A network analysis of anger, shame, proposed ICD-11 post-traumatic stress disorder, and different types of childhood trauma in foster care settings in a sample of adult survivors

Understanding the relationship between childhood abuse and affective symptoms in bipolar disorder: New insights from a network analysis

The impact of childhood abuse on the presentation of bipolar disorder could be further elucidated by comparing the networks of affective symptoms among individuals with and with no history of childhood abuse. Data from 476 participants in the Clinical Health Outcomes Initiative in Comparative Effectiveness for Bipolar Disorder study were used to fit several regularised Gaussian Graphical Models. Differences in the presentation of depressive and manic symptoms were uncovered: only among participants with a history of childhood abuse, inadequacy and pessimism were central symptoms in the network of depressive symptoms, while racing thoughts was an important symptom in the network of manic symptoms. Following network theory, focusing treatments at the symptom-level and on central symptoms - like inadequacy, pessimism, and racing thoughts - could be an effective approach for managing affective symptoms among the sizeable proportion of people with bipolar disorder who have experienced childhood abuse. This study contributes a thorough investigation of the networks of affective symptoms among participants with and with no history of childhood abuse, albeit limited by the use of a binary, self-report measure of childhood abuse, thereby emphasising the importance of assessing for childhood abuse and taking needed steps towards identifying novel targets for treating bipolar disorder.

Non-fear emotions in changes in posttraumatic stress disorder symptoms during treatment

BACKGROUND AND OBJECTIVES

Posttraumatic stress disorder (PTSD) is not only associated with fear but also with other emotions. The present study aimed to examine if changes in shame, guilt, anger, and disgust predicted changes in PTSD symptoms during treatment, while also testing if PTSD symptoms, in turn, predicted changes in these emotions.

METHODS

Participants (N = 155) with childhood-related PTSD received a maximum of 12 sessions of eye movement desensitization and reprocessing or imagery rescripting. The data was analyzed using Granger causality models across 12 treatment sessions and 6 assessment sessions (up until one year after the start of treatment). Differences between the two treatments were explored.

RESULTS

Across treatment sessions, shame, and disgust showed a reciprocal relationship with PTSD symptoms, while changes in guilt preceded PTSD symptoms. Across assessments, anger was reciprocally related to PTSD, suggesting that anger might play a more important role in the longer term.

LIMITATIONS

The individual emotion items were not yet validated, and the CAPS was not administered at all assessments.

CONCLUSIONS

These findings partly differ from earlier studies that suggested a unidirectional relationship in which changes in emotions preceded changes in PTSD symptoms during treatment. This is in line with the idea that non-fear emotions do play an important role in the treatment of PTSD and constitute an important focus of treatment and further research.

The Centrality of Humiliation in Complex Posttraumatic Stress Disorder

Victims of traumatic events that involve repeated interpersonal aggression and low or no chance of escape frequently report intense Self-Conscious Emotions (SCEs), such as Shame, Guilt, and Humiliation. Humiliation is the reaction to a forced loss of status and is hypothesized to have unique contributions to the development and maintenance of Posttraumatic Stress Disorder (PTSD) and Complex Posttraumatic Stress Disorder (CPTSD). However, previous studies did not include humiliation or did not simultaneously probe the relative contribution of each SCE to posttraumatic symptoms. This study aimed to investigate the dynamics between specific SCEs and trauma-related symptomatology in the general population who suffered a form of complex trauma. Four hundred forty-nine people (77.11% women) exposed to domestic violence and sexual abuse answered an online survey. We investigated whether each emotion would accurately predict probable PTSD and CPTSD levels above the proposed cutoff. We estimated a network model to understand the dynamics of their interactions and whether the traumatic event type would moderate relationships between SCEs and posttraumatic stress symptoms, comparing networks of two types of complex trauma. No SCE predicted PTSD, but humiliation was a predictor of CPTSD while controlling for Shame and Guilt. Humiliation was also the most central SCE domain in the networks of both traumatic events. Our results stress the relevance of Humiliation to understanding posttraumatic stress symptoms and the necessity to consider humiliation when studying the emotional processing in complex trauma.

Rebuilding wellbeing: Understanding the role of self-criticism, anger rumination, and death distress after the February 6, 2023, Türkiye Earthquake

This study investigated self-criticism, anger rumination, and death distress in wellbeing after one of the most devastating natural disasters of this century. The study included 399 participants from 56 different cities across Türkiye. Participants were from 3 groups: those who themselves or one of their nuclear families are earthquake survivors (group 1), those who had a loved one other than a nuclear family member who was an earthquake survivor (group 2), and those who were deeply affected by the earthquake through media networks (group 3). Results showed that women experienced higher death distress and anger rumination and lower mental wellbeing compared to men post-earthquake. Individuals in group 1 had significantly lower mental wellbeing and higher death distress than groups 2 and 3. However, the effect size of this significant differentiation depending on earthquake experience was small. Moreover, anger rumination and death distress fully mediated the link between self-criticism and mental wellbeing.

Childhood Trauma Questionnaire-Short Form: Evaluation of Factor Structure and Measurement Invariance

Childhood trauma is known to put individuals at risk for mental and physical challenges later in life. Retrospective assessment of early abuse and neglect is critical for prevention and intervention efforts targeted at reducing the negative impacts of childhood trauma. The Childhood Trauma Questionnaire-Short Form (CTQ-SF) is a widely used measure to assess trauma among adolescents and adults, though there are some inconsistencies with regard to its factor structure and psychometric properties. The purpose of the current study was twofold: (1) to evaluate the hypothesized five-factor structure of CTQ-SF and (2) to test measurement invariance (equivalence) of the instrument across gender and race in a large, nationally representative sample of US adults (N = 863). Confirmatory factor analysis results indicate that the five-factor model fit the data well. The results also show that the five-factor model is generally invariant by gender and racial/ethnic groups and that the form's subscales positively correlate with depression, anxiety, and abnormal inflammatory biomarker activity. Assessment is critical for the advocacy and treatment of individuals who have experienced abuse and neglect as children and adolescents. Our findings suggest that the CTQ-SF is a valuable tool for assessing childhood trauma and can be used in advocacy and treatment efforts.

Childhood trauma and anger in adults with and without depressive and anxiety disorders

BACKGROUND

Childhood trauma (CT) is associated with severe sequelae, including stress-related mental health disorders that can perpetuate long into adulthood. A key mechanism in this relationship seems to be emotion regulation. We aimed to investigate (1) whether childhood trauma is associated with anger in adulthood, and, if so, (2) to explore which types of childhood trauma predominate in the prediction of anger in a cohort that included participants with and without current affective disorders.

METHODS

In the Netherlands Study of Depression and Anxiety (NESDA), childhood trauma was assessed with a semi-structured Childhood Trauma Interview (CTI) at baseline, and analyzed in relation to anger as measured at a 4-year follow-up with the Spielberger Trait Anger Subscale (STAS), the Anger Attacks Questionnaire, and cluster B personality traits (i.e., borderline, antisocial) of the Personality Disorder Questionnaire 4 (PDQ-4), using analysis of covariance (ANCOVA) and multivariable logistic regression analyses. Post hoc analyses comprised cross-sectional regression analyses, using the Childhood Trauma Questionnaire-Short Form (CTQ-SF) also obtained at a 4-year follow-up.

RESULTS

Participants (n = 2271) were on average 42.1 years (SD = 13.1), and 66.2% were female. Childhood trauma showed a dose-response association with all anger constructs. All types of childhood trauma were significantly associated with borderline personality traits, independently of depression and anxiety. Additionally, all types of childhood trauma except for sexual abuse were associated with higher levels of trait anger, and a higher prevalence of anger attacks and antisocial personality traits in adulthood. Cross-sectionally, the effect sizes were larger compared with the analyses with the childhood trauma measured 4 years prior to the anger measures.

CONCLUSIONS

Childhood trauma is linked with anger in adulthood, which could be of particular interest in the context of psychopathology. Focus on childhood traumatic experiences and adulthood anger may help to enhance the effectiveness of treatment for patients with depressive and anxiety disorders. Trauma-focused interventions should be implemented when appropriate.

Why We Need a Developmentally Appropriate Trauma Diagnosis for Children: a 10-Year Update on Developmental Trauma Disorder

Developmental Trauma Disorder (DTD) was proposed almost two decades ago as a psychiatric diagnosis for children who have been traumatically victimized and whose attachment bonding with primary caregivers has been compromised. DTD was designed to complement and extend post-traumatic stress disorder (PTSD) by addressing forms of trauma-related biopsychosocial dysregulation not included in PTSD, many of which are attributed to other psychiatric disorders. In the past decade, evidence from clinician surveys and research field trial studies has provided evidence of DTD's validity and potential clinical utility. The growing evidence base for DTD is summarized and clinical rationales for the proposed DTD symptoms are described. DTD shows promise as a developmentally-attuned traumatic stress diagnosis for traumatized children.

A network analysis on biopsychosocial factors and pain-related outcomes assessed during a COVID-19 lockdown

Psychological stress, social isolation, physical inactivity, and reduced access to care during lockdowns throughout a pandemic negatively impact pain and function. In the context of the first COVID-19 lockdown in Spain, we aimed to investigate how different biopsychosocial factors influence chiropractic patients' pain-related outcomes and vice-versa. A total of 648 chiropractic patients completed online questionnaires including variables from the following categories: demographics, pain outcomes, pain beliefs, impact of the COVID-19 pandemic, stress/anxiety and self-efficacy. Twenty-eight variables were considered in a cross-sectional network analysis to examine bidirectional associations between biopsychosocial factors and pain outcomes. Subgroup analyses were conducted to estimate differences according to gender and symptom duration. The greatest associations were observed between pain duration and pain evolution during lockdown. Participants' age, pain symptoms' evolution during lockdown, and generalized anxiety were the variables with the strongest influence over the whole network. Negative emotions evoked by the pandemic were indirectly associated with pain outcomes, possibly via pain catastrophizing. The network structure of patients reporting acute pain showed important differences when compared to patients with chronic pain. These findings will contribute to identify which factors explain the deleterious effects of both the pandemic and the restrictions on patients living with pain.

Childhood trauma and depressive symptoms in bipolar disorder: A network analysis

BACKGROUND

Childhood trauma is related to an increased number of depressive episodes and more severe depressive symptoms in bipolar disorder. The evaluation of the networks of depressive symptoms-or the patterns of relationships between individual symptoms-among people with bipolar disorder with and without a history of childhood trauma may assist in further clarifying this complex relationship.

METHODS

Data from over 500 participants from the Heinz C. Prechter Longitudinal Study of Bipolar Disorder were used to construct a series of regularised Gaussian Graphical Models. The networks of individual depressive symptoms-self-reported (Patient Health Questionnaire-9; n = 543) and clinician-rated (Hamilton Depression Rating Scale-17; n = 529)-among participants with bipolar disorder with and without a history of childhood trauma (Childhood Trauma Questionnaire) were characterised and compared.

RESULTS

Across the sets of networks, depressed mood consistently emerged as a central symptom (as indicated by strength centrality and expected influence); regardless of participants' history of childhood trauma. Additionally, feelings of worthlessness emerged as a key symptom in the network of self-reported depressive symptoms among participants with-but not without-a history of childhood trauma.

CONCLUSION

The present analyses-although exploratory-provide nuanced insights into the impact of childhood trauma on the presentation of depressive symptoms in bipolar disorder, which have the potential to aid detection and inform targeted intervention development.

Differential associations between childhood maltreatment types and borderline personality disorder from the perspective of emotion dysregulation

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by pervasive instability in a range of areas including interpersonal relationships, self-image, and affect. Extant studies have consistently identified significant correlations between childhood maltreatment (CM) and BPD. While exploring this CM-BPD link, a number of cross-sectional studies commonly emphasize the role of emotion dysregulation (ED). A better understanding of the associations between BPD and (1) CM and (2) ED are essential in formulating early, effective intervention approaches, and in addressing varied adverse impacts.

METHODS

This cross-sectional study analyzed a subset of baseline data collected for a larger community-based longitudinal study. Given that our current focus on CM and ED, only those participants who completed the baseline CM assessment and ED measure (N = 144) were included for the primary analyses. We conducted stepwise multivariate linear models to examine the differential relationships between BPD features, ED, and multiple CM types. A path analysis with latent factors using the structural equation modeling (SEM) method was performed to test the indirect effect from CM to BPD features via ED.

RESULTS

Linear regression models revealed that only emotional abuse (relative to other trauma types) was significantly associated with high BPD features. The SEM, by constructing direct and indirect effects simultaneously, showed that (1) ED partially mediated the path from CM to BPD features; and (2) CM played an important role in which the direct effect remained significant even after accounting for the indirect effect through ED.

CONCLUSIONS

Our results highlight a most consistent association between emotional abuse and BPD, indicating its unique role in understanding BPD features in the context of CM. Further, shame-related negative appraisal and ED were found critical when examining the association between CM and BPD, possibly providing promising treatment targets for future practices.

Longitudinal symptom network structure in first-episode psychosis: a possible marker for remission

BACKGROUND

Network approach has been applied to a wide variety of psychiatric disorders. The aim of the present study was to identify network structures of remitters and non-remitters in patients with first-episode psychosis (FEP) at baseline and the 6-month follow-up.

METHODS

Participants (n = 252) from the Korean Early Psychosis Study (KEPS) were enrolled. They were classified as remitters or non-remitters using Andreasen's criteria. We estimated network structure with 10 symptoms (three symptoms from the Positive and Negative Syndrome Scale, one depressive symptom, and six symptoms related to schema and rumination) as nodes using a Gaussian graphical model. Global and local network metrics were compared within and between the networks over time.

RESULTS

Global network metrics did not differ between the remitters and non-remitters at baseline or 6 months. However, the network structure and nodal strengths associated with positive-self and positive-others scores changed significantly in the remitters over time. Unique central symptoms for remitters and non-remitters were cognitive brooding and negative-self, respectively. The correlation stability coefficients for nodal strength were within the acceptable range.

CONCLUSION

Our findings indicate that network structure and some nodal strengths were more flexible in remitters. Negative-self could be an important target for therapeutic intervention.

Six-year changes of posttraumatic stress symptoms and depressive symptoms among Chinese earthquake survivors: A network analysis

BACKGROUND

The risk factors of Posttraumatic Stress Symptoms (PTSS) and depressive symptoms have been well-established, but whether the network structure of their symptoms changes over time remains unclear. This study aims to examine the six-year changes of network structure of PTSS and depressive symptoms among Wenchuan earthquake adult survivors in China.

METHODS

In this pooled cross-sectional study, respondents were sampled from the same population at each of the five waves (N = 1343, 1205, 1177, 1376, and 1339). The network structure of them was investigated using network analyses.

RESULTS

The study shows network connections stable across waves were the positive connections between hyperarousal and intrusions, hyperarousal and somatic symptoms, and two dimensions of positive effects. Stable negative connections were those between depressed affects and positive effects, avoidance and depressed affects, avoidance with interpersonal symptoms and avoidance with somatic symptoms. Across waves, fearful emotion consistently was the strongest bridge symptom connecting with PTSS symptoms. However, for PTSS the strongest bridge symptom varied across time as it was avoidance in wave 1 but were hyperarousal in other four waves.

LIMITATIONS

This study was based on a pooled cross-sectional survey, which inhibits conclusions regarding causal influences between symptoms at the individual patient level.

CONCLUSIONS

The network structure of PTSS and depressive symptoms was partly stable, yet also varied across survey waves. Core symptom clusters for PTSS and depressive symptoms were avoidance and depressed affect, respectively. The central role of these clusters in PTSS and depressive symptoms has important implications to future psychiatric programs.

Connecting the Dots: Exploring Psychological Network Analysis as a Tool for Analyzing Organizational Survey Data

Organizations allocate considerable resources in surveys aimed at assessing how employees perceive certain job aspects. These perceptions are often modeled as latent constructs (e.g., job satisfaction) measured by multiple indicators. This approach, although useful, has several drawbacks such as a strong reliance on local independence and a lower performance in exploratory contexts with many variables. In this paper, we introduce psychological network analysis (PNA) as a novel method to examine organizational surveys. It is first argued how the network approach allows studying the complex patterns of attitudes, perceptions, and behaviors that make up an organizational survey by modeling them as elements in an interconnected system. Next, two empirical demonstrations are presented showcasing features of this technique using two datasets. The first demonstration relies on original organizational survey data (N = 4270) to construct a network of attitudes and behaviors related to innovative work behavior. In the second demonstration, drawing on archival leadership data from an organization (N = 337), the focus lies on comparing structural properties of leadership attitude networks between subsamples of supervisors and non-supervisors. We conclude this paper by discussing how PNA constitutes a promising avenue for researching organizational phenomena which typically constitute a set of interconnected elements.

Understanding the psychological mechanisms of return to sports readiness after anterior cruciate ligament reconstruction

PURPOSE

The psychological response to an Anterior Cruciate Ligament (ACL) injury is significant and can negatively impact return to sports outcomes. This study aimed to quantify the association between factors associated with return to sport using network analysis.

METHODS

441 participants who underwent primary ACL reconstruction. The 12-item ACL Return to Sport after Injury (ACL-RSI) scale was administered to all participants 12 months after surgery. Three network analyses were used to quantify the adjusted correlations between the 12 items of the ACL-RSI scale, and to determine the centrality indices of each item (i.e., the degree of connection with other items in the network). Further subgroup network analyses were conducted for those who had (n = 115) and had not returned (n = 326) to their pre-injury level of sport.

RESULTS

The greatest adjusted correlation was between Q7 and Q9 (fear of re-injury and afraid of accidentally injuring knee) of the ACL-RSI (group 0.48 (95%CI [0.40 to 0.57])) across all three networks. The most important item in the network was Q12 (relaxed about sport) across all three networks. Individuals who did return to sport had greater Strength centrality for Q8 (confidence in knee, P = 0.014) compared to those who did not return to sport.

CONCLUSION

Fear of re-injury and being relaxed about playing sport were the two most important nodes in the network models that describe the return to sport readiness. The importance of knee confidence at influencing psychological readiness was greater in athletes who did return to sport compared to those who did not. Our findings provide candidate therapeutic targets that could inform future interventions designed to optimize return to sport rates in athletes post ACL reconstruction.

Eating Disorders and Posttraumatic Stress Disorder: A Network Analysis of the Comorbidity

Eating disorders (EDs) and posttraumatic stress disorder (PTSD) commonly co-occur, but the mechanisms driving this co-occurrence are not well understood. The current study explored the relationships between symptoms of ED and PTSD in a sample of male and female undergraduate students in order to identify pathways that may maintain the comorbidity. Network analysis was conducted in a sample of 344 first-year undergraduates to visualize partial correlations between each symptom in the comorbidity. Core symptoms, bridge symptoms, and direct pathways between ED and PTSD symptoms were identified. The PTSD symptoms negative emotions (strength = 1.13) and negative beliefs (strength = 1.11) were the strongest symptoms in the network. The strongest bridge nodes were the ED symptoms restriction (bridge strength = 3.32) and binge eating (bridge strength = 2.63). The strongest edges between ED and PTSD nodes were between binge eating and concentration (part r = .16), restriction and sleep (part r = .14), and binge eating and positive emotions (part r = .11). Findings suggest that PTSD symptoms related to negative alterations in cognitions and mood may be highly influential in the ED-PTSD network due to their relatedness to all other symptoms. The pathway between binge eating and inability to experience positive emotions suggest that the comorbidity may be partially maintained through an affect regulation function of binge eating.

Understanding how individualised physiotherapy or advice altered different elements of disability for people with low back pain using network analysis

PURPOSE

The Oswestry Disability Index (ODI) is a common aggregate measure of disability for people with Low Back Pain (LBP). Scores on individual items and the relationship between items of the ODI may help understand the complexity of low back disorders and their response to treatment. In this study, we present a network analysis to explore how individualised physiotherapy or advice might influence individual items of the ODI, and the relationship between those items, at different time points for people with LBP.

METHODS

Data from a randomised controlled trial (n = 300) comparing individualised physiotherapy versus advice for low back pain were used. A network analysis was performed at baseline, 5, 10, 26 and 52 weeks, with the 10 items of the Oswestry Disability Index modelled as continuous variables and treatment group (Individualised Physiotherapy or Advice) modelled as a dichotomous variable. A Mixed Graphical Model was used to estimate associations between variables in the network, while centrality indices (Strength, Closeness and Betweenness) were calculated to determine the importance of each variable.

RESULTS

Individualised Physiotherapy was directly related to lower Sleep and Pain scores at all follow-up time points relative to advice, as well as a lower Standing score at 10-weeks, and higher Lifting and Travelling scores at 5-weeks. The strongest associations in the network were between Sitting and Travelling at weeks 5 and 26, between Walking and Standing at week 10, and between Sitting and Standing scores at week 52. ODI items with the highest centrality measures were consistently found to be Pain, Work and Social Life.

CONCLUSION

This study represents the first to understand how individualised physiotherapy or advice differentially altered disability in people with LBP. Individualised Physiotherapy directly reduced Pain and Sleep more effectively than advice, which in turn may have facilitated improvements in other disability items. Through their high centrality measures, Pain may be considered as a candidate therapeutic target for optimising LBP management, while Work and Socialising may need to be addressed via intermediary improvements in lifting, standing, walking, travelling or sleep. Slower (5-week follow-up) improvements in Lifting and Travelling as an intended element of the Individualised Physiotherapy approach did not negatively impact any longer-term outcomes.

TRIALS REGISTRATION

ACTRN12609000834257.

Sexual symptoms in post-traumatic stress disorder following childhood sexual abuse: a network analysis

BACKGROUND

Even though recent research indicates that sexual symptoms are highly prevalent in post-traumatic stress disorder following childhood sexual abuse and cause severe distress, current treatments neither address them nor are they effective in reducing them. This might be due to a lack of understanding of sexual symptoms' specific role in the often complex and comorbid psychopathology of post-traumatic stress disorder following childhood abuse.

METHODS

Post-traumatic, dissociative, depressive, and sexual symptoms were assessed in 445 inpatients with post-traumatic stress disorder following childhood sexual abuse. Comorbidity structure was analyzed using a partial correlation network with regularization.

RESULTS

A total of 360 patients (81%) reported difficulties engaging in sexual activities and 102 patients (23%) reported to suffer from their sexual preferences. Difficulties engaging in sexual activities were linked to depressive and hyperarousal symptoms, whereas sexual preferences causing distress were linked to anger and dissociation. Dissociative amnesia, visual intrusions, and physical reactions to trauma reminders were of central importance for the network. Dissociative amnesia, depressed mood, lack of energy, and difficulties engaging in sexual activities were identified as bridge symptoms. Local clustering analysis indicated the non-redundancy of sexual symptoms.

CONCLUSIONS

Sexual symptoms are highly prevalent in survivors of childhood sexual abuse with post-traumatic stress disorder. Further research is needed regarding the link of difficulties engaging in sexual activities, depression, and post-traumatic stress disorder, as well as regarding the association of dissociation and sexual preferences causing distress. Sexual symptoms require consideration in the treatment of post-traumatic stress disorder following childhood sexual abuse.

Network analysis of trauma in patients with early-stage psychosis

Childhood trauma (ChT) is a risk factor for psychosis. Negative lifestyle factors such as rumination, negative schemas, and poor diet and exercise are common in psychosis. The present study aimed to perform a network analysis of interactions between ChT and negative lifestyle in patients and controls. We used data of patients with early-stage psychosis (n = 500) and healthy controls (n = 202). Networks were constructed using 12 nodes from five scales: the Brief Core Schema Scale (BCSS), Brooding Scale (BS), Dietary Habits Questionnaire, Physical Activity Rating, and Early Trauma Inventory Self Report-Short Form (ETI). Graph metrics were calculated. The nodes with the highest predictability and expected influence in both patients and controls were cognitive and emotional components of the BS and emotional abuse of the ETI. The emotional abuse was a mediator in the shortest pathway connecting the ETI and negative lifestyle for both groups. The negative others and negative self of the BCSS mediated emotional abuse to other BCSS or BS for patients and controls, respectively. Our findings suggest that rumination and emotional abuse were central symptoms in both groups and that negative others and negative self played important mediating roles for patients and controls, respectively.

Trial Registration: ClinicalTrials.gov identifier: CUH201411002.

Network Analysis of PTSD Symptoms in a Sample of Polyvictimized Youth

Polyvictimization (i.e., the experience of multiple types of victimization) increases the risk for post-traumatic stress disorder (PTSD) relative to single-type victimization. Network analysis has been used to conceptualize PTSD among children and adolescents exposed to specific types of victimization (e.g., maltreatment, natural disasters), but not among those theorized to be at highest risk of poor outcomes (i.e., polyvictimized youth). The current study used network analysis to enhance our understanding of PTSD symptoms in a diverse sample of adolescents exposed to polyvictimization. Data were drawn from the Longitudinal Studies on Child Abuse and Neglect, a multi-site study of children and adolescents living in the United States (ages 0-18). Using indicators of seven different types of age-16 victimization, k-means cluster analysis identified a subgroup of polyvictimized youth. A PTSD symptom network was estimated for polyvictimized youth, with depersonalization, self-blame, and sadness emerging as central symptoms. Regression analyses indicated that depersonalization prospectively predicted age-18 anxiety symptoms, p = .033. Central symptoms did not predict age-18 PTSD or depression symptoms. To date, this is the first network study on a polyvictimized sample. While preliminary, our findings suggest that dissociation and self-blame may be central to polyvictimized youth and that dissociation may represent an important prevention target for anxiety.

Understanding the Psychophysiological Mechanisms Related to Widespread Pressure Pain Hyperalgesia Underpinning Carpal Tunnel Syndrome: A Network Analysis Approach

OBJECTIVE

Current evidence suggests that carpal tunnel syndrome (CTS) involves widespread pressure pain sensitivity as manifestion of central sensitization. This study aimed to quantify mechanisms driving widespread pressure pain hyperalgesia in CTS by using network analysis.

DESIGN

Cross-sectional.

SETTING

Urban hospital.

SUBJECTS

120 women with CTS who participated in a previous randomized clinical trial.

METHODS

Pain intensity, related-function, symptom's severity, depressive levels, and pressure pain threshold (PPTs) over median, radial and ulnar nerves, the cervical spine, the carpal tunnel, and the tibialis anterior were collected. Network analysis was used to quantify the adjusted correlations between the modelled variables, and to determine the centrality indices of each variable (i.e., the degree of connection with other symptoms in the network).

RESULTS

The estimated network showed several local associations between clinical variables and the psychophysical outcomes separately. The edges with the strongest weights were between PPT over the median and radial nerves (ρ: 0.34), function and depressive levels (ρ: 0.30), and PPT over the carpal tunnel and tibialis anterior (ρ: 0.29). The most central variables were PPT over the tibialis anterior (the highest Strength centrality), and PPT over the carpal tunnel (the highest Closeness and Betweenness centrality).

CONCLUSIONS

This is the first study to apply network analysis to understand the multivariate mechanisms of individuals with CTS. Our findings support a model where clinical, depression, and widespread pressure pain sensitivity are connected, albeit within separate clusters. Clinical implications of current findings, such as developing treatments targeting these mechanisms, are also discussed.

The trajectory of PTSD among youth in foster care: A survival analysis examining maltreatment experiences prior to entry into care

BACKGROUND

Youth in foster care are more likely than non-foster care youth to experience posttraumatic stress disorder (PTSD). While research has identified maltreatment as a risk factor for PTSD, this research remains limited because it tends to only (a) examine a single type or dimension of maltreatment and ignore the polyvictimization and heterogeneity in exposure, and (b) study this relation across a short period time or retrospectively at the end of care.

OBJECTIVE

The current study used survival analysis to simultaneously examine the influence of maltreatment characteristics on the risk of receiving a PTSD diagnosis at any time in care following entry into care.

PARTICIPANTS/SETTING

291 youth (Mean age at entry = 9.71; 53 % female; 49 % Black) in foster care and their primary caregivers from a large, Midwestern county.

METHODS

Information on PTSD diagnosis was extracted from Medicaid records, and information on maltreatment and time in care was extracted from case files. Survival analysis was then used to determine the association between maltreatment and risk of PTSD diagnosis.

RESULTS

When examined independently, each dimension (frequency, severity) of the four maltreatment types was significantly associated with PTSD diagnosis risk (all hazard ratio's [HR] > 1.00), except sexual abuse frequency. In the comprehensive model with all dimensions examined simultaneously, only neglect frequency for youth entering care in adolescence (HR: 1.13[1.03-1.23]), and neglect severity (HR: 1.27[1.05-1.52]) and emotional abuse frequency (HR: 1.24[1.00-1.53]) for youth entering care pre-adolescence, were associated with PTSD diagnosis risk. Additionally, age of entry into care was associated with PTSD diagnosis risk (HR: 2.34[1.88-2.92]), as adolescents tended to spend fewer days in care before receiving a diagnosis.

CONCLUSIONS

Results suggest that researchers who study PTSD in youth in foster care should consider the entirety of youth's maltreatment exposure and the context of care to more accurately determine what aspects of youth's history contributes to receiving a PTSD diagnosis.

'Caring for children who have experienced trauma' - an evaluation of a training for foster parents

BACKGROUND

Foster children, mostly maltreated in their birth families, may be fostered by parents who know little about the impact of traumatic experiences.

OBJECTIVE

The present study investigated whether the training Caring for Children who Have Experienced Trauma for foster parents can break the negative circle of traumatic stress. The hypothesis was that improvement in parents' knowledge on trauma and mind-mindedness would be associated with a reduction of their parenting stress, children's post-traumatic stress symptoms, and behaviour problems.

METHOD

Forty-eight foster parents (n female = 35) participated in a pre-test (T1), post-test (T2), and follow-up (T3) assessment. Questionnaires on knowledge on trauma, parenting stress, child post-traumatic stress symptoms, the child's behaviour, and the evaluation of the training were administered. Parents' mind-mindedness was assessed using the describe-your-child interview.

RESULTS

Foster parents highly appreciated the training, their knowledge on child trauma increased at T2 and this growth persisted at T3. The parents who gained most knowledge experienced a small decrease in parenting stress at T2. Although the general mind-mindedness did not significantly change, foster parents' mind-mindedness with positive valence substantially increased at T2 and T3, while their mind-mindedness with neutral valence decreased. Foster parents' report on child PTSS declined at T3 compared to T2, but not compared to T1. No changes were found in children's behaviour as reported by the foster parents. The proportion of foster children receiving trauma-focused treatment increased at T2 and T3.

CONCLUSION

This study provides evidence that training in trauma-informed parenting can be effective in improving foster parents' knowledge on the impact of traumatic experiences and in increasing a positive mental representation of their foster child as well as in reducing children's post-traumatic symptoms.

Associations Between Child Maltreatment, Autonomic Regulation, and Adverse Cardiovascular Outcome in an Urban Population: The HELIUS Study

INTRODUCTION

A mounting body of literature emphasizes the potential negative effects of adverse childhood experiences (ACEs) on both mental and physical health throughout life, including an increased risk for developing cardiovascular disease (CVD). Since CVD is one of the leading causes of mortality and morbidity worldwide, it is of great importance to advance our understanding of the effects of on CVD. This holds both for the actual incidence and for intermediate biological pathways that may convey CVD risk, such as imbalance in autonomic nervous system regulation, resulting in a chronically heightened sympathetic activity and lowered reactivity. In a large urban, multi-ethnic population-based cohort study we investigated whether there is an association between child maltreatment, CVD incidence and autonomic regulation.

METHODS

Within the Health in an Urban Setting (HELIUS) study, a large, multi-ethnic population cohort study including n = 22,165 Amsterdam residents, we used logistic regression analyses to investigate the association between the number of self-reported types of child maltreatment (range 0-4), and self-reported adverse cardiovascular outcome (aCVO). Self-reported child maltreatment included emotional neglect, emotional abuse, physical abuse, and sexual abuse. Furthermore, in a subsample (n = 10,260), mean age 44.3, we investigated associations between child maltreatment, autonomic regulation, and aCVO using linear regression analyses. Both baroreflex sensitivity (BRS) and heart rate variability (HRV) were assessed as non-invasive indices of autonomic regulation.

RESULTS

The number of endorsed child maltreatment types was significantly associated with a higher aCVO risk. The association remained significant after adjustment for demographic, socioeconomic, health-behavioral, and psychological covariates (p = 0.011, odds ratio: 1.078, confidence interval: 1.018-1.142). The cumulative exposure to child maltreatment was negatively associated with BRS and HRV, but the association was no longer significant after correction for socioeconomic and demographic covariates.

CONCLUSION

In a large, multi-ethnic urban-population cohort study we observed a positive association between number of endorsed child maltreatment types and self-reported aCVO but not autonomic regulation, over and above the effect of relevant demographic, health, and psychological factors. Future studies should examine the potential role of the dynamics of autonomic dysregulation as potential underlying biological pathways in the association between ACEs and CVD, as this could eventually facilitate the development of preventive and therapeutic strategies for CVD.

Examining the boundaries between ICD-11 PTSD/CPTSD and depression and anxiety symptoms: A network analysis perspective

BACKGROUND

Two newly identified sibling disorders - ICD-11 PTSD and CPTSD - have been well validated in the last few years. Although these trauma-related disorders are suggested to be neatly separated from depression and anxiety, no study has used a network analysis to examine those definitions' construct validity when they also interplay with symptoms of depression and anxiety. Additionally, no research has focused upon the specific boundaries between these four disorders' symptoms, the bridges between them, and the ways they influence each other among clinical populations.

METHODS

A sample of 234 men drawn randomly from a national sample of 1,600 Jewish men receiving treatment for domestic violence in Israel completed the ICD-11 International Trauma Questionnaire (ITQ) and Brief Symptom Inventory (BSI).

RESULTS

The ICD-11 CPTSD, depression and anxiety clustering network results revealed, within the EGA, a four-cluster solution in which PTSD and CPTSD symptoms are differentiated from two other distinct clusters of anxiety and depression symptoms. Feelings of worthlessness and avoiding internal reminders of the experience were the most central symptoms.

LIMITATIONS

Due to the use of a cross-sectional design, causal interpretation of the network correlation between symptoms should be made cautiously.

CONCLUSIONS

These findings strengthen the approach that ICD-11 PTSD and CPTSD have a distinct construct; however, they also reflect a strong positive connection to anxiety and depression symptoms and no clear boundaries between disorders. Specifically, dysphoria/avoidance-related symptoms act as a bridge between the disorders, which may be important targets for specific assessments and related interventions.

Nexus of despair: A network analysis of suicidal ideation among veterans

The objective of this study was to estimate a network model of risk and resilience factors of suicidal ideation among veterans. Two network models of suicidal ideation among Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn veterans (N = 276) incorporated key disorders, traumatic stress, and resilience constructs to contextualize suicidal ideation. Childhood trauma was positively connected with suicidal ideation and harassment and inversely connected with social support and distress tolerance. This exemplifies long-lasting associations between childhood trauma and re-victimization, emotion regulation, and ability to form supportive social relationships. A subsequent model including lower-order facets indicated that combat trauma was predominantly associated with posttraumatic stress disorder-intrusion symptoms. This study highlights the importance of addressing both risk and resilience to reduce suicide risk among veterans and increases understanding of factors that contribute to suicidal ideation.

Changes in the network structure of posttraumatic stress disorder symptoms at different time points among youth survivors: A network analysis

BACKGROUND

Despite considerable studies focused on the symptoms of posttraumatic stress disorder (PTSD), little is understood about how symptoms of PTSD change over time. The study aimed to use a network analysis approach to understand the nature of the association between PTSD symptoms at different time points among children and adolescents who experience an earthquake.

METHODS

A longitudinal study enrolled 1623 youth survivors who completed 3 assessments with the Children's Revised Impact of Event Scale at 2 weeks, 3 months and 6 months after the Lushan earthquake. The epicentre was Baoxing Country that located in the Ya'an city (Sichuan Province in China). A network analysis approach was used to investigate how symptom networks change at different time points.

RESULTS

A total of 1623 youth survivors (768 male and 855 female) completed three assessments. Different centrality symptoms existed at different time points. Flashback and upset by reminders were centrality symptoms at 2 weeks, 3 months and 6 months. The overall network connectivity was significantly stronger at 3 months than at 2 weeks (5.663 vs. 5.140, s = 0.523, p = 0.000), and significantly stronger at 6 months than at 2 weeks (6.094 vs. 5.663, s = 0.432, p = 0.020).

LIMITATIONS

Participants from a specific region might limit the generalizability of our results. A self-report questionnaire was used to assess PTSD symptoms.

CONCLUSIONS

Re-experience cluster (flashback and upset by reminders) and their interactions might play a key role in PTSD symptom evolution. Over time, the global connectivity becomes stronger, suggesting that youth survivors are more vulnerable in the chronic phases.

A decennial review of psychotraumatology: what did we learn and where are we going?

On 6 December 2019 we start the 10th year of the European Journal of Psychotraumatogy (EJPT), a full Open Access journal on psychotrauma. This editorial is part of a special issue/collection celebrating the 10 years anniversary of the journal where we will acknowledge some of our most impactful articles of the past decade (also discussed below and marked with * in the reference list). In this editorial the editors present a decennial review of the field addressing a range of topics that are core to both the journal and to psychotraumatology as a discipline. These include neurobiological developments (genomics, neuroimaging and neuroendocrine research), forms of trauma exposure and impact across the lifespan, mass trauma and early interventions, work-related trauma, trauma in refugee populations, and the potential consequences of trauma such as PTSD or Complex PTSD, but also resilience. We address innovations in psychological, medication (enhanced) and technology-assisted treatments, mediators and moderators like social support and finally how new research methods help us to gain insights in symptom structures or to better predict symptom development or treatment success. We aimed to answer three questions 1. Where did we stand in 2010? 2. What did we learn in the past 10 years? 3. What are our knowledge gaps? We conclude with a number of recommendations concerning top priorities for the future direction of the field of psychotraumatology and correspondingly the journal.

The Study of Psychopathology from the Network Analysis Perspective: A Systematic Review

BACKGROUND

Network analysis (NA) is an analytical tool that allows one to explore the map of connections and eventual dynamic influences among symptoms and other elements of mental disorders. In recent years, the use of NA in psychopathology has rapidly grown, which calls for a systematic and critical analysis of its clinical utility.

METHODS

Following PRISMA guidelines, a systematic review of published empirical studies applying NA in psychopathology, between 2010 and 2017, was conducted. We included the literature published in PubMed and PsycINFO using as keywords any combination of "network analysis" with the terms "anxiety," "affective disorders," "depression," "schizophrenia," "psychosis," "personality disorders," "substance abuse" and "psychopathology."

RESULTS

The review showed that NA has been applied in a plethora of mental disorders in adults (i.e., 13 studies on anxiety disorders; 19 on mood disorders; 7 on psychosis; 1 on substance abuse; 1 on borderline personality disorder; 18 on the association of symptoms between disorders), and 6 on childhood and adolescence.

CONCLUSIONS

A critical examination of the results of each study suggests that NA helps to identify, in an innovative way, important aspects of psychopathology like the centrality of the symptoms in a given disorder as well as the mutual dynamics among symptoms. Yet, despite these promising results, the clinical utility of NA is still uncertain as there are important limitations on the analytic procedures (e.g., reliability of indices), the type of data included (e.g., typically restricted to secondary analysis of already published data), and ultimately, the psychometric and clinical validity of the results.

Network Analysis and Precision Rehabilitation for the Post-concussion Syndrome

Some people experience persistent symptoms following a mild traumatic brain injury (MTBI), and the etiology of those symptoms has been debated for generations. Post-concussion-like symptoms are caused by many factors both before and after MTBI, and this non-specificity is the bedrock of the conundrum regarding the existence of the post-concussion syndrome. A latent model or common cause theory for the syndrome is inconsistent with the prevailing biopsychosocial conceptualization. It is the thesis of this paper that adopting a network perspective for persistent symptoms following MTBI, including the post-concussion syndrome, could lead to new insights and targeted treatment and rehabilitation strategies. The network perspective posits that symptoms co-occur because they are strongly inter-related, activating, amplifying, and mutually reinforcing, not because they arise from a common latent disease entity. This approach requires a conceptual shift away from thinking that symptoms reflect an underlying disease or disorder toward viewing inter-related symptoms as constituting the syndrome or disorder. The symptoms do not arise from an underlying syndrome—the symptoms are the syndrome. A network analysis approach allows us to embrace heterogeneity and comorbidity, and it might lead to the identification of new approaches to sequenced care. The promise of precision rehabilitation requires us to better understand the interconnections among symptoms and problems so that we can produce more individualized and effective treatment and rehabilitation.

Networks of Depression and Anxiety Symptoms Across Development

OBJECTIVE

Frequent co-occurrence and bidirectional longitudinal associations have led some researchers to question the boundaries between depression and anxiety. A longitudinal investigation of the interconnected symptom structure of these constructs may help determine the extent to which they are distinct, and whether this changes over development. Therefore, the present study used network analysis to examine these symptom-symptom associations developmentally from early childhood to mid-adolescence.

METHOD

We analyzed data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (N = 1,147). Depression and anxiety symptoms were assessed on 7 occasions between ages 5 and 14 years using maternal reports. Regularized partial correlation networks were constructed at each time point, and diagnostic boundaries were explored using empirical tests of network modularity (ie, clustering of symptom nodes). Nonparametric permutation tests were used to determine whether symptoms became more associated over development, and network centrality was examined to identify developmental changes in the overall importance of specific symptoms.

RESULTS

Symptoms formed highly interconnected networks, as evidenced by strong associations between depression and anxiety symptoms and a lack of distinct clustering. There was some evidence of an increase in overall connectivity as children aged. Feeling "anxious/fearful" and "unhappy/sad" were consistently the most central symptoms over development.

CONCLUSION

Minimal clustering of nodes indicated no separation of depression and anxiety symptoms from early childhood through mid-adolescence. An increase in connectivity over development suggests that symptoms may reinforce each other, potentially contributing to the high levels of lifetime continuity of these disorders.

Network analysis of empathy items from the interpersonal reactivity index in 1973 young adults

The aim of this work is to perform a network analysis on the French adaptation of the interpersonal reactivity index (IRI) scale from a large Belgian database and provide additional information for the construct of empathy. We analyze a database of 1973 healthy young adults who were queried on the IRI scale. A regularized partial correlation network is estimated. In the visualization of the model, items are displayed as nodes, edges represent regularized partial correlations between the nodes. Centrality denotes a node's connectedness with other nodes in the network. The spinglass algorithm and the walktrap algorithm are used to identify communities of items, and state-of-the-art stability analyses are carried out. The spinglass algorithm identifies four communities, the walktrap algorithm five communities. Positive edges are found among nodes belonging to the same community as well as among nodes belonging to different communities. Item 14 ("Other people's misfortunes do not usually disturb me a great deal") shows the highest strength centrality score. The network edges and node centrality order are accurately estimated. Network analysis highlights interesting connections between indicators of empathy; how these results impact empathy models must be assessed in further studies.