Posttraumatic intrusive symptoms across psychiatric disorders

Severe Dissociative Experiences beyond Detachment in a Large Clinical Sample of Inpatients with Post-Traumatic Stress Disorder: Diagnostic and Treatment Implications

INTRODUCTION

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains a dissociative subtype of post-traumatic stress disorder (PTSD) characterized by depersonalization and derealization. Yet, there is evidence that dissociative symptoms in PTSD go beyond this kind of detachment dissociation and that some patients present with additional compartmentalization dissociation in the form of auditory-verbal hallucination, amnesia, and identity alteration.

METHODS

Hence, in this study, we examined latent profiles of childhood trauma (Childhood Trauma Questionnaire), PTSD (Impact-of-Event Scale-Revised), and pathological dissociation (Dissociative Experiences Scale-Taxon; DES-T) in a large sample of severely traumatized inpatients with PTSD (N = 1,360).

RESULTS

Results support a three-class solution of the latent profile analysis with a PTSD class, a dissociative subtype class, and a third class characterized by more complex and more severe dissociative symptoms. Importantly, in our inpatient sample of patients with severe PTSD, the latter class was found to be the most prevalent. Both the exploratory character of our retrospective analysis of clinical routine data and the use of the DES-T limit the generalizability of our findings, which require methodologically more rigorous replication.

CONCLUSION

In severe PTSD, dissociative symptoms beyond detachment are highly prevalent. Diagnostic and treatment implications are discussed.

Recurrent involuntary memories and mind wandering are related but distinct

Spontaneous thought is common in daily life, and includes recurrent involuntary autobiographical memories (IAMs; memories retrieved unintentionally and repetitively) and mind wandering (MW). Both recurrent IAMs and MW are often unintentional or unconstrained, and both predict symptoms of mental health disorders. However, not all MW is unintentional, and not all IAMs are unconstrained. To what extent do recurrent IAMs and MW converge versus diverge? Undergraduates (N = 2,701) completed self-report measures of recurrent IAMs, trait MW, and psychopathology (i.e., PTSD, depression, anxiety). Regressions indicated that recurrent IAMs were significantly associated with spontaneous MW, but not deliberate MW. Further, both spontaneous MW and recurrent IAMs had unique relationships with disorder symptoms. Results suggest that recurrent IAMs are related to MW to the extent that recurrent IAMs are spontaneous. Conversely, recurrent IAMs are distinct from MW to the extent that recurrent IAMs' associations with disorder symptoms could not be solely explained by trait MW (and vice versa). This work highlights related, but distinguishable, forms of spontaneous thought and their transdiagnostic links with psychopathology.

Spatiotemporal dynamics of hippocampal-cortical networks underlying the unique phenomenological properties of trauma-related intrusive memories

Trauma-related intrusive memories (TR-IMs) possess unique phenomenological properties that contribute to adverse post-traumatic outcomes, positioning them as critical intervention targets. However, transdiagnostic treatments for TR-IMs are scarce, as their underlying mechanisms have been investigated separate from their unique phenomenological properties. Extant models of more general episodic memory highlight dynamic hippocampal-cortical interactions that vary along the anterior-posterior axis of the hippocampus (HPC) to support different cognitive-affective and sensory-perceptual features of memory. Extending this work into the unique properties of TR-IMs, we conducted a study of eighty-four trauma-exposed adults who completed daily ecological momentary assessments of TR-IM properties followed by resting-state functional magnetic resonance imaging (rs-fMRI). Spatiotemporal dynamics of anterior and posterior hippocampal (a/pHPC)-cortical networks were assessed using co-activation pattern analysis to investigate their associations with different properties of TR-IMs. Emotional intensity of TR-IMs was inversely associated with the frequency and persistence of an aHPC-default mode network co-activation pattern. Conversely, sensory features of TR-IMs were associated with more frequent co-activation of the HPC with sensory cortices and the ventral attention network, and the reliving of TR-IMs in the "here-and-now" was associated with more persistent co-activation of the pHPC and the visual cortex. Notably, no associations were found between HPC-cortical network dynamics and conventional symptom measures, including TR-IM frequency or retrospective recall, underscoring the utility of ecological assessments of memory properties in identifying their neural substrates. These findings provide novel insights into the neural correlates of the unique features of TR-IMs that are critical for the development of individualized, transdiagnostic treatments for this pervasive, difficult-to-treat symptom.

Specific topics, specific symptoms: linking the content of recurrent involuntary memories to mental health using computational text analysis

Researchers debate whether recurrent involuntary autobiographical memories (IAMs; memories of one's personal past retrieved unintentionally and repetitively) are pathological or ordinary. While some argue that these memories contribute to clinical disorders, recurrent IAMs are also common in everyday life. Here, we examined how the content of recurrent IAMs might distinguish between those that are maladaptive (related to worse mental health) versus benign (unrelated to mental health). Over two years, 6187 undergraduates completed online surveys about recurrent IAMs; those who experienced recurrent IAMs within the past year were asked to describe their memories, resulting in 3624 text descriptions. Using a previously validated computational approach (structural topic modeling), we identified coherent topics (e.g., "Conversations", "Experiences with family members") in recurrent IAMs. Specific topics (e.g., "Negative past relationships", "Abuse and trauma") were uniquely related to symptoms of mental health disorders (e.g., depression, PTSD), above and beyond the self-reported valence of these memories. Importantly, we also found that content in recurrent IAMs was distinct across symptom types (e.g., "Communication and miscommunication" was related to social anxiety, but not symptoms of other disorders), suggesting that while negative recurrent IAMs are transdiagnostic, their content remains unique across different types of mental health concerns. Our work shows that topics in recurrent IAMs-and their links to mental health-are identifiable, distinguishable, and quantifiable.

A systematic review and meta-analysis of the effect of cognitive interventions to prevent intrusive memories using the trauma film paradigm

There is an unmet need for effective early interventions that can relieve initial trauma symptoms and reduce symptoms of posttraumatic stress disorder (PTSD). We evaluated the efficacy of cognitive interventions compared to control in reducing intrusion frequency and PTSD symptoms in healthy individuals using the trauma film paradigm, in which participants view a film with aversive content as an experimental analogue of trauma exposure. A systematic literature search identified 41 experiments of different cognitive interventions targeting intrusions. In the meta-analysis, the pooled effect size of 52 comparisons comparing cognitive interventions to no-intervention controls on intrusions was moderate (g = -0.46, 95% CI [-0.61 to -0.32], p < .001). The pooled effect size of 16 comparisons on PTSD symptoms was also moderate (g = -0.31, 95% CI [-0.46 to -0.17], p < .001). Both visuospatial interference and imagery rescripting tasks were associated with significantly fewer intrusions than controls, whereas verbal interference and meta-cognitive processing tasks showed nonsignificant effect sizes. Interventions administered after viewing the trauma film showed significantly fewer intrusions than controls, whereas interventions administered during film viewing did not. No experiments had low risk of bias (ROB), 37 experiments had some concerns of ROB, while the remaining four experiments had high ROB. To the best of our knowledge, this is the first meta-analysis investigating the efficacy of cognitive interventions targeting intrusions in non-clinical samples. Results seem to be in favour of visuospatial interference tasks rather than verbal tasks. More research is needed to develop an evidence base on the efficacy of various cognitive interventions and test their clinical translation to reduce intrusive memories of real trauma.

Associations between the Trauma Memory Quality Questionnaire and posttraumatic stress symptoms in youth: A systematic review and meta-analysis

Cognitive models of posttraumatic stress disorder (PTSD) propose that trauma memory characteristics are implicated in the etiology of the disorder. Empirical support for cognitive models in youth is necessary to ensure psychological interventions are based on appropriate theory. This meta-analysis was conducted to quantitatively investigate the strength of the associations between self-reported trauma memory characteristics (e.g., sensory and temporal features), measured using the Trauma Memory Quality Questionnaire (TMQQ), and posttraumatic stress symptoms (PTSS) in children and adolescents. PsycINFO, MEDLINE, CINAHL, PTSDPubs, and ProQuest Dissertations and Theses Global were searched for relevant literature. In total, 11 studies (N = 1,270 participants) met the inclusion criteria for the random-effects meta-analysis. A large effect size was observed for the association between trauma memory characteristics and PTSS, r = .51, 95% CI [.44, .58], and was maintained in subgroup analyses of the prospective association between trauma memory characteristics and later PTSS (k = 5, n = 6 28), r = .51, 95% CI [.42, .59]. A slightly larger effect size was observed in subgroup analyses of the cross-sectional association between trauma memory characteristics and concurrent PTSS (k = 11, N = 1,270), r = .62, 95% CI [.53, .70]. Sensitivity analyses on study quality, TMQQ alteration, chronic trauma exposure, geographical location, and PTSS measure supported the robustness of these results. These findings provide empirical support for the role of trauma memory characteristics in PTSS, congruent with cognitive models, suggesting this theoretical framework is appropriate for youth populations. Limitations and recommendations for future research are discussed.

Post-traumatic stress disorder: clinical and translational neuroscience from cells to circuits

Post-traumatic stress disorder (PTSD) is a maladaptive and debilitating psychiatric disorder, characterized by re-experiencing, avoidance, negative emotions and thoughts, and hyperarousal in the months and years following exposure to severe trauma. PTSD has a prevalence of approximately 6-8% in the general population, although this can increase to 25% among groups who have experienced severe psychological trauma, such as combat veterans, refugees and victims of assault. The risk of developing PTSD in the aftermath of severe trauma is determined by multiple factors, including genetics - at least 30-40% of the risk of PTSD is heritable - and past history, for example, prior adult and childhood trauma. Many of the primary symptoms of PTSD, including hyperarousal and sleep dysregulation, are increasingly understood through translational neuroscience. In addition, a large amount of evidence suggests that PTSD can be viewed, at least in part, as a disorder that involves dysregulation of normal fear processes. The neural circuitry underlying fear and threat-related behaviour and learning in mammals, including the amygdala-hippocampus-medial prefrontal cortex circuit, is among the most well-understood in behavioural neuroscience. Furthermore, the study of threat-responding and its underlying circuitry has led to rapid progress in understanding learning and memory processes. By combining molecular-genetic approaches with a translational, mechanistic knowledge of fear circuitry, transformational advances in the conceptual framework, diagnosis and treatment of PTSD are possible. In this Review, we describe the clinical features and current treatments for PTSD, examine the neurobiology of symptom domains, highlight genomic advances and discuss translational approaches to understanding mechanisms and identifying new treatments and interventions for this devastating syndrome.

Gonadal steroid hormones and emotional memory consolidation: A systematic review and meta-analysis

Anxiety and stress-related disorders are more prevalent in women and associated with negative emotional memory consolidation as well as impaired fear extinction recall. Recent research has identified a role of gonadal steroid hormones in influencing emotional memories and fear extinction, however most individual studies have small samples and employed various protocols. A systematic review and meta-analysis were conducted on studies that examined sex hormones (estrogen, progesterone, testosterone, allopregnanolone, dehydroepiandrosterone) on four aspects of memory, namely, intentional recall (k = 13), recognition memory (k = 7), intrusive memories (k = 9), and extinction recall (k = 11). The meta-analysis on natural cycling women revealed that progesterone level was positively associated with negative recall and negative intrusive memories, and this effect on intentional recall was enhanced under stress induction. Estradiol level was positively associated with extinction recall. This study reveals an important role of progesterone and estradiol in influencing emotional memory consolidation. It highlights the need to control for these hormonal effects and examine progesterone and estradiol concurrently across all menstrual phases in future emotional memory paradigms.

Preoccupation as psychopathological process and symptom in adjustment disorder: A scoping review

In the ICD‐11 diagnostic guidelines, preoccupation has been introduced as the new core symptom of adjustment disorder. Despite this essential innovation, preoccupation has so far largely been defined as rumination and worry and does not feature a distinct character as an independent symptom. In order to investigate the nature of preoccupation, various cognitive approaches are evaluated and linked to preoccupation. Furthermore, the aim of this review is to define preoccupation more precisely and to distinguish it from other symptoms in psychopathology. The evaluation of key features of cognitive dissonance theory, attention bias theory, memory theories, and other cognitive paradigms indicates that preoccupation is constituted by a complex interaction of cognitive–emotional mechanisms. In addition, this review implies that preoccupation in AjD can be defined as stressor‐related factual thinking, which is time‐consuming and often associated with negative emotions. It is assumed that rumination and dysfunctional worry serve as reactive processes to cope with preoccupation. For further distinction, this review presents similarities and differences of preoccupation and other symptoms, including negative automatic thoughts, flashbacks, and yearning. Finally, implications and suggestions for future research on preoccupation are offered. Overall, it is plausible that preoccupation is not only associated with adjustment disorder but also possesses a transdiagnostic character.

Neuromodulation of Visual Cortex Reduces the Intensity of Intrusive Memories

Aversive events can be reexperienced as involuntary and spontaneous mental images of the event. Given that the vividness of retrieved mental images is coupled with elevated visual activation, we tested whether neuromodulation of the visual cortex would reduce the frequency and negative emotional intensity of intrusive memories. Intrusive memories of a viewed trauma film and their accompanied emotional intensity were recorded throughout 5 days. Functional connectivity, measured with resting-state functional magnetic resonance imaging prior to film viewing, was used as predictive marker for intrusions-related negative emotional intensity. Results indicated that an interaction between the visual network and emotion processing areas predicted intrusions’ emotional intensity. To test the causal influence of early visual cortex activity on intrusions’ emotional intensity, participants’ memory of the film was reactivated by brief reminders 1 day following film viewing, followed by inhibitory 1 Hz repetitive transcranial magnetic stimulation (rTMS) over early visual cortex. Results showed that visual cortex inhibitory stimulation reduced the emotional intensity of later intrusions, while leaving intrusion frequency and explicit visual memory intact. Current findings suggest that early visual areas constitute a central node influencing the emotional intensity of intrusive memories for negative events. Potential neuroscience-driven intervention targets designed to downregulate the emotional intensity of intrusive memories are discussed.

Attachment Style Moderates Polygenic Risk for Posttraumatic Stress in United States Military Veterans: Results From the National Health and Resilience in Veterans Study

BACKGROUND

A polygenic risk score (PRS) derived from genome-wide association studies of posttraumatic stress disorder (PTSD) may inform risk for this disorder. To date, however, no known study has examined whether social environmental factors such as attachment style may moderate the relation between PRS and PTSD.

METHODS

We evaluated main and interactive effects of PRS and attachment style on PTSD symptoms in a nationally representative sample of trauma-exposed European-American U.S. military veterans (N = 2030). PRS was derived from a genome-wide association study of PTSD re-experiencing symptoms (N = 146,660) in the Million Veteran Program cohort. Using one-sample Mendelian randomization with data from the UK Biobank (N = 115,099), we evaluated the effects of re-experiencing PRS and attachment style on PTSD symptoms.

RESULTS

Higher re-experiencing PRS and secure attachment style were independently associated with PTSD symptoms. A significant PRS-by-attachment style interaction was also observed (β = -.11, p = .006), with a positive association between re-experiencing PRS and PTSD symptoms observed only among veterans with an insecure attachment style. One-sample Mendelian randomization analyses suggested that the association between PTSD symptoms and attachment style is bidirectional. PRS enrichment analyses revealed a significant interaction between attachment style and a variant mapping to the IGSF11 gene (rs151177743, p = 2.1 × 10^-7), which is implicated in regulating excitatory synaptic transmission and plasticity.

CONCLUSIONS

Attachment style may moderate polygenic risk for PTSD symptoms, and a novel locus implicated in synaptic transmission and plasticity may serve as a possible biological mediator of this association. These findings may help inform interpersonally oriented treatments for PTSD for individuals with high polygenic risk for this disorder.

Demanding and effective: participants' experiences of internet-delivered prolonged exposure provided within two months after exposure to trauma

Background: The use of remotely delivered early intervention after trauma may prevent and/or reduce symptoms of post-traumatic stress. Our research group evaluated a novel three-week therapist-guided internet-delivered intervention based on prolonged exposure (Condensed Internet-Delivered Prolonged Exposure; CIPE) in a pilot trial. The results indicated that the intervention was feasible, acceptable and reduced symptoms of post-traumatic stress at post-intervention compared to a waiting-list condition. Exposure to traumatic memories can be emotionally demanding and there is a need for detailed investigation of participants' experiences in receiving this type of intervention remotely. Objective: Investigate participants' experiences of receiving CIPE early after trauma. Method: In this study, qualitative thematic analysis was used and semi-structured interviews with 11 participants six months after intervention completion were conducted. All interviews were audio-recorded and transcribed verbatim. Results: One overarching theme labelled as 'demanding and effective' was identified. Participants expressed that treatment effects could only be achieved by putting in a lot of effort and by being emotionally close to the trauma memory during exposure exercises. Participants reported CIPE to be a highly credible- and educative intervention that motivated them to fully engage in exposure exercises. The most distressing parts of the intervention was perceived as tolerable and important to do to heal psychologically after trauma. For many participants, the possibility to engage in the intervention whenever and where it suited them was helpful, although some participants described it as challenging to find a balance between their own responsibility and when to expect therapist support. The internet-based format was perceived as a safe forum for self-disclosure that helped some participants overcome avoidance due to shame during imaginal exposure. Conclusion: CIPE was considered demanding, yet effective by the interviewed participants. The most distressing parts of the intervention was perceived to be the most important and were tolerable and feasible to provide online.

Condensed internet-delivered prolonged exposure provided soon after trauma: A randomised pilot trial

Exposure to trauma is common and may have detrimental psychological consequences. Brief exposure therapy provided early after trauma has shown encouraging results in promoting recovery. To scale up treatment availability, we developed a 3-week internet-delivered intervention comprised of four modules based on prolonged exposure (condensed internet-delivered prolonged exposure; CIPE) with therapist support. In this pilot study, we assessed the feasibility, acceptability, and preliminary efficacy of CIPE delivered within 2 months after the index event. Thirty-three participants were randomised to CIPE or a waiting list (WL). The frequency, vividness and distress of intrusive recollections or flashback memories of the traumatic event were assessed using an intrusive memory smartphone app. Symptoms of post-traumatic stress were assessed by the PTSD Symptom Checklist for DSM-5 (PCL-5). The most common index traumas in the sample were rape, interpersonal violence and life-threatening accidents. A majority of participants (82%) randomised to CIPE completed all modules, and the number of logins per participant to the Internet platform was high during the three-week intervention (M = 19.6, SD = 11.8). At post-treatment, the CIPE participants had a more favourable reduction than the WL group on the vividness and distress ratings, as well as on the PCL-5 sum score (bootstrapped d = 0.85; 95% CI [0.25-1.45]). Treatment effects were sustained at 6-months follow up and no severe adverse events associated with the intervention were found. CIPE seems to be a feasible and possibly efficacious early intervention after trauma. Large-scale trials are needed to assess its efficacy and long-term benefits.

Cumulative Trauma Exposure and Chronic Homelessness Among Veterans: The Roles of Responses to Intrusions and Emotion Regulation

Veterans with mental health problems and a history of interpersonal and military trauma exposure are at increased risk for chronic homelessness. Although studies have examined posttraumatic stress disorder (PTSD) as a predictor of homelessness, there is limited understanding of specific mechanisms related to cumulative trauma exposure. We sought to elucidate how cumulative interpersonal and military trauma exposure may be linked to homelessness chronicity by examining the role of factors that influence trauma recovery and functional impairment. Specifically, we examined the indirect association of cumulative trauma exposure with homelessness chronicity through distress and responses to trauma-related intrusions and emotion regulation problems in a sample of 239 veterans in community-based homeless programs. Participants completed measures of trauma exposure, responses to intrusions, intrusion distress, difficulties with emotion regulation, and duration and episodes of homelessness. Structural equation modeling was used to test a serial indirect effect model in which cumulative trauma exposure was indirectly associated with homelessness chronicity through distress from and responses to intrusions as well as emotion regulation problems. The results supported the hypothesized sequential indirect effect for episodes of homelessness, indirect effect odds ratio (IE ORs) = 1.12-1.13, but not for current episode duration, IE OR = 1.05. Overall, the present findings elucidate specific trauma-related factors that may be particularly relevant to episodic patterns of homelessness and interfere with efforts to remain housed. These findings represent an important step toward shaping policy and program development to better meet mental health care needs and improve housing outcomes among homeless veterans.

Interrupting traumatic memories in the emergency department: a randomized controlled pilot study

BACKGROUND

The hours immediately following a traumatic event may present a window of opportunity to interrupt the consolidation of memories of the traumatic event, and this may prevent PTSD development. This theory has been validated in a series of analogue studies, showing that a visuo-spatial task reduces intrusive memories, however clinical studies are scarce.

OBJECTIVE

This pilot RCT examined the use of a semi-immersive Virtual Reality visuospatial task, as an intervention to interrupt memory consolidation, in the Emergency Department (ED) in the immediate hours following a traumatic event. We hypothesised that participants who had received the intervention would present with lower levels of PTSD symptoms than the control group who received no intervention.

METHOD

Seventy-seven adult survivors of traumatic events, meeting study criteria, were recruited in the ED of a Level III Trauma Centre. Survivors arrived at the ED less than one hour, on average, after the trauma. After signing informed consent, participants were randomized to the SnowWorld intervention or control group. Both groups completed self-report questionnaires, and the intervention group used SnowWorld for up to 10 minutes.

RESULTS

No significant differences between the intervention and control groups were found regarding PTSD symptom levels two weeks and six months following the traumatic event.

CONCLUSIONS

These results add to the growing literature examining the use of a concurrent task to reduce intrusions following a traumatic event. In contrast to previous clinical studies, this study did not show significant group differences; however, it replicates an analogue study that used a specifically developed app. Further studies are needed to elucidate possible reasons for these conflicting results.

Efficacy of Psychoeducation and Cognitive Rehabilitation After Mild Traumatic Brain Injury for Preventing Post-concussional Syndrome in Individuals With High Risk of Poor Prognosis: A Randomized Clinical Trial

Unfavorable outcomes (UO) occur in 15-20% of patients with mild traumatic brain injury (mTBI). Early identification of patients at risk of UO is crucial for suitable management to be initiated, increasing the chances of full recovery. We previously developed a prognostic tool for early identification (8-21 days after the injury) of patients likely to develop UO. Patients whose initial risk factors indicate UO are at risk of developing post-concussion syndrome (PCS). In the present study, we examined the beneficial effects of early multidimensional management (MM) on prognosis. We used our prognostic tool to classify 221 mTBI patients into a UO (97) group or a favorable outcome (FO) group (124). We randomized the UO patients into two subgroups: a group that underwent MM (involving psychoeducation and cognitive rehabilitation) (34) and a control group with no specific treatment other than psychoeducation (46). At 6 months, these two groups were compared to assess the impact of MM. Among the followed-up patients initially classified as having FO (101), 95% had FO at 6 months and only five had PCS [as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV classification]. Among the followed-up MM patients, 94% did not have PCS 6 months after injury, whereas 52% of the control patients had PCS. The effect of MM on the recovery of patients at 6 months, once adjusted for the main confounding factors, was significant (p < 0.001). These results show that the initiation of MM after early identification of at-risk mTBI patients can considerably improve their outcomes. Clinical Trials Registration: The study was registered at ClinicalTrials.gov (NCT03811626).

Trauma Memory Processing in Posttraumatic Stress Disorder Psychotherapy: A Unifying Framework

Trauma memory processing (TMP) is an empirically supported approach to psychotherapy for posttraumatic stress disorder (PTSD). However, TMP is not a single, uniform intervention but instead a paradigm that can be operationalized through a variety of component procedures that have not been systematically elucidated and formally tested. Based on findings from phenomenological/structural and neuroimaging research, a central feature of PTSD is theorized to be the involuntary immersion in trauma memories with diminished awareness or negative appraisals of self and current context. Such intrusive reexperiencing-which is epitomized by, but not limited to, flashbacks-is postulated to underlie PTSD's avoidance, altered emotions and cognitions, dissociative, and hyperarousal/hypervigilance symptoms; it is thus a logical target for TMP. The varied approaches to TMP for PTSD are conceptualized as having the common goal of activation of the neural networks in the brain that underlie two key capacities disrupted by intrusive reexperiencing in PTSD: intentional self-referential retrieval of memories and suppression of memory retrieval. Therefore, TMP is postulated to involve two core functions (purposeful reflective remembering and memory awareness in situ) and three essential types (in vivo, imaginal, and cognitive reappraisal). Several implications of this framework for clinical practice and research on TMP for PTSD are discussed.

Memory and Forgetting

PURPOSE OF REVIEW

I summarize recent developments in understanding the phenomenology of memory in PTSD, describe the most prominent theoretical models, and outline new forms of treatment aimed at modifying the traumatic memory.

RECENT FINDINGS

Intrusive memories that have the quality of being relived in the present have been highlighted in ICD-11. Debate over whether trauma memories are disorganized has led to a distinction between global narratives that are usually well rehearsed and episodic memories of the most frightening moments when disruptions and fragmentation may occur. Attempts to prevent the initial consolidation of trauma memories have promise in prevention but face practical difficulties. Theoretical developments have led to a number of promising treatments for established PTSD including pre-retrieval propranolol and imagery rescripting. Research has suggested real possibilities to improve the prevention and treatment of PTSD by modifying trauma recall even though the theoretical basis for these interventions remains controversial.

An investigation of potential neural correlates of intrusive retrieval of distressing memories

BACKGROUND AND OBJECTIVES

Despite the prevalence of intrusive memories across psychological disorders, little is known about the neural networks that underpin this form of memory. This study used functional magnetic resonance imaging (fMRI) to identify neural circuits associated with the retrieval of intrusive memories.

METHODS

Participants with moderate levels of anxiety (N = 30) underwent a cold pressor task to induce a physiological stress response, after which they viewed 10 neutral and 10 negative film clips. In a method designed to induce intrusive memories, participants then completed an fMRI scan in which they viewed short (2 s) depictions of neutral components from the original film clips.

RESULTS

There were no significant differences in activations during intrusion and non-intrusion responses. Exploratory analyses comparing intrusive responses to neutral stimuli found the insula, inferior frontal gyrus, precuneus, right cerebellum and bilateral supplementary motor area were uniquely activated during experience of intrusions (compared to the neutral cue baseline), whereas no significant activations were in response to negative scenes that did not trigger intrusions.

LIMITATIONS

This study did not compare the different neural processes implicated in intrusive and intentional emotional memories. The limited intrusions that could be elicited in the scanning environment restricted the number of trials that could be employed.

CONCLUSIONS

Although no differences in neural activations were observed between intrusive and non-intrusive responses, the observation of precuneus involvement is consistent with models that propose that intrusive memories are impacted by the extent to which there is contextual integration of the relevant memories.

Intrusive Memories of Trauma in the Laboratory: Methodological Developments and Future Directions

Purpose of the Review

Intrusive memories are those that spring to mind unbidden, e.g. sensory recollections of stressful/traumatic events. We review recent methods to monitor intrusions of a stressor (a trauma film) within the laboratory.

Recent Findings

Recent studies suggest three main methodologies after viewing a trauma film by which to monitor intrusions in the laboratory: during post-film rest periods, after exposure to trigger cues, and while performing an ongoing task. These approaches allow factors to be tested (e.g. psychological or pharmacological) that may influence the frequency of occurrence of intrusions.

Summary

We raise methodological considerations to guide trauma film studies using intrusion monitoring in the laboratory to complement monitoring approaches in daily life (e.g. diaries). Intrusion monitoring in the laboratory also confers greater experimental control and may open novel research avenues, to advance intervention development to mitigate problematic intrusive memory symptoms.

Development and testing of TraumaGameplay: an iterative experimental approach using the trauma film paradigm

Background: Vivid trauma-related intrusions are a hallmark symptom of posttraumatic stress disorder (PTSD), and may be involved in its onset. Effective interventions to reduce intrusions and to potentially prevent the onset of subsequent PTSD are scarce. Studies suggest that playing the videogame Tetris, shortly after watching aversive film clips, reduces subsequent intrusions. Other studies have shown that taxing working memory (WM) while retrieving an emotional memory reduces the memory's vividness and emotionality. Objective: We developed TraumaGameplay (TGP), a gaming app designed to reduce intrusions. This paper describes two successive experiments to determine whether playing TGP without memory retrieval (regular TGP) or TGP with memory retrieval (dual-task TGP) reduces intrusion frequency at one week compared to a no-game control. Method: For both experiments, healthy university students were recruited. Experiment 1: 92 participants were exposed to a trauma film and randomized to (1) regular TGP1 (n = 31), (2) dual-task TGP1 (n = 31) or (3) control (n = 30). In experiment 2, 120 healthy students were exposed to a trauma film and randomized to (1) regular TGP2 (n = 30), (2) dual-task TGP2 (n = 29), (3) recall only (n = 31) or (4) control (n = 30). Results: We found no significant difference between conditions on the number of intrusions for either playing regular TGP or dual-task TGP in both experiment 1 and experiment 2. Conclusion: Our results could not replicate earlier promising findings from preceding experimental research. Several reasons may underpin this difference ranging from the visuospatial videogame used in our experiments to the method of the experiment to the difficulties of replicability in general.

A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD

The World Health Organization's proposals for posttraumatic stress disorder (PTSD) in the 11th edition of the International Classification of Diseases, scheduled for release in 2018, involve a very brief set of symptoms and a distinction between two sibling disorders, PTSD and Complex PTSD. This review of studies conducted to test the validity and implications of the diagnostic proposals generally supports the proposed 3-factor structure of PTSD symptoms, the 6-factor structure of Complex PTSD symptoms, and the distinction between PTSD and Complex PTSD. Estimates derived from DSM-based items suggest the likely prevalence of ICD-11 PTSD in adults is lower than ICD-10 PTSD and lower than DSM-IV or DSM-5 PTSD, but this may change with the development of items that directly measure the ICD-11 re-experiencing requirement. Preliminary evidence suggests the prevalence of ICD-11 PTSD in community samples of children and adolescents is similar to DSM-IV and DSM-5. ICD-11 PTSD detects some individuals with significant impairment who would not receive a diagnosis under DSM-IV or DSM-5. ICD-11 CPTSD identifies a distinct group who have more often experienced multiple and sustained traumas and have greater functional impairment than those with PTSD.

Identification and treatment of Nepal 2015 earthquake survivors with posttraumatic stress disorder by nonspecialist volunteers: An exploratory cross-sectional study

CONTEXT

In April 2015, a major earthquake struck northern regions of Nepal affecting one-third of the population, and many suffered mental health problems.

AIMS

This study aimed to conduct a preliminary investigation of prevalence and feasibility of brief therapy for posttraumatic stress disorder (PTSD) among earthquake survivors.

SETTINGS AND DESIGN

This is an exploratory cross-sectional study of prevalence and feasibility of brief trauma-focused therapy for PTSD among survivors 3 and 11 months after the earthquake in affected areas near Kathmandu.

METHODOLOGY

A team of local nonspecialist mental health volunteers was trained to identify survivors with PTSD using the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5) (cutoff score 38). They were trained to deliver either shortened versions of narrative exposure therapy (NET)-revised or group-based control-focused behavioral treatment (CFBT).

RESULTS

Altogether, 333 survivors were surveyed (130 in July 2015 and 203 in March 2016) with PCL-5 as the screening instrument, using the cutoff score of 38 or more for diagnosing PTSD. A PTSD prevalence of 33% was noted in 2015 and 28.5% in 2016. This drop of 4.5% prevalence in the intervening 8 months suggests that a significant number of survivors are still suffering from PTSD. Most participants were female, aged 40 or above, married, and poorly educated. Compared to the brief (four sessions) individual NET-revised, a group-based CFBT was found more acceptable and affordable.

CONCLUSIONS

PTSD is common following earthquake trauma, and if untreated, survivors continue to suffer for a long time. Management of PTSD should be included in future disaster management plans.

'I Can't Concentrate': A Feasibility Study with Young Refugees in Sweden on Developing Science-Driven Interventions for Intrusive Memories Related to Trauma

Background

The number of refugees is the highest ever worldwide. Many have experienced trauma in home countries or on their escape which has mental health sequelae. Intrusive memories comprise distressing scenes of trauma which spring to mind unbidden. Development of novel scalable psychological interventions is needed urgently.

Aims

We propose that brief cognitive science-driven interventions should be developed which pinpoint a focal symptom alongside a means to monitor it using behavioural techniques. The aim of the current study was to assess the feasibility and acceptability of the methodology required to develop such an intervention.

Method

In this study we recruited 22 refugees (16–25 years), predominantly from Syria and residing in Sweden. Participants were asked to monitor the frequency of intrusive memories of trauma using a daily diary; rate intrusions and concentration; and complete a 1-session behavioural intervention involving Tetris game-play via smartphone.

Results

Frequency of intrusive memories was high, and associated with high levels of distress and impaired concentration. Levels of engagement with study procedures were highly promising.

Conclusions

The current work opens the way for developing novel cognitive behavioural approaches for traumatized refugees that are mechanistically derived, freely available and internationally scalable.

PTSD in Court I: Introducing PTSD for Court

The first part of the series of three articles on posttraumatic stress disorder (PTSD) in Court to appear in the journal reviews the history of the construct of PTSD and its presentation in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; American Psychiatric Association, 2013) and the ICD-11 (International Classification of Diseases, 11th Edition; World Health Organization, 2018). There are 20 symptoms of PTSD in the DSM-5. PTSD symptoms are arranged into a four-cluster model, which has received partial support in the literature. Other four-factor models have been found that fit the data even better than that of the DSM-5. There is a five-factor dysphoria model and two six-factor models that have been found to fit better the DSM-5 PTSD symptoms. Finally, research is providing support for a hybrid seven-factor model. An eighth factor on dissociation seems applicable to the minority of people who express the dissociative subtype. At the epidemiological level, individuals can expect trauma exposure to take place about 70% over one's lifetime. Also, traumatic exposure leads to traumatic reactions in about 10% of cases, with PTSD being a primary diagnosis for trauma. Once initiated, PTSD becomes prolonged in about 10% of cases. Polytrauma and comorbidities complicate these prevalence statistics. Moreover, the possibility of malingered PTSD presents confounds. However, the estimate for malingered PTSD varies extensively, from 1 to 50%, so that the estimate is too imprecise for use in court without further research. This first article in the series of three articles appearing in the journal on PTSD in Court concludes with discussion of complications related to comorbidities and heterogeneities, in particular. For example, PTSD and its comorbidities can be expressed in over one quintillion ways. This complexity in its current structure in the DSM-5 speaks to the individual differences involved in its expression.

Intrusive Memories of Distressing Information: An fMRI Study

Although intrusive memories are characteristic of many psychological disorders, the neurobiological underpinning of these involuntary recollections are largely unknown. In this study we used functional magentic resonance imaging (fMRI) to identify the neural networks associated with encoding of negative stimuli that are subsequently experienced as intrusive memories. Healthy partipants (N = 42) viewed negative and neutral images during a visual/verbal processing task in an fMRI context. Two days later they were assessed on the Impact of Event Scale for occurrence of intrusive memories of the encoded images. A sub-group of participants who reported significant intrusions (n = 13) demonstrated stronger activation in the amygdala, bilateral ACC and parahippocampal gyrus during verbal encoding relative to a group who reported no intrusions (n = 13). Within-group analyses also revealed that the high intrusion group showed greater activity in the dorsomedial (dmPFC) and dorsolateral prefrontal cortex (dlPFC), inferior frontal gyrus and occipital regions during negative verbal processing compared to neutral verbal processing. These results do not accord with models of intrusions that emphasise visual processing of information at encoding but are consistent with models that highlight the role of inhibitory and suppression processes in the formation of subsequent intrusive memories.

Activating Attachments Reduces Memories of Traumatic Images

Emotional memories, and especially intrusive memories, are a common feature of many psychological disorders, and are overconsolidated by stress. Attachment theory posits that activation of mental representations of attachment figures can reduce stress and boost coping. This study tested the proposition that attachment activation would reduce consolidation of emotional and intrusive memories. Sixty-seven undergraduate students viewed subliminal presentations of traumatic and neutral images, which were preceded by subliminal presentations of either attachment-related images or non-attachment-related images; free recall and intrusive memories were assessed two days later. Participants with low avoidant attachment tendencies who received the attachment primes recalled fewer memories and reported fewer intrusions than those who received the non-attachment primes. Unexpectedly, those with high anxious attachment tendencies reported fewer memories. These findings generally accord with attachment theory, and suggest that consolidation of emotional memories can be moderated by activation of attachment representations.

Differences in Intrusive Memory Experiences in Post-traumatic Stress Disorder after Single, Re- and Prolonged Traumatization

Intrusive memory experiences (IMEs) are a common symptom of post-traumatic stress disorder (PTSD). Sensory perceptions of IMEs in the PTSD context vary substantially. The present research examined 20 patients with a single trauma, 20 re-traumatized patients and 80 Holocaust-traumatized patients who suffered from PTSD. Our results revealed significant differences in IME frequency based on the types of trauma experience. The findings suggest that patients with prolonged (Holocaust) traumata suffered from visual (65%) and combined visual/acoustic intrusive memories (29%), whereas visual memory experiences were most frequent (90%) among single-trauma patients. The trauma experience and the intrusive memory trigger stimulus were interdependent. The type of trauma critically affects the traumatic experience. Future studies should focus on these findings to improve PTSD therapeutic options.

A Comparison of DSM-5 and DSM-IV Diagnostic Criteria for Posttraumatic Stress Disorder in Traumatized Refugees

The aim of this study was to compare the prevalence rate and factor structure of posttraumatic stress disorder (PTSD) based on the diagnostic criteria of the fourth and fifth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; DSM-5; American Psychiatric Association, , ) in traumatized refugees. There were 134 adult treatment-seeking, severely and multiply traumatized patients from various refugee backgrounds were assessed in their mother tongue using a computerized set of questionnaires consisting of a trauma list, the Posttraumatic Diagnostic Scale, and the new PTSD items that had been suggested by the DSM-5 Task Force of the American Psychiatric Association. Using DSM-IV, 60.4% of participants met diagnostic criteria for PTSD; using DSM-5, only 49.3% fulfilled all criteria (p < .001). Confirmatory factor analysis of DSM-IV and DSM-5 items showed good and comparable model fits. Furthermore, classification functions in the DSM-5 were satisfactory. The new Cluster D symptoms showed relatively high sensitivity, specificity, positive predictive power, and negative predictive power. The DSM-5 symptom structure appears to be applicable to traumatized refugees. Negative alterations in cognitions and mood may be especially useful for clinicians, not only to determine the extent to which an individual refugee is likely to meet criteria for PTSD, but also in providing targets for clinical intervention.

Re-experiencing traumatic events in PTSD: new avenues in research on intrusive memories and flashbacks

Posttraumatic flashbacks, consisting of the intrusive re-experiencing of traumatic experiences in the present, have been more clearly defined for the first time in DSM-5 and have been identified as a unique symptom of posttraumatic stress disorder in the proposed ICD-11 diagnostic criteria. Relatively little research into flashbacks has been conducted, however, and new research efforts are required to understand the cognitive and biological basis of this important symptom. In addition, there is considerable scope for research into how flashbacks should be assessed and into flashbacks occurring in different contexts, such as psychosis or intensive care.

The role of frontal EEG asymmetry in post-traumatic stress disorder

Frontal alpha asymmetry, a biomarker derived from electroencephalography (EEG) recordings, has often been associated with psychological adjustment, with more left-sided frontal activity predicting approach motivation and lower levels of depression and anxiety. This suggests high relevance to post-traumatic stress disorder (PTSD), a disorder comprising anxiety and dysphoria symptoms. We review this relationship and show that frontal asymmetry can be plausibly linked to neuropsychological abnormalities seen in PTSD. However, surprisingly few studies (k = 8) have directly addressed frontal asymmetry in PTSD, mostly reporting that trait frontal asymmetry has little (if any) predictive value. Meanwhile, preliminary evidence suggest that state-dependent asymmetry during trauma-relevant stimulation distinguishes PTSD patients from resilient individuals. Thus, exploring links between provocation-induced EEG asymmetry and PTSD appears particularly promising. Additionally, we recommend more fine-grained analyses into PTSD symptom clusters in relation to frontal asymmetry. Finally, we highlight hypotheses that may guide future research and help to fully apprehend the practical and theoretical relevance of this biological marker.

Trauma-Related Altered States of Consciousness (TRASC) and Functional Impairment I: Prospective Study in Acutely Traumatized Persons

A theoretical framework referred to as a 4-D model has been described for classifying posttraumatic stress symptoms into those potentially occurring within normal waking consciousness (NWC) versus those thought to intrinsically exemplify dissociative experiences, specifically, trauma-related altered states of consciousness (TRASC). As a further test of this theoretical distinction, this prospective study evaluated whether TRASC and NWC forms of distress incrementally and prospectively predicted functional impairment at 6 and 12 weeks following presentation at hospital emergency departments in the acute aftermath of traumatic events in 180 persons. Establishing the clinical significance of both TRASC and NWC-distress symptoms, we found that 6-week markers of TRASC and NWC-distress independently predicted 12-week self-reported levels of social and occupational impairment. We also observed broad support for various predictions of the 4-D model except that, in contrast with hypotheses, childhood trauma history was generally more strongly correlated with symptoms of NWC-distress than with TRASC. Future research directions are discussed.

DSM-5's posttraumatic stress disorder with dissociative symptoms: challenges and future directions

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, formally recognizes a dissociative subtype of posttraumatic stress disorder (PTSD; PTSD with dissociative symptoms). This nomenclative move will boost empirical and theoretical efforts to further understand the links between dissociation, trauma, and PTSD. This article examines the empirical literature showing that patients with PTSD can be divided into 2 different groups based on their neurobiology, psychological symptom profile, history of exposure to early relational trauma, and depersonalization/derealization symptoms. It then explores the conceptual and empirical challenges of conceiving 1 of these types as reflecting a "dissociative" type of PTSD. First, this classification is based on the presence of a limited subset of dissociative symptoms (i.e., depersonalization, derealization). This sets aside an array of positive and negative psychoform and somatoform dissociative symptoms that may be related to PTSD. Second, empirical evidence suggests heightened dissociation in PTSD compared to many other disorders, indicating that dissociation is relevant to PTSD more broadly rather than simply to the so-called dissociative subtype. This article sets out important issues to be examined in the future study of dissociation in PTSD, which needs to be informed by solid conceptual understandings of dissociation.

Impact of the diagnostic changes to post-traumatic stress disorder for DSM-5 and the proposed changes to ICD-11

BACKGROUND

There have been changes to the criteria for diagnosing post-traumatic stress disorder (PTSD) in DSM-5 and changes are proposed for ICD-11.

AIMS

To investigate the impact of the changes to diagnostic criteria for PTSD in DSM-5 and the proposed changes in ICD-11 using a large multisite trauma-exposed sample and structured clinical interviews.

METHOD

Randomly selected injury patients admitted to four hospitals were assessed 72 months post trauma (n = 510). Structured clinical interviews for PTSD and major depressive episode, as well as self-report measures of disability and quality of life were administered.

RESULTS

Current prevalence of PTSD under DSM-5 scoring was not significantly different from DSM-IV (6.7% v. 5.9%, z = 0.53, P = 0.59). However, the ICD-11 prevalence was significantly lower than ICD-10 (3.3% v. 9.0%, z = -3.8, P<0.001). The PTSD current prevalence was significantly higher for DSM-5 than ICD-11 (6.7% v. 3.3%, z = 2.5, P = 0.01). Using ICD-11 tended to show lower rates of comorbidity with depression and a slightly lower association with disability.

CONCLUSIONS

The diagnostic systems performed in different ways in terms of current prevalence rates and levels of comorbidity with depression, but on other broad key indicators they were relatively similar. There was overlap between those with PTSD diagnosed by ICD-11 and DSM-5 but a substantial portion met one but not the other set of criteria. This represents a challenge for research because the phenotype that is studied may be markedly different according to the diagnostic system used.

Capturing intrusive re-experiencing in trauma survivors' daily lives using ecological momentary assessment

Intrusive memories are common following traumatic events and among the hallmark symptoms of posttraumatic stress disorder (PTSD). Most studies assess summarized accounts of intrusions retrospectively. We used an ecological momentary approach and index intrusive memories in trauma survivors with and without PTSD using electronic diaries. Forty-six trauma survivors completed daily diaries for 7 consecutive days recording a total of 294 intrusions. Participants with PTSD experienced only marginally more intrusions than those without PTSD, but experienced them with more "here and now quality," and responded with more fear, helplessness, anger, and shame than those without PTSD. Most frequent intrusion triggers were stimuli that were perceptually similar to stimuli from the trauma. Individuals with PTSD experienced diary-prompted voluntary trauma memories with the same sense of nowness and vividness as involuntary intrusive trauma memories. The findings contribute to a better understanding of everyday experiences of intrusive reexperiencing in trauma survivors with PTSD and offer clinical treatment implications.

Visual mental imagery in psychopathology--implications for the maintenance and treatment of depression

Negative mental images are a common feature in a range of mental disorders as well as in healthy subjects. Intrusive negative mental images have only recently become a focus of attention in clinical research on depression. Research so far indicates that they can be an important factor regarding the onset and chronicity of affective disorders. This article is the first to provide an extensive overview of the current state of research in the field of visual mental images in depression. It aims to investigate disorder-specific characteristics, as well as the role of imagery as a maintaining factor. A detailed definition and description of empirical results about mental images in depressive disorders is followed by a presentation and analysis of treatment studies using imagery techniques in depressed samples. Additionally, methodological issues like small sample sizes and the lack of control groups are pointed out and implications for future research are discussed. Case vignettes are included in the appendix to exemplify the importance of negative mental images in patients suffering from depression.

"I wouldn't start from here"--an alternative perspective on PTSD from the ICD-11: comment on Friedman (2013)

This commentary briefly summarizes some of the criticism directed at the diagnosis of posttraumatic stress disorder (PTSD) according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) including the issues of complexity and comorbidity, and offers a rationale for attempting a simpler approach to diagnosis that can be used in minimally resourced, non-English-speaking countries. Rather than describe comprehensively the features of PTSD, the World Health Organization in its upcoming edition of the International Classification of Diseases has opted to define a much smaller number of symptoms that will effectively discriminate PTSD from other related conditions. Parallel research on the two approaches to diagnosis promises to add greatly to our understanding of the condition.

Animal models in translational studies of PTSD

Understanding the neurobiological mechanisms of post-traumatic stress disorder (PTSD) is of vital importance for developing biomarkers and more effective pharmacotherapy for this disorder. The design of bidirectional translational studies addressing all facets of PTSD is needed. Animal models of PTSD are needed not only to capture the complexity of PTSD behavioral characteristics, but also to address experimentally the influence of variety of factors which might determine an individual's vulnerability or resilience to trauma, e.g., genetic predisposition, early-life experience and social support. The current review covers recent translational approaches to bridge the gap between human and animal PTSD research and to create a framework for discovery of biomarkers and novel therapeutics.

A comparison of the quality of intrusive memories in post-traumatic stress disorder and depression

As in post-traumatic stress disorder (PTSD), intrusive memories (IMs) also play an important role in depression. Evidence about the comparative quality of IMs in PTSD and depression is limited and inconsistent. A total of 28 adults with PTSD, 29 with depression, and 30 controls identified intrusive and voluntary segments of narrative memories of key events. Self-report and language measures of memory quality were obtained. Depressed and PTSD participants reported higher frequency of IMs and higher IM-related interference than controls. IMs in PTSD participants were distinguished from depressed and control participants by higher self-rated distress, higher self-rated sensory quality, and a higher proportion of sensory words in the narrative. The depressed and control groups did not differ on IM quality. PTSD IM segments had more sensory content than voluntary segments and fewer temporal markers. The IM segments of the depressed and control groups had fewer temporal markers than the voluntary segments. Depression severity predicted fewer sensory words in the IM after considering peri-event dissociation and arousal but did not add to the prediction of other IM qualities. A strong sensory quality is a distinctive feature of IMs in PTSD but not in depression. Basic sensory processes contribute to the intrusiveness of remembering in PTSD but not in depression.

Classification of trauma and stressor-related disorders in DSM-5

This review examines the question of whether there should be a cluster of disorders, including the adjustment disorders (ADs), acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and the dissociative disorders (DDs), in a section devoted to abnormal responses to stress and trauma in the DSM-5. Environmental risk factors, including the individual's developmental experience, would thus become a major diagnostic consideration. The relationship of these disorders to one another is examined and also their relationship to other anxiety disorders to determine whether they are better grouped with anxiety disorders or a new specific grouping of trauma and stressor-related disorders. First how stress responses have been classified since DSM-III is reviewed. The major focus is on PTSD because it has received the most attention, regarding its proper placement among the psychiatric diagnoses. It is discussed whether PTSD should be considered an anxiety disorder, a stress-induced fear circuitry disorder, an internalizing disorder, or a trauma and stressor-related disorder. Then, ASD, AD, and DD are considered from a similar perspective. Evidence is examined pro and con, and a conclsion is offered recommending inclusion of this cluster of disorders in a section entitled "Trauma and Stressor-Related Disorders." The recommendation to shift ASD and PTSD out of the anxiety disorders section reflects increased recognition of trauma as a precipitant, emphasizing common etiology over common phenomenology. Similar considerations are addressed with regard to AD and DD.