The sense of self in the aftermath of trauma: lessons from the default mode network in posttraumatic stress disorder

Neuroimaging evidence of disturbed self-appraisal in posttraumatic stress disorder: A systematic review

BACKGROUND

The experience of self-hood in posttraumatic stress disorder (PTSD) is altered cognitively and somatically. Dysfunctional negative cognitions about the self are a central mechanism of PTSD symptomatology and treatment. However, while higher-order brain models of disturbances in self-appraisal (i.e., cognitive processes relating to evaluating the self) have been examined in other psychiatric disorders, it is unclear how normative brain function during self-appraisal is impaired in PTSD.

METHODS

This paper presents a PRISMA systematic review of functional neuroimaging studies (n = 5), to establish a neurobiological account of how self-appraisal processes are disturbed in PTSD. The review was prospectively registered with PROSPERO (CRD42023450509).

RESULTS

Self-appraisal in PTSD is linked to disrupted activity in core self-processing regions of the Default Mode Network (DMN); and regions involved in cognitive control and emotion regulation, salience and valuation.

LIMITATIONS

Because self-appraisal in PTSD is relatively under-studied, only a small number of studies could be included for review. Cross-study heterogeneity in analytic approaches and trauma-exposure history prohibited a quantitative meta-analysis.

CONCLUSIONS

This paper proposes a mechanistic account of how neural dysfunctions may manifest clinically in PTSD and inform targeted selection of appropriate treatment options. We present a research agenda for future work to advance the field.

Self-construal modulates default mode network connectivity in refugees with PTSD

BACKGROUND

While self-construal and posttraumatic stress disorder (PTSD) are independently associated with altered self-referential processes and underlying default mode network (DMN) functioning, no study has examined how self-construal affects DMN connectivity in PTSD.

METHODS

A final sample of 93 refugee participants (48 with DSM-5 PTSD or sub-syndromal PTSD and 45 matched trauma-exposed controls) completed a 5-minute resting state fMRI scan to enable the observation of connectivity in the DMN and other core networks. A self-construal index was calculated by substracting scores on the collectivistic and individualistic sub-scales of the Self Construal Scale.

RESULTS

Independent components analysis identified 9 active networks-of-interest, and functional network connectivity was determined. A significant interaction effect between PTSD and self-construal index was observed in the anterior ventromedial DMN, with spatial maps localizing this to the left ventromedial prefrontal cortex (vmPFC), extending to the ventral anterior cingulate cortex. This effect revealed that connectivity in the vMPFC showed greater reductions in those with PTSD with higher levels of collectivistic self-construal.

LIMITATIONS

This is an observational study and causality cannot be assumed. The specialized sample of refugees means that the findings may not generalize to other trauma-exposed populations.

CONCLUSIONS

Such a finding indicates that self-construal may shape the core neural architecture of PTSD, given that functional disruptions to the vmPFC underpin the core mechanisms of extinction learning, emotion dysregulation and self-referential processing in PTSD. Results have important implications for understanding the universality of neural disturbances in PTSD, and suggest that self-construal could be an important consideration in the assessment and treatment of post-traumatic stress reactions.

Childhood maltreatment and transdiagnostic connectivity of the default-mode network: The importance of duration of exposure

Childhood maltreatment (CM) has been demonstrated to be associated with changes in resting-state functional connectivity of the default-mode network (DMN) across various mental disorders. Growing evidence regarding severity of CM is available but transdiagnostic research considering the role of both severity and duration of CM for DMN connectivity at rest is still scarce. We recruited a sample of participants with varying levels of CM suffering from three disorders in which a history of CM is frequently found, namely, post-traumatic stress disorder, major depressive disorder, or somatic symptom disorder, as well as healthy volunteers to examine DMN connectivity in a transdiagnostic sample. We expected to find changes in inter-network connectivity of the DMN related to higher self-reported levels of CM severity and duration. Resting-state functional magnetic resonance imaging scans of 128 participants were analyzed focusing on regions of interest (ROI-to-ROI approach) and whole-brain Seed-to-Voxel analyses with retrospectively assessed CM as predictor in a regression model. Changes in connectivity between nodes of the DMN and the visual network were identified to be associated with CM duration but not severity. CM duration showed associations with increased connectivity of the precuneus and visual regions, as well as sensory-motor regions. The observed changes in connectivity could be interpreted as an impairment of information transfer between the transmodal DMN and unimodal visual and sensory-motor regions with impairment increasing with duration of exposure to CM.

The Emotional Aftermath of Surviving an Attempted Intimate Partner Homicide

While the issue of intimate partner homicide (IPH) has gained increasing focus, research that pinpoints the experiences of women who survived an attempted IPH is limited. Specifically, studies that aim to understand the aftermath of surviving such incidents are scarce. Thus, the aim of the present study was to explore the emotional experience of IPH survivors following the attack. An interpretive phenomenological analysis was used to analyze the narratives of 11 women who had survived an attempted homicide by their partner. Four major themes emerged: Living between dichotomies: A fragmented identity; Embodied fear: A fear that will not go away; The loss of future: A life divided; and The loneliness of surviving the "unsurvivable." Utilizing the ambiguous loss theory to examine the emotional ramifications of IPH indicates that survivors navigate persistent confusion and struggle to comprehend the loss. This involves challenges in moving forward and achieving resolution, conflicting emotions related to the loss, minimal recognition of the grief, and limited support from the social environment.

Indistinguishable behavioural and neural correlates of perceptual self-other distinction in autistic and neurotypical adults

Previous research has suggested that self-bias (i.e., enhanced cognitive processing of self-versus other-relevant information) may be atypical in autism spectrum conditions (ASC), perhaps due to difficulties with self-other distinction. However, empirical evidence for this is inconsistent, and the neural basis of processing differences remains unknown. We present two experiments that aimed to test perceptual self-bias and familiarity effects in ASC using a perceptual-association task. Participants were asked to distinguish face/label associations of the self from those of other people of differing levels of familiarity (i.e., friend vs stranger). Experiment 1 took an individual differences approach by testing whether behavioural self-bias is associated with the number of autistic traits in a neurotypical adult sample (N = 59). Experiment 2 took a case-control approach by testing whether behavioural self-bias and associated ERP responses differ between neurotypical (N = 27) and autistic (N = 30) adults. Across both experiments, behavioural results showed that participants experienced a self-bias (self > friend and stranger) and a familiarity effect (e.g., friend > stranger); neither effect was affected by the number of autistic traits or autism diagnosis. In Experiment 2, analysis of N1, N2, and P3 ERP components revealed a typical self-bias in both groups (self distinct from friend and stranger), and only the autistic group showed evidence of a familiarity effect (N2 more negative-going for stranger than friend). The findings are discussed in relation to self-other distinction ability, and the relevance of other neuropsychological and psychiatric conditions such as anxiety and alexithymia are also considered.

A prospective study on EEG default mode network associated with subsequent posttraumatic stress disorder following sexual assault

This study aimed to explore the predictors of posttraumatic stress disorder (PTSD) in women who have recently experienced sexual assault, by examining psychological and neurophysiological factors using a prospective design with resting-state electroencephalogram (EEG) functional connectivity. The study enrolled 33 women who had been recently traumatized by sexual assault and conducted assessments within a month of the trauma. These survivors were evaluated for PTSD three months later and were classified into two groups: PTSD positive (n = 12) and PTSD negative (n = 21). They were compared to two control groups comprising women who had not experienced any extremely traumatic events: 25 with depression and 25 healthy controls. The evaluation focused on resting-state EEG functional connectivity within default mode network (DMN) using small-worldness (SW), based on graph theory. We also assessed self-reported levels of depression, anxiety, anger, and executive functions. The findings indicated that survivors who developed PTSD three months post-trauma exhibited higher anxiety levels and reduced DMN SW in the beta 3 frequency, compared to those who did not develop PTSD. Contrary to expectations, survivors without PTSD showed decreased executive functioning and lower prefrontal centrality compared to those with PTSD. This study underscores the importance of early assessment and intervention for sexual assault survivors at risk of developing PTSD.

Giving Voice to Women with Substance Use Disorder: Findings from Expressive Writing About Trauma

Background

Trauma exposure is a risk factor for substance use disorders (SUD) among women. This study explores written content from an expressive writing (EW) intervention conducted within a residential SUD program to examine themes across trauma experiences and characterize their deep insight into such experiences.

Materials and Methods

This qualitative study is a secondary data analysis of written content of the first writing session from women (n = 44) randomized to an EW condition while in residential SUD treatment.

Results

Nearly all participants (72.7% African American; mean age 37.3 years) reported a significant trauma event (93.2%) with an average of 3.7 types of trauma events (54.4% had a current posttraumatic stress disorder diagnosis). Four primary themes emerged: (1) trauma across the lifespan; (2) loss of safety; (3) altered self-concept; and (4) desire to move on. Most participants identified interpersonal trauma, especially at an early age, as well as parental neglect and physical and/or sexual violence. These themes indicate a pattern of interpersonal betrayal and paint a picture of trauma and the subsequent "rippling effect" such that the physical, mental, and emotional consequences were often as impactful as the event itself. However, there was also a desire to move on and gain a sense of normalcy.

Conclusions

Findings highlight the importance of the written word and addressing underlying trauma in addiction treatment to facilitate healing and the woman's desire to move on.

What Predicts Beneficial Outcomes in Psychedelic Use? A Quantitative Content Analysis of Psychedelic Health Outcomes

Interest in psychedelics and their possible therapeutic potential has been growing. Metaphysical belief theory asserts that these benefits stem from the adoption of comforting supernatural beliefs following a mystical experience. By contrast, predictive self-binding theory suggests that the beneficial outcomes of psychedelics are primarily driven by psychological insights. The present study tests these competing models of psychedelic benefits. We conducted a quantitative content analysis on unsolicited self-reports of psychedelic users available on Erowid.org, to examine the potential relations between psychological insight, ego dissolution, therapeutic intent, altered metaphysical belief, and enduring health outcomes. We randomly selected, coded, and analyzed two hundred forty psychedelic experience reports from the website. Path analysis using structural equation modeling showed that psychological insight, not metaphysical beliefs, uniquely predicted beneficial outcomes. Moreover, beneficial outcomes' positive relation to ego dissolution and therapeutic intent was fully mediated by psychological insight. These findings support the predictive self-binding model over the metaphysical belief model.

"Finding My Worth as a Sexual Being": A Qualitative Gender Analysis of Sexual Self-Concept and Coping in Survivors of Childhood Sexual Abuse

Childhood sexual abuse (CSA) is likely to have impacts on adult survivors' sexuality, particularly on their sexual self-concept. However, little is known about how survivors cope with CSA-related sexual impacts, including sexual self-concept impairments. Thus, this study aimed to examine the interplay between sexual self-concept and coping strategies in CSA survivors by (1) documenting the manifestations of their impaired sexual self-concepts; (2) identifying their strategies to cope with the sexual impacts of CSA; and (3) examining gender differences on sexual self-concept impairments and coping strategies. Content analysis was conducted on semi-structured interviews with 25 women and 26 men adult survivors of CSA recruited via social networks and victim support organizations. Analyses yielded three conceptual categories: (1) Developing an unconsolidated and unfavorable sexual self-concept following CSA; (2) Avoiding CSA-related sexual impacts and impaired sexual self-concept; (3) Approaching CSA-related sexual impacts with more authenticity. Men often managed their suffering and compensated for their impaired sexual self-concept by engaging in sexual dominance and over-investment, by accepting their sexual difficulties and relying on medication to overcome them. Women tended to restrict themselves and disconnect sexually to avoid suffering, complied with their partners' sexual demands out of a sense of duty, prioritized sexual intimacy over orgasm, and seek professional help. Interventions with survivors should promote the development of approach strategies to cope with sexual difficulties, including self-concept impairments, and foster sexual authenticity.

The Vestibulocerebellum and the Shattered Self: a Resting-State Functional Connectivity Study in Posttraumatic Stress Disorder and Its Dissociative Subtype

The flocculus is a region of the vestibulocerebellum dedicated to the coordination of neck, head, and eye movements for optimal posture, balance, and orienting responses. Despite growing evidence of vestibular and oculomotor impairments in the aftermath of traumatic stress, little is known about the effects of chronic psychological trauma on vestibulocerebellar functioning. Here, we investigated alterations in functional connectivity of the flocculus at rest among individuals with post-traumatic stress disorder (PTSD) and its dissociative subtype (PTSD + DS) as compared to healthy controls. Forty-four healthy controls, 57 PTSD, and 32 PTSD + DS underwent 6-min resting-state MRI scans. Seed-based functional connectivity analyses using the right and left flocculi as seeds were performed. These analyses revealed that, as compared to controls, PTSD and PTSD + DS showed decreased resting-state functional connectivity of the left flocculus with cortical regions involved in bodily self-consciousness, including the temporo-parietal junction, the supramarginal and angular gyri, and the superior parietal lobule. Moreover, as compared to controls, the PTSD + DS group showed decreased functional connectivity of the left flocculus with the medial prefrontal cortex, the precuneus, and the mid/posterior cingulum, key regions of the default mode network. Critically, when comparing PTSD + DS to PTSD, we observed increased functional connectivity of the right flocculus with the right anterior hippocampus, a region affected frequently by early life trauma. Taken together, our findings point toward the crucial role of the flocculus in the neurocircuitry underlying a coherent and embodied self, which can be compromised in PTSD and PTSD + DS.

Sex differences in the effects of trait anxiety and age on resting-state functional connectivities of the amygdala

Background

Numerous studies characterized how resting-state functional connectivities (rsFCs) of the amygdala were disrupted in emotional disorders and varied with emotional traits, including anxiety. With trait anxiety known to diminish with age, a critical issue concerns disambiguating the effects of age and anxiety on amygdala rsFCs in studying the neural bases of individual differences in anxiety.

Methods

Two-hundred adults (83 women) 19-85 years of age underwent fMRI and assessment for trait anxiety. Amygdala rsFC correlates were identified using multiple regression with age and anxiety in the same model for all and separately in men and women. The rsFC correlates were examined for age-anxiety interaction.

Results

Anxiety was negatively correlated with amygdala-temporooccipital gyri rsFC in all and in men alone. In women, amgydala rsFC with the thalamus/pallidum, angular/supramarginal gyri, inferior temporal gyrus, and posterior insula correlated positively and rsFC with calcarine cortex and caudate correlated negatively with anxiety. We also observed sex differences in age correlation of amgydala-posterior cingulate cortex/precuneus and -insula/temporoparietal rsFCs, with stronger associations in women. In women alone, anxiety and age interacted to determine amygdala rsFC with the thalamus/pallidum, calcarine cortex, and caudate, with older age associated with stronger correlation between anxiety and the rsFCs.

Limitations

The findings need to be validated in an independent sample and further explored using task-based data.

Conclusion

Highlighting anxiety- and age- specific as well as interacting correlates of amygdala rsFCs and sex differences in the correlates, the findings may shed light on the neural markers of anxiety.

Learning a Lesson: Spiritual Attributions of Sexual Trauma and Revictimization

This study aims to explore how individuals with affiliation to spirituality and victimization attribute sexual trauma and revictimization to spiritual principles and its perceived impact on victim assistance. A phenomenological research was conducted with 36 participants divided into three groups: female survivors who turned to spirituality as part of their recovery process (n = 17), spiritually oriented therapists who treat survivors (n = 10), and spiritual leaders and teachers who are often consulted by survivors and their close ones (n = 9). Findings show three prominent themes: (a) ephemeral and eternal components of existence; (b) learning a lesson; and (c) Tikkun Olam (Hebrew: world's repairment). The findings contribute theoretical and practical applications: they offer deep insights into the spiritual reason for revictimization and its cessation, and suggest innovative external explanations anchored in ancient knowledge that can alleviate survivors' suffering from self-blame. The study lays the foundation for an upcoming theory entitled Spiritual Victimology.

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.

Spiritual Victimology: Basic Principles

This study aims to describe the spiritual characteristics of sexual victimization and the recovery journey of survivors via applying spiritual principles, in order to harness the findings for the development of the theory of Spiritual Victimology. Two research questions were asked: what spiritual principles characterize victimization and recovery from it, and how can spiritual perceptions assist survivors? In a phenomenological study, 17 sexual trauma survivors who view their recovery as a spiritual journey, 10 spiritually-oriented therapists, and 9 spiritual leaders were interviewed. Findings show that a unique, victimized self-centeredness characterized sexual trauma, attaching survivors to a victim identity. By applying spiritual principles, the survivors were gradually opened up to love and developed a new, spiritual sense of self, with better inter- and intra-personal connections, as well as a transpersonal one. This connection was perceived as highly important to survivors' recovery, freeing them from loneliness and isolation, and helping them to restore some order to the chaos which the trauma and its consequences had imposed on their lives.

How the body remembers: Examining the default mode and sensorimotor networks during moral injury autobiographical memory retrieval in PTSD

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

Altered Resting-State functional connectivity in the anterior and posterior hippocampus in Post-traumatic stress disorder: The central role of the anterior hippocampus

BACKGROUND

Post-traumatic stress disorder can be viewed as a memory disorder, with trauma-related flashbacks being a core symptom. Given the central role of the hippocampus in autobiographical memory, surprisingly, there is mixed evidence concerning altered hippocampal functional connectivity in PTSD. We shed light on this discrepancy by considering the distinct roles of the anterior versus posterior hippocampus and examine how this distinction may map onto whole-brain resting-state functional connectivity patterns among those with and without PTSD.

METHODS

We first assessed whole-brain between-group differences in the functional connectivity profiles of the anterior and posterior hippocampus within a publicly available data set of resting-state fMRI data from 31 male Vietnam war veterans diagnosed with PTSD (mean age = 67.6 years, sd = 2.3) and 29 age-matched combat-exposed male controls (age = 69.1 years, sd = 3.5). Next, the connectivity patterns of each subject within the PTSD group were correlated with their PTSD symptom scores. Finally, the between-group differences in whole-brain functional connectivity profiles discovered for the anterior and posterior hippocampal seeds were used to prescribe post-hoc ROIs, which were then used to perform ROI-to-ROI functional connectivity and graph-theoretic analyses.

RESULTS

The PTSD group showed increased functional connectivity of the anterior hippocampus with affective brain regions (anterior/posterior insula, orbitofrontal cortex, temporal pole) and decreased functional connectivity of the anterior/posterior hippocampus with regions involved in processing bodily self-consciousness (supramarginal gyrus). Notably, decreased anterior hippocampus connectivity with the posterior cingulate cortex/precuneus was associated with increased PTSD symptom severity. The left anterior hippocampus also emerged as a central locus of abnormal functional connectivity, with graph-theoretic measures suggestive of a more central hub-like role for this region in those with PTSD compared to trauma-exposed controls.

CONCLUSIONS

Our results highlight that the anterior hippocampus plays a critical role in the neurocircuitry underlying PTSD and underscore the importance of the differential roles of hippocampal sub-regions in serving as biomarkers of PTSD. Future studies should investigate whether the differential patterns of functional connectivity stemming from hippocampal sub-regions is observed in PTSD populations other than older war veterans.

The role of early attachment experiences in modulating defensive peripersonal space

Selecting appropriate defensive behaviours for threats approaching the space surrounding the body (peripersonal space, PPS) is crucial for survival. The extent of defensive PPS is measured by recording the hand-blink reflex (HBR), a subcortical defensive response. Higher-order cortical areas involved in PPS representation exert top-down modulation on brainstem circuits subserving HBR. However, it is not yet known whether pre-existing models of social relationships (internal working models, IWM) originating from early attachment experiences influence defensive responses. We hypothesized that organized IWM ensure adequate top-down regulation of brainstem activity mediating HBR, whereas disorganized IWM are associated with altered response patterns. To investigate attachment-dependent modulation on defensive responses, we used the Adult Attachment Interview to determine IWM and recorded HBR in two sessions (with or without the neurobehavioral attachment system activated). As expected, the HBR magnitude in individuals with organized IWM was modulated by the threat proximity to the face, regardless of the session. In contrast, for individuals with disorganized IWM, attachment system activation enhances HBR regardless of the threat position, suggesting that triggering emotional attachment experiences magnifies the threatening valence of external stimuli. Our results indicate that the attachment system exerts a strong modulation on defensive responses and the magnitude of PPS.

Posterior cingulate cortex targeted real-time fMRI neurofeedback recalibrates functional connectivity with the amygdala, posterior insula, and default-mode network in PTSD

BACKGROUND

Alterations within large-scale brain networks-namely, the default mode (DMN) and salience networks (SN)-are present among individuals with posttraumatic stress disorder (PTSD). Previous real-time functional magnetic resonance imaging (fMRI) and electroencephalography neurofeedback studies suggest that regulating posterior cingulate cortex (PCC; the primary hub of the posterior DMN) activity may reduce PTSD symptoms and recalibrate altered network dynamics. However, PCC connectivity to the DMN and SN during PCC-targeted fMRI neurofeedback remains unexamined and may help to elucidate neurophysiological mechanisms through which these symptom improvements may occur.

METHODS

Using a trauma/emotion provocation paradigm, we investigated psychophysiological interactions over a single session of neurofeedback among PTSD (n = 14) and healthy control (n = 15) participants. We compared PCC functional connectivity between regulate (in which participants downregulated PCC activity) and view (in which participants did not exert regulatory control) conditions across the whole-brain as well as in a priori specified regions-of-interest.

RESULTS

During regulate as compared to view conditions, only the PTSD group showed significant PCC connectivity with anterior DMN (dmPFC, vmPFC) and SN (posterior insula) regions, whereas both groups displayed PCC connectivity with other posterior DMN areas (precuneus/cuneus). Additionally, as compared with controls, the PTSD group showed significantly greater PCC connectivity with the SN (amygdala) during regulate as compared to view conditions. Moreover, linear regression analyses revealed that during regulate as compared to view conditions, PCC connectivity to DMN and SN regions was positively correlated to psychiatric symptoms across all participants.

CONCLUSION

In summary, observations of PCC connectivity to the DMN and SN provide emerging evidence of neural mechanisms underlying PCC-targeted fMRI neurofeedback among individuals with PTSD. This supports the use of PCC-targeted neurofeedback as a means by which to recalibrate PTSD-associated alterations in neural connectivity within the DMN and SN, which together, may help to facilitate improved emotion regulation abilities in PTSD.

Psychotherapeutic and neurobiological processes associated with ayahuasca: A proposed model and implications for therapeutic use

Ayahuasca is a psychoactive Amazonian plant brew. It is usually made from the Banisteriopsis caapi vine (Spruce ex Griseb. Morton, Malpighiaceae), which contains three primary harmala alkaloids, along with the leaves of Psychotria viridis (Ruiz et Pavon, Rubiaceae) in which the potent psychedelic dimethyltryptamine (DMT) is found. DMT-harmaloid concoctions have gained popularity in recent years, due to growing anecdotal and scientific reports of therapeutic benefits associated with their consumption. Ayahuasca is now ingested in a variety of different settings across the globe, from traditional ethnobotanical to so called "neo-shamanic" ceremonies. Furthermore, related preparations involving alternative sources of DMT and harmala alkaloids are becoming increasingly common as knowledge of ayahuasca continues to spread internationally. This article reviews the existing literature and draws on original qualitative data from a large cross-sectional study of ayahuasca drinkers, to propose a model of psychotherapeutic processes associated with the consumption of ayahuasca. We assert that it is these processes, facilitated by a range of neurobiological effects, that lead to beneficial mental health and wellbeing outcomes. Our proposed model identifies five key psychotherapeutic processes or effects inherent to the ayahuasca experience; somatic effects; introspection and emotional processing; increased Self-connection; increased spiritual connection, and finally the gaining of insights and new perspectives. We note some important differences in these processes compared with other classic psychedelics as well as the implications of the model for the therapeutic use of ayahuasca. Improved understanding of the psychotherapeutic processes involved with the ayahuasca experience will better equip practitioners to work with this potentially transformative concoction and enable the optimization of therapeutic treatment models for potential clinical use.

From childhood trauma to hyperarousal in adults: The mediating effect of maladaptive shame coping and insomnia

Introduction

A new line of insomnia research focuses on the developmental trajectories from early live stress to insomnia in adulthood. Adverse childhood experiences (ACE's) might create a vulnerability for later maladaptive coping with distress, as seen in chronic hyperarousal or insomnia. In an functional magnetic resonance imaging (fMRI) study, failure to dissociate the neurobiological components of shame from autobiographical shameful memories in insomnia was reflected by continued activation of the dorsal anterior cingulate cortex (dACC), which may be a result of maladaptive coping in the wake of ACE's. Following up on that study, the current pilot study explores the relation between ACE's, shame coping-styles, adult insomnia, hyperarousal, and neurobiology of autobiographical memory.

Methods

We used existing data (N = 57) from individuals with insomnia (N = 27) and controls (N = 30), and asked these participants to complete the childhood trauma questionnaire (CTQ). Two structural equation models were used to test the hypotheses that shame-coping styles and insomnia symptom severity mediate the association between ACE's and (1) self-rated hyperarousal symptoms and (2) dACC activation to recall of autobiographical memories.

Results

For the association between ACE's and hyperarousal, there was a significant mediation of shame-coping style (p < 0.05). This model also indicated worse shame coping with more ACE's (p < 0.05) and worse insomnia symptoms with more ACES's (p < 0.05), but no association between shame coping and insomnia symptoms (p = 0.154). In contrast, dACC activation to recall of autobiographical memories could only be explained by its direct association with ACE's (p < 0.05), albeit that in this model more ACE's were also associated with worse insomnia symptoms.

Discussion

These findings could have an implication for the approach of treatment for insomnia. It could be focused more on trauma and emotional processing instead of conventional sleep interventions. Future studies are recommended to investigate the relationship mechanism between childhood trauma and insomnia, with additional factors of attachment styles, personality, and temperament.

Toward staging differentiation for posttraumatic stress disorder treatment

OBJECTIVES

Several medical and psychiatric disorders have stage-based treatment decision-making methods. However, international treatment guidelines for posttraumatic stress disorder (PTSD) fail to give specific treatment recommendations based on chronicity or stage of the disorder. There is convincing evidence of a finite range of PTSD symptom trajectories, implying that different phenotypes of the disorder can be distinguished, which are highly relevant for a staging typology of PTSD.

METHODS

State-of-the-art review building on prior work on staging models in other disorders as a mapping tool to identify and synthesize toward PTSD.

RESULTS

We propose a four-stage model of PTSD ranging from stage 0: trauma-exposed asymptomatic but at risk to stage 4: severe unremitting illness of increasing chronicity. We favor a symptom description in various chronological characteristics based on neurobiological markers, information processing systems, stress reactivity, and consciousness dimensions. We also advocate for a separate phenomenology of treatment resistance since this can yield treatment recommendations.

CONCLUSION

A staging perspective in the field of PTSD is highly needed. This can facilitate the selection of interventions that are proportionate to patients' current needs and risk of illness progression and can also contribute to an efficient framework to organize biomarker data and guide service delivery. Therefore, we propose that a neurobiologically driven trajectory-based typology of PTSD can help deduct several treatment recommendations leading to a more personalized and refined grid to strategize, plan and evaluate treatment interventions.

The brain-body disconnect: A somatic sensory basis for trauma-related disorders

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

Hyperexcitability: From Normal Fear to Pathological Anxiety and Trauma

Hyperexcitability in fear circuits is suggested to be important for development of pathological anxiety and trauma from adaptive mechanisms of fear. Hyperexcitability is proposed to be due to acquired sensitization in fear circuits that progressively becomes more severe over time causing changing symptoms in early and late pathology. We use the metaphor and mechanisms of kindling to examine gains and losses in function of one excitatory and one inhibitory neuropeptide, corticotrophin releasing factor and somatostatin, respectively, to explore this sensitization hypothesis. We suggest amygdala kindling induced hyperexcitability, hyper-inhibition and loss of inhibition provide clues to mechanisms for hyperexcitability and progressive changes in function initiated by stress and trauma.

Contrasting Associations Between Heart Rate Variability and Brainstem-Limbic Connectivity in Posttraumatic Stress Disorder and Its Dissociative Subtype: A Pilot Study

Background

Increasing evidence points toward the need to extend the neurobiological conceptualization of posttraumatic stress disorder (PTSD) to include evolutionarily conserved neurocircuitries centered on the brainstem and the midbrain. The reticular activating system (RAS) helps to shape the arousal state of the brain, acting as a bridge between brain and body. To modulate arousal, the RAS is closely tied to the autonomic nervous system (ANS). Individuals with PTSD often reveal altered arousal patterns, ranging from hyper- to blunted arousal states, as well as altered functional connectivity profiles of key arousal-related brain structures that receive direct projections from the RAS. Accordingly, the present study aims to explore resting state functional connectivity of the RAS and its interaction with the ANS in participants with PTSD and its dissociative subtype.

Methods

Individuals with PTSD (n = 57), its dissociative subtype (PTSD + DS, n = 32) and healthy controls (n = 40) underwent a 6-min resting functional magnetic resonance imaging and pulse data recording. Resting state functional connectivity (rsFC) of a central node of the RAS – the pedunculopontine nuclei (PPN) – was investigated along with its relation to ANS functioning as indexed by heart rate variability (HRV). HRV is a prominent marker indexing the flexibility of an organism to react adaptively to environmental needs, with higher HRV representing greater effective adaptation.

Results

Both PTSD and PTSD + DS demonstrated reduced HRV as compared to controls. HRV measures were then correlated with rsFC of the PPN. Critically, participants with PTSD and participants with PTSD + DS displayed inverse correlations between HRV and rsFC between the PPN and key limbic structures, including the amygdala. Whereas participants with PTSD displayed a positive relationship between HRV and PPN rsFC with the amygdala, participants with PTSD + DS demonstrated a negative relationship between HRV and PPN rsFC with the amygdala.

Conclusion

The present exploratory investigation reveals contrasting patterns of arousal-related circuitry among participants with PTSD and PTSD + DS, providing a neurobiological lens to interpret hyper- and more blunted arousal states in PTSD and PTSD + DS, respectively.

Decreased brain network global efficiency after attachment memories retrieval in individuals with unresolved/disorganized attachment-related state of mind

The main aim of the study was to examine how brain network metrics change after retrieval of attachment memories in individuals with unresolved/disorganized (U/D) attachment-related state of mind and those with organized/resolved (O/R) state of mind. We focused on three main network metrics associated with integration and segregation: global (E_glob) efficiency for the first function, local (E_loc) efficiency and modularity for the second. We also examined assortativity and centrality metrics. Electroencephalography (EEG) recordings were performed before and after the Adult Attachment Interview (AAI) in a sample of 50 individuals previously assessed for parenting quality. Functional connectivity matrices were constructed by means of the exact Low-Resolution Electromagnetic Tomography (eLORETA) software and then imported into MATLAB to compute brain network metrics. Compared to individuals with O/R attachment-related state of mind, those with U/D show a significant decrease in beta E_glob after AAI. No statistically significant difference among groups emerged in E_loc and modularity metrics after AAI, neither in assortativity nor in betweenness centrality. These results may help to better understand the neurophysiological patterns underlying the disintegrative effects of retrieving traumatic attachment memories in individuals with disorganized state of mind in relation to attachment.

A systematic review of the neural correlates of sexual minority stress: towards an intersectional minority mosaic framework with implications for a future research agenda

BACKGROUND

Systemic oppression, particularly towards sexual minorities, continues to be deeply rooted in the bedrock of many societies globally. Experiences with minority stressors (e.g. discrimination, hate-crimes, internalized homonegativity, rejection sensitivity, and microaggressions or everyday indignities) have been consistently linked to adverse mental health outcomes. Elucidating the neural adaptations associated with minority stress exposure will be critical for furthering our understanding of how sexual minorities become disproportionately affected by mental health burdens.

METHODS

Following PRISMA-guidelines, we systematically reviewed published neuroimaging studies that compared neural dynamics among sexual minority and heterosexual populations, aggregating information pertaining to any measurement of minority stress and relevant clinical phenomena.

RESULTS

Only 1 of 13 studies eligible for inclusion examined minority stress directly, where all other studies focused on investigating the neurobiological basis of sexual orientation. In our narrative synthesis, we highlight important themes that suggest minority stress exposure may be associated with decreased activation and functional connectivity within the default-mode network (related to the sense-of-self and social cognition), and summarize preliminary evidence related to aberrant neural dynamics within the salience network (involved in threat detection and fear processing) and the central executive network (involved in executive functioning and emotion regulation). Importantly, this parallels neural adaptations commonly observed among individuals with posttraumatic stress disorder (PTSD) in the aftermath of trauma and supports the inclusion of insidious forms of trauma related to minority stress within models of PTSD.

CONCLUSIONS

Taken together, minority stress may have several shared neuropsychological pathways with PTSD and stress-related disorders. Here, we outline a detailed research agenda that provides an overview of literature linking sexual minority stress to PTSD and insidious trauma, moral affect (including shame and guilt), and mental health risk/resiliency, in addition to racial, ethnic, and gender related minority stress. Finally, we propose a novel minority mosaic framework designed to inform future directions of minority stress neuroimaging research from an intersectional lens.

Differential mechanisms of posterior cingulate cortex downregulation and symptom decreases in posttraumatic stress disorder and healthy individuals using real-time fMRI neurofeedback

BACKGROUND

Intrinsic connectivity networks, including the default mode network (DMN), are frequently disrupted in individuals with posttraumatic stress disorder (PTSD). The posterior cingulate cortex (PCC) is the main hub of the posterior DMN, where the therapeutic regulation of this region with real-time fMRI neurofeedback (NFB) has yet to be explored.

METHODS

We investigated PCC downregulation while processing trauma/stressful words over 3 NFB training runs and a transfer run without NFB (total n = 29, PTSD n = 14, healthy controls n = 15). We also examined the predictive accuracy of machine learning models in classifying PTSD versus healthy controls during NFB training.

RESULTS

Both the PTSD and healthy control groups demonstrated reduced reliving symptoms in response to trauma/stressful stimuli, where the PTSD group additionally showed reduced symptoms of distress. We found that both groups were able to downregulate the PCC with similar success over NFB training and in the transfer run, although downregulation was associated with unique within-group decreases in activation within the bilateral dmPFC, bilateral postcentral gyrus, right amygdala/hippocampus, cingulate cortex, and bilateral temporal pole/gyri. By contrast, downregulation was associated with increased activation in the right dlPFC among healthy controls as compared to PTSD. During PCC downregulation, right dlPFC activation was negatively correlated to PTSD symptom severity scores and difficulties in emotion regulation. Finally, machine learning algorithms were able to classify PTSD versus healthy participants based on brain activation during NFB training with 80% accuracy.

CONCLUSIONS

This is the first study to investigate PCC downregulation with real-time fMRI NFB in both PTSD and healthy controls. Our results reveal acute decreases in symptoms over training and provide converging evidence for EEG-NFB targeting brain networks linked to the PCC.

An Integrative Systems-Oriented Interpersonal/Relational Group Approach to Understanding and Treating Mass Trauma, Dissociation and Enactments During the COVID-19 Pandemic

The coronavirus pandemic (COVID-19) is a new ongoing, long-term mass trauma event occurring simultaneously with overwhelming sociopolitical stressors. We propose an integrative, psychodynamic, systems-oriented, interpersonal/relational trauma group model to address the multiple losses, heightened anxieties, and complicated grief that have resulted from the pandemic, as well as various forms of interpersonal abuse associated with racist and oppressive systems. These manifest as dissociation and unconscious enactments in small and large psychotherapy groups. We examine the role and responsibilities of the group leader in working therapeutically with these phenomena. Case examples for large and small psychotherapy groups are provided.

Reward Processing and Circuit Dysregulation in Posttraumatic Stress Disorder

Past decades have witnessed substantial progress in understanding of neurobiological mechanisms that contribute to generation of various PTSD symptoms, including intrusive memories, physiological arousal and avoidance of trauma reminders. However, the neurobiology of anhedonia and emotional numbing in PTSD, that have been conceptualized as reward processing deficits - reward wanting (anticipation of reward) and reward liking (satisfaction with reward outcome), respectively, remains largely unexplored. Empirical evidence on reward processing in PTSD is rather limited, and no studies have examined association of reward processing abnormalities and neurocircuitry-based models of PTSD pathophysiology. The manuscript briefly summarizes "state of the science" of both human reward processing, and of PTSD implicated neurocircuitry, as well as empirical evidence of reward processing deficits in PTSD. We then summarize current gaps in the literature and outline key future directions, further illustrating it by the example of two alternative explanations of PTSD pathophysiology potentially affecting reward processing via different neurobiological pathways. Studying reward processing in PTSD will not only advance the understanding of their link, but also could enhance current treatment approaches by specifically targeting anhedonia and emotional symptoms in PTSD patients.

A randomized, controlled trial of alpha-rhythm EEG neurofeedback in posttraumatic stress disorder: A preliminary investigation showing evidence of decreased PTSD symptoms and restored default mode and salience network connectivity using fMRI

OBJECTIVE

The default-mode network (DMN) and salience network (SN) have been shown to display altered connectivity in posttraumatic stress disorder (PTSD). Restoring aberrant connectivity within these networks with electroencephalogram neurofeedback (EEG-NFB) has been shown previously to be associated with acute decreases in symptoms. Here, we conducted a double-blind, sham-controlled randomized trial of alpha-rhythm EEG-NFB in participants with PTSD (n = 36) over 20-weeks. Our aim was to provide mechanistic evidence underlying clinical improvements by examining changes in network connectivity via fMRI.

METHODS

We randomly assigned participants with a primary diagnosis of PTSD to either the experimental group (n = 18) or sham-control group (n = 18). We collected resting-state fMRI scans pre- and post-NFB intervention, for both the experimental and sham-control PTSD groups. We further compared baseline brain connectivity measures pre-NFB to age-matched healthy controls (n = 36).

RESULTS

With regard to the primary outcome measure of PTSD severity, we found a significant main effect of time in the absence of a group × time interaction. Nevertheless, we found significantly decreased PTSD severity scores in the experimental NFB group only, when comparing post-NFB (dz = 0.71) and 3-month follow-up scores (dz = 0.77) to baseline measures. Interestingly, we found evidence to suggest a shift towards normalization of DMN and SN connectivity post-NFB in the experimental group only. Both decreases in PTSD severity and NFB performance were correlated to DMN and SN connectivity post-NFB in the experimental group. Critically, remission rates of PTSD were significant higher in the experimental group (61.1%) as compared to the sham-control group (33.3%).

CONCLUSION

The current study shows mechanistic evidence for therapeutic changes in DMN and SN connectivity that are known to be associated with PTSD psychopathology with no patient dropouts. This preliminary investigation merits further research to demonstrate fully the clinical efficacy of EEG-NFB as an adjunctive therapy for PTSD.