Trauma exposure and post-traumatic stress disorder in the general population

Post-epileptic seizure posttraumatic stress Disorder: A mediation analysis

OBJECTIVE

Previous studies investigated the varying prevalence of post-epileptic seizure posttraumatic stress disorder (PS-PTSD). The current study aimed first to compare the profiles of patients with and without PS-PTSD and, second, to study the interaction between other past traumatic experiences, subjective ictal anxiety, psychiatric comorbidities, and PS-PTSD in people with epilepsy (PWE).

METHODS

We conducted an observational study, investigating past traumatic experiences and PS-PTSD through standardized scales (CTQ-28, LEC-5 and PCL-5). We used semi-structured interviews and validated psychometric scales (NDDIE for depression and GAD-7 for anxiety) to collect data on general psychiatric comorbidities. We also assessed epilepsy specific psychiatric symptoms (interictal and peri-ictal). We performed a mediation analysis through PROCESS for SPSS to evaluate the effect of history of past trauma and subjective ictal anxiety on PS-PTSD through interictal depression and anxiety symptoms.

RESULTS

We enrolled 135 PWE, including 35 patients with PS-PTSD (29.5 %). Patients with PS-PTSD had significantly higher depression (12.87 vs 10; p = 0.005) and anxiety (7.74 vs 5.01; p = 0.027) scores and higher prevalence of peri-ictal psychiatric symptoms, compared to patients without PS-PTSD. The relationship between other past traumatic experiences and PS-PTSD was totally mediated by interictal depression and anxiety. We found a significant indirect effect of interictal anxiety symptoms on the path between subjective ictal anxiety and PS-PTSD.

SIGNIFICANCE

Our results showed that patients with PS-PTSD have a more severe psychopathological profile (more peri ictal and inter ictal depressive and anxiety symptoms). Both inter ictal and subjective ictal anxiety appear to have a significant role in PS-PTSD.

A nationally representative survey of ICD-11 PTSD among Danish adolescents and young adults aged 15-29

Posttraumatic stress disorder (PTSD) is recognized as a debilitating psychiatric disorder affecting populations worldwide. This has inspired many countries to estimate the national prevalence rates of PTSD in Europe and beyond. At present, there are no published representative studies that have assessed the occurrence of trauma exposure and PTSD in Denmark using a valid measurement based on ICD-11 criteria. A national sample of the general population of young Danish residents, ranging in age between 15 to 29 years (n = 2,434), was surveyed cross-sectionally from April to October 2022. Data weights were applied to ensure representativity of the sample. Multiple regression was used to study the relationship between trauma exposure, sex, age, and PTSD. Accidents and violence were the most common types of trauma exposure with females being more likely to experience sexual violence. A total of 7.7% endorsed probable PTSD with women reporting higher rates of clinical and subclinical PTSD (12.3% and 12.7%, respectively) than men (3.5% and 7.3%, respectively). Findings from the multiple regression showed that female gender was associated with higher PTSD-severity, although the strongest predictor was trauma-type with other types of traumas, and sexual violence displaying the strongest relationship to PTSD-severity overall. A dose-response relationship between the number of trauma types and PTSD symptomatology was found. This is the first study of PTSD in a nationally representative Danish sample using a valid measure of ICD-11 PTSD. The identified PTSD rates were higher than Danish official estimates in a representative sample of the Danish adolescent and young adult population (7.7% weighted compared to 1%). The study replicated international findings of sex differences in probable PTSD endorsement.

Factors associated with depression among war-affected population in Northeast, Ethiopia

BACKGROUND

Depression is the most common mental health outcome of exposure to war-related traumatic stressors. Due to inter-communal conflict, Dessie City residents have experienced prolonged armed conflict in 2021. This conflict leads to widespread violence, negative impact on mental health, and large-scale forced migration. However, the problem is not properly addressed in Ethiopia. Therefore, this study aimed to assess the prevalence and risk factors of depression in the war-affected area in Dessie City, Ethiopia.

METHOD

A cross-sectional study design was conducted among 785 participants in 2022. The study subjects were selected using a multi-stage cluster sampling technique. The outcome measures used in the study were validated with the Patient Health Questionnaire (PHQ-9). Data was entered using Epi-data version 3.1 and SPSS version 25 was used to analyze data. Bivariate and multivariable logistic regressions were done to identify factors related to depression. In multivariable logistic regression variables with a p-value less than 0.05 were considered significant and, adjusted OR (AOR) with 95% CI was used to present the strength of the association.

RESULT

The prevalence of depression among participants was found to be 24.5% (95% CI,21.7, 27.5). In multivariable analysis, post-traumatic stress disorder (AOR = 2.79, 95% CI 1.76-4.43), middle-perceived life threats (AOR = 8.25, 95% CI 2.47-17.49), low social support (AOR = 1.90, 95% CI 1.23-2.96) were variables significantly associated with depression.

CONCLUSION

This study found a high prevalence of depression among Dessie City residents. post-traumatic stress disorder, middle-perceived life threats, and low social support were associated with depression. Interventional strategies should be implemented to promote healing, resilience, and the overall well-being of individuals and communities. However, the findings underscore the need to address the current lack of mental health care resources in post-conflict populations.

Gender Differences in the Relationship between Lifetime Exposure to Trauma and the Development of Pathological Personality Traits

Gender differences in the prevalence, types and outcomes of traumas have consistently been reported in the literature. Other research has documented that exposure to trauma is associated with the development and maintenance of pathological personality traits. In the current study, we examined the moderating role of gender in the association between lifetime exposure to trauma and pathological personality traits. The sample included 148 clients who sought treatment at a community mental health clinic. All participants completed online questionnaires including demographic information, the Trauma History Questionnaire (THQ), and the Personality Inventory for DSM-5-Brief Form (PID-5-BF) at the entry to treatment. Our findings documented a significant association between exposure to trauma and pathological personality traits in men, but not in women. Furthermore, this pattern of results was specifically evident within two personality domains: antagonism and detachment. These findings contribute to the theoretical understanding of the interplay between trauma, gender, and the development of pathological personality traits. They expand upon the growing knowledge about the mental health crisis among boys and men by shedding light on the unique vulnerabilities that men face in response to traumatic experiences and how these experiences can have a lasting impact on their adaptive functioning. Consequently, at the clinical level, the current study emphasizes the importance of paying particular attention to men's trauma histories and explicitly exploring these during the intake session.

Prevalence and associated factors of common mental disorders among internally displaced people by armed conflict in Cabo Delgado, Mozambique: a cross-sectional community-based study

Background

Humanitarian emergencies are a major global health challenge with the potential to have a profound impact on people's mental and psychological health. Displacement is a traumatic event that disrupts families and affects physical and psychological health at all ages. A person may endure or witness a traumatic incident, such as being exposed to war, and, as a result, develop post-traumatic stress disorder (PTSD). There is a lack of information about post-traumatic stress disorder, depression, and anxiety disorder in low and middle-income countries in humanitarian emergency contexts such as Mozambique. This study aimed to assess the prevalence of PTSD, depression, and anxiety, and associated factors among armed conflict survivors in Cabo Delgado, north region of Mozambique in 2023.

Methods

A community-based cross-sectional study was conducted between January and April 2023 among 750 participants, who were selected by convenience. A face-to-face interview used the Primary Care Post-Traumatic Stress Disorder Checklist (PC-PTSD-5) to evaluate PTSD, the Generalized Anxiety Disorder Scale (GAD-7) to evaluate anxiety and the Patient Health Questionnaire - Mozambique (PHQ-9 MZ) to evaluate depression. The association between PTSD and demographic and psychosocial characteristics was analyzed using bivariate and multivariable binary logistic regression. We used a 5% significance level.

Results

The three mental disorders assessed were highly prevalent in our sample with 74.3% PTSD, 63.8% depression, and 40.0% anxiety. The chance of developing PTSD was higher in females (AOR = 2.30, 95% CI 1.50-3.51), in patients with depression symptoms (AOR = 8.27, 95% CI = 4.97-13.74) and anxiety symptoms (AOR = 1.45, 95% CI = 0.84-2.50).

Conclusion

This study reported that the prevalence of PTSD, depression, and anxiety were high. Patients having depressive symptoms, anxiety symptoms, and being female are more at risk of developing PTSD. There is a need to integrate screening for common mental disorders in the context of humanitarian emergencies and its adapted integration of psychosocial interventions.

Engagement in Meaningful Activity Mediates the Relationship Between Stressful Life Events and Functional Resilience

Resilience during stressful life events is a priority for administering the most client-centered care as possible. Occupational therapy practitioners have the unique opportunity to support resilience through promoting meaningful participation. The current study aims to understand the associations between meaningful activity engagement, resilience, and stressful life events. We specifically focused on answering if meaningful participation mediates the relationship between stressful life events and resilience. 492 participants from a non-clinical convenience sample of Amazon's MTurk completed the study. Participants completed an online survey and reported their experiences of stressful life events, resilience, well-being, and meaningful participation. We used SPSS and PROCESS to analyze our data. Stressful event severity and resilience were inversely related. When accounting for the effect of meaningful participation, the relationship became non-significant, indicating evidence of mediation. Implications: Focusing on measuring meaningful participation may be worth studying in further research.

Amygdala-derived-EEG-fMRI-pattern neurofeedback for the treatment of chronic post-traumatic stress disorder. A prospective, multicenter, multinational study evaluating clinical efficacy

We conducted a prospective, single arm, multisite, multinational, open label trial assessing the safety and efficacy of a novel amygdala derived neurofeedback treatment, designated Amygdala-Derived-EFP, for chronic PTSD. Participants, including veterans and civilians, underwent screening, training, 15 neurofeedback sessions over 8 weeks and; baseline, termination (8 weeks) and 3 month post treatment assessments with validated measures. The primary endpoint was more than 50 % of the participants demonstrating a Minimally Clinically Important Difference (MCID) defined as a 6-point reduction, on the Clinician Administered PTSD Scale (CAPS-5) total score at 3 months. Secondary measures included the PCL-5, ERQ, PHQ-9, and CGI. Statistical analyses were performed using SAS®V9.4. The primary endpoint was met, with a CAPS-5 MCID response rate of 66.7 %. The average reduction in CAPS-5 total scores at 3 month follow up was 13.5 points, more than twice the MCID. Changes from baseline in CAPS-5, PCL-5, PHQ-9 scores at 8 weeks and the 3 month follow-up demonstrated statistically significant improvements in response and; demonstrated effect sizes ranging from 0.46 to 1.07. Adverse events were mild and resolved after treatment. This study builds on prior research demonstrating similar outcomes using amygdala-derived neurofeedback. Positive attributes of this therapy include monitoring by non-physician personnel, affordability, accessibility, and tolerability.

Proposition of a transdiagnostic processual approach of emotion dysregulation based on core triggers and interpersonal styles

Emotion dysregulation (ED) has primarily been described in patients suffering from borderline personality disorder (BPD) and is an integral part of this diagnosis, but it is also a transdiagnostic construct that can be found in several other psychiatric disorders. The strong relationships between ED and BPD may lead clinicians to underestimate ED associated to other clinical contexts. This can lead to difficulties in diagnostic and treatment orientation, especially in the context of comorbidities. In this article, after reviewing the literature on the development and functioning of emotion dysregulation, and on the evidence for emotion dysregulation in eight disorders (borderline personality disorder, pathological narcissism with/without narcissistic personality disorder, obsessive-compulsive personality disorder, antisocial personality disorder, bipolar disorder, autism spectrum disorder, complex post-traumatic stress disorder, and adult attention deficit hyperactivity disorder), we present a transdiagnostic processual model of emotion dysregulation based on core triggers and interpersonal styles to try to address this issue and to provide a simple but technical tool to help clinicians in their diagnostic assessment and treatment orientation. By focusing more on typical patterns and interpersonal dynamics than only on categories, we believe that this model may contribute to the actual need for improvement of our current psychiatric classifications, alongside other well-studied and under-used dimensional models of psychopathology (e.g., HiTOP, AMPD), and may be useful to build more specific treatment frameworks for patients suffering from ED.

Obsessive-compulsive symptoms, perceived burdensomeness, and thwarted belongingness: Associations and implications among US veterans

OBJECTIVE

Obsessive-compulsive disorder (OCD) is among the most debilitating psychiatric disorders worldwide, but has gone relatively unnoticed within the US veteran population. Simultaneously, suicide rates continue to remain high within this population despite the high volume of veterans who receive psychiatric care. With recent research demonstrating OCD's unique relationship with suicidality, it is imperative to explore this association and factors that may explain this association within veterans.

METHODS

The present study investigated OCD symptoms and their relationship with two known risk factors of suicide, perceived burdensomeness (PB) and thwarted belongingness (TB), in two samples of veterans.

RESULTS

In the first study (N = 100), OCD symptoms were found to be uniquely related to both PB and TB even after covarying for demographics, trauma exposure, and probable depression. In the second study (N = 99), these relationships were replicated longitudinally. OCD symptoms at baseline were found to be indirectly related to suicidal ideation severity at a 1-month follow-up via PB and TB at post-treatment.

CONCLUSION

This study highlights the importance of assessing and addressing OCD symptoms within veterans due to the unique relationship these symptoms have with suicidal constructs. A deeper understanding of the impact of OCD within the veteran population will inform future prevention and intervention efforts.

The role of locus coeruleus neuroimmune signaling in the response to social stress in female rats

Neuropsychiatric disorders that result from stress exposure, including post-traumatic stress disorder and substance abuse, are highly associated with central inflammation. Our previous work established that females selectively exhibit increased proinflammatory cytokine release within the noradrenergic locus coeruleus (LC) in response to witnessing social stress, which was associated with a hypervigilant phenotype. Thus, neuroimmune activation in the LC may be responsible for the heightened risk of developing mental health disorders following stress in females. Further, ablation of microglia using pharmacological techniques reduces the hypervigilant behavioral response exhibited by females during social stress. Therefore, these studies were designed to further investigate the impact of stress-induced neuroimmune signaling on the long-term behavioral and neuronal consequences of social stress exposure in females using DREADDs. We first characterized the use of an AAV-CD68-Gi-DREADD virus targeted to microglia within the LC. While the use of AAVs in preclinical research has been limited by observations regarding poor transfection efficiency in mice, recent data suggest that species specific differences in microglial genetics may render rats more receptive to chemogenetic targeting of microglia using a CD68 promoter. Therefore, clozapine-n-oxide (CNO) was used to activate the microglial expressed hM4Di to inhibit microglial activity during acute exposure to vicarious social defeat (witness stress, WS) in female rats. Neuroimmune activity within the LC, quantified by microglial morphology and cytokine release, was augmented by WS and prevented by chemogenetic microglial inhibition. Following confirmation of DREADD selectivity and efficacy, we utilized this technique to inhibit microglial activity during repeated WS. Subsequently, rats were tested in a marble burying paradigm and exposed to the WS cues and context to measure hypervigilant behaviors. Chemogenetic-mediated inhibition of microglial activity prior to each WS exposure prevented both acute and long-term hypervigilant responses induced by WS across multiple behavioral paradigms. Further, a history of microglial inactivation during WS prevented the heightened LC activity typically observed in response to stress cues. These studies are among the first to use a chemogenetic approach to inhibit microglia within the female brain in vivo and establish LC inflammation as a key mechanism underlying the behavioral and neuronal responses to social stress in females.

The posttraumatic cognitive appraisal inventory (PTCAI): development and validation

Objective

This study aims to develop and validate the Posttraumatic Cognitive Appraisal Inventory (PTCAI) for accidental trauma survivors.

Method

Based on interviews and expert feedback, the initial item pool was generated for the Negative Cognitive Appraisal Inventory of Loss and Feeling Threatened, and the Positive Cognitive Appraisal Inventory of Positively Face, Self-Sense, and Relationships. Then, we recruited two groups of accidental trauma survivors to examine the reliability and validity of the PTCAI. Item analysis and exploratory factor analysis (EFA) were conducted on Sample 1. Confirmatory factor analysis (CFA), Pearson correlation analysis, and internal consistency reliability analysis were applied to Sample 2. After 2 weeks, 20 survivors completed the PTCAI again to test temporal stability.

Results

Following item analysis, the PTCAI was reduced to 27 items. The results of the EFA demonstrated that the five-factor, 27-item solution of the PTCAI was appropriate, which accounted for 63.931% of the total variation. The CFA indicated that the five-factor second-order model offered an excellent fit to the data. Loss and Feeling threatened were equally important in the study participants' negative cognitive appraisal of accidental traumas. Self-sence was the most important positive cognitive appraisal of accidental traumas by the study participants. Positively Face and Relationships were somewhat behind. Additionally, the PTCAI demonstrated high concurrent validity and reliability (test-retest and internal consistency).

Conclusion

The PTCAI appears to be a reliable and valid instrument for assessing cognitive appraisals of accidental trauma survivors.

Investigation of grief and posttraumatic growth related to patient loss in pediatric intensive care nurses: a cross-sectional study

BACKGROUND AND AIM

Pediatric Intensive Care Units (PICUs) are clinical settings where patient loss is frequently experienced. A sense of professional grief and posttraumatic growth in nurses who have experienced patient loss has a significant impact on psychological and physical health, work satisfaction, turnover rates, as well as on personal and professional relations, and employee loyalty. The aim of this study was to investigate grief and posttraumatic growth in PICU nurses and to examine related factors.

METHODS

The study is of cross-sectional design and was conducted with 200 nurses who were working in 87 PICU's around Turkey during the period March 30 - June 30, 2021. Data were collected with a Descriptive Information Form, the Texas Revised Inventory of Grief (TRIG), the Posttraumatic Growth Inventory (PTGI), and an open-ended question asking for suggestions as to how nurses can cope with loss. Online questionnaires were used in the data collection. Descriptive statistics, the student t-test, one-way analysis of variance, and post-hoc tests were employed in the analysis of the data.

RESULTS

The nurses' mean scores were 49.425 ± 10.868 on TRIG and 61.450 ± 24.934 on PTGI. A negative weak correlation was found between the intensity of the nurses' grief and their posttraumatic growth (r = 0.144, p = 0.041). Receiving training on dealing with a patient's terminal stage (t=-2.688, p = 0.001), feeling comfortable about providing the patient's care (t = 2.624, p = 0.009) and providing the family with emotional support during patient care (t = 1.979, p = 0.049), and the presence of supporting health professionals reduced levels of grief (t = 2.797, p = 0.000). Being a woman (t = 3.299, p = 0.001), willingness to work in the unit (t=-3.219, p = 0.002), and being given enough time to accept the loss (t = 3.986, p = 0.000) were correlated with higher levels of posttraumatic growth. The nurses most commonly wanted more time allotted to recuperate after a loss (n = 35) and professional support (n = 22).

CONCLUSIONS

Nurses experience a moderate sense of grief after a patient's loss. As levels of grief decrease, posttraumatic growth increases. Healthcare administrators and future researchers can benefit from these findings when planning supportive interventions to help nurses cope with their feelings of grief and achieve posttraumatic growth.

STRENGTHS AND LIMITATIONS

A limitation of the study is that it was conducted only with nurses who were Association members.

Is pre-college interpersonal trauma associated with cannabis use?

OBJECTIVE

To examine the prevalence and correlates of lifetime cannabis use (i.e., experimental [use 1-5 times] and non-experimental [use ≥ 6 times]) in relation to interpersonal trauma (IPT) above and beyond relevant covariates.

PARTICIPANTS

A large (n = 9,889) representative sample of college students at an urban university in the southeastern part of the United States.

METHODS

Participants were 4 cohorts of first-year college students who completed measures of demographics, cannabis, alcohol, nicotine, and IPT. Associations were estimated using multinomial logistic regressions.

RESULTS

The prevalence of lifetime cannabis use was 28.1% and 17.4% for non-experimental and experimental cannabis use, respectively. IPT was significantly associated with experimental and non-experimental cannabis use above and beyond effects of sex, race, cohort, alcohol, and nicotine.

CONCLUSIONS

Results show that cannabis use is prevalent among college students and is associated with IPT above and beyond associations with sex, race, and other substance use.

Post-conflict acute stress reactions in Kazakhstan in the aftermath of January 2022 unrests: A national survey

Background

In January 2022 Kazakhstan experienced unprecedented nationwide protests that quickly turned to violent riots. Although the number of individuals affected physically by the disturbances were cited, the emotional toll of the events remains undetermined. The aim of this study was to evaluate the comparative rates of acute stress reactions in Kazakhstan in the aftermath of the unrests.

Methods

A cross-sectional, population-based online survey was conducted one month after the start of the disturbances. The study questionnaire were completed anonymously and included the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and the General Anxiety Disorder-7 (GAD-7), as well as socio-demographic and event exposure information.

Results

Of the 7021 people who initially agreed to participate, 6510 were able to complete the full survey. For a cut-off of ≥3 on the PC-PTSD-5, 14.8 % of the study participants exhibited symptoms. With a cut-off of ≥4, this percentage reduced to 4.6 %. Participants from Almaty city and Almaty region who experienced the most extensive disturbances showed a doubled prevalence compared to the national level (30.0 % for a cut-off of ≥3, and 10.1 % for a cut-off of ≥4). At the national level, the prevalence of anxiety symptoms, defined as a score of ≥10 on the GAD-7, stood at 10.9 %. This prevalence decreased to 4.2 % when considering a cut-off of ≥15.

Conclusion

Health authorities of riot-affected areas ought to be aware of the population level mental health impact of the civil conflict and consider provision of targeted interventions to mitigate the long-term consequence of these lifespan disorders, while also seeking for the peaceful resolution of the ensuing conflicts.

Impact of the intensive psychological intervention care on post-traumatic stress disorder and negative emotions of teenage female patients seeking an induced abortion

Aim

This study aimed to investigate the effects of intensive psychological intervention care on adverse emotions and post-traumatic stress disorder (PTSD) symptoms in female teenage patients after induced abortion.

Methods

This prospective cohort study included 100 teenage female patients seeking induced abortion who were randomly divided into two groups: the intervention group (n = 50) and the control group (n = 50). The intervention group received intensive psychological intervention care, while the control group received standard routine nursing. The scores of the PTSD checklist for DSM-5 (PCL-5), self-rating depression (SDS), and self-rating anxiety scale (SAS) were compared between the two groups at 1 month and 3 months after the operation.

Results

The intervention group had lower risk of developing PTSD (24% vs. 44%), depression (10% vs. 32%), and anxiety (0% vs. 12%) symptoms at 1 month after the surgery. However, there were no significant differences observed between the two groups at 3 months after the surgery. Furthermore, the intervention group had significantly lower scores in PCL-5 (27.4 ± 5.4 vs. 31.8 ± 5.7; 20.5 ± 7.1 vs. 25.0 ± 7.5; p < 0.05), SDS (31.8 ± 5.4 vs. 37.8 ± 6.6; 26.8 ± 5.0 vs. 31.4 ± 7.2; p < 0.05), and SAS (32.7 ± 5.0 vs. 39.8 ± 6.9; 25.0 ± 2.7 vs. 27.5 ± 2.8; p < 0.05) at 1 month and 3 months after induced abortion.

Conclusion

These findings suggest that intensive psychological intervention care can reduce the incidence and severity of depression, anxiety, and PTSD symptoms in teenage patients who undergo induced abortion.

Clinical trial registration

https://www.chictr.org.cn/showproj.html?proj=185200, identifier ChiCTR2300067531.

S100a9 Protects Against the Effects of Repeated Social Defeat Stress

Background

Posttraumatic stress disorder, a consequence of psychological trauma, is associated with increased inflammation and an elevated risk of developing comorbid inflammatory diseases. However, the mechanistic link between this mental health disorder and inflammation remains elusive. We previously found that S100a8 and S100a9 messenger RNA, genes that encode the protein calprotectin, were significantly upregulated in T lymphocytes and positively correlated with inflammatory gene expression and the mitochondrial redox environment in these cells. Therefore, we hypothesized that genetic deletion of calprotectin would attenuate the inflammatory and redox phenotype displayed after psychological trauma.

Methods

We used a preclinical mouse model of posttraumatic stress disorder known as repeated social defeat stress (RSDS) combined with pharmacological and genetic manipulation of S100a9 (which functionally eliminates calprotectin). A total of 186 animals (93 control, 93 RSDS) were used in these studies.

Results

Unexpectedly, we observed worsening of behavioral pathology, inflammation, and the mitochondrial redox environment in mice after RSDS compared with wild-type animals. Furthermore, loss of calprotectin significantly enhanced the metabolic demand on T lymphocytes, suggesting that this protein may play an undescribed role in mitochondrial regulation. This was further supported by single-cell RNA sequencing analysis demonstrating that RSDS and loss of S100a9 primarily altered genes associated with mitochondrial function and oxidative phosphorylation.

Conclusions

These data demonstrate that the loss of calprotectin potentiates the RSDS-induced phenotype, which suggests that its observed upregulation after psychological trauma may provide previously unexplored protective functions.

Predictors of alcohol and substance use among people with post-traumatic stress disorder (PTSD): findings from the NESARC-III study

PURPOSE

The self-medication hypothesis suggests people may develop Alcohol Use Disorder (AUD) or Non-Alcohol Substance Use Disorder (NA-SUD) following PTSD as a maladaptive way of coping with PTSD symptoms. Given that an accumulation of trauma experiences and interpersonal trauma increase the likelihood and severity of PTSD, we sought to determine whether the number and type of traumas additionally predict AUD and NA-SUD following PTSD.

METHODS

We analysed data from 36,309 adult participants in the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) study (M = 45.63 years, SD = 17.53, 56.3% female) who were administered semi-structured diagnostic interviews of trauma exposure and PTSD, AUD and NA-SUD symptoms.

RESULTS

Individuals with PTSD were more likely to have an AUD or NA-SUD than those without PTSD. Endorsement of a greater number of traumas was associated with greater odds of having PTSD, AUD, or NA-SUD. Experience of interpersonal trauma was related to greater odds of having PTSD and subsequent AUD or NA-SUD than not experiencing interpersonal trauma. Multiple experiences of interpersonal trauma compared to one interpersonal trauma exposure also increased the odds of having PTSD followed by AUD or NA-SUD.

CONCLUSIONS

Interpersonal trauma and multiple experiences of interpersonal trauma may result in individuals turning to alcohol and substances as a way to alleviate intolerable PTSD symptomology, aligning with the self-medication hypothesis. Our findings highlight the importance of ensuring services and support for interpersonal trauma survivors and for those who have experienced multiple traumas given their increased for unfavourable outcomes.

The COPE Staff study: Study description and initial report regarding job satisfaction, work-life conflicts, stress, and burnout among Swedish maternal and neonatal healthcare workers during the COVID-19 pandemic

OBJECTIVE

To describe the study design of the COPE Staff cohort study on working conditions for maternal and neonatal healthcare workers (MNHCWs), and present baseline data regarding job satisfaction, work-life conflicts, stress, and burnout.

METHODS

Between January and April 2021, 957 MNHCWs (administrative and medical staff) completed a baseline survey. Average levels of job satisfaction, work-life conflicts, stress, and burnout, and associations to perceived workload were assessed.

RESULTS

The average levels of job satisfaction, work-life conflicts, stress, and burnout were 68.6 (95% confidence interval [CI] 64.3-72.8), 42.6 (95% CI 37.3-48.0), 42.0 (95% CI 37.7-46.3), and 1.9 (95% CI 1.6-2.2), respectively. The respondents scoring above critical values indicating clinical burnout ranged between 3% and 18%, respectively, for the four burnout sub-dimensions. Women reported significantly higher levels of stress and burnout. Younger participants had lower job satisfaction and higher levels of work-life conflicts, stress, and burnout. Higher perceived workload was significantly associated with lower job satisfaction levels and higher levels of work-life conflicts, stress, and burnout.

CONCLUSIONS

Our results indicate associations between MNHCWs perceived workload and job satisfaction, work-life conflicts, stress, and burnout during the COVID-19 pandemic. Eighteen percent scored above critical values for exhaustion.

Psychological Reactions during and after a Lockdown: Self-Efficacy as a Protective Factor of Mental Health

The aim of the present study was to investigate the effects of home confinement/social isolation (i.e., lockdown), imposed to reduce large-scale spread of a disease in the population, on the mental health of individuals. Through an online survey during the lockdown (DL) related to COVID-19 (1085 respondents, 627 females, agerange: 18-82) (Italy, 23 April-2 May 2020), we revealed that situational factors, i.e., the presence of children at home and female gender, and psychological factors, i.e., a greater sense of isolation, lower perception of safety outside the home and higher trait anxiety, predicted higher levels of state anxiety (R2 = 0.58). The same factors, but with young age instead of the presence of children, predicted higher levels of perceived stress (R2 = 0.63). Then, these data were compared with those collected after the lockdown (AL) (174 respondents, 128 females, agerange: 19-78) (Italy, 1 July-31 October 2021). The results showed that along with a reduced sense of isolation (DL = 2.90 vs. AL = 2.10) and an increased perception of safety outside the home (DL = 2.63 vs. AL = 3.05), a reduction in state anxiety (DL = 45.76 vs. AL= 40.88) and stress appeared (DL = 18.84 vs. AL = 17.63). However, the situation was better for men than for women. Perceived self-efficacy emerged as a protective factor for mental health (R2range: 0.03-0.27). The results are discussed in light of the evidence on the effects of lockdown on individuals worldwide. These results may be used to make more educated decisions on targeted help for individuals who may be most adversely affected by the adoption of lockdowns in the future.

The impact of adversities across the lifespan on psychological symptom profiles in late adulthood: a latent profile analysis

People commonly face adverse circumstances throughout life, which increases risk for psychiatric disorders, such as anxiety, depression, psychosis, and posttraumatic stress disorder (PTSD). Adversities may occur during different periods in life. Especially adversity during early periods has been suggested to put individuals at risk for adverse mental health outcomes. Here, we investigated whether timing of adversity during the prenatal period, childhood, or mid-to-late adulthood differentially impacted classification into late adulthood symptom profiles. We performed sex-stratified Latent Profile Analysis to identify latent profiles regarding anxious, depressive, psychotic, and PTSD symptoms in n = 568 Dutch famine birth cohort members (n = 294 women, n = 274 men, mean age(SD) = 72.9(0.8)). Cross-sectional late adulthood symptomatology, childhood traumatic maltreatment, and adulthood trauma were based on self-report questionnaires. Prenatal adversity was considered present when individuals were prenatally exposed to the 1944-45 Dutch famine. In both men and women we identified one anxious/depressive profile and three profiles with approximately equal severity of all symptom types within each profile, yet differentiating in overall severity (low, mild, high) between profiles. We additionally found a PTSD symptom profile in women. In men, logistic regression models showed significant associations between prenatal, childhood and adulthood adversity, and profile classification, with differential effects depending on timing and most profound effects of child maltreatment. In women, childhood and adulthood adversity significantly increased classification probability into almost all profiles, with no significant effect of prenatal adversity. These findings support a time-dependent and sex-specific impact of adversity during different periods across the lifespan on psychological health, with consequences into late adulthood.

PTSD and crime propensity: Stress systems, brain structures, and the nature of the relationship

Post-traumatic stress disorder (PTSD) is the most commonly found disorder among the prison population; however, research has been slow to study it as a potential cause of crime. This review examines the neurophysiological changes in the organism associated with PTSD and connects them to crime and antisocial behaviour. Patients with PTSD suffer from a hyperactive sympathetic nervous system (SNS), an overactive amygdala that results in a hypoactive hypothalamic‒pituitary‒adrenal (HPA) axis, and a reduced hippocampal volume. All these features have been separately associated with aggressivity and antisocial behaviour; however, no consensus has been reached. Moreover, very little research has addressed the need to study the interaction between several stress-response systems. As a result, although there is some indication that patients with PTSD are probabilistically more likely to commit acts of crime, no conclusive results on the influence of PTSD on crime propensity can yet be drawn. Future research should address the interaction between the stress-response systems to understand the nature of antisocial behaviour and violence as well as to study any possible links between PTSD prevalence and possible unrest in prisons.

An open trial of VA CONNECT: Caring for Our Nation's Needs Electronically during the COVID-19 Transition

The COVID-19 pandemic impacted emotional well-being due to safety concerns, grief, employment impacts, and social interaction limitations. Face-to-face mental health treatment restrictions were especially impactful to veterans who often gain social enrichment from Veterans Health Administration (VHA) care. We present results from a novel group-based telehealth intervention, VA Caring for Our Nation's Needs Electronically during the COVID-19 Transition (VA CONNECT), which integrates skills training and social support to develop a COVID-19 Safety & Resilience Plan. Veterans (n ​= ​29) experiencing COVID-related stress participated in an open trial of this 10-session, manualized group VHA telehealth intervention. We examined whether COVID-19-related stress, adjustment disorder symptoms, and loneliness decreased, and coping strategy use increased after participation in VA CONNECT. Between baseline and two-month follow-up, participants reported a significant reduction in perceived stress and adjustment disorder symptoms, and an increase in planning coping skills use. Significant changes were not observed in loneliness or other specific coping strategies. Findings may support the utility of VA CONNECT as an intervention for pandemic-related stress and improving certain coping skills. Future research should explore group-based telehealth interventions like VA CONNECT with other populations within and outside of the VA, which have value during major disruptions to face-to-face mental healthcare access.

PROTOCOL: Group-based interventions for posttraumatic stress disorder: A systematic review and meta-analysis of the role of trauma type

This is the protocol for a Campbell systematic review. The primary objective is to assess the effects of group-based treatments on posttraumatic stress disorder (PTSD) symptomology in people diagnosed with PTSD (by a clinician or screening instrument) or referred to a PTSD treatment group for their symptoms by a medical professional. We will also examine a range of moderators that may affect the efficacy of group-based treatments, including the nature of the trauma (interpersonal, stigmatized) and the group fit (in terms of gender and shared vs. unshared trauma). Further, we will also explore what, if any, group-based and social identity factors are recorded and how they relate to PTSD outcomes.

Trauma Across the Life Span and Multisystem Morbidity in Women With HIV

OBJECTIVE

Sexual and physical abuse are highly prevalent among women living with HIV (WLWH) and are risk factors for the development of mental health and substance use disorders (MHDs, SUDs), and cognitive and medical comorbidities. We examined empirically derived patterns of trauma, MHD, and SUD, and associations with later cognitive and health outcomes.

METHODS

A total of 1027 WLWH (average age = 48.6 years) in the Women's Interagency HIV Study completed the World Mental Health Composite International Diagnostic Interview from 2010 to 2013 to identify MHDs, SUDs, and age at onset of sexual and physical abuse. Then, cognitive impairment, cardiovascular/metabolic conditions, and HIV disease outcomes were assessed for up to 8.8 years. Latent class analysis identified patterns of co-occurring trauma, MHDs, and/or SUDs. Generalized estimating equations determined associations between these patterns and midlife cognitive and medical outcomes.

RESULTS

Six distinct profiles emerged: no/negligible sexual/physical trauma, MHD, or SUD (39%); preadolescent/adolescent sexual trauma with anxiety and SUD (22%); SUD only (16%); MHD + SUD only (12%); early childhood sexual/physical trauma only (6%); and early childhood sexual/physical trauma with later MHD + SUD (4%). Profiles including early childhood trauma had the largest number of midlife conditions (i.e., cognitive, cardiovascular, HIV-related). Preadolescent/adolescent sexual trauma with anxiety and SUD predicted both global and domain-specific cognitive declines. Only SUD without trauma predicted lower CD4, whereas childhood trauma with MHD + SUD predicted increased CD8.

CONCLUSIONS

WLWH have complex multisystem profiles of abuse, MHD, and/or SUD that predict midlife cognitive, metabolic/cardiovascular, and HIV outcomes. Understanding the interplay between these factors over time can identify risks and personalize preventative and treatment interventions.

Genetic Associations Between Stress-Related Disorders and Autoimmune Disease

Objective: Emerging evidence supports a bidirectional phenotypic association between stress-related disorders and autoimmune disease. However, the biological underpinnings remain unclear. Here, the authors examined whether and how shared genetics contribute to the observed phenotypic associations. Methods: Based on data from 4,123,631 individuals identified from Swedish nationwide registers, familial coaggregation of stress-related disorders (any disorder or posttraumatic stress disorder [PTSD]) and autoimmune disease were initially estimated in seven cohorts with different degrees of kinship. Polygenic risk score (PRS) analyses were then performed with individual-level genotyping data from 376,871 participants in the UK Biobank study. Finally, genetic correlation analyses and enrichment analyses were performed with genome-wide association study (GWAS) summary statistics. Results: Familial coaggregation analyses revealed decreasing odds of concurrence of stress-related disorders and autoimmune disease with descending kinship or genetic relatedness between pairs of relatives; adjusted odds ratios were 1.51 (95% CI=1.09–2.07), 1.28 (95% CI=0.97–1.68), 1.16 (95% CI=1.14–1.18), and 1.01 (95% CI=0.98–1.03) for monozygotic twins, dizygotic twins, full siblings, and half cousins, respectively. Statistically significant positive associations were observed between PRSs of stress-related disorders and autoimmune disease, as well as between PRSs of autoimmune disease and stress-related disorders. GWAS summary statistics revealed a genetic correlation of 0.26 (95% CI=0.14–0.38) between these two phenotypes and identified 10 common genes and five shared functional modules, including one module related to G-protein–coupled receptor pathways. Similar analyses performed for PTSD and specific autoimmune diseases (e.g., autoimmune thyroid disease) largely recapitulated the results of the main analyses. Conclusions: This study demonstrated familial coaggregation, genetic correlation, and common biological pathways between stress-related disorders and autoimmune disease.

Sex-related difference of association of mitochondrial DNA copy number with PTSD in U.S. service members

Gender differences in the lifetime prevalence of post-traumatic stress disorder (PTSD) have been well described with rates reported as approximately 10%-12% in females and 5%-6% in males (Olff, 2017). This study examined whether the sex-related difference of mitochondrial DNA copy number (mtDNAcn), an emerging systemic index of mitochondrial biogenesis and function can serve as a potential biomarker for PTSD. Leukocyte mtDNAcn of service members with PTSD (male = 127, female = 24) or without PTSD (male = 621, female = 78) was assessed using a TaqMan assay. The results were validated by the absolute quantification of QX-200 droplet digital PCR (ddPCR). PTSD symptoms and symptom severity were assessed using the PTSD Checklist (PCL), a 17-item, DSM-based, self-report questionnaire with well-established validity and reliability. DSM-IV criteria and PTSD were determined by PCL total score. We found that mtDNAcn of female subjects with PTSD was significantly higher compared to either male or female non-PTSD controls or male subjects with PTSD (p < 0.05). There was no significant difference in mtDNAcn between males with PTSD and male/female controls without PTSD. Using in vitro cultured SH-SY5Y cells (human neuroblastoma), we demonstrated that estrogen (Estro) treatment significantly decreased mtDNAcn (P < 0.001) compared to the vehicle control. We also found that pre-treatment with either synthetic glucocorticoid dexamethasone (Dex) or Estro blocker tamoxifen (Tamox) attenuated the estrogen-induced decreases of mtDNAcn. Our data suggest that mtDNAcn may be gender-dependent in the Servicemembers with PTSD. Glucocorticoid and/or estrogen receptors may play a role in the regulation of mtDNAcn. The sex-related difference of mtDNAcn may serve as a PTSD biomarker for females.

Effects of positive reappraisal and self-distancing on the meaningfulness of everyday negative events

Current work on meaning-making has primarily focused on major negative life events such as trauma and loss, leaving common daily adversities unexplored. This study aimed to examine how utilizing meaning-making strategies such as positive reappraisal and self-distancing (in isolation or in combination) can facilitate an adaptive processing of these daily negative experiences. Overall meaning and facets of meaning (coherence, purpose, and significance/mattering) were assessed at both global and situational levels. Results suggested that positive reappraisal was generally effective for enhancing situational meaning but not under all conditions. Specifically, when negative experiences were high on emotional intensity, reflecting on the experience from a distanced (third-person) perspective enhanced coherence and existential mattering more than engaging in positive reappraisal. However, when negative experiences were low on intensity, distanced reflection led to less coherence and mattering than positive reappraisal. The findings of this study elucidated the importance of examining the multidimensional construct of meaning at the facet level and highlighted the importance of applying different coping strategies to effectively make meaning out of daily negative experiences.

Neuroscience-based psychotherapy: A position paper

In the recent years, discoveries in neuroscience have greatly impacted upon the need to modify therapeutic practice starting from the evidence showing some cerebral mechanisms capable of coping with mental health crisis and traumatic events of the individual's life history by redesigning the narrative plot and the person's sense of the Self. The emerging dialogue between neuroscience and psychotherapy is increasingly intense and modern psychotherapy cannot ignore the heritage deriving from studies about neuropsychological modification of memory traces, neurobiology of attachment theory, cognitive mechanisms involved in psychopathology, neurophysiology of human empathy, neuroimaging evidence about psychotherapeutic treatment, and somatoform disorders connecting the brain and the body. In the present article, we critically examined sectorial literature and claimed that psychotherapy has to referred to a neuroscience-based approach in order to adopt the most tailored interventions for specific groups of patients or therapy settings. We also provided recommendations for care implementation in clinical practice and illustrated challenges of future research.

Mental health indicators in Sweden over a 12-month period during the COVID-19 pandemic - Baseline data of the Omtanke2020 Study

BACKGROUND

The ongoing COVID-19 pandemic has had an unprecedented impact on the lives of people globally and is expected to have profound effects on mental health. Here we aim to describe the mental health burden experienced in Sweden using baseline data of the Omtanke2020 Study.

METHOD

We analysed self-reported, cross-sectional baseline data collected over a 12-month period (June 9, 2020-June 8, 2021) from the Omtanke2020 Study including 27,950 adults in Sweden. Participants were volunteers or actively recruited through existing cohorts and, after providing informed consent, responded to online questionnaires on socio-demographics, mental and physical health, as well as COVID-19 infection and impact. Poisson regression was fitted to assess the relative risk of demonstrating high level symptoms of depression, anxiety, and COVID-19 related distress.

RESULT

The proportion of persons with high level of symptoms was 15.6 %, 9.5 % and 24.5 % for depression, anxiety, and COVID-19 specific post-traumatic stress disorder (PTSD), respectively. Overall, 43.4 % of the participants had significant, clinically relevant symptoms for at least one of the three mental health outcomes and 7.3 % had significant symptoms for all three outcomes. We also observed differences in the prevalence of these outcomes across strata of sex, age, recruitment type, COVID-19 status, region, and seasonality.

CONCLUSION

While the proportion of persons with high mental health burden remains higher than the ones reported in pre-pandemic publications, our estimates are lower than previously reported levels of depression, anxiety, and PTSD during the pandemic in Sweden and elsewhere.

PTSD and depression severity are associated with cardiovascular disease symptoms in trauma-exposed women

Background: Posttraumatic stress disorder (PTSD) and depression are associated with increased risk for cardiovascular disease (CVD), which is the leading cause of death and disability worldwide. Epidemiological studies have revealed these illnesses to be highly comorbid, particularly among women. In the current study, we explored associations between indices of cardiovascular health, PTSD, and depression among a sample of trauma-exposed individuals assigned female at birth.Methods: Participants were N = 49 individuals without CVD who reported lifetime Criterion A trauma exposure. Blood pressure (BP), heart rate (HR), and high-frequency heart rate variability (HF-HRV) were collected during a 5-minute resting period. Symptoms of CVD (e.g. extremity pain and swelling, shortness of breath), PTSD, and depression were assessed, along with an exploratory measure of anhedonia.Results: Trauma exposure was positively correlated with systolic BP (r = .32, p = .029) and diastolic BP (r = .30, p = .040). The number of reported CVD symptoms was positively correlated with symptoms of PTSD (r = .41, p = .004), depression (r = .40, p = .005) and anhedonia (r = .38, p = .007). CVD symptoms were also significantly associated with PTSD (β = .41, t = 2.43, p = .023), depression (β = .40, t = 2.76, p = .009), and anhedonia (β = .38, t = 2.51, p = .017) after controlling for age and trauma exposure. These associations were not moderated by HF-HRV in our sample.Conclusions: Our results support the association between PTSD and depressive symptoms and worse cardiovascular functioning among an often-overlooked population that is particularly vulnerable to these illnesses. Future studies should investigate residual impacts of PTSD and depression treatment on CVD risk among trauma-exposed individuals, particularly women.

Post-traumatic stress disorder and associated factors among adult war survivors in Northwest Ethiopia: Community-based, cross-sectional study

Background

A person may endure or witness a traumatic incident, such as being exposed to war, and, as a result, develop post-traumatic stress disorder (PTSD). There is a lack of information about post-traumatic stress disorder in low and middle-income countries such as Ethiopia. However, armed conflict, abuse of human rights, and violence motivated by race are becoming more commonplace. This study aimed to assess the prevalence of PTSD and associated factors among war survivors in Nefas Meewcha Town, South Gondar Zone, Ethiopia, 2022.

Methods

A community based cross-sectional study was carried out. 812 study participants were chosen using a multi-stage sampling process. A face-to-face interview used a post-traumatic stress disorder checklist (PCL-5) to evaluate PTSD. The association between PTSD and other demographic and psychosocial characteristics was investigated using bivariate and multivariable binary logistic regression analysis. A P-value of 0.05 was declared as statistical significance.

Result

The prevalence of PTSD in this study was 40.8% with a 95% CI of 36.2 to 46.7. The likelihood of developing PTSD was significantly associated with the fallowing factors. A close family member killed or seriously injured (AOR = 4.53, 95% CI = 3.25-6.46), being female (AOR = 1.98, 95% CI = 1.3-3.0), moderate (AOR = 3.51, 95% CI = 2.52-4.68) and high perceived stress (AOR = 5.23, 95% CI = 3.47-8.26), depression symptoms (AOR = 4.92, 95% CI = 3.57-6.86), anxiety disorder symptoms (AOR = 5.24, 95% CI = 3.72-7.63), a chronic medical illness (AOR = 3.51, 95% CI = 2.52-5.41), physical assault (AOR = 2.12, 95% CI = 1.05-3.72) and being in a war fighting situation (AOR = 1.41, 95% CI = 1.21-3.14).

Conclusion

This study reported that the prevalence of PTSD was high. Being female, having a previous history of chronic medical illness, depressive symptoms, anxiety symptoms, history of a family member or friend was injured or killed, poor social support, high perceived stress, physical assault, and being in a war fighting situation were statistically associated with PTSD. Hence, regular patient assessment by mental health organizations for those with a history of trauma and facilitation of ways to support such residents is highly recommended.

Immunization with a heat-killed preparation of Mycobacterium vaccae NCTC 11659 enhances auditory-cued fear extinction in a stress-dependent manner

Stress-related psychiatric disorders including anxiety disorders, mood disorders, and trauma and stressor-related disorders, such as posttraumatic stress disorder (PTSD), affect millions of people world-wide each year. Individuals with stress-related psychiatric disorders have been found to have poor immunoregulation, increased proinflammatory markers, and dysregulation of fear memory. The "Old Friends" hypothesis proposes that a lack of immunoregulatory inputs has led to a higher prevalence of inflammatory disorders and stress-related psychiatric disorders, in which inappropriate inflammation is thought to be a risk factor. Immunization with a soil-derived saprophytic bacterium with anti-inflammatory and immunoregulatory properties, Mycobacterium vaccae NCTC 11659, can lower proinflammatory biomarkers, increase stress resilience, and, when given prior to or after fear conditioning in a rat model of fear-potentiated startle, enhance fear extinction. In this study, we investigated whether immunization with heat-killed M. vaccae NCTC 11659 would enhance fear extinction in contextual or auditory-cued fear conditioning paradigms and whether M. vaccae NCTC 11659 would prevent stress-induced exaggeration of fear expression or stress-induced resistance to extinction learning. Adult male Sprague Dawley rats were immunized with M. vaccae NCTC 11659 (subcutaneous injections once a week for three weeks), and underwent either: Experiment 1) one-trial contextual fear conditioning; Experiment 2) two-trial contextual fear conditioning; Experiment 3) stress-induced enhancement of contextual fear conditioning; Experiment 4) stress-induced enhancement of auditory-cued fear conditioning; or Experiment 5) stress-induced enhancement of auditory-cued fear conditioning exploring short-term memory. Immunizations with M. vaccae NCTC 11659 had no effect on one- or two-trial contextual fear conditioning or contextual fear extinction, with or without exposure to inescapable stress. However, inescapable stress increased resistance to auditory-cued fear extinction. Immunization with M. vaccae NCTC 11659 prevented the stress-induced increase in resistance to auditory-cued fear extinction learning. Finally, in an auditory-cued fear conditioning paradigm exploring short-term memory and fear acquisition, immunization with M. vaccae did not prevent fear acquisition, either with or without exposure to inescapable stress, consistent with the hypothesis that M. vaccae NCTC 11659 has no effect on fear acquisition but enhances fear extinction. These data are consistent with the hypothesis that increased immunoregulation following immunization with M. vaccae NCTC 11659 promotes stress resilience, in particular by preventing stress-induced resistance to fear extinction, and may be a potential therapeutic intervention for trauma- and stressor-related disorders such as PTSD.

Aberrant ventral dentate gyrus structure and function in trauma susceptible mice

Post-traumatic stress disorder (PTSD) is a psychiatric disorder vulnerable individuals can develop following a traumatic event, whereas others are resilient. Enhanced insight into the mechanistic underpinnings contributing to these inter-individual differences in trauma susceptibility is key to improved treatment and prevention. Aberrant function of the hippocampal dentate gyrus (DG) may contribute to its psychopathology, with the dorsal DG potentially encoding trauma memory generalization and the ventral DG anxiety. Using a mouse model, we hypothesized that susceptibility to develop PTSD-like symptoms following trauma will be underpinned by aberrant DG structure and function. Mice were exposed to a traumatic event (unpredictable, inescapable foot shocks) and tested for PTSD-like symptomatology following recovery. In four independent experiments, DG neuronal morphology, synaptic protein gene and protein expression, and neuronal activity during trauma encoding and recall were assessed. Behaviorally, trauma-susceptible animals displayed increased anxiety-like behavior already prior to trauma, increased novelty-induced freezing, but no clear differences in remote trauma memory recall. Comparison of the ventral DG of trauma susceptible vs resilient mice revealed lower spine density, reduced expression of the postsynaptic protein homer1b/c gene and protein, a larger population of neurons active during trauma encoding, and a greater presence of somatostatin neurons. In contrast, the dorsal DG of trauma-susceptible animals did not differ in terms of spine density or gene expression but displayed more active neurons during trauma encoding and a lower amount of somatostatin neurons. Collectively, we here report on specific structural and functional changes in the ventral DG in trauma susceptible male mice.

Epidemiology of posttraumatic stress disorder: A prospective cohort study based on multiple nationwide Swedish registers of 4.6 million people

BACKGROUND

Experiencing exceptionally threatening or horrifying traumas can lead to posttraumatic stress disorder (PTSD). Increasing political unrest/war/natural disasters worldwide could cause more traumatic events and change the population burden of PTSD. Most PTSD research is based on surveys, prone to selection/recall biases with inconsistent results. The aim was therefore, to use register-based data to identify the occurrence of PTSD and contributing factors in the Swedish general population.

METHODS

This register-based cohort study used survival analysis. Individuals born between 1960-1995, aged ≥15 years, registered and living in Sweden, not emigrating, anytime between 1990-2015, not receiving specialized care for PTSD before 2006 were included (N = 4,673,764), and followed from their 15th/16th birth date until first PTSD diagnosis between 2006-2016 or study endpoint (31-December-2016). PTSD cases (ICD-10: F43.1) were identified from the national patient register. Mean follow-up time was 18.8 years.

RESULTS

Between 2006-2016, the incidence of specialized healthcare utilization for PTSD nearly doubled, and 0.7% of the study population received such care. The highest risk was observed for refugees [aHR 8.18; 95% CI:7.85-8.51] and for those with depressive disorder [aHR 4.51; 95% CI:3.95-5.14]. Higher PTSD risk was associated with female sex, older age, low education, single parenthood, low household income, urbanicity, and being born to a foreign-born parent.

CONCLUSIONS

PTSD is more common among refugee migrants, individuals with psychiatric disorders, and the socioeconomically disadvantaged. It is important that provision of services for PTSD are made available, particularly to these higher risk, and often hard-to-reach groups.

Effects of acute pain medications on posttraumatic stress symptoms in early aftermath of trauma

Posttraumatic stress symptoms (PTSS) develop as sequelae from traumatic injuries. Limited studies suggest that using opioids to reduce acute pain immediately after trauma may also reduce subsequent PTSS, but other pain medications rarely have been examined for preventing acute PTSS. The current study examined the effects of commonly used pain medications, opioid and nonsteroidal anti-inflammatory drugs (NSAIDs), on PTSS after acute traumatic injuries. Participants ( n = 71) were categorized into opioid or NSAID group according to their medical records and self-reported medication use. Their PTSS were assessed using posttraumatic stress disorder checklist twice within 2 weeks after trauma. Participants' pain levels reduced from pretreatment to follow-up in both groups, F (1, 55) = 6.696, P = 0.012, partial η 2 = 0.109. Interestingly, a significant interaction between time and medication group on PTSS reached statistical significance, F (1, 69) = 6.014, P = 0.017, partial η 2 = 0.080. Follow-up analyses revealed that this interaction was driven by a significant PTSS reduction only in opioid but not in NSAID group. These findings suggested that pain reduction alone is not sufficient to reduce acute PTSS in the NSAID group, highlighting the need to continue further investigations into the mechanisms by which opioids reduce PTSS in the early posttrauma period.

Trauma exposure and eating disorders: Results from a United States nationally representative sample

OBJECTIVE

Sexual assault, child abuse, and combat have been linked to eating disorders (EDs). However, noninterpersonal trauma is relatively understudied, and therefore it is unknown whether noninterpersonal trauma is associated with EDs. Furthermore, most previous studies do not account for multiple trauma exposures, or the relative association of traumatic events with EDs in the same statistical model.

METHOD

Multinomial regression was used to examine the association of lifetime ED diagnosis (anorexia nervosa [AN], bulimia nervosa [BN], binge eating disorder [BED]) with trauma type (sexual interpersonal, other interpersonal, war/combat, and noninterpersonal) in a nationally representative dataset of US adults in bivariate and multivariable (i.e., with all trauma types) models.

RESULTS

Sexual interpersonal trauma was significantly positively associated with AN and BED in bivariate and multivariable models. In the multivariable model, only BED was found to be equally associated with sexual interpersonal, other interpersonal, and noninterpersonal trauma.

DISCUSSION

These results indicate a strong positive association between sexual trauma and EDs, even when controlling for experiences of other trauma events. Future research should examine longitudinal mediators between trauma and EDs, especially sexual trauma, to identify what factors may explain this relationship.

PUBLIC SIGNIFICANCE STATEMENT

Individuals with eating disorders often experience traumatic events but it is unclear whether specific trauma types are more or less common in this population. This study found that only events such as rape and sexual assault are associated with anorexia nervosa, but that most trauma types are associated with binge eating disorder. Therefore, the relationship between trauma and binge eating disorder may function differently than other eating disorders.

Posttraumatic stress disorder symptoms and timing of menopause and gynecological surgery in the Nurses' Health Study II

BACKGROUND

Earlier menopause, either natural or through gynecologic surgeries, has been associated with various negative health sequelae. While posttraumatic stress disorder (PTSD) has been linked to dysregulated biological processes, including reproductive system changes that could alter menopausal timing, little work has examined whether trauma and PTSD are associated with greater risk of early cessation of menses.

METHODS

Data are from 46,639 women in the Nurses' Health Study II, a prospective cohort study of women followed for up to 26 years. Lifetime trauma and PTSD symptoms were assessed with the Brief Trauma Questionnaire and a PTSD symptom screener in 2008. Age at cessation of menses and reason for cessation of menses (i.e., natural menopause, gynecologic surgery including hysterectomy and/or bilateral salpingo-oophorectomy [BSO]) were assessed. Cox proportional hazards models estimated hazards ratios (HR) of cessation of menses (separately for naturally or surgically) associated with trauma alone or PTSD symptoms, relative to no trauma, adjusting for covariates.

RESULTS

Trauma/PTSD status was associated with earlier cessation of menses due to surgery, but not natural menopause. Women with trauma exposure, low, and high PTSD symptoms had higher hazard of cessation of menses due to surgery relative to those with no trauma exposure (HR_trauma = 1.16, 95%CI 1.07-1.26; HR_{low PTSD} = 1.25, 95%CI 1.15-1.36; HR_{high PTSD} = 1.29, 95%CI 1.17-1.42). Trauma exposure and PTSD symptoms were associated with similarly increased risk of hysterectomy and BSO surgeries.

CONCLUSIONS

Women who experienced trauma and PTSD may be at elevated risk for common gynecological surgeries premenopausally, potentially due to increased clinical indications or gynecological conditions.

Incremental Influence of Betrayal Trauma and Personality Traits on PTSD Symptoms

Symptoms of posttraumatic stress disorder (PTSD) are common reactions to trauma. One factor that influences the manifestation of PTSD symptoms is the type of trauma experienced. Traumas perpetrated by someone on whom the trauma survivor trusts and relies on for support (i.e., betrayal traumas) are especially predictive of PTSD symptoms. However, the degree to which this is true differs somewhat across men and women. Another factor that influences PTSD symptoms is personality, which is most often operationalized in terms of discrete personality traits. Among these traits, Neuroticism (the tendency to experience negative affect) is linked to a wide range of psychological dysfunction in general and to PTSD symptoms in particular. However, there is little research on how trauma type and personality differentially influence PTSD symptoms. To address this gap, in this study we examined the incremental effects of traumas with varying degrees of betrayal and personality traits on PTSD symptoms in a sample of college students (N = 276) using a Bayesian approach to multiple regression. Results suggest that Neuroticism and trauma at all levels of betrayal were associated with higher levels of PTSD symptoms, although this differed across sex. These results are consistent with previous research that identifies Neuroticism as a risk factor for a wide range of mental health problems and clarifies earlier findings on betrayal trauma.

Effects of Emergency Duties on Cardiovascular Diseases in Firefighters: A 13-Year Retrospective Cohort Study

OBJECTIVES

This study aimed to examine the effects of firefighters' emergency duties on the incidence of cardiovascular disease (CVD).

METHODS

We used a 13-year follow-up in a nationwide retrospective cohort study. A total of 363,137 employees were recruited. The sex-and age-specific incidence of CVD (hypertension, angina pectoris, and acutemyocardial infarction [AMI]) in firefighters and public officials was estimated.

RESULTS

The overall age-specific sex-based incidence of CVD, except for hypertension, was higher in firefighters than in public officials. The age-stratified hazard ratios for the three types of CVD in male firefighters were also higher. AMI was more common in younger firefighters, whereas angina pectoris and hypertension were common in older firefighters.

CONCLUSIONS

Firefighters' duties are more likely to increase the risk of CVD, and preventive strategies with proven benefits are required.

Post-traumatic stress disorder: a psychiatric disorder requiring urgent attention

Post-traumatic stress disorder (PTSD) is a severe and heterogenous psychiatric disorder that was first defined as a mental disorder in 1980. Currently, the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and the International Classification of Diseases 11th Edition (ICD-11) offer the most widely accepted diagnostic guidelines for PTSD. In both diagnostic categories, experiencing a traumatic event (TE) is the necessary criterion for diagnosing PTSD. The TEs described in the DSM-5 include actual or threatened death, serious injury, sexual violence, and other extreme stressors, either directly or indirectly. More than 70% of adults worldwide are exposed to a TE at least once in their lifetime, and approximately 10% of individuals develop PTSD after experiencing a TE. The important features of PTSD are intrusion or re-experiencing fear memories, pervasive sense of threat, active avoidance, hyperarousal symptoms, and negative alterations of cognition and mood. Individuals with PTSD have high comorbidities with other psychiatric diseases, including major depressive disorder, generalized anxiety disorder, and substance use disorder. Multiple lines of evidence suggest that the pathophysiology of PTSD is complex, involving abnormal neural circuits, molecular mechanisms, and genetic mechanisms. A combination of both psychotherapy and pharmacotherapy is used to treat PTSD, but has limited efficacy in patients with refractory PTSD. Because of the high prevalence, heavy burden, and limited treatments, PTSD is a psychiatric disorder that requires urgent attention. In this review, we summarize and discuss the diagnosis, prevalence, TEs, pathophysiology, and treatments of PTSD and draw attention to its prevention.

For there is nothing either good or bad: a study of the mediating effect of interpretation bias on the association between mindfulness and reduced post-traumatic stress vulnerability

BACKGROUND

Despite increasing interest in the association between mindfulness and reduced trauma vulnerability, and the use of mindfulness in the latest interventions for Post-Traumatic Stress Disorder (PTSD), few studies have examined the mechanisms through which mindfulness may influence post-trauma psychopathology. The present study aimed to determine whether negative interpretation bias, the tendency to interpret ambiguous information as negative or threatening rather than positive or safe, mediates the association between higher levels of trait mindfulness and lower levels of PTSD symptoms. Negative interpretation bias was examined due to prior evidence indicating it is associated with being less mindful and post trauma psychopathology.

METHODS

The study examined 133 undergraduate students who reported exposure to one or more potentially traumatic events in their lifetime. Participants completed self-report measures of trait mindfulness (Five Facet Mindfulness Questionnaire - Short Form; FFMQ-SF) and PTSD symptoms (Post-Traumatic Stress Disorder Checklist - Civilian version; PCL-C) as well an interpretation bias task that assessed the degree to which participants interpreted a range of everyday hypothetical scenarios to be threatening to their physical and/or psychological wellbeing.

RESULTS

Results of a mediation analysis indicated a significant negative direct effect of trait mindfulness on PTSD symptomatology (p < .001). There was no evidence that negative interpretation bias mediated this relationship [BCa CI [-0.04, 0.03)], nor was it associated with trait mindfulness (p = .90) and PTSD symptomatology (p = .37).

CONCLUSIONS

The results of the current study provide further evidence of the link between trait mindfulness and reduced post-trauma psychopathology while providing no support for the role of negative interpretation bias in this relationship.

Sensitivity and specificity of the Posttraumatic Stress Disorder Checklist for DSM-5 in a Canadian psychiatric outpatient sample

The Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) is a widely used, self-report measure that is employed to assess PTSD symptom severity and determine the presence of probable PTSD in various trauma-exposed populations. The PCL-5 is often administered in clinical settings as a screening tool for PTSD, with a suggested cutoff score of 33 indicating a probable PTSD diagnosis. Recent research indicates that a higher cutoff may be required in psychiatric samples. In the present study, we aimed to determine the sensitivity and specificity of the PCL-5 in a Canadian outpatient psychiatric sample and establish an optimal cutoff score for detecting probable PTSD in this sample. Participants were 673 individuals who reported a history of trauma exposure and were assessed using a semistructured interview and self-report measures. Individuals diagnosed with PTSD (N = 193) reported a mean PCL-5 score of 56.57, whereas individuals without PTSD (N = 480) reported a mean score of 33.56. A score of 45 was determined to be the optimal cutoff score in this sample, balancing sensitivity and specificity while detecting a probable diagnosis of PTSD. Consistent with findings in other psychiatric samples, these findings indicate that in an outpatient psychiatric sample with a history of exposure to a variety of trauma types, a higher cutoff score is required to determine probable PTSD. In addition, given the estimated rate of false positives even with a higher cutoff, follow-up diagnostic assessments are recommended.

Efficacy, Benefits, and Harms of a Self-management App in a Swedish Trauma-Exposed Community Sample (PTSD Coach): Randomized Controlled Trial

BACKGROUND

Self-guided interventions may complement and overcome obstacles to in-person treatment options. The efficacy of app interventions targeting posttraumatic stress disorder (PTSD) is unclear, and results from previous studies on PTSD Coach-an app for managing trauma-related distress-are inconsistent.

OBJECTIVE

This study investigates whether access to the Swedish version of the PTSD Coach affects posttraumatic stress, depressive, and somatic symptoms. In addition, we aim to assess the perceived helpfulness, satisfaction, negative effects, response, and remission related to PTSD Coach.

METHODS

Adults who had experienced potentially traumatic events in the past 2 years were randomized (1:1) to have access to PTSD Coach (n=89) or be on the waitlist (n=90). We assessed clinical characteristics at baseline (semistructured interviews and self-rating scales) and after 3 months (self-rating scales). We analyzed the data in R software using linear mixed effects models, chi-square tests, and Fisher exact test.

RESULTS

Intention-to-treat analyses indicated that access to PTSD Coach decreased posttraumatic stress and depressive symptoms but not somatic symptoms. More participants who had access to PTSD Coach responded with clinically significant improvement and fewer instances of probable PTSD after 3 months compared with waitlist controls. Overall, participants found that PTSD Coach was slightly to moderately helpful and moderately satisfactory. Half of the intervention group (36/71, 51%) reported at least one negative reaction related to using PTSD Coach (eg, disappointment with the app or its results, arousal of stress, or distressing memories).

CONCLUSIONS

Using PTSD Coach may trigger symptoms among a few users; however, most of them perceived PTSD Coach as helpful and satisfactory. This study showed that having access to PTSD Coach helped improve psychological trauma-related symptoms. In addition, we have discussed implications for future research and clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04094922; https://clinicaltrials.gov/ct2/show/NCT04094922.

Self-reported mental health status of pregnant women in Sweden during the COVID-19 pandemic: a cross-sectional survey

Background

The COVID-19 pandemic has contributed to unprecedented worries and challenges for pregnant women due to social restrictions and changes in maternity care provision. We aimed to investigate the mental health impact of COVID-19 pandemic on pregnant women in Sweden and explore factors associated with poor perinatal mental health in this specific context.

Method

This was a nation-wide cross-sectional survey of pregnant women living in Sweden. Validated questionnaires were distributed through non-profit organizations´ websites and social media channels from May 2020 to February 2021. Perinatal depression, anxiety, and acute stress reaction were assessed using the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder-7 (GAD-7) and Impact Event Scale (Revised) (IES-R), respectively. Sociodemographic characteristics and self-perceived mental well-being were also obtained. Factors associated with mental health outcomes were analyzed using multivariate logistic regression model.

Results

Among a total of 470 participants, 43.2% (n = 203) reported depression (EPDS ≥13), 25.7% (n = 121) moderate to severe anxiety (GAD-7 score ≥ 10), and 23.7% (n = 110) moderate to severe acute stress reaction (IES-R ≥ 33). 27.4% participants (n = 129) expressed concerns regarding their mental well-being during the pandemic. Pregnant mothers who had sick family members reported poorer mental health outcomes than those who did not (median [Interquartile range (IQR)] EPDS scores: 14.0 [8.75–18.0] vs 11.0 [6.25–15.0], p < .001; median (IQR) GAD7 scores: 7.0 [4.0–12.25] vs 6.0 [3.0–9.0], p = .003); median (IQR) IES-R scores: 20.0 [9.0–38.0] vs 15.0 [7.0–30.0], p = .048). Logistic regression analyses revealed that risk factors for poor mental health outcomes were having a sick family member with any illness, unemployment, and experiencing a substantially stressful life event. Having a higher educational level and a younger age during the pandemic were protective.

Conclusion

Depression and anxiety were highly prevalent among pregnant women in Sweden during the COVID-19 pandemic, indicating a need for professional mental health support for this vulnerable group of population. Unemployment was an associated risk factor whereas younger age and higher educational level were protective suggesting an important role of socio-economic factors in modulating the impact of COVID-19 pandemic on perinatal mental health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04553-x.

[Posstraumatic stress disorder in nurses during the COVID-19 pandemic]

Aim

To analyse the prevalence of post-traumatic stress disorder (PTSD) in nursing staff and the variables that may contribute to its development.

Method

Cross-sectional study using a self-administered questionnaire given to nurses, nursing assistants and nursing supervisors in June 2020. It included sociodemographic, mental health, occupational, COVID-19 related variables, Modified Risk Perception Scale (modified RPS) score, Brief Resilience Scale (BRS) and Davidson Trauma Scale (DTS) score for the assessment of PTSD. Descriptive, bivariate, and multivariate analyses were performed.

Results

Of the 344 participants, 88.7% were women and 93.6% cared for infected patients; 45.9% had PTSD (DTS≥40). The variables associated with PTSD were previous PTSD symptoms (OR=6.1, 95% CI [2.68-14.03]), death of a family member or friend due to COVID-19 (OR=2.3, 95% CI [1.22-4.39]), and higher scores on the modified RPS (OR= 1.1, 95% CI [1.07-1.31]). Higher BRS scores were associated with a lower risk of PTSD (OR=0.4, 95% CI [0.31-0.68]).

Conclusions

The prevalence of PTSD in nursing staff is high, mainly in professionals with previous PTSD symptoms, family members or friends deceased from COVID-19, high risk perception and/or low resilience.

Identification With the Aggressor and Inward and Outward Aggression in Abuse Survivors

Childhood abuse survivors may display both inward and outward aggression manifested in self-injurious behavior (SIB) and violent acts toward others. Scrutinizing the literature reveals that the relational dynamics between victims and their perpetrators might be involved in these phenomena. Yet, research on this subject matter has been sparse. Filling this gap, this study investigated the contribution of the singular bonds between victims and their perpetrators, known as identification with the aggressor, in explaining survivors' aggression. The study was conducted among 306 Israeli college/university students who reported a history of childhood abuse. Results revealed that levels of adopting the perpetrator's experience, identifying with the perpetrator's aggression, and replacing one's agency with that of the perpetrator were significantly associated with survivors' inward and outward aggression. Moreover, profile type-that is, having high versus low levels of identification with the aggressor-was implicated in participants' SIBs, urge to harm others, and violent acts toward others, above and beyond the effects of gender and posttraumatic stress disorder (PTSD) symptoms. The present findings suggest that identification with the aggressor might make survivors prone to the re-enactment of past abusive dynamics, which, in turn, could eventuate in aggression toward themselves and others.

Intimate Partner Violence Predicts Posttraumatic Stress Disorder Severity Independent of Early Life and Deployment-Related Trauma in Deployed Men and Women Veterans

Intimate partner violence (IPV) refers to emotional, physical, and/or sexual abuse perpetrated by a current or former partner. IPV affects both genders, though little is known about its effects on men as victims. The aims of this study were to determine if IPV is a factor contributing to posttraumatic stress disorder (PTSD) severity independently of deployment-related trauma, and to determine if there are gender differences in these associations. Participants were 46 female and 471 male post-9/11 veterans. Four sequential regressions were employed to examine the independent contribution of IPV among multiple trauma types on PTSD severity in men and women at two epochs, post-deployment (participants were anchored to deployment-related PTSD symptoms) and current (within the past month). Models were significant for both epochs in men (ps < .001) but not in women (ps > .230). In men, IPV independently predicted PTSD severity in both epochs (β > .093). However, in women, early life trauma (β = .284), but not IPV was a significant and independent predictor for current PTSD. Thus, there are distinct gender differences in how trauma type contributes to PTSD symptom severity. Although the statistical models were not significant in women, we observed similar patterns of results as in men and, in some cases, the β was actually higher in women than in men, suggesting a lack of power in our analyses. More research is clearly needed to follow-up these results; however, our findings indicate that IPV is a contributing factor to PTSD severity in veterans.

Posstraumatic stress disorder in nursing staff during the COVID-19 pandemic

Aim

To analyse the prevalence of post-traumatic stress disorder (PTSD) in nursing staff and the variables that may contribute to its development.

Method

Cross-sectional study using a self-administered questionnaire given to nurses, nursing assistants and nursing supervisors in June 2020. It included sociodemographic, mental health, occupational, COVID-19 related variables, Modified Risk Perception Scale (modified RPS) score, Brief Resilience Scale (BRS) and Davidson Trauma Scale (DTS) score for the assessment of PTSD. Descriptive, bivariate, and multivariate analyses were performed.

Results

Of the 344 participants, 88.7% were women and 93.6% cared for infected patients; 45.9% had PTSD (DTS≥40). The variables associated with PTSD were previous PTSD symptoms (OR=6.1, 95% CI [2.68-14.03]), death of a family member or friend due to COVID-19 (OR=2.3, 95% CI [1.22-4.39]), and higher scores on the modified RPS (OR= 1.1, 95% CI [1.07-1.31]). Higher BRS scores were associated with a lower risk of PTSD (OR=0.4, 95% CI [0.31-0.68]).

Conclusions

The prevalence of PTSD in nursing staff is high, mainly in professionals with previous PTSD symptoms, family members or friends deceased from COVID-19, high risk perception and/or low resilience.

Value estimation and latent-state update-related neural activity during fear conditioning predict posttraumatic stress disorder symptom severity

Learning theories of posttraumatic stress disorder (PTSD) purport that fear-learning processes, such as those that support fear acquisition and extinction, are impaired. Computational models designed to capture specific processes involved in fear learning have primarily assessed model-free, or trial-and-error, reinforcement learning (RL). Although previous studies indicated that aspects of model-free RL are disrupted among individuals with PTSD, research has yet to identify whether model-based RL, which is inferential and contextually driven, is impaired. Given empirical evidence of aberrant contextual modulation of fear in PTSD, the present study sought to identify whether model-based RL processes are altered during fear conditioning among women with interpersonal violence (IPV)-related PTSD (n = 85) using computational modeling. Model-free, hybrid, and model-based RL models were applied to skin conductance responses (SCR) collected during fear acquisition and extinction, and the model-based RL model was found to provide the best fit to the SCR data. Parameters from the model-based RL model were carried forward to neuroimaging analyses (voxel-wise and independent component analysis). Results revealed that reduced activity within visual processing regions during model-based updating uniquely predicted higher PTSD symptoms. Additionally, after controlling for model-based updating, greater value estimation encoding within the left frontoparietal network during fear acquisition and reduced value estimation encoding within the dorsomedial prefrontal cortex during fear extinction predicted greater PTSD symptoms. Results provide evidence of disrupted RL processes in women with assault-related PTSD, which may contribute to impaired fear and safety learning, and, furthermore, may relate to treatment response (e.g., poorer response to exposure therapy).