PTSD, Endophenotypes, the RDoC, and the DSM-5

Resilience, Trauma, and Coping

The study and use of resilience is of the utmost importance to psychodynamic psychiatry. It is deeply ingrained in ideas about well-being and the treatment and care of patients. However, its neurobiology is incompletely understood, its terminology and relation to trauma and coping not well defined, and its efficacy underutilized in clinical practice. This article reviews the scientific literature on resilience, especially as it relates to trauma and coping. It also attempts to point the way for its greater application in psychiatry and mental health by utilizing resilience in more informed and individualized approaches.

Specific Phobias: Maintaining Control in the Face of Chaotic Threats

Introduction: Drawing on existential psychology we examine the possibility that specific phobias can serve a psychological function. Specifically, we propose that phobic objects allow individuals to focalize anxieties about haphazard existential threats into a more manageable form, reducing perceptions of risk and bolstering control.

Method: We tested this by assessing perceived control among participants with varying levels of spider fear who were reminded of chaotic hazards (or not) and exposed to spiders images (or not).

Results: Study 1 (N = 940) found that among those high in spider fear, salient uncontrollable threats (vs. controllable threats or uncontrollable non-threats) reduced feelings of control unless participants were exposed to their phobic object. Similarly, exposure to spider (vs. non-spider) images bolstered perceived control in the face of salient hazards, but only for those high in spider fear. A second preregistered study (N = 1349) found that the palliative effects of focusing on a phobic object were partially explained by a decreased concern with haphazard harms.

Discussion: This supports the premise that phobic objects help to maintain control by narrowing the source of disordered risks, creating a more controllable conception of reality.

Investigating the latent dimensions of posttraumatic stress disorder and the role of anxiety sensitivity in combat-exposed Filipino soldiers

Identifying the optimal factor structure of posttraumatic stress disorder (PTSD) has recently been reinvigorated in literature due to the substantial changes to its diagnostic criteria in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Currently, six models of PTSD are supported in literature, but there is no consensus on the best-fitting factor structure. Additionally, the extant literature examining the relationship between PTSD symptom-grouping and AS in the latent level has been scarce. The present study's objectives are two-fold: first, we aimed to identify the best-fitted model of PTSD by comparing the six empirically-supported models, and; second, we examined the relationship between the best-fitting model with anxiety sensitivity (AS). Utilizing a sample of 476 combat-exposed soldiers, the results suggest that both the anhedonia and hybrid models provide the best fit to the data, with the anhedonia model achieving slightly better fit indices. Further, the examination on the influence of AS to PTSD reveal that while there is a pattern of decreasing factor loadings and factor correlations when accounting for AS, the changes are not significant to alter the PTSD symptom-structure. Based on these results, our findings suggest further investigation on the possible mediating or moderating mechanisms by which AS may influence PTSD.

Acute Posttrauma Resting-State Functional Connectivity of Periaqueductal Gray Prospectively Predicts Posttraumatic Stress Disorder Symptoms

BACKGROUND

Posttraumatic stress disorder (PTSD) is characterized by hyperarousal, avoidance, and intrusive/re-experiencing symptoms. The periaqueductal gray (PAG), which generates behavioral responses to physical and psychological stressors, is also implicated in threat processing. Distinct regions of the PAG elicit opposing responses to threatening or stressful stimuli; the ventrolateral PAG evokes passive coping strategies (e.g., analgesia), whereas the dorsolateral PAG (dlPAG) promotes active responses (e.g., fight or flight). We investigated whether altered PAG resting-state functional connectivity (RSFC) prospectively predicted PTSD symptoms.

METHODS

A total of 48 trauma-exposed individuals underwent an RSFC scan 2 weeks posttraumatic injury. Self-report measures, including the visual analog scale for pain and the Impact of Event Scale, were collected at 2 weeks and 6 months posttrauma. We analyzed whether acute bilateral PAG RSFC was a marker of risk for total 6-month symptom severity and specific symptom clusters. In an exploratory analysis, we investigated whether dlPAG RSFC predicted PTSD symptoms.

RESULTS

After adjusting for physical pain ratings, greater acute posttrauma PAG-frontal pole and PAG-posterior cingulate cortex connectivity was positively associated with 6-month total PTSD symptoms. Weaker dlPAG-superior/inferior parietal lobule connectivity predicted both higher hyperarousal and higher intrusive symptoms, while weaker dlPAG-supramarginal gyrus RSFC was associated with only hyperarousal symptoms.

CONCLUSIONS

Altered connectivity of the PAG 2 weeks posttrauma prospectively predicted PTSD symptoms. These findings suggest that aberrant PAG function may serve as a marker of risk for chronic PTSD symptoms, possibly by driving specific symptom clusters, and more broadly that connectivity of specific brain regions may underlie specific symptom profiles.

From Posttraumatic Stress Disorder to Posttraumatic Growth: A Paradigm Shift or Paradox?

Trauma, unfortunately, is an all too common part of today's world. The construct posttraumatic stress disorder (PTSD) has been the dominant paradigm to guide researchers and clinicians in the United States and around the world in their efforts to understand and help persons who have experienced trauma. However, PTSD as a diagnosis and this theoretical construct has some problems and limitations, particularly when considered from a global perspective. The author explores the less widely studied construct of posttraumatic growth (PTG) as a phenomenon that avoids some of the problems of PTSD and asks the question: Does it represent a paradigm shift or a paradox? The author seeks to consider this issue from a global perspective and discusses Syrian refugees as a case study.

Integrating NIMH Research Domain Criteria (RDoC) into PTSD Research

Three and a half decades of research on posttraumatic stress disorder (PTSD) has produced substantial knowledge on the pathobiology of this frequent and debilitating disease. However, despite all research efforts, so far no drug that has specifically targeted PTSD core symptoms progressed to clinical use. Instead, although not overly efficient, serotonin re-uptake inhibitors continue to be considered the gold standard of PTSD pharmacotherapy. The psychotherapeutic treatment and symptom-oriented drug therapy options available for PTSD treatment today show some efficacy, although not in all PTSD patients, in particular not in a substantial percent of those suffering from the detrimental sequelae of repeated childhood trauma or in veterans with combat related PTSD. PTSD has this in common with other psychiatric disorders - in particular effective treatment for incapacitating conditions such as resistant major depression, chronic schizophrenia, and frequently relapsing obsessive-compulsive disorder as well as dementia has not yet been developed through modern neuropsychiatric research.In response to this conundrum, the National Institute of Mental Health launched the Research Domain Criteria (RDoC) framework which aims to leave diagnosis-oriented psychiatric research behind and to move on to the use of research domains overarching the traditional diagnosis systems. To the best of our knowledge, the paper at hand is the first that has systematically assessed the utility of the RDoC system for PTSD research. Here, we review core findings in neurobiological PTSD research and match them to the RDoC research domains and units of analysis. Our synthesis reveals that several core findings in PTSD such as amygdala overactivity have been linked to all RDoC domains without further specification of their distinct role in the pathophysiological pathways associated with these domains. This circumstance indicates that the elucidation of the cellular and molecular processes ultimately decisive for regulation of psychic processes and for the expression of psychopathological symptoms is still grossly incomplete. All in all, we find the RDoC research domains to be useful but not sufficient for PTSD research. Hence, we suggest adding two novel domains, namely stress and emotional regulation and maintenance of consciousness. As both of these domains play a role in various if not in all psychiatric diseases, we judge them to be useful not only for PTSD research but also for psychiatric research in general.

Resilience, Trauma, and Coping

The study and use of resilience is of the utmost importance to psychodynamic psychiatry. It is deeply ingrained in ideas about well-being and the treatment and care of patients. However, its neurobiology is incompletely understood, its terminology and relation to trauma and coping not well defined, and its efficacy underutilized in clinical practice. This article reviews the scientific literature on resilience, especially as it relates to trauma and coping. It also attempts to point the way for its greater application in psychiatry and mental health by utilizing resilience in more informed and individualized approaches.

PTSD in Court III: Malingering, assessment, and the law

This journal's third article on PTSD in Court focuses especially on the topic's "court" component. It first considers the topic of malingering, including in terms of its definition, certainties, and uncertainties. As with other areas of the study of psychological injury and law, generally, and PTSD (posttraumatic stress disorder), specifically, malingering is a contentious area not only definitionally but also empirically, in terms of establishing its base rate in the index populations assessed in the field. Both current research and re-analysis of past research indicates that the malingering prevalence rate at issue is more like 15±15% as opposed to 40±10%. As for psychological tests used to assess PTSD, some of the better ones include the TSI-2 (Trauma Symptom Inventory, Second Edition; Briere, 2011), the MMPI-2-RF (Minnesota Multiphasic Personality Inventory, Second Edition, Restructured Form; Ben-Porath & Tellegen, 2008/2011), and the CAPS-5 (The Clinician-Administered PTSD Scale for DSM-5; Weathers, Blake, Schnurr, Kaloupek, Marx, & Keane, 2013b). Assessors need to know their own possible biases, the applicable laws (e.g., the Daubert trilogy), and how to write court-admissible reports. Overall conclusions reflect a moderate approach that navigates the territory between the extreme plaintiff or defense allegiances one frequently encounters in this area of forensic practice.