Search

ABSTRACTBackground: Healthcare workers (HCWs) across the globe have reported symptoms of Post-Traumatic Stress Disorder (PTSD) during the COVID-19 pandemic. Moral Injury (MI) has been associated with PTSD in military populations, but is not well studied in healthcare contexts. Moral Distress (MD), a related concept, may enhance understandings of MI and its relation to PTSD among HCWs. This study examined the independent and combined impact of MI and MD on PTSD symptoms in Canadian HCWs during the pandemic.Methods: HCWs participated in an online survey between February and December 2021, with questions regarding sociodemographics, mental health and trauma history (e.g. MI, MD, PTSD, dissociation, depression, anxiety, stress, childhood adversity). Structural equation modelling was used to analyze the independent and combined impact of MI and MD on PTSD symptoms (including dissociation) among the sample when controlling for sex, age, depression, anxiety, stress, and childhood adversity.Results: A structural equation model independently regressing both MI and MD onto PTSD accounted for 74.4% of the variance in PTSD symptoms. Here, MI was strongly and significantly associated with PTSD symptoms (β = .412, p

IntroductionRespiratory therapists (RTs) faced morally distressing situations throughout the COVID-19 pandemic, including working with limited resources and facilitating video calls for families of dying patients. Moral distress is associated with a host of adverse psychological and functional outcomes (e.g. depression, anxiety, symptoms of posttraumatic stress disorder [PTSD] and functional impairment) and consideration of position departure. The purpose of this study was to understand the impact of moral distress and its associated psychological and functional outcomes on consideration to leave a clinical position among Canadian RTs during the COVID-19 pandemic. MethodsCanadian RTs (N = 213) completed an online survey between February and June 2021. Basic demographic information (e.g. age, sex, gender) and psychometrically validated measures of moral distress, depression, anxiety, stress, PTSD, dissociation, functional impairment, resilience and adverse childhood experiences were collected. ResultsOne in four RTs reported considering leaving their position. RTs considering leaving reported elevated levels of moral distress and adverse psychological and functional outcomes compared to RTs not considering leaving. Over half (54.5%) of those considering leaving scored above the cut-off for potential diagnosis of PTSD. Previous consideration to leave a position and having left a position in the past each significantly increased the odds of currently considering leaving, along with system-related moral distress and symptoms of PTSD, but the contribution of these latter factors was small. ConclusionCanadian RTs considering leaving their position reported elevated levels of distress and adverse psychological and functional outcomes, yet these individual-level factors appear unlikely to be the primary factors underlying RTs’ consideration to leave, because their effects were small. Further research is required to identify broader, organizational factors that may contribute to consideration of position departure among Canadian RTs.

IntroductionLes thérapeutes respiratoires ont été confrontés à des situations moralement difficiles tout au long de la pandémie de COVID-19, en particulier le fait d’avoir peu de ressources pour effectuer leur travail ou encore la participation à des appels vidéo avec les familles de patients mourants. La détresse morale est associée à une foule de conséquences psychologiques et fonctionnelles négatives (dépression, anxiété, symptômes du trouble de stress post-traumatique [TSPT], déficience fonctionnelle, etc.) et au fait d’envisager de quitter son poste. L’objectif de cette étude était de comprendre l’effet de la détresse morale et de ses conséquences psychologiques et fonctionnelles sur le fait que des thérapeutes respiratoires canadiens aient envisagé de quitter leur poste clinique pendant la pandémie de COVID-19. MéthodologieDes thérapeutes respiratoires canadiens (N = 213) ont répondu à un sondage en ligne entre février et juin 2021. Des caractéristiques inividuelles de base (âge, sexe/genre, etc.) ont été recueillies, ainsi que des mesures psychométriques validées de la détresse morale, de la dépression, de l’anxiété, du stress, du TSPT, de la dissociation, de la déficience fonctionnelle, de la résilience et des expériences négatives vécues durant l’enfance. RésultatsUn thérapeute respiratoire sur quatre a déclaré envisager de quitter son poste. Ceux qui envisageaient de le faire ont fait état de niveaux élevés de détresse morale et de conséquences psychologiques et fonctionnelles négatives comparativement aux thérapeutes respiratoires qui n’envisageaient pas de quitter leur poste. Plus de la moitié (54,5 %) de ceux qui envisageaient de quitter leur poste ont obtenu un score supérieur au seuil indiquant un diagnostic potentiel de TSPT. Le fait d’avoir déjà envisagé de quitter un poste auparavant et le fait d’avoir effectivement quitté un poste antérieur augmentaient significativement la probabilité d’envisager de quitter son poste, tout comme la détresse morale liée au système et les symptômes de TSPT, mais la contribution de ces derniers facteurs était faible. ConclusionLes thérapeutes respiratoires canadiens qui envisageaient de quitter leur poste ont signalé des niveaux élevés de détresse et de conséquences psychologiques et fonctionnelles négatives. Il semble néanmoins peu probable que ces facteurs individuels soient les principaux facteurs pour lesquels ils envisageaient de quitter leur poste, car les effets en étaient faibles. D’autres recherches sont nécessaires pour cerner les facteurs organisationnels plus vastes susceptibles d’inciter les thérapeutes respiratoires canadiens à vouloir quitter leur poste.

Introduction: Healthcare professionals (HCPs) appear to be at increased risk for negative psychological outcomes [e.g. depression, anxiety, post-traumatic stress disorder (PTSD), moral distress] and associated impacts on functioning throughout the COVID-19 pandemic. HCPs working on designated COVID-19 units may be further impacted than their colleagues not on these units given added demands of patient care and risk of contracting COVID-19. Little is known, however, about the mental health and functioning of specific professional groups beyond nurses and physicians, including respiratory therapists (RTs), over the course of the pandemic. Accordingly, the purpose of the present study was to characterize the mental health and functioning of Canadian RTs and compare profiles between RTs working on and off designated COVID-19 units. Methods: Canadian RTs completed an online survey between February and June 2021, including demographic information (e.g. age, sex, gender,) and measures of depression, anxiety, stress, PTSD, moral distress and functional impairment. Descriptive statistics, correlation analyses and between-groups comparisons were conducted to characterize RTs and compare profiles between those on and off COVID-19 units. Results: Two hundred and eighteen (N = 218) RTs participated in this study. The estimated response rate was relatively low (6.2%) Approximately half of the sample endorsed clinically relevant symptoms of depression (52%), anxiety (51%) and stress (54%) and one in three (33%) screened positively for potential PTSD. All symptoms correlated positively with functional impairment (p's < .05). RTs working on COVID-19 units reported significantly greater patient-related moral distress compared to those not on these units (p < .05). Conclusion: Moral distress and symptoms of depression, anxiety, stress and PTSD were prevalent among Canadian RTs and were associated with functional impacts. These results must be interpreted with caution given a low response rate, yet raise concern regarding the long-term impacts of pandemic service among RTs.

IntroductionReal-time fMRI-based neurofeedback (rt-fMRI-NFB) is a non-invasive technology that enables individuals to self-regulate brain activity linked to neuropsychiatric symptoms, including those associated with post-traumatic stress disorder (PTSD). Selecting the target brain region for neurofeedback-mediated regulation is primarily informed by the neurobiological characteristics of the participant population. There is a strong link between PTSD symptoms and multiple functional disruptions in the brain, including hyperactivity within both the amygdala and posterior cingulate cortex (PCC) during trauma-related processing. As such, previous rt-fMRI-NFB studies have focused on these two target regions when training individuals with PTSD to regulate neural activity. However, the differential effects of neurofeedback target selection on PTSD-related neural activity and clinical outcomes have not previously been investigated.MethodsHere, we compared whole-brain activation and changes in PTSD symptoms between PTSD participants (n = 28) that trained to downregulate activity within either the amygdala (n = 14) or the PCC (n = 14) while viewing personalized trauma words.ResultsFor the PCC as compared to the amygdala group, we observed decreased neural activity in several regions implicated in PTSD psychopathology – namely, the bilateral cuneus/precuneus/primary visual cortex, the left superior parietal lobule, the left occipital pole, and the right superior temporal gyrus/temporoparietal junction (TPJ) – during target region downregulation using rt-fMRI-NFB. Conversely, for the amygdala as compared to the PCC group, there were no unique (i.e., over and above that of the PCC group) decreases in neural activity. Importantly, amygdala downregulation was not associated with significantly improved PTSD symptoms, whereas PCC downregulation was associated with reduced reliving and distress symptoms over the course of this single training session. In this pilot analysis, we did not detect significant between-group differences in state PTSD symptoms during neurofeedback. As a critical control, the PCC and amygdala groups did not differ in their ability to downregulate activity within their respective target brain regions. This indicates that subsequent whole-brain neural activation results can be attributed to the effects of the neurofeedback target region selection in terms of neurophysiological function, rather than as a result of group differences in regulatory success.ConclusionIn this study, neurofeedback-mediated downregulation of the PCC was differentially associated with reduced state PTSD symptoms and simultaneous decreases in PTSD-associated brain activity during a single training session. This novel analysis may guide researchers in choosing a neurofeedback target region in future rt-fMRI-NFB studies and help to establish the clinical efficacy of specific neurofeedback targets for PTSD. A future multi-session clinical trial of rt-fMRI-NFB that directly compares between PCC and amygdala target regions is warranted.

Background: Advanced neuroscientific insights surrounding post-traumatic stress disorder (PTSD) and its associated symptomatology should beget psychotherapeutic treatments that integrate these insights into practice. Deep Brain Reorienting (DBR) is a neuroscientifically-guided psychotherapeutic intervention that targets the brainstem-level neurophysiological sequence that transpired during a traumatic event. Given that contemporary treatments have non-response rates of up to 50% and high drop-out rates of >18%, DBR is investigated as a putative candidate for effective treatment of some individuals with PTSD. Objective: To conduct an interim evaluation of the effectiveness of an eight-session clinical trial of videoconference-based DBR versus waitlist (WL) control for individuals with PTSD. Method: Fifty-four individuals with PTSD were randomly assigned to DBR (N = 29) or WL (N = 25). At baseline, post-treatment, and three-month follow-up, participants’ PTSD symptom severity was assessed using the Clinician Administered PTSD Scale (CAPS-5). This is an interim analysis of a clinical trial registered with the U. S. National Institute of Health (NCT04317820). Results: Significant between-group differences in CAPS-total and all subscale scores (re-experiencing, avoidance, negative alterations in cognitions/mood, alterations in arousal/reactivity) were found at post-treatment (CAPS-total: Cohen’s d = 1.17) and 3-month-follow-up (3MFU) (CAPS-total: Cohen’s d = 1.18). Significant decreases in CAPS-total and all subscale scores were observed within the DBR group pre – to post-treatment (36.6% CAPS-total reduction) and pre-treatment to 3MFU (48.6% CAPS-total reduction), whereas no significant decreases occurred in the WL group. After DBR, 48.3% at post-treatment and 52.0% at 3MFU no longer met PTSD criteria. Attrition was minimal with one participant not completing treatment; eight participants were lost to 3MFU. Conclusions: These findings provide emerging evidence for the effectiveness of DBR as a well-tolerated treatment that is based on theoretical advances highlighting alterations to subcortical mechanisms in PTSD and associated symptomatology. Additional research utilizing larger sample sizes, neuroimaging data, and comparisons or adjacencies with other psychotherapeutic approaches is warranted. Trial registration: ClinicalTrials.gov identifier: NCT04317820..

Abstract Background Alterations within large‐scale brain networks—namely, the default mode (DMN) and salience networks (SN)—are present among individuals with posttraumatic stress disorder (PTSD). Previous real‐time functional magnetic resonance imaging (fMRI) and electroencephalography neurofeedback studies suggest that regulating posterior cingulate cortex (PCC; the primary hub of the posterior DMN) activity may reduce PTSD symptoms and recalibrate altered network dynamics. However, PCC connectivity to the DMN and SN during PCC‐targeted fMRI neurofeedback remains unexamined and may help to elucidate neurophysiological mechanisms through which these symptom improvements may occur. Methods Using a trauma/emotion provocation paradigm, we investigated psychophysiological interactions over a single session of neurofeedback among PTSD (n = 14) and healthy control (n = 15) participants. We compared PCC functional connectivity between regulate (in which participants downregulated PCC activity) and view (in which participants did not exert regulatory control) conditions across the whole‐brain as well as in a priori specified regions‐of‐interest. Results During regulate as compared to view conditions, only the PTSD group showed significant PCC connectivity with anterior DMN (dmPFC, vmPFC) and SN (posterior insula) regions, whereas both groups displayed PCC connectivity with other posterior DMN areas (precuneus/cuneus). Additionally, as compared with controls, the PTSD group showed significantly greater PCC connectivity with the SN (amygdala) during regulate as compared to view conditions. Moreover, linear regression analyses revealed that during regulate as compared to view conditions, PCC connectivity to DMN and SN regions was positively correlated to psychiatric symptoms across all participants. Conclusion In summary, observations of PCC connectivity to the DMN and SN provide emerging evidence of neural mechanisms underlying PCC‐targeted fMRI neurofeedback among individuals with PTSD. This supports the use of PCC‐targeted neurofeedback as a means by which to recalibrate PTSD‐associated alterations in neural connectivity within the DMN and SN, which together, may help to facilitate improved emotion regulation abilities in PTSD.

Neural representations of sensory percepts and motor responses constitute key elements of autobiographical memory. However, these representations may remain as unintegrated sensory and motor fragments in traumatic memory, thus contributing toward re-experiencing and reliving symptoms in trauma-related conditions such as post-traumatic stress disorder (PTSD). Here, we investigated the sensorimotor network (SMN) and posterior default mode network (pDMN) using a group independent component analysis (ICA) by examining their functional connectivity during a script-driven memory retrieval paradigm of (potentially) morally injurious events in individuals with PTSD and healthy controls. Moral injury (MI), where an individual acts or fails to act in a morally aligned manner, is examined given its inherent ties to disrupted motor planning and thus sensorimotor mechanisms. Our findings revealed significant differences in functional network connectivity across the SMN and pDMN during MI retrieval in participants with PTSD (n = 65) as compared to healthy controls (n = 25). No such significant group-wise differences emerged during retrieval of a neutral memory. PTSD-related alterations included hyperconnectivity between the SMN and pDMN, enhanced within-network connectivity of the SMN with premotor areas, and increased recruitment of the supramarginal gyrus into both the SMN and the pDMN during MI retrieval. In parallel with these neuroimaging findings, a positive correlation was found between PTSD severity and subjective re-experiencing intensity ratings after MI retrieval. These results suggest a neural basis for traumatic re-experiencing, where reliving and/or re-enacting a past morally injurious event in the form of sensory and motor fragments occurs in place of retrieving a complete, past-contextualized narrative as put forth by Brewin and colleagues (1996) and Conway and Pleydell-Pearce (2000). These findings have implications for bottom-up treatments targeting directly the sensory and motoric elements of traumatic experiences.

Background: Posttraumatic stress disorder (PTSD) has been found to be associated with emotion under-modulation from the prefrontal cortex and a breakdown of the top-down control of cognition and emotion. Novel adjunct therapies such as neurofeedback (NFB) have been shown to normalize aberrant neural circuits that underlie PTSD psychopathology at rest. However, little evidence exists for NFB-linked neural improvements under emotionally relevant cognitive load. The current study sought to address this gap by examining the effects of alpha-down NFB in the context of an emotional n-back task. Methods: We conducted a 20-week double-blind randomized, sham-controlled trial of alpha-down NFB and collected neuroimaging data before and after the NFB protocol. Participants performed an emotional 1-back and 2-back working memory task, with interleaved trauma-neutral and trauma-relevant cues in the fMRI scanner. Data from 35 participants with a primary diagnosis of PTSD were analyzed in this study (n = 18 in the experimental group undergoing alpha-down NFB, n = 17 in the sham-control group). Results: Firstly, within-group analyses showed clinically significant reductions in PTSD symptom severity scores at the post-intervention timepoint and 3-month follow-up for the experimental group, and not for the sham-control group. The neuroimaging analyses revealed that alpha-down NFB enhanced engagement of top-down cognitive and emotional control centers, such as the dorsolateral prefrontal cortex (dlPFC), and improved integration of the anterior and posterior parts of the default mode network (DMN). Finally, our results also indicate that increased alpha-down NFB performance correlated with increased activity in brain regions involved in top-down control and bodily consciousness/embodied processing of self (TPJ and posterior insula). Conclusion: This is the first study to provide mechanistic insights into how NFB may normalize dysfunctional brain activity and connectivity in PTSD under cognitive load with simultaneous symptom provocation, adding to a growing body of evidence supporting the therapeutic neuromodulatory effects of NFB. This preliminary study highlights the benefits of alpha-down NFB training as an adjunctive therapy for PTSD and warrants further investigation into its therapeutic effects on cognitive and emotion control in those with PTSD.

Although the manifestation of trauma in the body is a phenomenon well-endorsed by clinicians and traumatized individuals, the neurobiological underpinnings of this manifestation remain unclear. The notion of somatic sensory processing, which encompasses vestibular and somatosensory processing and relates to the sensory systems concerned with how the physical body exists in and relates to physical space, is introduced as a major contributor to overall regulatory, social-emotional, and self-referential functioning. From a phylogenetically and ontogenetically informed perspective, trauma-related symptomology is conceptualized to be grounded in brainstem-level somatic sensory processing dysfunction and its cascading influences on physiological arousal modulation, affect regulation, and higher-order capacities. Lastly, we introduce a novel hierarchical model bridging somatic sensory processes with limbic and neocortical mechanisms regulating an individual’s emotional experience and sense of a relational, agentive self. This model provides a working framework for the neurobiologically informed assessment and treatment of trauma-related conditions from a somatic sensory processing perspective.

Background Systemic oppression, particularly towards sexual minorities, continues to be deeply rooted in the bedrock of many societies globally. Experiences with minority stressors (e.g. discrimination, hate-crimes, internalized homonegativity, rejection sensitivity, and microaggressions or everyday indignities) have been consistently linked to adverse mental health outcomes. Elucidating the neural adaptations associated with minority stress exposure will be critical for furthering our understanding of how sexual minorities become disproportionately affected by mental health burdens. Methods Following PRISMA-guidelines, we systematically reviewed published neuroimaging studies that compared neural dynamics among sexual minority and heterosexual populations, aggregating information pertaining to any measurement of minority stress and relevant clinical phenomena. Results Only 1 of 13 studies eligible for inclusion examined minority stress directly, where all other studies focused on investigating the neurobiological basis of sexual orientation. In our narrative synthesis, we highlight important themes that suggest minority stress exposure may be associated with decreased activation and functional connectivity within the default-mode network (related to the sense-of-self and social cognition), and summarize preliminary evidence related to aberrant neural dynamics within the salience network (involved in threat detection and fear processing) and the central executive network (involved in executive functioning and emotion regulation). Importantly, this parallels neural adaptations commonly observed among individuals with posttraumatic stress disorder (PTSD) in the aftermath of trauma and supports the inclusion of insidious forms of trauma related to minority stress within models of PTSD. Conclusions Taken together, minority stress may have several shared neuropsychological pathways with PTSD and stress-related disorders. Here, we outline a detailed research agenda that provides an overview of literature linking sexual minority stress to PTSD and insidious trauma, moral affect (including shame and guilt), and mental health risk/resiliency, in addition to racial, ethnic, and gender related minority stress. Finally, we propose a novel minority mosaic framework designed to inform future directions of minority stress neuroimaging research from an intersectional lens.

Healthcare workers (HCWs) and public safety personnel (PSP) across the globe have continued to face ethically and morally challenging situations during the COVID-19 pandemic that increase their risk for the development of moral distress (MD) and moral injury (MI). To date, however, the global circumstances that confer risk for MD and MI in these cohorts have not been systematically explored, nor have the unique circumstances that may exist across countries been explored. Here, we sought to identify and compare, across the globe, potentially morally injurious or distressful events (PMIDEs) in HCWs and PSP during the COVID-19 pandemic. A scoping review was conducted to identify and synthesize global knowledge on PMIDEs in HCWs and select PSP. Six databases were searched, including MEDLINE, EMBASE, Web of Science, PsychInfo, CINAHL, and Global Health. A total of 1,412 articles were retrieved, of which 57 articles were included in this review. These articles collectively described the experiences of samples from 19 different countries, which were comprised almost exclusively of HCWs. Given the lack of PSP data, the following results should not be generalized to PSP populations without further research. Using qualitative content analysis, six themes describing circumstances associated with PMIDEs were identified: (1) Risk of contracting or transmitting COVID-19; (2) Inability to work on the frontlines; (3) Provision of suboptimal care; (4) Care prioritization and resource allocation; (5) Perceived lack of support and unfair treatment by their organization; and (6) Stigma, discrimination, and abuse. HCWs described a range of emotions related to these PMIDEs, including anxiety, fear, guilt, shame, burnout, anger, and helplessness. Most PMIDE themes appeared to be shared globally, particularly the ‘Risk of contracting or transmitting COVID-19’ and the ‘Perceived lack of support and unfair treatment by their organization.’ Articles included within the theme of ‘Stigma, discrimination, and abuse’ represented the smallest global distribution of all PMIDE themes. Overall, the present review provides insight into PMIDEs encountered by HCWs across the globe during COVID-19. Further research is required to differentiate the experience of PSP from HCWs, and to explore the impact of social and cultural factors on the experience of MD and MI.

BackgroundIncreasing evidence points toward the need to extend the neurobiological conceptualization of posttraumatic stress disorder (PTSD) to include evolutionarily conserved neurocircuitries centered on the brainstem and the midbrain. The reticular activating system (RAS) helps to shape the arousal state of the brain, acting as a bridge between brain and body. To modulate arousal, the RAS is closely tied to the autonomic nervous system (ANS). Individuals with PTSD often reveal altered arousal patterns, ranging from hyper- to blunted arousal states, as well as altered functional connectivity profiles of key arousal-related brain structures that receive direct projections from the RAS. Accordingly, the present study aims to explore resting state functional connectivity of the RAS and its interaction with the ANS in participants with PTSD and its dissociative subtype.MethodsIndividuals with PTSD (n = 57), its dissociative subtype (PTSD + DS, n = 32) and healthy controls (n = 40) underwent a 6-min resting functional magnetic resonance imaging and pulse data recording. Resting state functional connectivity (rsFC) of a central node of the RAS – the pedunculopontine nuclei (PPN) – was investigated along with its relation to ANS functioning as indexed by heart rate variability (HRV). HRV is a prominent marker indexing the flexibility of an organism to react adaptively to environmental needs, with higher HRV representing greater effective adaptation.ResultsBoth PTSD and PTSD + DS demonstrated reduced HRV as compared to controls. HRV measures were then correlated with rsFC of the PPN. Critically, participants with PTSD and participants with PTSD + DS displayed inverse correlations between HRV and rsFC between the PPN and key limbic structures, including the amygdala. Whereas participants with PTSD displayed a positive relationship between HRV and PPN rsFC with the amygdala, participants with PTSD + DS demonstrated a negative relationship between HRV and PPN rsFC with the amygdala.ConclusionThe present exploratory investigation reveals contrasting patterns of arousal-related circuitry among participants with PTSD and PTSD + DS, providing a neurobiological lens to interpret hyper- and more blunted arousal states in PTSD and PTSD + DS, respectively.

The COVID-19 pandemic has resulted in a still-unfolding series of novel, potentially traumatic moral and ethical challenges that place many healthcare workers at risk of developing moral injury. Moral injury is a type of psychological response that may arise when one transgresses or witnesses another transgress deeply held moral values, or when one feels that an individual or institution that has a duty to provide care has failed to do so. Despite knowledge of this widespread exposure, to date, empirical data are scarce as to how to prevent and, where necessary, treat COVID-19-related moral injury in healthcare workers. Given the relation between moral injury and post-traumatic stress disorder (PTSD), we point here to social and interpersonal factors as critical moderators of PTSD symptomology and consider how this knowledge may translate to interventions for COVID-19-related moral injury. Specifically, we first review alterations in social cognitive functioning observed among individuals with PTSD that may give rise to interpersonal difficulties. Drawing on Nietlisbach and Maercker's 2009 work on interpersonal factors relevant to survivors of trauma with PTSD, we then review the role of perceived social support, social acknowledgment and social exclusion in relation to potential areas of targeted intervention for COVID-19-related moral injury in healthcare workers. Finally, building on existing literature (e.g., Phoenix Australia—Centre for Posttraumatic Mental Health and the Canadian Centre of Excellence—PTSD, 2020) we conclude with individual and organizational considerations to bolster against the development of moral injury in healthcare workers during the pandemic.

Microstates offer a promising framework to study fast-scale brain dynamics in the resting-state electroencephalogram (EEG). However, microstate dynamics have yet to be investigated in post-traumatic stress disorder (PTSD), despite research demonstrating resting-state alterations in PTSD. We performed microstate-based segmentation of resting-state EEG in a clinical population of participants with PTSD (N = 61) and a non-traumatized, healthy control group (N = 61). Microstate-based measures (i.e., occurrence, mean duration, time coverage) were compared group-wise using broadband (1–30 Hz) and frequency-specific (i.e., delta, theta, alpha, beta bands) decompositions. In the broadband comparisons, the centro-posterior maximum microstate (map E) occurred significantly less frequently (d = -0.64, pFWE = 0.03) and had a significantly shorter mean duration in participants with PTSD as compared to controls (d = -0.71, pFWE

Abstract 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.

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.

Recent meta-analyses highlight alterations in cognitive functioning among individuals with major depressive disorder (MDD), with performance deficits observed across multiple cognitive domains including executive functioning, memory, and attention. Moreover, impaired concentration is a formal diagnostic criterion for a major depressive episode. Notably, cognitive impairment is reported frequently in MDD and is associated with poor treatment response. Despite this knowledge, research examining the effectiveness of top-down, adjunctive treatments for cognitive dysfunction in MDD remains in its infancy. The primary aim of the present study was to perform a pilot investigation of the implementation of a standardized cognitive remediation program, Goal Management Training (GMT), among individuals with a primary diagnosis of MDD. A secondary aim was to explore how comorbid symptoms of post-traumatic stress disorder (PTSD) among those MDD patients exposed to trauma may affect treatment response. A final sample of thirty individuals were randomized to either participate in the nine-week GMT program (active group; n = 16) or to complete a nine-week waiting period (waitlist control; n = 14). One participant was excluded from the GMT group analysis following study completion due to meeting an exclusion criteria. In total, 60% of the individuals allocated to the GMT program were trauma exposed (n = 9). Groups were assessed at baseline, post-treatment, and at three-month follow-up. The assessment comprised neuropsychological tasks assessing a variety of cognitive domains, subjective measures of functioning and symptom severity, as well as a clinical interview to establish a primary diagnosis of MDD. Significant gains in processing speed, attention/concentration, and response inhibition were observed for the participants in the GMT condition relative to participants in the waitlist control condition. Individuals in the GMT condition also reported improvements in subjective cognitive functioning from baseline to post-treatment. Heightened PTSD symptom severity was associated with reduced response to treatment with respect to the domain of processing speed. The results of this pilot investigation highlight not only the potential utility of GMT as an augmentative treatment in MDD, but also highlight the contribution of comorbid symptoms of PTSD to diminished treatment response among trauma-exposed individuals with MDD. The study is limited primarily by its small pilot sample and the absence of a program evaluation component to gauge participant opinions and feedback of the treatment protocol.

Post-traumatic stress disorder (PTSD) is triggered by an individual experiencing or witnessing a traumatic event, often precipitating persistent flashbacks and severe anxiety that are associated with a fearful and hypervigilant presentation. Approximately 14–30% of traumatized individuals present with the dissociative subtype of PTSD, which is often associated with repeated or childhood trauma. This presentation includes symptoms of depersonalization and derealization, where individuals may feel as if the world or self is “dream-like” and not real and/or describe “out-of-body” experiences. Here, we review putative neural alterations that may underlie how sensations are experienced among traumatized individuals with PTSD and its dissociative subtype, including those from the outside world (e.g., touch, auditory, and visual sensations) and the internal world of the body (e.g., visceral sensations, physical sensations associated with feeling states). We postulate that alterations in the neural pathways important for the processing of sensations originating in the outer and inner worlds may have cascading effects on the performance of higher-order cognitive functions, including emotion regulation, social cognition, and goal-oriented action, thereby shaping the perception of and engagement with the world. Finally, we introduce a theoretical neurobiological framework to account for altered sensory processing among traumatized individuals with and without the dissociative subtype of PTSD.

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.

Peripersonal space (PPS) is defined as the space surrounding the body where we can reach or be reached by external entities, including objects or other individuals. PPS is an essential component of bodily self-consciousness that allows us to perform actions in the world (e.g., grasping and manipulating objects) and protect our body while interacting with the surrounding environment. Multisensory processing plays a critical role in PPS representation, facilitating not only to situate ourselves in space but also assisting in the localization of external entities at a close distance from our bodies. Such abilities appear especially crucial when an external entity (a sound, an object, or a person) is approaching us, thereby allowing the assessment of the salience of a potential incoming threat. Accordingly, PPS represents a key aspect of social cognitive processes operational when we interact with other people (for example, in a dynamic dyad). The underpinnings of PPS have been investigated largely in human models and in animals and include the operation of dedicated multimodal neurons (neurons that respond specifically to co-occurring stimuli from different perceptive modalities, e.g., auditory and tactile stimuli) within brain regions involved in sensorimotor processing (ventral intraparietal sulcus, ventral premotor cortex), interoception (insula), and visual recognition (lateral occipital cortex). Although the defensive role of the PPS has been observed in psychopathology (e.g., in phobias) the relation between PPS and altered states of bodily consciousness remains largely unexplored. Specifically, PPS representation in trauma-related disorders, where altered states of consciousness can involve dissociation from the body and its surroundings, have not been investigated. Accordingly, we review here: (1) the behavioral and neurobiological literature surrounding trauma-related disorders and its relevance to PPS; and (2) outline future research directions aimed at examining altered states of bodily self-consciousness in trauma related-disorders.

Trauma can profoundly affect the sense of self, where both cognitive and somatic disturbances to the sense of self are reported clinically by individuals with posttraumatic stress disorder (PTSD). These disturbances are captured eloquently by clinical accounts, such as, ‘I do not know myself anymore,’ ‘I will never be able to experience normal emotions again,’ and, ‘I feel dead inside.’ Self-related thoughts and experiences are represented neurobiologically by a large-scale, cortical network located along the brain’s mid-line and referred to as the default mode network (DMN). Recruited predominantly during rest in healthy participants, the DMN is also active during self-referential and autobiographical memory processing – processes which, collectively, are thought to provide the foundation for a stable sense of self that persists across time and may be available for conscious access. In participants with PTSD, however, the DMN shows substantially reduced resting-state functional connectivity as compared to healthy individuals, with greater reductions associated with heightened PTSD symptom severity. Critically, individuals with PTSD describe frequently that their traumatic experiences have become intimately linked to their perceived sense of self, a perception which may be mediated, in part, by alterations in the DMN. Accordingly, identification of alterations in the functional connectivity of the DMN during rest, and during subliminal, trauma-related stimulus conditions, has the potential to offer critical insight into the dynamic interplay between trauma- and self-related processing in PTSD. Here, we discuss DMN-related alterations during these conditions, pointing further towards the clinical significance of these findings in relation to past- and present-centred therapies for the treatment of PTSD.

Post-traumatic stress disorder (PTSD) is a severe psychiatric illness that disproportionately affects military personnel, veterans, and public safety personnel (PSP). Evidence demonstrates that PTSD is significantly associated with difficulties with emotion regulation (ER) and difficulties with cognitive functioning, including difficulties with attention, working memory, and executive functioning. A wide body of evidence suggests a dynamic interplay among cognitive dysfunction, difficulties with ER, and symptoms of PTSD, where numerous studies have identified overlapping patterns of alterations in activation among neuroanatomical regions and neural circuitry. Little work has examined interventions that may target these symptoms collectively. The primary objective of this pilot randomized controlled trial (RCT) with a parallel experimental design was to assess the effectiveness of goal management training (GMT), a cognitive remediation intervention, in reducing difficulties with cognitive functioning, and to determine its effects on PTSD symptoms and symptoms associated with PTSD, including difficulties with ER, dissociation, and functioning among military personnel, veterans, and PSP. Forty-two military personnel, veterans, and PSP between the ages of 18 and 70 with symptoms of PTSD were recruited across Ontario, Canada between October 2017 and August 2019. Participants were randomized to either the waitlist (WL) (n = 18) or the GMT (n = 22) condition. Participants in both conditions received self-report measures and a comprehensive neuropsychological assessment at baseline, post-intervention, and 3-month follow-up. Following their completion of the 3-month follow-up, participants in the WL condition were given the opportunity to participate in GMT. Assessors and participants were blind to intervention allocation during the initial assessment. A series of 2 (time) × 2 (group) ANOVAs were conducted to assess the differences between the WL and GMT conditions from pre- to post-intervention for the self-report and neuropsychological measures. The results demonstrated significant improvements in measures of executive functioning (e.g., verbal fluency, planning, impulsivity, cognitive shifting, and discrimination of targets) and trending improvements in short-term declarative memory for participants in the GMT condition. Participants in the GMT condition also demonstrated significant improvements from pre- to post-testing in measures of subjective cognition, functioning, PTSD symptom severity, difficulties with ER, dissociative symptom severity, and depression and anxiety symptoms. No adverse effects were reported as a result of participating in GMT. The results of this pilot RCT show promise that GMT may be a useful intervention to improve symptoms of cognitive dysfunction, symptoms of PTSD, and symptoms associated with PTSD within military personnel, veterans, and PSP. Future work is needed to address the small sample size and the durability of these findings.

Across three studies, we provide a proof-of-concept evaluation of an integrative psychotherapeutic application of virtual reality (VR) technology. Study 1 (n = 36) evaluated an unguided “safe-place” imagery task, where participants were instructed “to create a safe space… [such as] a scene, item, design, or any visual representation that makes you feel safe” using either the Google Tilt Brush application (VR condition), the standard Microsoft Paint application (2-D condition), or via eyes-closed mental imagery alone (IMG condition). Study 2 (n = 48) evaluated a narrative episodic recall task, where participants viewed their childhood and adult homes and places of schooling either using either the Google Earth VR application (VR condition) or the standard Google Earth application (2-D condition) or recalled these places with their eyes closed via mental imagery alone (IMG condition). Finally, Study 3 (n = 48) evaluated a guided wilderness imagery task, during which different scripts were narrated, specifically, a trail walk in autumn, a spring meadow, and a hillside walk in snowy winter, while either these same scenes were visually presented using the Nature Treks VR application (VR condition), the scenes were presented using the same software but shown on standard computer monitor (2-D condition), or participants’ eyes were closed (IMG condition). Order of intervention format was randomized across participants. Across all three studies, quantitative survey ratings showed that the VR format of intervention delivery produced greater positive affect and satisfaction and perceived credibility ratings as an intervention for trauma- and stressor-related disorders and psychological well-being as rated by university students who varied in traumatic and stressful life event history and symptoms of posttraumatic stress disorder, whereas qualitative findings revealed additional themes of experiential response including increased experience of presence and vividness in the VR condition. Future research directions and clinical applications are discussed.

Objective: The default-mode network (DMN) and salience network (SN) have been shown to display altered connectivity in posttraumatic stress disorder (PTSD). Restoring aberrant connectivity within these networks with electroencephalogram neurofeedback (EEG-NFB) has been shown previously to be associated with acute decreases in symptoms. Here, we conducted a double-blind, sham-controlled randomized trial of alpha-rhythm EEG-NFB in participants with PTSD (n = 36) over 20-weeks. Our aim was to provide mechanistic evidence underlying clinical improvements by examining changes in network connectivity via fMRI. Methods: We randomly assigned participants with a primary diagnosis of PTSD to either the experimental group (n = 18) or sham-control group (n = 18). We collected resting-state fMRI scans pre- and post-NFB intervention, for both the experimental and sham-control PTSD groups. We further compared baseline brain connectivity measures pre-NFB to age-matched healthy controls (n = 36). Results: With regard to the primary outcome measure of PTSD severity, we found a significant main effect of time in the absence of a group × time interaction. Nevertheless, we found significantly decreased PTSD severity scores in the experimental NFB group only, when comparing post-NFB (dz = 0.71) and 3-month follow-up scores (dz = 0.77) to baseline measures. Interestingly, we found evidence to suggest a shift towards normalization of DMN and SN connectivity post-NFB in the experimental group only. Both decreases in PTSD severity and NFB performance were correlated to DMN and SN connectivity post-NFB in the experimental group. Critically, remission rates of PTSD were significant higher in the experimental group (61.1%) as compared to the sham-control group (33.3%). Conclusion: The current study shows mechanistic evidence for therapeutic changes in DMN and SN connectivity that are known to be associated with PTSD psychopathology with no patient dropouts. This preliminary investigation merits further research to demonstrate fully the clinical efficacy of EEG-NFB as an adjunctive therapy for PTSD.

Self-related processes define assorted self-relevant or social-cognitive functions that allow us to gather insight and to draw inferences related to our own mental conditions. Self-related processes are mediated by the default mode network (DMN), which, critically, shows altered functionality in individuals with posttraumatic stress disorder (PTSD). In PTSD, the midbrain periaqueductal gray (PAG) demonstrates stronger functional connectivity with the DMN [i.e., precuneus (PCN), medial prefrontal cortex (mPFC)] as compared to healthy individuals during subliminal, trauma-related stimulus processing. Here, we analyzed the directed functional connectivity between the PAG and the PCN, as well as between the PAG and the mPFC to more explicitly characterize the functional connectivity we have observed previously on the corresponding sample and paradigm. We evaluated three models varying with regard to context-dependent modulatory directions (i.e., bi-directional, bottom-up, top-down) among individuals with PTSD (n = 26) and healthy participants (n = 20), where Bayesian model selection was used to identify the most optimal model for each group. We then compared the effective connectivity strength for each parameter across the models and between our groups using Bayesian model averaging. Bi-directional models were found to be favoured across both groups. In PTSD, we revealed the PAG to show stronger excitatory effective connectivity to the PCN, as well as to the mPFC as compared to controls. In PTSD, we further demonstrated that PAG-mediated effective connectivity to the PCN, as well as to the mPFC were modulated more strongly during subliminal, trauma-related stimulus conditions as compared to controls. Clinical disturbances towards self-related processes are reported widely by participants with PTSD during trauma-related stimulus processing, where altered functional connectivity directed by the PAG to the DMN may elucidate experiential links between self- and trauma-related processing in traumatized individuals.

Intrinsic connectivity networks (ICNs), including the default mode network (DMN), the central executive network (CEN), and the salience network (SN) have been shown to be aberrant in patients with posttraumatic stress disorder (PTSD). The purpose of the current study was to a) compare ICN functional connectivity between PTSD, dissociative subtype PTSD (PTSD+DS) and healthy individuals; and b) to examine the use of multivariate machine learning algorithms in classifying PTSD, PTSD+DS, and healthy individuals based on ICN functional activation. Our neuroimaging dataset consisted of resting-state fMRI scans from 186 participants [PTSD (n = 81); PTSD + DS (n = 49); and healthy controls (n = 56)]. We performed group-level independent component analyses to evaluate functional connectivity differences within each ICN. Multiclass Gaussian Process Classification algorithms within PRoNTo software were then used to predict the diagnosis of PTSD, PTSD+DS, and healthy individuals based on ICN functional activation. When comparing the functional connectivity of ICNs between PTSD, PTSD+DS and healthy controls, we found differential patterns of connectivity to brain regions involved in emotion regulation, in addition to limbic structures and areas involved in self-referential processing, interoception, bodily self-consciousness, and depersonalization/derealization. Machine learning algorithms were able to predict with high accuracy the classification of PTSD, PTSD+DS, and healthy individuals based on ICN functional activation. Our results suggest that alterations within intrinsic connectivity networks may underlie unique psychopathology and symptom presentation among PTSD subtypes. Furthermore, the current findings substantiate the use of machine learning algorithms for classifying subtypes of PTSD illness based on ICNs.

Background: Oculomotor movements have been shown to aid in the retrieval of episodic memories, serving as sensory cues that engage frontoparietal brain regions to reconstruct visuospatial details of a memory. Frontoparietal brain regions not only are involved in oculomotion, but also mediate, in part, the retrieval of autobiographical episodic memories and assist in emotion regulation. Objective: We sought to investigate how oculomotion influences retrieval of traumatic memories by examining patterns of frontoparietal brain activation during autobiographical memory retrieval in post-traumatic stress disorder (PTSD) and in healthy controls. Method: Thirty-nine participants (controls, n = 19; PTSD, n = 20) recollected both neutral and traumatic/stressful autobiographical memories while cued simultaneously by horizontal and vertical oculomotor stimuli. The frontal (FEF) and supplementary (SEF) eye fields were used as seed regions for psychophysiological interaction analyses in SPM12. Results: As compared to controls, upon retrieval of a traumatic/stressful memory while also performing simultaneous horizontal eye movements, PTSD showed: i) increased SEF and FEF connectivity with the right dorsolateral prefrontal cortex, ii) increased SEF connectivity with the right dorsomedial prefrontal cortex, and iii) increased SEF connectivity with the right anterior insula. By contrast, as compared to PTSD, upon retrieval of a traumatic/stressful memory while also performing simultaneous horizontal eye movements, controls showed: i) increased FEF connectivity with the right posterior insula and ii) increased SEF connectivity with the precuneus. Conclusions: These findings provide a neurobiological account for how oculomotion may influence the frontoparietal cortical representation of traumatic memories. Implications for eye movement desensitization and reprocessing are discussed.

Background: There is increasing evidence that moral injuries (MIs) may affect the mental health of Canadian Armed Forces (CAF) members and veterans. Despite knowledge suggesting that MIs are related to multiple negative mental health outcomes, including the onset of post-traumatic stress disorder (PTSD), it is unknown whether pre-traumatic variables, including the presence of childhood abuse, are related to MIs. Objective: This study seeks to investigate the potential relationship between adverse childhood experiences and later onset MI in military members. Methods: Thirty-three patients newly admitted to an inpatient unit for treatment of trauma-related disorders received a standardized self-assessment package, including the PTSD Checklist for DSM-5 (PCL-5), the Moral Injury Events Scale (MIES; adapted for the Canadian context), and the Adverse Childhood Experiences Questionnaire (ACE-Q), which is a retrospective measure of childhood abuse. Results: Analyses revealed a significant relation between childhood emotional abuse and the presence of MI in adulthood. Specifically, emotional abuse during childhood was correlated with total score on the MIES (p = 0.006) and with its two subscales, perceived betrayals (p = 0.022) and perceived transgressions (p = 0.016). These correlations remained significant when controlling for age and gender. Conclusions: Among CAF members and veterans, childhood events are related to the presence of MI during adulthood. These preliminary data are provocative in suggesting that emotional abuse during childhood may increase the likelihood of endorsing MI during adult military service. Further work is needed to identify pre-traumatic variables that may serve to increase risk or enhance resilience to the development of MI in military members.

Background: Sleep disturbances are a hallmark of posttraumatic stress disorder (PTSD), yet few studies have evaluated the role of dysregulated endogenous melatonin secretion in this condition.Methods: This study compared the sleep quality and nocturnal salivary melatonin profiles of Canadian Armed Forces (CAF) personnel diagnosed with PTSD, using the Clinician Administered PTSD Scale (CAPS score ≥50), with two healthy CAF control groups; comprising, a “light control” (LC) group with standardized evening light exposure and “normal control” (NC) group without light restriction. Participants were monitored for 1-week using wrist actigraphy to assess sleep quality, and 24-h salivary melatonin levels were measured (every 2h) by immunoassay on the penultimate day in a dim-light (< 5 lux) laboratory environment.Results: A repeated measures design showed that mean nocturnal melatonin concentrations for LC were higher than both NC (p = .03) and PTSD (p = .003) with no difference between PTSD and NC. Relative to PTSD, NC had significantly higher melatonin levels over a 4-h period (01 to 05 h), whereas the LC group had higher melatonin levels over an 8-h period (23 to 07 h). Actigraphic sleep quality parameters were not different between healthy controls and PTSD patients, likely due to the use of prescription sleep medications in the PTSD group.Conclusions: These results indicate that PTSD is associated with blunted nocturnal melatonin secretion, which is consistent with previous findings showing lower melatonin after exposure to trauma and suggestive of severe chronodisruption. Future studies targeting the melatonergic system for therapeutic intervention may be beneficial for treatment-resistant PTSD.

Background Brainstem and midbrain neuronal circuits that control innate, reflexive responses and arousal are increasingly recognized as central to the neurobiological framework of post-traumatic stress disorder (PTSD). The reticular activation system represents a fundamental neuronal circuit that plays a critical role not only in generating arousal but also in coordinating innate, reflexive responding. Accordingly, the present investigation aims to characterize the resting state functional connectivity of the reticular activation system in PTSD and its dissociative subtype. Methods We investigated patterns of resting state functional connectivity of a central node of the reticular activation system, namely, the pedunculopontine nuclei, among individuals with PTSD (n = 77), its dissociative subtype (PTSD+DS; n = 48), and healthy controls (n = 51). Results Participants with PTSD and PTSD+DS were characterized by within-group pedunculopontine nuclei resting state functional connectivity to brain regions involved in innate threat processing and arousal modulation (i.e., midbrain, amygdala, ventromedial prefrontal cortex). Critically, this pattern was most pronounced in individuals with PTSD+DS, as compared to both control and PTSD groups. As compared to participants with PTSD and controls, individuals with PTSD+DS showed enhanced pedunculopontine nuclei resting state functional connectivity to the amygdala and the parahippocampal gyrus as well as to the anterior cingulate and the ventromedial prefrontal cortex. No group differences emerged between PTSD and control groups. In individuals with PTSD+DS, state derealization/depersonalization was associated with reduced resting state functional connectivity between the left pedunculopontine nuclei and the anterior nucleus of the thalamus. Altered connectivity in these regions may restrict the thalamo-cortical transmission necessary to integrate internal and external signals at a cortical level and underlie, in part, experiences of depersonalization and derealization. Conclusions The present findings extend the current neurobiological model of PTSD and provide emerging evidence for the need to incorporate brainstem structures, including the reticular activation system, into current conceptualizations of PTSD and its dissociative subtype.

Background The innate alarm system consists of a subcortical network of interconnected midbrain, lower brainstem, and thalamic nuclei, which together mediate the detection of evolutionarily-relevant stimuli. The periaqueductal gray is a midbrain structure innervated by the innate alarm system that coordinates the expression of defensive states following threat detection. In participants with post-traumatic stress disorder, the periaqueductal gray displays overactivation during the subliminal presentation of trauma-related stimuli as well as altered resting-state functional connectivity. Aberrant functional connectivity is also reported in post-traumatic stress disorder for the default-mode network, a large-scale brain network recruited during self-referential processing and autobiographical memory. Here, research lacks investigation on the extent to which functional interactions are displayed between the midbrain and the large-scale cortical networks in post-traumatic stress disorder. Methods Using a subliminal threat presentation paradigm, we investigated psycho-physiological interactions during functional neuroimaging in participants with post-traumatic stress disorder (n = 26) and healthy control subjects (n = 20). Functional connectivity of the periaqueductal gray was investigated across the whole-brain of each participant during subliminal exposure to trauma-related and neutral word stimuli. Results As compared to controls during subliminal threat presentation, the post-traumatic stress disorder group showed significantly greater periaqueductal gray functional connectivity with regions of the default-mode network (i.e., angular gyrus, precuneus, superior frontal gyrus). Moreover, multiple regression analyses revealed that the functional connectivity between the periaqueductal gray and the regions of the default-mode network correlated positively to symptoms of avoidance and state dissociation in post-traumatic stress disorder. Conclusion Given that the periaqueductal gray engages the expression of defensive states, stronger midbrain functional coupling with the default-mode network may have clinical implications to self-referential and trauma-related processing in participants with post-traumatic stress disorder.

Background Posttraumatic stress disorder (PTSD) is associated with dysfunction across multiple cognitive domains including executive functioning, attention, and verbal memory. This dysfunction is associated with negative impacts on functional outcomes (e.g., work or social functioning) and reduced response to psychotherapy for PTSD. Despite this knowledge, little work has investigated the efficacy of cognitive remediation strategies in improving cognition and functional outcomes among individuals with PTSD. Objective The current study investigated the efficacy of an established cognitive remediation program, Goal Management Training (GMT), in improving cognitive functioning in a pilot sample of individuals with PTSD symptoms in an inpatient treatment setting. Method Thirty-four inpatients with PTSD symptoms participated in either GMT in addition to treatment as usual (TAU; consisting of psychiatric management, group and individual psychotherapy) (TAU+GMT; n = 18) or TAU alone ( n = 16). The TAU+GMT group received neuropsychological assessment at baseline and posttreatment, while both the TAU+GMT and TAU groups received assessment with clinical self-report measures at baseline and posttreatment. Results Paired-sample t-tests revealed significant improvements on measures of executive functioning (e.g., response inhibition, cognitive flexibility), processing speed, sustained attention, and verbal memory in the TAU+GMT group. Mixed-design analyses of variance (ANOVAs) revealed a trend toward an interaction effect indicating potentially greater improvements on a measure of the ability to engage in goal-directed behaviors while highly emotional in the TAU+GMT group as compared to the TAU group. Discussion The results of this small feasibility investigation of GMT in PTSD point toward the potential efficacy of GMT in ameliorating cognitive difficulties in individuals with PTSD.

Background Peri-traumatic tonic immobility has been associated with the development and course of post-traumatic stress disorder. Despite serving as an adaptive late-stage defense response, tonic immobility that continues in response to post-traumatic reminders may lead to reduced functioning and a diminished sense of well-being. At present, no validated self-report measures assess post-traumatic tonic immobility responses specifically. Methods The primary objective of the present study was to evaluate the Scale for Tonic immobility Occurring Post-trauma (STOP), the first self-report measure developed to assess for the presence and severity of tonic immobility responses that persist following trauma exposure as part of post-traumatic symptomatology. Trauma-exposed clinical and non-clinical participants ( N = 462) with a history of tonic immobility completed a demographic questionnaire, the STOP, and measures of post-traumatic symptoms, dissociation, anxiety, and depression. Results STOP assessed four latent constructs, which were interpreted following the human defense cascade model. Together, these factors capture the sensorimotor and perceptual alterations , and dissociative experiences, associated with post-traumatic tonic immobility as a trauma-related altered state. Residual symptoms and the experience of negative affect following this response (including guilt and shame) are also represented. STOP scores demonstrated excellent reliability, as well as good construct and convergent validity, with other measures of dissociation and post-traumatic stress disorder. Results from the present study suggest tonic immobility is most consistent with other dissociative post-traumatic symptomatology. Conclusions STOP demonstrates excellent preliminary psychometric properties and may be useful for researchers and clinicians wishing to assess chronic forms of tonic immobility across trauma-exposed, clinical and community samples.

Background The innate alarm system, a network of interconnected midbrain, other brainstem, and thalamic structures, serves to rapidly detect stimuli in the environment prior to the onset of conscious awareness. This system is sensitive to threatening stimuli and has evolved to process these stimuli subliminally for hastened responding. Despite the conscious unawareness, the presentation of subliminal threat stimuli generates increased activation of limbic structures, including the amygdala and insula, as well as emotionally evaluative structures, including the cerebellum and orbitofrontal cortex. Posttraumatic stress disorder (PTSD) is associated with an increased startle response and decreased extinction learning to conditioned threat. The role of the innate alarm system in the clinical presentation of PTSD, however, remains poorly understood. Methods Here, we compare midbrain, brainstem, and cerebellar activation in persons with PTSD (n = 26) and matched controls (n = 20) during subliminal threat presentation. Subjects were presented with masked trauma-related and neutral stimuli below conscious threshold. Contrasts of subliminal brain activation for the presentation of neutral stimuli were subtracted from trauma-related brain activation. Group differences in activation, as well as correlations between clinical scores and PTSD activation, were examined. Imaging data were preprocessed utilizing the spatially unbiased infratentorial template toolbox within SPM12. Results Analyses revealed increased midbrain activation in PTSD as compared to controls in the superior colliculus, periaqueductal gray, and midbrain reticular formation during subliminal threat as compared to neutral stimulus presentation. Controls showed increased activation in the right cerebellar lobule V during subliminal threat presentation as compared to PTSD. Finally, a negative correlation emerged between PTSD patient scores on the Multiscale Dissociation Inventory for the Depersonalization/Derealization subscale and activation in the right lobule V of the cerebellum during the presentation of subliminal threat as compared to neutral stimuli. Conclusion We interpret these findings as evidence of innate alarm system overactivation in PTSD and of the prominent role of the cerebellum in the undermodulation of emotion observed in PTSD.

Background: Early traumatic experiences are thought to be causal factors in the development of trauma-related dissociative experiences, including depersonalization and derealization. The rubber hand illusion (RHI), a well-known paradigm that measures multi-sensorial integration of a rubber hand into one's own body representation, has been used to investigate alterations in the experience of body ownership and of body representation. Critically, however, it has never been studied in individuals with trauma-related disorders. Objective: To investigate body representation distortions occurring in trauma-related disorders in response to the RHI. Method: The RHI was administered to three individuals with the dissociative subtype of posttraumatic stress disorder (PTSD), and subjective, behavioral, cardiovascular and skin conductance responses were recorded. Results: Participants’ subjective experiences of the RHI were differentiated and complex. The illusion was induced following both synchronous and asynchronous brushing and variably evoked subjective distress, depersonalization and derealization experiences, tonic immobility, increased physiological arousal and flashbacks. Conclusions: The present findings point towards the RHI as a strong provocation stimulus that elicits individual patterns of symptom presentation, including experiences of distress and dissociation, in individuals with trauma-related disorders, including the dissociative subtype of PTSD. Highlights of the article:

Background: Although preliminary work suggests that dissociative symptoms may impact neuropsychological performance in trauma-exposed populations, the relation between dissociation and cognitive performance has not been explored in patients with depression. Objective: The present study examined dissociative symptoms in relation to neuropsychological performance in participants with a primary diagnosis of recurrent major depressive disorder (MDD) and a history of trauma exposure. Method: Twenty-three participants with MDD and 20 healthy controls who did not differ in age, sex, education, or IQ were assessed. In addition to a standardized neuropsychological battery assessing frontotemporally mediated cognitive processes, participants completed clinical measures assessing dissociative symptoms, illness severity, and past history of trauma exposure. Results: Among participants with MDD, greater severity of derealization was associated with reduced performance on measures of delayed visuospatial recall and recognition on a task of verbal memory recognition. In addition, more severe depersonalization was associated with slower processing speed and a response style lending itself toward better performance in a less active environment. Conclusions: These findings point toward dissociative symptoms as a transdiagnostic factor associated with neuropsychological dysfunction in patients with depression and a history of trauma. Limitations and recommendations for future research are discussed.

Objective: Electroencephalogram (EEG) neurofeedback aimed at reducing the amplitude of the alpha-rhythm has been shown to alter neural networks associated with posttraumatic stress disorder (PTSD), leading to symptom alleviation. Critically, the amygdala is thought to be one of the central brain regions mediating PTSD symptoms. In the current study, we compare directly patterns of amygdala complex connectivity using fMRI, before and after EEG neurofeedback, in order to observe subcortical mechanisms associated with behavioural and alpha oscillatory changes among patients. Method: We examined basolateral (BLA), centromedial (CMA), and superficial (SFA) amygdala complex resting-state functional connectivity using a seed-based approach via SPM Anatomy Toolbox. Amygdala complex connectivity was measured in twenty-one individuals with PTSD, before and after a 30-minute session of EEG neurofeedback targeting alpha desynchronization. Results: EEG neurofeedback was associated with a shift in amygdala complex connectivity from areas implicated in defensive, emotional, and fear processing/memory retrieval (left BLA and left SFA to the periaqueductal gray, and left SFA to the left hippocampus) to prefrontal areas implicated in emotion regulation/modulation (right CMA to the medial prefrontal cortex). This shift in amygdala complex connectivity was associated with reduced arousal, greater resting alpha synchronization, and was negatively correlated to PTSD symptom severity. Conclusion: These findings have significant implications for developing targeted non-invasive treatment interventions for PTSD patients that utilize alpha oscillatory neurofeedback, showing evidence of neuronal reconfiguration between areas highly implicated in the disorder, in addition to acute symptom alleviation.

Objective To overview the phenomenology, etiology, assessment, and treatment of psychotic-like symptoms in trauma-related disorders focusing on the proposed role of temporal lobe dysfunction. Method We describe the literature pertaining to (i) psychotic-like symptoms and temporal lobe dysfunction in trauma-related disorders and (ii) psychological testing profiles in trauma-related disorders. We define trauma-related disorders as borderline personality disorder, post-traumatic stress disorder, and the dissociative disorders. Our search terms were dissociative disorders, temporal lobe, trauma, post-traumatic stress disorder, borderline personality disorder, psychosis, and malingering. Results Trauma-related psychotic-like symptoms are common and can differ in phenomenology from primary psychotic symptoms. Hallucinations consist of auditory and nonauditory content that may or may not relate to traumatic content. Child voices are highly suggestive of complex dissociative disorders. Critically, not only do these symptoms resemble those seen in temporal lobe epilepsy, but the temporal lobe is implicated in trauma-related disorders, thus providing a plausible neurobiological explanation. Despite such evidence, these symptoms are frequently considered atypical and misdiagnosed. Indeed, common structured psychological assessment tools categorize these symptoms as possible indicators of invalid testing profiles. Conclusion Psychotic-like symptoms are common in trauma-related disorders, may be related to temporal lobe dysfunction, and are frequently misinterpreted. This may lead to ineffective treatment and inappropriate determinations of malingering in the forensic system.

Traumatic experiences have been linked to the development of altered states of consciousness affecting bodily perception, including alterations in body ownership and in sense of agency, the conscious experience of the body as one's own and under voluntary control. Severe psychological trauma and prolonged distress may lead to posttraumatic stress disorder (PTSD). Together, symptoms of derealization and, related specifically to the sense of body ownership and agency, of depersonalization (where parts of the body or the entire body itself is perceived as detached and out of control), constitute the dissociative subtype (PTSD+DS). In this study, we explored the Rubber Hand Illusion, an experimental paradigm utilized to manipulate sense of body ownership in PTSD (n = 4) and PTSD+DS (n = 6) as compared to healthy controls (n = 7). Perceived finger location and self-report questionnaires were used as behavioral and subjective measures of the illusion, respectively. In addition, the correlation between the illusion's effect and sense of agency as a continuous feeling of controlling one's own body movements was explored. Here, a lower illusion effect was observed in the PTSD as compared to the control group after synchronous stimulation for both the proprioceptive drift and subjectively perceived illusion. Moreover, by both proprioceptive drift and by subjective ratings, the PTSD+DS group showed a response characterized by high variance, ranging from a very strong to a very weak effect of the illusion. Finally, sense of agency showed a trend toward a negative correlation with the strength of the illusion as subjectively perceived by participants with PTSD and PTSD+DS. These findings suggest individuals with PTSD may, at times, maintain a rigid representation of the body as an avoidance strategy, with top-down cognitive processes weakening the impact of manipulation of body ownership. By contrast, the response elicited in PTSD+DS appeared to be driven by either an increased vulnerability to manipulation of embodiment or by a dominant top-down cognitive representation of the body, with disruption of multisensory integration processes likely in both cases. Taken together, these findings further our understanding of bodily consciousness in PTSD and its dissociative subtype and highlight the supportive role played by sense of agency for the maintenance of body ownership.

Background: Posttraumatic Stress Disorder (PTSD) is associated with significant functional impairment in important areas, including interpersonal relationships and occupational or educational roles. Preliminary evidence suggests that the dissociative subtype of PTSD (PTSD+DS), characterized by marked symptoms of depersonalization and derealization, is associated with increased functional impairment and disease severity, including among military members and veterans diagnosed with PTSD. Similarly, first responders (e.g. police, fire, paramedics) have also been found to experience dissociative symptoms. Despite these findings, little work has investigated whether dissociative symptoms are related to heightened functional impairment among these populations. Objective: We examined the relation between functional impairment and symptom level variables, including dissociative symptoms of depersonalization and derealization among military members, veterans, and first responders with probable PTSD. We further investigated the hypothesis that dissociative symptoms mediate the relation between PTSD symptomatology and functional impairment. Method: Eighty-one medical charts of inpatients at a residential PTSD treatment programme were accessed via retrospective review. Sixty-two were included in the present analyses. Comparison of means on symptom measures between first responders and military members/veterans were conducted, followed by correlational and mediation analyses. Results: Compared with first responders, military members and veterans showed higher levels of derealization, functional impairment, alexithymia, anxiety, and depression. Within the total sample, dissociative symptoms emerged as the strongest correlate of functional impairment and, among the dissociative symptom clusters, derealization symptoms demonstrated the strongest relation with impairment. Mediation analyses revealed that total dissociative symptoms and derealization symptoms significantly mediated the relation between PTSD symptoms and functional impairment. Conclusions: These findings highlight the importance of assessing and treating dissociative symptoms, consistent with the dissociative subtype of PTSD, among military members, veterans, and first responders with PTSD. Successful recovery on a functional and symptomatic level may necessitate treatment of dissociative symptoms, particularly derealization.

The primary aim of this commentary is to describe trauma-related dissociation and altered states of consciousness in the context of a four-dimensional model that has recently been proposed (Frewen & Lanius, 2015). This model categorizes symptoms of trauma-related psychopathology into (1) those that occur within normal waking consciousness and (2) those that are dissociative and are associated with trauma-related altered states of consciousness (TRASC) along four dimensions: (1) time; (2) thought; (3) body; and (4) emotion. Clinical applications and future research directions relevant to each dimension are discussed. Conceptualizing TRASC across the dimensions of time, thought, body, and emotion has transdiagnostic implications for trauma-related disorders described in both the Diagnostic Statistical Manual and the International Classifications of Diseases. The four-dimensional model provides a framework, guided by existing models of dissociation, for future research examining the phenomenological, neurobiological, and physiological underpinnings of trauma-related dissociation.

Objective: A dissociative subtype has been recognized based on the presence of experiences of depersonalization and derealization in relation to DSM-IV posttraumatic stress disorder (PTSD). However, the dissociative subtype has not been assessed in a community sample in relation to the revised DSM-5 PTSD criteria. Moreover, the 20-item PTSD Checklist for DSM-5 (PCL-5) currently does not assess depersonalization and derealization. Method: We therefore evaluated two items for assessing depersonalization and derealization in 557 participants recruited online who endorsed PTSD symptoms of at least moderate severity on the PCL-5. Results: A five-class solution identified two PTSD classes who endorsed dissociative experiences associated with either 1) severe or 2) moderate PTSD symptom severity (D-PTSD classes). Those in the severe dissociative class were particularly likely to endorse histories of childhood physical and sexual abuse. A principal axis factor analysis of the symptom list identified six latent variables: 1) Reexperiencing, 2) Emotional Numbing/Anhedonia, 3) Dissociation, 4) Negative Alterations in Cognition & Mood, 5) Avoidance, and 6) Hyperarousal. Conclusions: The present results further support the presence of a dissociative subtype within the DSM-5 criteria for PTSD.

Background: Three intrinsic connectivity networks in the brain, namely the central executive, salience, and default mode networks, have been identified as crucial to the understanding of higher cognitive functioning, and the functioning of these networks has been suggested to be impaired in psychopathology, including posttraumatic stress disorder (PTSD). Objective: 1) To describe three main large-scale networks of the human brain; 2) to discuss the functioning of these neural networks in PTSD and related symptoms; and 3) to offer hypotheses for neuroscientifically-informed interventions based on treating the abnormalities observed in these neural networks in PTSD and related disorders. Method: Literature relevant to this commentary was reviewed. Results: Increasing evidence for altered functioning of the central executive, salience, and default mode networks in PTSD has been demonstrated. We suggest that each network is associated with specific clinical symptoms observed in PTSD, including cognitive dysfunction (central executive network), increased and decreased arousal/interoception (salience network), and an altered sense of self (default mode network). Specific testable neuroscientifically-informed treatments aimed to restore each of these neural networks and related clinical dysfunction are proposed. Conclusions: Neuroscientifically-informed treatment interventions will be essential to future research agendas aimed at targeting specific PTSD and related symptoms.

Background : Current psychometric measures of childhood trauma history generally fail to assess the relational-socioecological context within which childhood maltreatment occurs, including the relationship of abusers to abused persons, the emotional availability of caregivers, and the respondent's own thoughts, feelings, and actions in response to maltreatment. Objective : To evaluate a computerized approach to measuring the relational-socioecological context within which childhood maltreatment occurs. Method : The psychometric properties of a Childhood Attachment and Relational Trauma Screen (CARTS) were evaluated as a retrospective survey of childhood maltreatment history designed to be appropriate for completion by adults. Participants were undergraduates (n=222), an internet sample (n=123), and psychiatric outpatients (n=30). Results : The internal reliability, convergent, and concurrent validity of the CARTS were supported across samples. Paired differences in means and correlations between rated item-descriptiveness to self, mothers, and fathers also accorded with findings of prior attachment and maltreatment research, illustrating the utility of assessing the occurrence and effects of maltreatment within a relational-socioecological framework. Conclusions : Results preliminarily support a new survey methodology for assessing childhood maltreatment within a relational-socioecological framework. Further psychometric evaluation of the CARTS is warranted.

Symptoms of anhedonia, or deficits in the ability to experience positive affect, are increasingly recognized as an outcome of traumatic stress including in individuals with PTSD. However, little research has investigated negative affective responses to what would normally be considered pleasant events (e.g., receiving a compliment or gift, physical affection) in traumatized persons. We demonstrate not only self-reported decreased positive affect but also increased negative affect in response to positive events in 55 women with PTSD, in comparison with 35 women without PTSD, via their response to a Hedonic Deficit & Interference Scale (HDIS). The HDIS demonstrated strong internal validity, convergent and incremental validity relative to other measures of anhedonia, and discriminant validity in relation to depression versus anxiety symptoms in this sample. In addition, in response to imagery of social versus non-social positive events, HDIS scores predicted self-report positive and negative affective responses. In a sub-sample of participants completing the imagery task while undergoing fMRI (n=12), HDIS scores also predicted BOLD response within the left orbitofrontal cortex, ventromedial prefrontal cortex, amygdala, and cerebellum. Future research and clinical directions are discussed.For the abstract or full text in other languages, please see Supplementary files under Reading Tools online.

Symptoms of anhedonia, or deficits in the ability to experience positive affect, are increasingly recognized as an outcome of traumatic stress. Herein we demonstrate a phenomenon of “negative affective interference”, specifically, negative affective responses to positive events, in association with childhood trauma history. Young adults (n=99) completed a Hedonic Deficit & Interference Scale (HDIS), a self-report measure developed for this study, as well as a modified version of the Fawcette-Clarke Pleasure Capacity Scale that assessed not only positive but also negative affective responses to positive events. The two assessment approaches demonstrated convergent validity and predicted concurrent individual differences in trait positive and negative affect, and extraversion and neuroticism. Histories of childhood emotional and sexual abuse were differentially associated with negative affective responses to positive events. Future research and clinical directions are discussed.For the abstract or full text in other languages, please see Supplementary files under Reading Tools online.

The newly proposed criteria for posttraumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual (DSM-V) include dysregulation of a variety of emotional states including fear, anger, guilt, and shame, in addition to dissociation and numbing. Consistent with these revisions, we postulate two models of emotion dysregulation in PTSD in which fear is not the prevailing emotion but is only one of several components implicated in a dysregulated emotional system that also mediates problems regulating anger, guilt, shame, dissociation, and numbing.We discuss whether there is a relationship between fear and other emotion regulation systems that may help further our understanding of PTSD and its underlying neurocircuitry. Two pathways describing the relationship between fear and other emotion regulation systems in PTSD are proposed. The first pathway describes emotion dysregulation as an outcome of fear conditioning through stress sensitization and kindling. The second pathway views emotion dysregulation as a distal vulnerability factor and hypothesizes a further exacerbation of fear and other emotion regulatory problems, including the development of PTSD after exposure to one or several traumatic event(s) later in life. Future research and treatment implications are discussed.