magnetic resonance imaging (fMRI) modalities. Further, implications for the treatment of PTSD via neurofeedback in the military member and Veteran population is examined.

Introduction: Recently, there has been substantial interest in exploring the heterogeneity of posttraumatic stress disorder (PTSD) on a neurobiological level, as individuals with PTSD, including military members and Veterans, vary in their presentation of symptoms. Methods: Critically, a dissociative subtype of PTSD (PTSD+DS) has been defined, where a large body of evidence suggests that the unique presentation of symptoms among PTSD+DS patients is associated with aberrant neurobiological underpinnings. Results: PTSD+DS is often characterized by emotion overmodulation, with increased top-down activation from emotion regulation areas, which is associated with emotional detachment, depersonalization, and derealization. This is in stark contrast to the symptoms commonly observed in individuals with PTSD, who exhibit emotion undermodulation, which involves decreased top-down regulation of hyperactive emotion generation areas and is associated with vivid re-experiencing of trauma memories and hyperarousal. Discussion: This article examines a clinical case example that clearly illustrates this heterogeneous presentation of PTSD symptomatology and psychopathology. It discusses the implications this evidence base holds for a neurobiologically-informed, personalized medicine approach to treatment for military members and Veterans.

Background Intrinsic connectivity networks, including the default mode network (DMN), are frequently disrupted in individuals with posttraumatic stress disorder (PTSD). The posterior cingulate cortex (PCC) is the main hub of the posterior DMN, where the therapeutic regulation of this region with real‐time fMRI neurofeedback (NFB) has yet to be explored. Methods We investigated PCC downregulation while processing trauma/stressful words over 3 NFB training runs and a transfer run without NFB (total n = 29, PTSD n = 14, healthy controls n = 15). We also examined the predictive accuracy of machine learning models in classifying PTSD versus healthy controls during NFB training. Results Both the PTSD and healthy control groups demonstrated reduced reliving symptoms in response to trauma/stressful stimuli, where the PTSD group additionally showed reduced symptoms of distress. We found that both groups were able to downregulate the PCC with similar success over NFB training and in the transfer run, although downregulation was associated with unique within‐group decreases in activation within the bilateral dmPFC, bilateral postcentral gyrus, right amygdala/hippocampus, cingulate cortex, and bilateral temporal pole/gyri. By contrast, downregulation was associated with increased activation in the right dlPFC among healthy controls as compared to PTSD. During PCC downregulation, right dlPFC activation was negatively correlated to PTSD symptom severity scores and difficulties in emotion regulation. Finally, machine learning algorithms were able to classify PTSD versus healthy participants based on brain activation during NFB training with 80% accuracy. Conclusions This is the first study to investigate PCC downregulation with real‐time fMRI NFB in both PTSD and healthy controls. Our results reveal acute decreases in symptoms over training and provide converging evidence for EEG‐NFB targeting brain networks linked to the PCC., This is the first study to investigate PCC downregulation with real‐time fMRI NFB in both PTSD and healthy controls. Our results reveal acute decreases in symptoms over training and provide converging evidence for EEG‐NFB targeting brain networks linked to the PCC.

Background Post-traumatic stress disorder affects 9% of individuals across their lifetime and increases nearly fourfold to 35% in Canadian public safety personnel (PSP). On-the-job experiences of PSP frequently meet criteria for traumatic events, making these individuals highly vulnerable to exposures of trauma and the negative consequences of PTSD. Few studies have reported on the clinical characteristics of Canadian samples of PSP and even fewer have examined the dissociative subtype of PTSD, which is associated with more severe, chronic traumatic experiences, and worse outcomes. Objective This study aimed to characterize dissociative symptoms, PTSD symptom severity, and other clinical variables among Canadian PSP with presumptive PTSD. Methods We sampled current and past PSP in Canada from both inpatient and outpatient populations (N = 50) that were enrolled in a psychological intervention. Only baseline testing data (prior to any intervention) were analysed in this study, such as PTSD symptom severity, dissociative symptoms, emotion dysregulation, and functional impairment. Results In our sample, 24.4% self-reported elevated levels of dissociation, specifically symptoms of depersonalization and derealization. Depersonalization and derealization symptoms were associated with more severe PTSD symptoms, greater emotion dysregulation, and functional impairment. Conclusions Nearly a quarter of this sample of Canadian PSP reported experiencing elevated levels of PTSD-related dissociation (depersonalization and derealization). These high levels of depersonalization and derealization were consistently positively associated with greater illness severity across clinical measures. It is imperative that dissociative symptoms be better recognized in patient populations that are exposed to chronic traumatic events such as PSP, so that treatment interventions can be designed to target a more severe illness presentation., HIGHLIGHTS 24.4% of traumatized Canadian public safety personnel reported elevated levels of depersonalization and derealization, which was associated with a severe illness profile characterized by greater trauma symptoms, emotional dysregulation, and difficulty with life tasks.

Real-time fMRI neurofeedback is an increasingly popular neuroimaging technique that allows an individual to gain control over his/her own brain signals, which can lead to improvements in behavior in healthy participants as well as to improvements of clinical symptoms in patient populations. However, a considerably large ratio of participants undergoing neurofeedback training do not learn to control their own brain signals and, consequently, do not benefit from neurofeedback interventions, which limits clinical efficacy of neurofeedback interventions. As neurofeedback success varies between studies and participants, it is important to identify factors that might influence neurofeedback success. Here, for the first time, we employed a big data machine learning approach to investigate the influence of 20 different design-specific (e.g. activity vs. connectivity feedback), region of interest-specific (e.g. cortical vs. subcortical) and subject-specific factors (e.g. age) on neurofeedback performance and improvement in 608 participants from 28 independent experiments. With a classification accuracy of 60% (considerably different from chance level), we identified two factors that significantly influenced neurofeedback performance: Both the inclusion of a pre-training no-feedback run before neurofeedback training and neurofeedback training of patients as compared to healthy participants were associated with better neurofeedback performance. The positive effect of pre-training no-feedback runs on neurofeedback performance might be due to the familiarization of participants with the neurofeedback setup and the mental imagery task before neurofeedback training runs. Better performance of patients as compared to healthy participants might be driven by higher motivation of patients, higher ranges for the regulation of dysfunctional brain signals, or a more extensive piloting of clinical experimental paradigms. Due to the large heterogeneity of our dataset, these findings likely generalize across neurofeedback studies, thus providing guidance for designing more efficient neurofeedback studies specifically for improving clinical neurofeedback-based interventions. To facilitate the development of data-driven recommendations for specific design details and subpopulations the field would benefit from stronger engagement in open science research practices and data sharing. publishedVersion

A growing number of studies have examined alterations in white matter organization in people with posttraumatic stress disorder (PTSD) using diffusion MRI (dMRI), but the results have been mixed, which may be partially due to relatively small sample sizes among studies. Altered structural connectivity may be both a neurobiological vulnerability for, and a result of, PTSD. In an effort to find reliable effects, we present a multi-cohort analysis of dMRI metrics across 3,047 individuals from 28 cohorts currently participating in the PGC-ENIGMA PTSD working group (a joint partnership between the Psychiatric Genomics Consortium and the Enhancing NeuroImaging Genetics through Meta-Analysis consortium). Comparing regional white matter metrics across the full brain in 1,426 individuals with PTSD and 1,621 controls (2174 males/873 females) between ages 18–83, 92% of whom were trauma-exposed, we report associations between PTSD and disrupted white matter organization measured by lower fractional anisotropy (FA) in the tapetum region of the corpus callosum (Cohen’s d=−0.11, p=0.0055). The tapetum connects the left and right hippocampus, structures for which structure and function have been consistently implicated in PTSD. Results remained significant/similar after accounting for the effects of multiple potentially confounding variables: childhood trauma exposure, comorbid depression, history of traumatic brain injury, current alcohol abuse or dependence, and current use of psychotropic medications. Our results show that PTSD may be associated with alterations in the broader hippocampal network.

Posttraumatic stress disorder (PTSD) is a complex psychiatric condition that has generated much attention in the neuroimaging literature. A neurocircuitry model supporting fronto-limbic dysfunction as a major player in facilitating clinical symptoms of PTSD is well-characterized; however, recent literature suggests that network-based approaches may provide additional insight into neural dysfunction in PTSD. Our analysis uses resting-state neuroimaging scans of 1063 adults from the PGC-ENIGMA PTSD Consortium to investigate a network-based model of functional connectivity in PTSD. With a novel, resolution limit-free community detection approach, 16 communities corresponding to functionally meaningful networks were detected with high quality. After group-level community detection, participants were classified into three groups (PTSD, n=418, trauma-exposed controls without PTSD, n=434, and non-trauma exposed healthy controls, n=211). Individual network connectivity metrics were calculated, including whole-brain, default mode network, and central executive network participation coefficient and connectivity strength. Linear mixed effects models revealed group differences in the whole-brain, default mode, and central executive network participation coefficient and connectivity strength such that individuals with PTSD demonstrated overall greater values. We also described sex differences such that males demonstrate greater whole-brain participation coefficient vs. females and females demonstrate greater default mode network connectivity strength vs. males. Our results suggest that PTSD in adults is associated with reduced specialization and enhanced inter-module communication throughout the brain network, which may contribute to inefficient information processing and poor emotional regulation. This study presents a novel use of resolution limit-free community detection in a large PTSD sample, revealing robust differences in resting-state network topology.

Background The impacts of the COVID-19 pandemic have disproportionally affected different population groups. Veterans are more likely to have pre-existing mental health conditions compared to the general Canadian population, experience compounded stressors resulting from disruptions to familial, social, and occupational domains, and were faced with changes in health-care delivery (e.g. telehealth). The objectives of this study are to assess (a) the mental health impact of COVID-19 and related life changes on the well-being of Veterans and (b) perceptions of and satisfaction with changes in health-care treatments and delivery during the pandemic. Methods A total of 1136 Canadian Veterans participated in an online survey. Participants completed questions pertaining to their mental health and well-being, lifestyle changes, and concerns relating to the COVID-19 pandemic, as well as experiences and satisfaction with health-care treatments during the pandemic. Results Results showed that 55.9% of respondents reported worse mental health functioning compared to before the pandemic. The frequency of probable posttraumatic stress disorder, major depressive disorder, generalized anxiety disorder, alcohol use disorder, and suicidal ideation were 34.2%, 35.3%, 26.8%, 13.0%, and 22.0%, respectively. Between 38.6% and 53.1% of respondents attributed their symptoms as either directly related to or exacerbated by the pandemic. Approximately 18% of respondents reported using telehealth for mental health services during the pandemic, and among those, 72.8% indicated a choice to use telehealth even after the pandemic. Conclusions This study found that Veterans experienced worsening mental health as a result of the COVID-19 pandemic. The use of telehealth services was widely endorsed by mental health treatment-seeking Veterans who transitioned to virtual care during the pandemic. Our findings have important clinical and programmeadministrator implications, emphasizing the need to reach out to support veterans, especially those with pre-existing mental health conditions and to enhance and maintain virtual care even post-pandemic., HIGHLIGHTS Over 50% of Veterans reported worse mental health compared to before the pandemic.Probable mental health conditions based on self-reports ranged from 13% to 35%.Nearly 1 in 5 Veterans surveyed reported using telehealth for mental health services during the pandemic.

The present study evaluated focused attention, affective response, and other subjective experiences during a mindfulness meditation exercise, relative to participant exposure to lifetime trauma, life stress experienced in the past year, and trauma-related symptoms experienced over the past month. Participants were recruited from a university introductory psychology course (n = 151). Meditation Breath Attention Scores (MBAS) were used to assess focused attention during a brief mindfulness meditation, and self-report questionnaires assessing subjective responses to the meditation were administered afterward. All participants completed self-report questionnaires assessing trauma exposure, life stress, and trauma-related symptoms prior to the meditation. Participant history of stressful and traumatic life events and trauma- and stressor-related symptoms that were assessed prior to the meditation were found to be predictive of distress experienced during the meditation. We conclude that mindfulness meditation-based therapy for persons with trauma-related mental health problems should be trauma-informed. Limitations of the study and future research directions are discussed.

Individuals with dissociative disorders (DDs) are underrecognized, underserved, and often severely psychiatrically ill, characterized by marked dissociative and posttraumatic stress disorder (PTSD) symptoms with significant disability. Patients with DD have high rates of nonsuicidal self-injury (NSSI) and suicide attempts. Despite this, there is a dearth of training about DDs. We report the outcome of a web-based psychoeducational intervention for an international sample of 111 patients diagnosed with dissociative identity disorder (DID) or other complex DDs. The Treatment of Patients with Dissociative Disorders Network (TOP DD Network) program was designed to investigate whether, over the course of a web-based psychoeducational program, DD patients would exhibit improved functioning and decreased symptoms, including among patients typically excluded from treatment studies for safety reasons. Using video, written, and behavioral practice exercises, the TOP DD Network program provided therapists and patients with education about DDs as well as skills for improving emotion regulation, managing safety issues, and decreasing symptoms. Participation was associated with reductions in dissociation and PTSD symptoms, improved emotion regulation, and higher adaptive capacities, with overall sample |d|s = 0.44-0.90, as well as reduced NSSI. The improvements in NSSI among the most self-injurious patients were particularly striking. Although all patient groups showed significant improvements, individuals with higher levels of dissociation demonstrated greater and faster improvement compared to those lower in dissociation |d|s = 0.54-1.04 vs. |d|s = 0.24-0.75, respectively. These findings support dissemination of DD treatment training and initiation of treatment studies with randomized controlled designs.

ObjectiveResearch is urgently needed to understand health care workers’ (HCWs’) experiences of moral-ethical dilemmas encountered throughout the COVID-19 pandemic, and their associations with organizational perceptions and personal well-being. The purpose of this research is to evaluate associations between workplace experiences during COVID-19, moral distress, and the psychological well-being of Canadian HCWs.MethodA total of 1383 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in an online survey. Participants completed measures reflecting moral distress, perceptions of organizational response to the pandemic, burnout, and symptoms of psychological disorders, including depression, anxiety, and posttraumatic stress disorder.ResultsStructural equation modeling showed that when organizational predictors were considered together, resource adequacy, positive work life impact, and ethical work environment negatively predicted severity of moral distress, whereas COVID-19 risk perception positively predicted severity of moral distress. Moral distress also significantly and positively predicted symptoms of depression, anxiety, PTSD, and burnout.ConclusionsOur findings highlight an urgent need for HCW organizations to implement strategies designed to prevent long-term moral and psychological distress within the workplace. Ensuring availability of adequate resources, reducing HCW risk of contracting COVID-19, providing organizational support regarding individual priorities, and upholding ethical considerations are crucial to reducing severity of moral distress in HCWs.

Individuals with posttraumatic stress disorder (PTSD) are at increased risk for the development of various forms of dementia. Nevertheless, the neuropathological link between PTSD and neurodegeneration remains unclear. Degeneration of the human basal forebrain constitutes a pathological hallmark of neurodegenerative diseases, such as Alzheimer's and Parkinson's disease. In this seed‐based resting‐state (rs‐)fMRI study identifying as outcome measure the temporal BOLD signal fluctuation magnitude, a seed‐to‐voxel analyses assessed temporal correlations between the average BOLD signal within a bilateral whole basal forebrain region‐of‐interest and each whole‐brain voxel among individuals with PTSD (n = 65), its dissociative subtype (PTSD+DS) (n = 38) and healthy controls (n = 46). We found that compared both with the PTSD and healthy controls groups, the PTSD+DS group exhibited increased BOLD signal variability within two nuclei of the seed region, specifically in its extended amygdaloid region: the nucleus accumbens and the sublenticular extended amygdala. This finding is provocative, because it mimics staging models of neurodegenerative diseases reporting allocation of neuropathology in early disease stages circumscribed to the basal forebrain. Here, underlying candidate etiopathogenetic mechanisms are neurovascular uncoupling, decreased connectivity in local‐ and large‐scale neural networks, or disrupted mesolimbic dopaminergic circuitry, acting indirectly upon the basal forebrain cholinergic pathways. These abnormalities may underpin reward‐related deficits representing a putative link between persistent traumatic memory in PTSD and anterograde memory deficits in neurodegeneration. Observed alterations of the basal forebrain in the dissociative subtype of PTSD point towards the urgent need for further exploration of this region as a potential candidate vulnerability mechanism for neurodegeneration in PTSD., In this seed‐based resting‐state (rs‐)fMRI study we investigated the role of the human basal forebrain in PTSD, as a putative neuroimaging marker of PTSD‐related neurodegeneration. We observed an increased hemodynamic BOLD signal variability within the basal forebrain of PTSD subtype dissociative group, which mimics previous reports of dysfunction and degeneration of the basal forebrain in early phases of neurodegenerative diseases such as Alzheimer's disease. Observed alterations of the basal forebrain in the dissociative subtype of PTSD point toward the urgent need for further exploration of this region as a potential candidate vulnerability mechanism for neurodegeneration in PTSD.

Background: Several intrinsic networks in the brain, including the default mode network, the salience network, and the central executive network, have shown to be critical to higher cognitive functioning. Importantly, these networks have been demonstrated to be compromised in psychopathology, including posttraumatic stress disorder (PTSD) (Akiki, Averill, & Abdallah, 2017; Lanius, Frewen, Tursich, Jetly, & McKinnon, 2015; Lanius, Terpou, & McKinnon, 2020; Szeszko & Yehuda, 2020). Objective: 1) To outline the major large-scale networks of the human brain and their impaired functioning in PTSD; 2) to describe neuroscientifically-informed interventions targeting directly the abnormalities observed in these brain networks in PTSD. Methods: Literature relevant to this topic will be reviewed. Results: Increasing evidence for impaired functioning of the default mode network, the salience network, the central executive network, and the dorsal/ventral attention networks in PTSD has been described. Each network has been proposed to be associated with specific clinical symptoms observed in PTSD, including an altered sense of self (default mode network), increased or decreased or arousal/interoception (salience network), cognitive dysfunction (central executive network; attentional networks). Specific neuroscientifically-informed treatments designed to restore each of these brain networks and the related clinical symptomatology will be discussed. Conclusions: Neuroscientifically-informed treatments will be critical to future research and personalized medicine agendas aimed at targeting specific PTSD symptomatology and restoring functioning in the aftermath of this often devastating disorder.

Background Research is urgently needed to understand health care workers’ (HCWs’) experiences of moral-ethical dilemmas encountered throughout the COVID-19 pandemic, and their associations with organizational perceptions and personal well-being. This research is important to prevent long-term moral and psychological distress and to ensure that workers can optimally provide health services. Objective Evaluate associations between workplace experiences during COVID-19, moral distress, and the psychological well-being of Canadian HCWs. Method A total of 1362 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in an online survey. Participants completed measures reflecting moral distress, perceptions of organizational response to the pandemic, burnout, and symptoms of psychological disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD). Results Structural equation modelling showed that when organizational predictors were considered together, resource adequacy, positive work life impact, and ethical work environment negatively predicted severity of moral distress, whereas COVID-19 risk perception positively predicted severity of moral distress. Moral distress also significantly and positively predicted symptoms of depression, anxiety, PTSD, and burnout. Conclusions Our findings highlight an urgent need for HCW organizations to implement strategies designed to prevent long-term moral and psychological distress within the workplace. Ensuring availability of adequate resources, reducing HCW risk of contracting COVID-19, providing organizational support regarding individual priorities, and upholding ethical considerations are crucial to reducing severity of moral distress in HCWs., HIGHLIGHTS We sought to evaluate associations between workplace experiences during COVID-19, moral distress, and the well-being of Canadian health care workers.Organizational variables predicted severity of moral distress.Moral distress predicted symptoms of mental health conditions.

Real-time fMRI neurofeedback is an increasingly popular neuroimaging technique that allows an individual to gain control over his/her own brain signals, which can lead to improvements in behavior in healthy participants as well as to improvements of clinical symptoms in patient populations. However, a considerably large ratio of participants undergoing neurofeedback training do not learn to control their own brain signals and, consequently, do not benefit from neurofeedback interventions, which limits clinical efficacy of neurofeedback interventions. As neurofeedback success varies between studies and participants, it is important to identify factors that might influence neurofeedback success. Here, for the first time, we employed a big data machine learning approach to investigate the influence of 20 different design-specific (e.g. activity vs. connectivity feedback), region of interest-specific (e.g. cortical vs. subcortical) and subject-specific factors (e.g. age) on neurofeedback performance and improvement in 608 participants from 28 independent experiments.With a classification accuracy of 60% (considerably different from chance level), we identified two factors that significantly influenced neurofeedback performance: Both the inclusion of a pre-training no-feedback run before neurofeedback training and neurofeedback training of patients as compared to healthy participants were associated with better neurofeedback performance. The positive effect of pre-training no-feedback runs on neurofeedback performance might be due to the familiarization of participants with the neurofeedback setup and the mental imagery task before neurofeedback training runs. Better performance of patients as compared to healthy participants might be driven by higher motivation of patients, higher ranges for the regulation of dysfunctional brain signals, or a more extensive piloting of clinical experimental paradigms. Due to the large heterogeneity of our dataset, these findings likely generalize across neurofeedback studies, thus providing guidance for designing more efficient neurofeedback studies specifically for improving clinical neurofeedback-based interventions. To facilitate the development of data-driven recommendations for specific design details and subpopulations the field would benefit from stronger engagement in Open Science and data sharing.

Background Moral injury (MI) is consistently associated with adverse mental health outcomes, including the development of posttraumatic stress disorder (PTSD) and suicidality. Methods We investigated neural activation patterns associated with MI event recall using functional magnetic resonance imaging in participants with military and public safety-related PTSD, relative to civilian MI-exposed controls. Results MI recall in the PTSD as compared to control group was associated with increased neural activation among salience network nodes involved in viscerosensory processing and hyperarousal (right posterior insula, dorsal anterior cingulate cortex; dACC), regions involved in defensive responding (left postcentral gyrus), and areas responsible for top-down cognitive control of emotions (left dorsolateral prefrontal cortex; dlPFC). Within the PTSD group, measures of state and trait shame correlated negatively with activity among default mode network regions associated with self-related processing and moral cognition (dorsomedial prefrontal cortex; dmPFC) and salience network regions associated with viscerosensory processing (left posterior insula), respectively. Conclusions These findings suggest that MI event processing is altered in military and public safety-related PTSD, relative to MI-exposed controls. Here, it appears probable that as individuals with PTSD recall their MI event, they experience a surge of blame-related processing of bodily sensations within salience network regions, including the right posterior insula and the dACC, which in turn, prompt regulatory strategies at the level of the left dlPFC aimed at increasing cognitive control and inhibiting emotional affect. These results are consistent with previous findings showing enhanced sensory processing and altered top-down control in PTSD samples during autobiographical memory recall.

After a disaster, population rates of psychological distress tend to double or triple. Acute-phase reactions and disorders generally resolve within a year; however, there is considerable variation in recovery times.[1][1] Subsequent to the accident at the Fukushima Daiichi Nuclear Power Plant, for