Posttraumatic stress and social anxiety: the interaction of traumatic events and interpersonal fears

Artemisinin reduces PTSD-like symptoms, improves synaptic plasticity, and inhibits apoptosis in rats subjected to single prolonged stress

Post-Traumatic Stress Disorder (PTSD) is a chronic mental disorder characterized by symptoms of panic and anxiety, depression, impaired cognitive functioning, and difficulty in social interactions. While the effect of the traditional Chinese medicine artemisinin (AR) on PTSD is unknown, its therapeutic benefits have been demonstrated by studies on models of multiple neurological disorders. This study aimed to extend such findings by investigating the effects of AR administration on a rat model of PTSD induced by a regimen of single prolonged stress (SPS). After rats were subjected to the SPS protocol, AR was administered and its impact on PTSD-like behaviors was evaluated. In the present study, rats were subjected to a multitude of behavioral tests to evaluate behaviors related to anxiety, memory function, and social interactions. The expression of hippocampal synaptic plasticity-related proteins was detected using Western blot and immunofluorescence. The ultrastructure of synapses was observed under transmission electron microscopy. The apoptosis of hippocampal neurons was examined with Western blot, TUNEL staining, and HE staining. The results showed that AR administration alleviated the PTSD-like phenotypes in SPS rats, including behavior indicative of anxiety, cognitive deficits, and diminished sociability. AR administration was further observed to improve synaptic plasticity and inhibit neuronal apoptosis in SPS rats. These findings suggest that administering AR after the onset of severe traumatic events may alleviate anxiety, cognitive deficits, and impaired social interaction, improve synaptic plasticity, and diminish neuronal apoptosis. Hence, the present study provides evidence for AR's potential as a multi-target agent in the treatment of PTSD.

Pre-COVID resting-state brain activity in the fusiform gyrus prospectively predicts social anxiety alterations during the pandemic

BACKGROUND

Social anxiety (SA) has been linked to the coronavirus disease 2019 (COVID-19) pandemic, but the neurobiopsychological mechanisms underlying this relationship remain unclear. This study aimed to elucidate the neurofunctional markers for COVID-induced SA development and the potential role of COVID-related posttraumatic stress symptoms (PTSS) in the brain-SA alterations link.

METHODS

Before the COVID-19 pandemic (T1), 100 general college students underwent resting-state magnetic resonance imaging and behavioral tests. During the period of community-level outbreaks (T2), these students were re-contacted to undergo follow-up behavioral assessments.

RESULTS

Whole-brain correlation and prediction analyses found that pre-pandemic spontaneous neural activity (measured by fractional amplitude of low-frequency fluctuations) in the right fusiform gyrus (FG) was positively correlated to SA alterations (T2 - T1). Mediation analyses revealed that COVID-specific PTSS mediated the effects of right FG on SA alterations.

LIMITATIONS

The results should be interpreted carefully because only one-session neuroimaging data in a sample of normal adults were included.

CONCLUSIONS

The results provide evidence for neurofunctional markers of COVID-induced SA and may help develop targeted brain-based interventions that reduce SA.

Development and Validation of the Bullied Cognitions Inventory (BCI)

Background

Bullying increases risk of social anxiety and can produce symptoms of posttraumatic stress disorder (PTSD). According to cognitive models, these are maintained by unhelpful beliefs, which are therefore assessed and targeted in cognitive therapy. This paper describes psychometric validation of a new measure of beliefs related to bullying experiences.

Methods

In an online survey of 1879 young people before starting university or college in the UK, 1279 reported a history of bullying (N = 1279), and 854 rated their agreement with beliefs about self and others related to bullying experiences and completed symptom measures of social anxiety and PTSD related to bullying. An empirical structure for a Bullied Cognitions Inventory was established using exploratory and confirmatory factor analyses and assessed using model fit statistics and tests of reliability and validity.

Results

Fifteen items clustered into four themes: "degraded in the eyes of others", "negative interpretations of reactions to bullying", "recognisable as a bullying victim" and "social defeat". The measure has acceptable reliability and validity and, accounting for existing cognitive measures, explained additional variance in symptoms of PTSD but not social anxiety.

Conclusions

The Bullied Cognitions Inventory (BCI) is a valid and reliable tool for measuring cognitions related to bullying. It may be useful in therapy for identifying and monitoring unhelpful cognitions in those who were bullied.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-023-10412-6.

A predictive model of perceived stress during the first wave of the COVID-19 pandemic in university students Ecuadorians

Background and objectives

The situation caused by the confinement due to the COVID-19 pandemic and the mobility restriction implemented by governments worldwide had a significant impact on people's routines. Stressors are known to increase emotional imbalance, uncertainty, and frustration in the general population. This study explores the factors that predispose to the risk of perceived stress from COVID-19 and determines the underlying mediating mechanisms in the Ecuadorian population.

Method

The cross-sectional study an incidental non-probabilistic sample of n = 977 participating student volunteers from the four regions of the Republic of Ecuador (68.6% women and 31.4% men). Data on emotional regulation (ERQ), perceived stress (PSS), active procrastination (APS), diagnosis and symptoms related to COVID-19, social isolation, coexistence, and a sociodemographic questionnaire (biological sex, marital status, and age) were recruited. Statistical analysis was based on a structural equation model.

Results

The risk of suffering perceived stress in the COVID-19 pandemic was higher for single women who have lived longer in social isolation, have lived with more people, have poor emotional regulation and high rates of procrastination. This structural model is similar in all Ecuadorian regions χ² = 21.54 (p = 0.760), RMSEA = 0.001 (95%CI, 0.00-0.02), CFI = 0.998; TLI = 0.999; SRMR = 0.020.

Discussion

Although our findings are consistent and revealing for the scientific community, the lack of discrimination of the data due to strict isolation measures, taken at different periods by the Ecuadorian government against positive cases of COVID-19, is discussed. The research was applied to the university population, it would be representative to extend the study to schools and colleges.

Conclusion

We consider this work as a starting point for the creation of preventive models against perceived stress in the university environment in the event of health emergencies.

Appraisals of Social Trauma and Their Role in the Development of Post-Traumatic Stress Disorder and Social Anxiety Disorder

Cognitive theories of post-traumatic stress disorder (PTSD) feature appraisal of trauma as a critical factor in the development and maintenance of the disorder. Here we explored appraisals of social trauma (severe rejection or humiliation). Participants were outpatients with social anxiety disorder (SAD) and clinically significant PTSD symptoms (PTSS) after social trauma (n = 15); two clinical control groups of either SAD (n = 32) or obsessive-compulsive disorder (OCD; n = 13); and a control group with no diagnoses (n = 38). Measures included a clinical interview to assess social trauma and related open-ended appraisals and the Posttraumatic Cognitions Inventory (PTCI). Raters blind to group assignment performed content analyses of appraisals. Results showed that the PTSS group scored significantly higher than either clinical group on the PTCI SELF subscale. Only the SELF subscale predicted a diagnosis of both PTSS and SAD. All but one PTSS participant reported primarily negative beliefs about their social trauma, and the most common categories were flawed self and others are critical or cruel. Post-traumatic appraisals implicated in the course of PTSD are significant in how individuals respond to social trauma, with negative self-cognitions linked to both PTSS and SAD.

Anxiety, sleep habits and executive function during the COVID-19 pandemic through parents’ perception: a longitudinal study

The present study therefore aims to examine trait and state anxiety, sleep habits and executive functioning during 1 year and a half of the COVID-19 pandemic in children and adolescents through the lens of parents. Assessments were conducted at three different times: April 2020 (T1), October 2020 (T2) and October 2021 (T3). The main sample included 953 children and adolescents aged 6 to 18 years, and scales were used to assess anxiety (STAIC), sleep habits (BEARS) and executive functioning (BRIEF-2). The results showed that 6 months after the outbreak of the pandemic, state and trait anxiety, sleep disturbances and executive dysfunctions increased significantly. One and a half year later, trait anxiety and sleep disturbances have been maintained, while state anxiety and executive dysfunction have decreased their scores obtaining scores similar to those of April 2020. In conclusion, there has been a further decrease in children and adolescents’ mental health since the beginning of the pandemic, and it seems to remain at the present time, such as trait anxiety as a part of the personality.

Demographic and clinical correlates of social anxiety disorder among US veterans: findings from the NESARC-III study

PURPOSE

Social anxiety disorder (SAD) is among the most highly prevalent and debilitating psychiatric disorders within the US population, but SAD has gone relatively unnoticed within the US veteran population. Preliminary research has demonstrated that SAD is related to decreased mental and physical functioning as well as posttraumatic stress disorder (PTSD) and depression among veterans.

METHODS

The present study investigated SAD and its relationship with demographic factors, psychiatric disorders, suicidality, treatment seeking, and social support among veterans. Multivariate survey weighted logistic regression analyses were conducted to observe these associations utilizing data from National Epidemiologic Survey on Alcohol and Related Conditions which contained data on 3119 veterans.

RESULTS

SAD was found to be strongly related to PTSD and other anxiety disorder, and these disorders were related to increased treatment seeking for SAD. Further, SAD was associated with lifetime suicide attempts and decreased perceived social support in multivariate models adjusting for demographic factors and psychiatric comorbidities.

CONCLUSION

This study highlights the relationships of SAD among veterans by demonstrating its associations with other psychiatric disorders, treatment seeking, suicide attempts, and social support. A deeper understanding of the impact of SAD within the veteran population will inform future prevention and treatment efforts.

The Role of Anxiety and Depression in the Emotion Regulation Strategies of People Suffering from Post-Traumatic Stress Disorder

Researchers have explored the links between cognitive emotion regulation, impaired cognitive functioning, and anxiety-depression, including the link to anxiety and depression levels. However, very few studies have examined these dimensions in clinical populations with post-traumatic stress disorder (PTSD). A sample of 183 participants was divided into three groups: 59 trauma-exposed with PTSD, 61 trauma-exposed without PTSD, and 63 non-trauma-exposed non-PTSD (controls). All participants were assessed on the following dimensions: PTSD (PCL-5), cognitive emotion regulation (CERQ), anxiety and depression (HADS). Results indicate a specific profile of emotion regulation associated with PTSD. Compared to other groups, participants with PTSD showed more difficulty managing their emotions, with more rumination, self-blame, and catastrophizing. Moreover, these difficulties were also correlated with levels of anxiety and depression, that is, participants with PTSD who had higher anxiety and depression scores used more maladaptive strategies. The PTSD group used significantly more maladaptive cognitive emotion regulation strategies than the other groups, with distinct profiles related to anxiety and depressive symptomatology.

Assessing the impact of the Royal Canadian Mounted Police (RCMP) protocol and Emotional Resilience Skills Training (ERST) among diverse public safety personnel

BACKGROUND

Public safety personnel (PSP; e.g., border services personnel, correctional workers, firefighters, paramedics, police, public safety communicators) are frequently exposed to potentially psychologically traumatic events. Such events contribute to substantial and growing challenges from posttraumatic stress injuries (PTSIs), including but not limited to posttraumatic stress disorder.

METHODS

The current protocol paper describes the PSP PTSI Study (i.e., design, measures, materials, hypotheses, planned analyses, expected implications, and limitations), which was originally designed to evaluate an evidence-informed, proactive system of mental health assessment and training among Royal Canadian Mounted Police for delivery among diverse PSP (i.e., firefighters, municipal police, paramedics, public safety communicators). Specifically, the PSP PTSI Study will: (1) adapt, implement, and assess the impact of a system for ongoing (i.e., annual, monthly, daily) evidence-based assessments; (2) evaluate associations between demographic variables and PTSI; (3) longitudinally assess individual differences associated with PTSI; and, (4) assess the impact of providing diverse PSP with a tailored version of the Emotional Resilience Skills Training originally developed for the Royal Canadian Mounted Police in mitigating PTSIs based on the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders. Participants are assessed pre- and post-training, and then at a follow-up 1-year after training. The assessments include clinical interviews, self-report surveys including brief daily and monthly assessments, and daily biometric data. The current protocol paper also describes participant recruitment and developments to date.

DISCUSSION

The PSP PTSI Study is an opportunity to implement, test, and improve a set of evidence-based tools and training as part of an evidence-informed solution to protect PSP mental health. The current protocol paper provides details to inform and support translation of the PSP PTSI Study results as well as informing and supporting replication efforts by other researchers.

TRIAL REGISTRATION

Hypotheses Registration: aspredicted.org, #90136. Registered 7 March 2022-Prospectively registered.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05530642. Registered 1 September 2022-Retrospectively registered. The subsequent PSP PTSI Study results are expected to benefit the mental health of all participants and, ultimately, all PSP.

The scarring impact of status loss in social anxiety: An evolutionary perspective

Evolutionary models suggest that social anxiety (SA) is associated with sensitivity to status loss. These models make several additional predictions concerning the strength as well as the specificity of the association between post-event distress (PED) following status losses and SA. First, the strength of this association is postulated to be enhanced in men, especially following status losses inflicted by other men (intra-male status losses). Second, given the evolutionary postulated relationship between social status and physical fitness, sensitivity to status loss in SA is expected to extend to physically threatening events. We examined these predictions in four online samples (total N = 1123; 59% females, 27% above the cutoff for clinically elevated SA). In all studies, participants recalled social status-loss events and rated the emotional and distressing impact of these experiences. In two samples, participants also identified and recalled physically threatening events. Our findings were consistent with evolutionary predictions. SA was associated with PED following social status-loss events (β = 0.27). This association was stronger in men than in women (β = 0.40, β = 0.16, respectively). Moreover, the SA-PED association was especially enhanced following intra-male, compared to intra-female and inter-gender, status losses (β = 0.47, β = 0.26, and β = 0.17, respectively). Furthermore, SA was uniquely associated with PED following physically threatening events, over and above PED following social status-loss events (β = 0.21). Our data highlights the significant impact of socially and physically threatening events and delineates the scarring signature of such events in SA.

Anxiolytic-like effects of extremely low frequency electric field in stressed rats: involvement of 5-HT2C receptors

BACKGROUND

Possible modulatory effects of noninvasive brain stimulation have gained interest recently. In our study, the effect of low frequency electric fields (LF-EF) on stress-induced electrophysiological, behavioral changes and the possible involvement of serotonergic 5-HT2C receptors were investigated.

MATERIALS AND METHODS

A total of eight groups including the control groups were formed by applying LF-EF with or without a 5-HT2C receptor agonist to naïve or acute stress exposed rats to demonstrate the effects of LF-EF. LF-EF administration at 10 kV/m was started 30 min before acute stress application and lasted for 1 h in total. Anxiety levels and social interaction were evaluated using the elevated plus maze test and social interaction test, respectively. Auditory evoked potentials (AEP) were recorded by using ascending loudness paradigms. Loudness dependence AEP (LDAEP) was calculated by using amplitude values to analyze serotonergic transmission. Serotonin and glucocorticoid levels were measured in the frontal cortex and hippocampus.

RESULTS

It was observed that the applied LF-EF reduced the anxiety behavior, and attenuated the LDAEP responses in stress and/or 5-HT2C receptor agonist applied groups. In parallel, an increase in serotonin levels and a decrease in glucocorticoid levels were observed. However, LF-EF exposure was ineffective in impaired social interaction.

CONCLUSIONS

Our findings show that 10 kV/m LF-EF administration may modulate the neural network and physiological responses associated with mild acute stress. 5-HT2C receptor dependent functions are thought to play a role in the anxiolytic effect of LF-EF.

A salience hypothesis of stress in PTSD

Attention to key features of contexts and things is a necessary tool for all organisms. Detecting these salient features of cues, or simply, salience, can also be affected by exposure to traumatic stress, as has been widely reported in individuals suffering from post-traumatic stress disorder (PTSD). Interestingly, similar observations have been robustly replicated across many animal models of stress as well. By using evidence from such rodent stress paradigms, in the present review, we explore PTSD through the lens of salience processing. In this context, we propose that interaction between the neurotrophin brain-derived neurotrophic factor (BDNF) and glucocorticoids determines the long lasting cellular and behavioural consequences of stress salience. We also describe the dual effect of glucocorticoid therapy in the amelioration of PTSD symptoms. Finally, by integrating in vivo observations at multiple scales of plasticity, we propose a unifying hypothesis that pivots on a crucial role of glucocorticoid signalling in dynamically orchestrating stress salience.

The hidden burden of social anxiety disorder in U.S. military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

Social anxiety disorder (SAD) is a chronic and disabling psychiatric disorder associated with low levels of help-seeking. To date, however, scarce research has examined the epidemiology of SAD in veterans. This study examined the prevalence, comorbidities and incremental burden of SAD in relation to suicidality and functioning in a representative sample of U.S. military veterans.

METHODS

A nationally representative sample of 3,157 U.S. veterans completed a web survey containing measures of SAD symptoms, trauma history, psychiatric history and functioning. Multivariable analyses were conducted to examine associations between SAD and psychiatric comorbidities, suicidality and functioning.

RESULTS

A total 9.5% (n = 272) of the sample screened positive for lifetime SAD. Veterans with SAD were more likely than those without SAD to be younger, female, single, racial/ethnic minorities and to have experienced childhood abuse. They also had substantially elevated rates of comorbid psychiatric disorders, particularly lifetime major depression (odds ratio [OR]=5.8) and posttraumatic stress disorder (OR=3.1), as well as current suicidal ideation (OR=3.3). Veterans with SAD scored lower on measures of functioning, particularly social, emotional and mental health functioning (d's=0.21-0.34).

LIMITATIONS

Data were collected cross-sectionally using self-report.

CONCLUSIONS

SAD in U.S. veterans is prevalent and associated with psychiatric comorbidities, functional impairment and a more than 3-fold greater risk for suicidal ideation . Given that SAD is associated with low treatment seeking and engagement, it may be undetected and undertreated relative to other psychiatric morbidities. These results underscore the importance of screening, monitoring and treating SAD in this population along with other prevalent mental disorders.

The same stress has divergent effects on social versus asocial manifestations of anxiety-like behavior over time

Stress may lead to augmented anxiety, which may, with time culminate in some form of anxiety disorder. Behavioral alterations related to increased anxiety can be broadly classified into two types-social, affecting interactions between individuals, and self-oriented, affecting the anxious individual only. While a growing body of literature now exists describing the effects of stress-induced anxiety on self-oriented behavior in animal models of anxiety disorders, the effects of such aberrant anxiety on social behavior has largely remained uncharacterized in these models. This study aims to fill this gap in our understanding by examining changes in social behavior following a single 2-hour episode of immobilization stress, which has been shown to cause delayed structural and functional changes in the amygdala. To this end, we examined social behavior, measured as active social interactions, anogenital sniffing, nose-to-nose contacts, allogrooming, actively following and crawling under, as well as self-oriented asocial behavior, manifested as self-grooming and rearing, in adult male rats. Stressed animals showed reduced social interaction 1 day after immobilization stress and this decrease was persistent for at least 10 days after stress. In contrast, individualistic behaviors were impaired only 10 days, but not 1 day later. Together, these results not only show that the same single episode of stress can elicit divergent effects on social and asocial measures of anxiety in the same animal, but also suggest that enhanced social anxiety soon after stress may also serve as an early indicator of its delayed behavioral effects.

Corticosterone after acute stress prevents the delayed effects on the amygdala

Even a single 2-hour episode of immobilization stress is known to trigger anxiety-like behavior and increase spine-density in the basolateral amygdala (BLA) of rats 10 days later. This delayed build-up of morphological and behavioral effects offers a stress-free time window of intervention after acute stress, which we used to test a protective role for glucocorticoids against stress. We observed that post-stress corticosterone, given 1 day after acute stress in drinking water, reversed enhanced anxiety-like behavior 10 days later. Quantification of spine-density on Golgi-stained BLA principal neurons showed that the same intervention also prevented the increase in spine numbers in the amygdala, at the same delayed time-point. Further, stress elevated serum corticosterone levels in rats that received vehicle in the drinking water. However, when stress was followed 24 h later by corticosterone in the drinking water, the surge in corticosterone was prevented. Together, these observations suggest that corticosterone, delivered through drinking water even 24 h after acute stress, is capable of reversing the delayed enhancing effects on BLA synaptic connectivity and anxiety-like behavior. Strikingly, although the immobilization-induced surge in corticosterone by itself has delayed detrimental effects on amygdalar structure and function, there exists a window of opportunity even after stress to mitigate its impact with a second surge of exogenously administered corticosterone. This provides a framework in the amygdala for analyzing how the initial physiological and endocrine processes triggered by traumatic stress eventually give rise to debilitating emotional symptoms, as well as the protective effects of glucocorticoids against their development.

A projection from the paraventricular nucleus of the thalamus to the shell of the nucleus accumbens contributes to footshock stress-induced social avoidance

The paraventricular nucleus of the thalamus (PVT) is an area of the dorsal midline thalamus that contributes to footshock induced anxiety. The PVT sends a dense projection to the shell of the nucleus accumbens (NAcSh) and the present study explored if this projection is involved in the behavioral changes produced by a single exposure of rats to inescapable footshocks. The inhibitory Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) hM4Di was transduced in PVT neurons that project to the NAcSh. Rats were exposed to an episode of moderately intense footshock (1.5 mA × 2 s × 5) and assigned to either high-responder (HR) or low-responder groups (LR) according to their level of fear generalization 24 h later. The effect of chemogenetic inhibition of the PVT-NAcSh projection on anxiety- and fear-like behaviors was assessed at approximately 2 weeks post-footshock. HR showed a higher level of social avoidance compared to non-shocked animals and LR. The elevated level of social avoidance was attenuated in the HR treated with the hM4Di agonist clozapine (0.01 mg/kg, i.p.) or clozapine N-oxide (CNO) administrations in the NAcSh while avoidance of open spaces and contextual fear expression were not affected. Analysis of protein product of the early to immediate gene cfos indicated that these effects were mediated by dynorphin neurons in the NAcSh. This study provides evidence for a role of a projection from the PVT to the NAcSh in stress-induced social avoidance independent of anxiety to non-social stimuli and contextual fear mechanisms.

Social anxiety among unaccompanied minor refugees in Norway.The association with pre-migration trauma and post-migration acculturation related factors

OBJECTIVE

Unaccompanied refugee minors (URMs), are at high risk for mental health problems, yet there is a lack of knowledge about social anxiety among these youths. The aim of this study was to investigate symptoms of social anxiety among URMs resettled in Norway, and the combined effects of pre-migration traumatic events, post-migration acculturation related factors (perceived discrimination and culture competence in relation both to the heritage and majority cultures) and demographic background variables, over and above the effect of concurrent depressive symptoms.

METHODS

Cross-sectional self-report questionnaire data were collected from 557 URMs from 31 different countries, mainly from Afghanistan (49,6%), Somalia (11,1%), and Iraq (7,0%).

RESULTS

The findings from structural equation model (SEM) showed that the effect of pre-migration traumatic events on social anxiety was non-significant (β = 0.001, p = .09), while perceived discrimination and majority culture competence had unique effects on social anxiety (β = 0.39, p < .001 and β = -0.12, p = .008, respectively) over and above depressive symptoms (β = 0.30, p < .001).

CONCLUSIONS

The findings show that factors of the current socio-cultural developmental context rather than pre-migration war-related traumatic events the youths experienced before migration accounts for variation in social anxiety. Potential practical implications of the findings for social workers, educational staff and clinicians are discussed.

Perfectionism and Perceived Control in Posttraumatic Stress Disorder Symptoms

In this study, we sought to examine associations between dimensions of trait perfectionism and posttraumatic stress disorder (PTSD) symptoms among a community sample of adults who experienced at least one traumatic event and determine whether the associations between trait perfectionism dimensions and PTSD symptomatology varied as a function of perceived control. A sample of 161 (57% women; M = 33.24 years, SD = 10.84 years) community adults who experienced at least one traumatic event in their lives completed self-report measures of trait perfectionism, perceived control, personality, and PTSD symptomatology. Results from multiple regression analyses indicated that socially prescribed perfectionism was associated with higher levels of PTSD symptomatology. However, this finding was qualified by a significant interaction with perceived control such that higher levels of socially prescribed perfectionism were associated with greater PTSD symptomatology only under conditions of low perceived control. Findings underscore the importance of individual differences in socially prescribed perfectionism and perceived control for PTSD symptomatology.

Social trauma and its association with posttraumatic stress disorder and social anxiety disorder

The key characteristic of a traumatic event as defined by the Diagnostic and Mental Manual of Mental Disorders (DSM) seems to be a threat to life. However, evidence suggests that other types of threats may play a role in the development of PTSD and other disorders such as social anxiety disorder (SAD). One such threat is social trauma, which involves humiliation and rejection in social situations. In this study, we explored whether there were differences in the frequency, type and severity of social trauma endured by individuals with a primary diagnosis of SAD (n = 60) compared to a clinical control group of individuals with a primary diagnosis of obsessive compulsive disorder (OCD, n = 19) and a control group of individuals with no psychiatric disorders (n = 60). The results showed that most participants in this study had experienced social trauma. There were no clear differences in the types of experiences between the groups. However, one third of participants in the SAD group (but none in the other groups) met criteria for PTSD or suffered from clinically significant PTSD symptoms in response to their most significant social trauma. This group of SAD patients described more severe social trauma than other participants. This line of research could have implications for theoretical models of both PTSD and SAD, and for the treatment of individuals with SAD suffering from PTSD after social trauma.

The Role of Traumatic Experiences and Posttraumatic Stress on Social Anxiety in a Youth Sample in Lithuania

Emerging adulthood is a developmental stage with an increased vulnerability to mental disorders. Social anxiety disorder (SAD) is highly prevalent anxiety disorder especially among adolescents and young adults. Furthermore, SAD is highly comorbid with posttraumatic stress disorder (PTSD). The aim of this study was to evaluate the prevalence of SAD, life-time traumatic experiences and PTSD among Lithuanian young adults studying at the Universities. We also aimed to search for associations between social anxiety, traumatic experiences, and posttraumatic stress in our sample. In total 590 young adults (67.7% female), aged 20 years on average and studying at the Universities in Lithuania were recruited for this study. Self-report measures were used to measure SAD and PTSD. SAD was measured using the Social Phobia Inventory (SPIN), and PTSD was measured using the Impact of Event Scale - Revised (IES-R). SAD prevalence based on SPIN cut-off >26 in our sample was 15.3%, life-time trauma exposure was 67.5%. No association between accumulative trauma exposure and SAD was found. SAD symptoms were highly correlated with PTSD symptoms. Comorbidity between SAD and PTSD was high, with 32.2% cases of PTSD in SAD group. We found high comorbidity between SAD and PTSD in our study among young adults. Further studies are needed to explore development of SAD and PTSD in longitudinal studies.

Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges

Comorbid disorders are highly prevalent in patients with social anxiety disorder, occurring in as many as 90% of patients. The presence of comorbidity may affect the course of the disease in several ways such as comorbidity in patients with social anxiety disorder (SAD) is related to earlier treatment-seeking behavior, increased symptom severity, treatment resistance and decreased functioning. Moreover, comorbidities cause significant difficulties in nosology and diagnosis, and may cause treatment challenges. In this review, major psychiatric comorbidities that can be encountered over the course of SAD as well as comorbidity associated diagnostic and therapeutic challenges will be discussed.

Depression with or without comorbid social anxiety: Is attachment the culprit?

Major depressive disorder (MDD) frequently co-occurs with social anxiety disorder (SAD), and their comorbidity (MDD-SAD) increases clinical severity and functional impairment. Still, the specific psychological vulnerabilities of individuals with MDD-SAD are poorly understood. Individual attachment characteristics develop early in life through interactions with primary caregivers, and tend to persist throughout life. Early trauma can worsen attachment insecurity, increasing the risk for future anxiety and depression. The purpose of this study is to examine differences in individual attachment and history of trauma in depressed individuals with or without comorbid SAD and controls. One hundred sixty-two participants were categorized into three groups based on SCID-I interview: healthy controls (HC), individuals with current MDD without SAD (MDD), and individuals with current MDD comorbid with SAD (MDD-SAD). MDD-SAD group had significantly greater attachment anxiety and attachment avoidance compared to the MDD and HC groups. MDD-SAD group had greater clinician-rated depression severity and dysfunction compared to MDD group. In summary, the study further supports the clinical risks associated with MDD-SAD and suggests that insecure attachment might represent an associated vulnerability and a possible pathway which warrants further research and clinical attention.

Comorbid PTSD and Social Anxiety Disorder: Associations With Quality of Life and Suicide Attempts

Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) frequently co-occur. Preliminary data from treatment-seeking and veteran samples suggest that the impact of PTSD-SAD comorbidity may be additive, conferring distress and impairment beyond that of either disorder alone. The current study sought to clarify and extend existent research using wave 2 of the National Epidemiologic Survey of Alcohol and Related Conditions, an epidemiological sample of American adults. Individuals who met criteria for comorbid PTSD-SAD were compared to those with either disorder alone on measures of lifetime suicide attempts or quality of life as measured by the Medical Outcomes Study Questionnaire. Relative to those with either PTSD or SAD, individuals with comorbid PTSD-SAD demonstrated an elevated risk of lifetime suicide attempts and substantially lower levels of physical and mental quality of life. The psychosocial consequences of PTSD-SAD comorbidity are substantial. Patients may benefit from early interventions to remediate social distress and improve support networks before more intensive psychotherapeutic interventions.

Metacognitive therapy versus disorder-specific CBT for comorbid anxiety disorders: A randomized controlled trial

Few studies have compared the effects of Metacognitive therapy (MCT) and Cognitive behavioral therapy (CBT) for comorbid anxiety disorders. In the current study we compared CBT and MCT for heterogeneous anxiety disorders in a residential setting. Ninety patients with a primary diagnosis of Post Traumatic Stress Disorder, Social Phobia or Panic disorder, with and without Agoraphobia, were randomized to either CBT or MCT. Patients were assessed at pre-treatment, post-treatment and one-year follow-up. Primary outcome measures were Beck Anxiety Inventory and ADIS IV and secondary outcome measures were SCID II, Beck Depression Inventory, Penn State Worry Questionnaire, The Symptom Checklist-90 and the Inventory of Interpersonal Problems-64. Treatment fidelity was satisfactory and therapist credibility was equal in both treatments. There was a significant difference in the level of anxiety favouring MCT at post-treatment (d=0.7), but there were no differences at one-year follow-up, mainly due to a further improvement in the CBT group during the follow-up period. Both treatments were efficacious. No differences in effect on comorbid diagnoses and symptoms were found, but MCT produced larger change in personality problems. MCT seems to have a more rapid effect on anxiety symptoms, but there were no significant differences in the long term for patients with comorbid anxiety disorders.

PTSD, social anxiety disorder, and trauma: An examination of the influence of trauma type on comorbidity using a nationally representative sample

Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) are highly comorbid (Collimore et al., 2010). Trauma may present a shared environmental factor contributing to the development of comorbidity; however, existent research has been hampered by use of restrictive samples and limitations in the range of traumas investigated. The current study examines the relationship between a broad range of potentially traumatic events and the comorbidity between PTSD and SAD using Wave 2 of the National Epidemiological Survey of Alcohol and Related Conditions (n=34,653). Multiple logistic regressions and cross-tabulations were used to evaluate differences in the prevalence of potentially traumatic events among those who met criteria for comorbid PTSD-SAD compared to those with PTSD without SAD and SAD without PTSD. Those in the comorbid PTSD-SAD group were significantly more likely than those in the PTSD without SAD or SAD without PTSD groups to report experiencing specific types of assaultive violence, childhood maltreatment, and other shocking events. Associations between comorbidity and childhood maltreatment were significant for females only. Individuals diagnosed with comorbid PTSD-SAD are more likely than those diagnosed with either disorder alone to report exposure to specific types of traumatic events within their lifetime.

A single prolonged stress paradigm produces enduring impairments in social bonding in monogamous prairie voles

Traumatic events such as natural disasters, violent crimes, tragic accidents, and war, can have devastating impacts on social relationships, including marital partnerships. We developed a single prolonged stress (SPS) paradigm, which consisted of restraint, forced swimming, and ether anesthesia, to establish an animal model relevant to post-traumatic stress disorder. We applied a SPS paradigm to a monogamous rodent, the prairie vole (Microtus ochrogaster) in order to determine whether a traumatic event affects the establishment of pair bonds. We did not detect effects of the SPS treatment on anhedonic or anxiety-like behavior. Sham-treated male voles huddled with their partner females, following a 6day cohabitation, for a longer duration than with a novel female, indicative of a pair bond. In contrast, SPS-treated voles indiscriminately huddled with the novel and partner females. Interestingly, the impairment of pair bonding was rescued by oral administration of paroxetine, a selective serotonin reuptake inhibitor (SSRI), after the SPS treatment. Immunohistochemical analyses revealed that oxytocin immunoreactivity (IR) was significantly decreased in the supraoptic nucleus (SON), but not in the paraventricular nucleus (PVN), 7days after SPS treatment, and recovered 14days after SPS treatment. After the presentation of a partner female, oxytocin neurons labeled with Fos IR was significantly increased in SPS-treated voles compared with sham-treated voles regardless of paroxetine administration. Our results suggest that traumatic events disturb the formation of pair bond possibly through an interaction with the serotonergic system, and that SSRIs are candidates for the treatment of social problems caused by traumatic events. Further, a vole SPS model may be useful for understanding mechanisms underlying the impairment of social bonding by traumatic events.

Fear conditioning induced by interpersonal conflicts in healthy individuals

Psychophysiological markers have been focused to investigate the psychopathology of psychiatric disorders and personality subtypes. In order to understand neurobiological mechanisms underlying these conditions, fear-conditioning model has been widely used. However, simple aversive stimuli are too simplistic to understand mechanisms because most patients with psychiatric disorders are affected by social stressors. The objective of this study was to test the feasibility of a newly-designed conditioning experiment using a stimulus to cause interpersonal conflicts and examine associations between personality traits and response to that stimulus. Twenty-nine healthy individuals underwent the fear conditioning and extinction experiments in response to three types of stimuli: a simple aversive sound, disgusting pictures, and pictures of an actors’ face with unpleasant verbal messages that were designed to cause interpersonal conflicts. Conditioned response was quantified by the skin conductance response (SCR). Correlations between the SCR changes, and personality traits measured by the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) and Revised NEO Personality Inventory were explored. The interpersonal conflict stimulus resulted in successful conditioning, which was subsequently extinguished, in a similar manner as the other two stimuli. Moreover, a greater degree of conditioned response to the interpersonal conflict stimulus correlated with a higher ZAN-BPD total score. Fear conditioning and extinction can be successfully achieved, using interpersonal conflicts as a stimulus. Given that conditioned fear caused by the interpersonal conflicts is likely associated with borderline personality traits, this paradigm could contribute to further understanding of underlying mechanisms of interpersonal fear implicated in borderline personality disorder.

Prognostic influence of witness/victim experiences and PTSD-specific symptoms on working and educational capacity: a comparison between two groups of individuals post-trauma

BACKGROUND

Trauma exposure depends of the type of trauma and can result in the development of posttraumatic stress disorder (PTSD). The type of traumatization (such as Holocaust experiences and other sources of trauma) and specific symptoms of PTSD have influences on the outcome, and specific symptoms of PTSD influence personal and professional outcomes. Another factor is the role of the victim in their traumatization. Some patients are actively traumatized through being victims of torture, while others are passively traumatized by witnessing the traumatization of others.

METHODS

We compared two groups of victim/witness trauma sufferers (PTSD vs. Holocaust-experience PTSD (HE-PTSD)) with regard to PTSD symptoms, educational and working capacity, and functional outcome parameters.

RESULTS

HE-PTSD survivors with victim/witness trauma experience showed substantially more specific PTSD symptoms and higher symptom-specific intensities but had high social function and education levels. The intensity and type of intrusive memories and sociodemographic factors do not seem to have a prognostic influence on working or educational outcomes.

CONCLUSIONS

Identifying the combined victim/witness experience seems to play an important prognostic role in the assessment of PTSD victims. Further studies should consider these findings within other specific traumatization groups.

Latent profile analysis and principal axis factoring of the DSM-5 dissociative subtype

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.

Social anxiety disorder is associated with PTSD symptom presentation: an exploratory study within a nationally representative sample

Posttraumatic stress disorder (PTSD) and social anxiety disorder (SAD) demonstrate a high degree of comorbidity (ranging from 14.8% to 46.0%); however, little is known about the nature of this association. Contemporary research has largely focused on treatment-seeking or veteran samples, and may not generalize to the population as a whole. Large-scale epidemiological studies are needed to fill existing gaps in the literature and to clarify this association for the general population. The current study examined whether the presence of comorbid SAD influenced PTSD symptom presentation. The rate of individual PTSD symptoms was investigated among individuals with PTSD and SAD in comparison to those with PTSD alone. Data were obtained from Wave 2 of the National Epidemiological Survey of Alcohol and Related Conditions, a large, nationally representative survey of American adults (n = 34,653). Analyses revealed elevated rates of PTSD symptoms among those with comorbid PTSD and SAD across all symptom clusters, with significant odds ratios ranging from 1.5 to 4.87. Adjusting for depression and other Axis I disorders did not substantially alter study findings. Results suggest that the presence of SAD is associated with differences in the expression of PTSD symptoms.

Comorbidity of PTSD in anxiety and depressive disorders: prevalence and shared risk factors

The present study aims to assess comorbidity of posttraumatic stress disorder (PTSD) in anxiety and depressive disorders and to determine whether childhood trauma types and other putative independent risk factors for comorbid PTSD are unique to PTSD or shared with anxiety and depressive disorders. The sample of 2402 adults aged 18-65 included healthy controls, persons with a prior history of affective disorders, and persons with a current affective disorder. These individuals were assessed at baseline (T0) and 2 (T2) and 4 years (T4) later. At each wave, DSM-IV-TR based anxiety and depressive disorder, neuroticism, extraversion, and symptom severity were assessed. Childhood trauma was measured at T0 with an interview and at T4 with a questionnaire, and PTSD was measured with a standardized interview at T4. Prevalence of 5-year recency PTSD among anxiety and depressive disorders was 9.2%, and comorbidity, in particular with major depression, was high (84.4%). Comorbidity was associated with female gender, all types of childhood trauma, neuroticism, (low) extraversion, and symptom severity. Multivariable significant risk factors (i.e., female gender and child sexual and physical abuse) were shared among anxiety and depressive disorders. Our results support a shared vulnerability model for comorbidity of anxiety and depressive disorders with PTSD. Routine assessment of PTSD in patients with anxiety and depressive disorders seems warranted.

Factors associated with comorbidity patterns in full and partial PTSD: findings from the PsyCoLaus study

Subtypes of comorbid conditions and their associated trauma and clinical characteristics in full and partial PTSD were examined. Data from 289 subjects from the general population that met criteria for full or partial PTSD were analyzed. Latent class analyses (LCA) were performed to derive homogeneous patterns of DSM-IV Axis-I disorders and anti-social personality comorbid to PTSD. Logistic regression models were conducted to characterize these classes by trauma-related and clinical features. The LCA revealed three classes: (1) low comorbidity; (2) high comorbidity with primarily substance-related disorders and a higher proportion of males; and (3) more severe PTSD-symptomatology and higher comorbid anxiety disorders and depression, almost entirely represented by females. Exposure to sexual abuse was more likely in the substance-dependent class and contributed strongly to the distinction between classes. Affective disorders tended to precede the onset of PTSD in the substance-dependent class, whereas phobias were more likely to follow PTSD in the depressed-anxious class. Posttrauma onset of alcohol use disorders in the substance dependent class confirmed the self-medication hypothesis. The three classes of comorbidity and their sequence of onset with PTSD suggest different mechanisms involved in their development. Our findings suggest that PTSD-related comorbidity subtypes also apply to individuals with partial PTSD.

Predictors of the long-term course of comorbid PTSD: a naturalistic prospective study

OBJECTIVES

The study examined the long-term course of posttraumatic stress disorder (PTSD) by analyzing rates of recurrence and the predictive value of comorbid psychiatric disorders and psychosocial functioning.

METHODS

This study is based on diagnostic assessments administered at intake and subsequent follow-up interviews over a period of 15 years in a sample of 90 anxiety-disordered patients with comorbid PTSD who participated in the Harvard Brown Anxiety Research project (HARP). Kaplan-Meier life table analysis revealed a 0.20 probability of full remission during the 15 years of follow-up.

RESULTS

Latent growth model (LGM) analysis revealed that the number of trauma exposures was a predictor of a worse course of PTSD but only during some intervals of the 15-year follow-up. Subjects with full social phobia were more likely to experience worsening of PTSD over time in comparison with subjects with less severe social phobia. Role functioning in the areas of household and employment was a significant predictor of a declining course of PTSD.

CONCLUSIONS

These findings revealed the dynamic nature of the predictive value of traumatic experiences, the deleterious effect of social phobia and the long term effect of psychosocial functioning on the course of PTSD. Implications for treatment planning and development of interventions for PTSD are discussed.

Social vs. environmental stress models of depression from a behavioural and neurochemical approach

Major depression is a mental disorder often preceded by exposure to chronic stress or stressful life events. Recently, animal models based on social conflict such as chronic social defeat stress (CSDS) are proposed to be more relevant to stress-induced human psychopathology compared to environmental models like the chronic mild stress (CMS). However, while CMS reproduces specifically core depressive symptoms such as anhedonia and helplessness, CSDS studies rely on the analysis of stress-induced social avoidance, addressing different neuropsychiatric disorders. Here, we study comparatively the two models from a behavioural and neurochemical approach and their possible relevance to human depression. Mice (C57BL/6) were exposed to CMS or CSDS for six weeks and ten days. Anhedonia was periodically evaluated. A battery of test applied during the fourth week after the stress procedure included motor activity, memory, anxiety, social interaction and helplessness. Subsequently, we examined glutamate, GABA, 5-HT and dopamine levels in the prefrontal cortex, hippocampus and brainstem. CMS induced a clear depressive-like profile including anhedonia, helplessness and memory impairment. CSDS induced anhedonia, hyperactivity, anxiety and social avoidance, signs also common to anxiety and posttraumatic stress disorders. While both models disrupted the excitatory inhibitory balance in the prefrontal cortex, CMS altered importantly this balance in the brainstem. Moreover, CSDS decreased dopamine in the prefrontal cortex and brainstem. We suggests that while depressive-like behaviours might be associated to altered aminoacid neurotransmission in cortical and brain stem areas, CSDS induced anxiety behaviours might be linked to specific alteration of dopaminergic pathways involved in rewarding processes.

Risk factors for post-injury mental health problems

Serious nonfatal physical injuries and burns are common occurrences that can have substantial implications for personal, social, and occupational functioning. Such injuries are frequently associated with significant mental health issues, and compromised quality of life and well-being. The purpose of this review is to summarize the current literature on physical, psychological, and social risk factors for mental health issues post-injury and to contextualize findings using Engel's biopsychosocial framework. We distinguish between pre-injury, injury-related, and post-injury risk factors for mental health problems. Female sex, history of mental health problems or trauma, type of injury, and level of pain are among the strong risk factors for mental health problems post-injury. We highlight inconsistent findings in the literature, identify directions for future research, and explore the implications of the risk factors identified for treatment and prevention.

Posttraumatic stress symptoms and mental health services utilization in adolescents with social anxiety disorder and experiences of victimization

Recent findings from studies on adults show similarities between social anxiety disorder (SAD) and posttraumatic stress in the form of recurrent memories and intrusive and distressing images of earlier aversive events. Further, treatment models for SAD in adults have been successfully developed by using transdiagnostic knowledge on posttraumatic stress symptoms (PTSS). Studies on adolescents are though missing. The present study aimed at exploring the association between PTSS and SAD in Swedish adolescents. A second aim was to study mental health services utilization in relation to these conditions. A total of 5,960 high-school students participated and reported on SAD, life time victimization, PTSS and mental health service utilization. Socially anxious adolescents reported significantly higher levels of PTSS than adolescents not reporting SAD and this difference was seen in victimized as well as non-victimized subjects. Contact with a school counselor was the most common mental health service utilization in subjects with SAD and those with elevated PTSS. In the prediction of contact with a CAP-clinic, significant odds ratios were found for a condition of SAD and elevated PTSS (OR = 4.88, 95% CI = 3.53-6.73) but not for SAD only. Screening of PTSS in adolescents with SAD is recommended. The service of school counselors is important in detecting and helping young people with SAD and elevated PTSS. Clinical studies on SAD and PTSS in adolescents could aid in modifying treatment models for SAD.

Stress history increases alcohol intake in relapse: relation to phosphodiesterase 10A

Stressful experiences can result in elevated alcohol drinking, as exemplified in many individuals with post-traumatic stress disorder. However, how stress history, rather than acute stressors, influences alcohol intake remains uncertain. To model the protracted effects of past stress, male Wistar rats were subjected to light-cued footshock (stress history) or light cues alone (control) prior to acquisition of alcohol self-administration (1-hour sessions, fixed ratio 1-3, 100 µl of 10% v/v alcohol as reinforcer). Stress history did not alter mean alcohol intake during acquisition of self-administration, but it increased preference for the alcohol-paired lever over the inactive lever. Following an extinction period, rats with a history of stress exposure and low baseline alcohol intake showed a twofold elevation in alcohol self-administration, as compared with low-drinking rats with no stress history. Similar effects were not seen in rats self-administering 0.1% sucrose. Analysis of mRNA levels of phosphodiesterase 10A (PDE10A), a dual-specificity cyclic adenosine monophosphate and cyclic guanosine monophosphate hydrolyzing enzyme, showed that stress history increased Pde10a mRNA levels in the basolateral amygdala and, in low-drinking rats, the prelimbic prefrontal cortex (plPFC). Pde10a mRNA levels in the plPFC correlated directly with greater alcohol self-administration during the relapse-like phase, and greater BLA Pde10a mRNA levels correlated with increased ethanol preference after acquisition. The data demonstrate that stress history sensitizes otherwise low alcohol drinkers to consume more alcohol in a relapse-like situation and identify stress-induced neuroadaptations in amygdala and prefrontal cortical Pde10a expression as changes that may drive heightened alcohol intake and preference in susceptible individuals.

Assessing the latent structure of the intolerance of uncertainty construct: an initial taxometric analysis

Researchers have increasingly suggested that people with anxiety disorders share a common fear that the uncertain future will be catastrophic. Intolerance of uncertainty (IU) - the tendency to consider possible negative events as unacceptable and threatening, irrespective of probabilities - is representative of such fears. A key role has been indicated for IU in several anxiety and mood disorders; however, the present study appears to be the first latent structure examination of IU. Responses were obtained from a large sample (n=977; 65% women) unselected with regard to IU level, comprising anxiety disorder outpatients (i.e., putative taxon members), and community residents (i.e., putative complement class members). MAXEIG, MAMBAC, and L-Mode were performed with indicator sets drawn from the Intolerance of Uncertainty Scale-12. Assessments also included objective Comparison Curve Fit Indices. Results yielded converging evidence that IU symptoms have a dimensional latent structure. Comprehensive findings, implications, and future research directions are discussed.

The relationship between interpersonal traits and posttraumatic stress disorder symptoms: analyses from Wenchuan earthquake adolescent survivors in China

This study explores the relationship between interpersonal traits and posttraumatic stress disorder (PTSD) symptoms in a sample of 617 middle and high school students 16 months after the Wenchuan earthquake in China using the Impact of Event Scale-Revised (IES-R) and the Interpersonal Self-Supporting Scale (ISSS). Even when the effects of gender and grade level were controlled for, the results from regression analyses revealed that greater interpersonal independence, interpersonal initiative, interpersonal responsibility, and interpersonal openness are associated with lesser PTSD symptoms 16 months later.

Chronic alcohol neuroadaptation and stress contribute to susceptibility for alcohol craving and relapse

Alcoholism is a chronic relapsing disorder. Major characteristics observed in alcoholics during an initial period of alcohol abstinence are altered physiological functions and a negative emotional state. Evidence suggests that a persistent, cumulative adaptation involving a kindling/allostasis-like process occurs during the course of repeated chronic alcohol exposures that is critical for the negative symptoms observed during alcohol withdrawal. Basic studies have provided evidence for specific neurotransmitters within identified brain sites being responsible for the negative emotion induced by the persistent cumulative adaptation following intermittent-alcohol exposures. After an extended period of abstinence, the cumulative alcohol adaptation increases susceptibility to stress- and alcohol cue-induced negative symptoms and alcohol seeking, both of which can facilitate excessive ingestion of alcohol. In the alcoholic, stressful imagery and alcohol cues alter physiological responses, enhance negative emotion, and induce craving. Brain fMRI imaging following stress and alcohol cues has documented neural changes in specific brain regions of alcoholics not observed in social drinkers. Such altered activity in brain of abstinent alcoholics to stress and alcohol cues is consistent with a continuing ethanol adaptation being responsible. Therapies in alcoholics found to block responses to stress and alcohol cues would presumably be potential treatments by which susceptibility for continued alcohol abuse can be reduced. By continuing to define the neurobiological basis of the sustained alcohol adaptation critical for the increased susceptibility of alcoholics to stress and alcohol cues that facilitate craving, a new era is expected to evolve in which the high rate of relapse in alcoholism is minimized.