Autonomic dysregulation and the Window of Tolerance model of the effects of complex emotional trauma

A Trauma-Informed Workshop Targeting the Attitudes of Mental Health Providers in a Rural, Racially Diverse Community Bordering Tribal lands

Purpose

This study examines a three-day trauma informed workshop with 32 mental health providers in a rural community that borders an American Indian reservation to determine if there is an association with positive trauma-informed care (TIC) attitudes.

Methods

Thirty-two workshop participants were invited to take the Attitudes Related to Trauma Informed Care (ARTIC-45) scale pre-workshop, post-, and six months- after the workshop. Results were analyzed at the group-level using t-tests and Wilcoxon signed-rank tests for subscales that were not normally distributed.

Results

Pre- to Post- (Time 1) findings reveal statistically significant positive changes in all ARTIC subscales. However, post-workshop to six months follow-up (Time 2) four subscales showed statistically significant decreases. This seems to be an indication that these trauma-informed attitudes, knowledge, and beliefs had gotten worse with time. There were three subscales without significant change.

Conclusion

The findings should be interpreted with caution but point to plausible implications related to the decline in trauma-informed attitudes such as, lack of ongoing training following the workshop, limitations in workforce and resources within the rural community, unaddressed implicit bias, and needing more organizational leadership buy-in and resources.

Multilayer depressive symptom networks in adults with bodily pain living in precarious housing or homelessness

Housing insecurity is associated with co-occurring depression and pain interfering with daily activities. Network analysis of depressive symptoms along with associated risk or protective exposures may identify potential targets for intervention in patients with co-occurring bodily pain. In a community-based sample of adults (n = 408) living in precarious housing or homelessness in Vancouver, Canada, depressive symptoms were measured by the Beck Depression Inventory; bodily pain and impact were assessed with the 36-item Short Form Health Survey. Network and bootstrap permutation analyses were used to compare depressive symptoms endorsed by Low versus Moderate-to-Severe (Mod + Pain) groups. Multilayer networks estimated the effects of risk and protective factors. The overall sample was comprised of 78% men, mean age 40.7 years, with 53% opioid use disorder and 14% major depressive disorder. The Mod + Pain group was characterized by multiple types of pain, more persistent pain, more severe depressive symptoms and a higher rate of suicidal ideation. Global network connectivity did not differ between the two pain groups. Suicidal ideation was a network hub only in the Mod + Pain group, with high centrality and a direct association with exposure to lifetime trauma. Antidepressant medications had limited impact on suicidal ideation. Guilt and increased feelings of failure represented symptoms from two other communities of network nodes, and completed the shortest pathway from trauma exposure through suicidal ideation, to the non-prescribed opioid exposure node. Interventions targeting these risk factors and symptoms could affect the progression of depression among precariously housed patients.

Illness representations of people with later-onset functional seizures

PURPOSE

Although functional seizures can start at any age, little is known about the individuals for whom onset occurs after the age of 40. It has been proposed that health-related traumatic events are more relevant causal factors for people with 'later-onset functional seizures' than for those whose functional seizures begin earlier in life, however, the illness representations of people with later-onset functional seizures have not yet been investigated. This study aimed to understand the experiences and illness representations of people with later-onset functional seizures.

METHODS

This was a mixed-methods study. People with later-onset functional seizures were recruited via a neurologist's caseload and online membership-led organisations. Semi-structured interview transcripts were analysed using Template Analysis according to the Common-Sense Model (CSM). Self-report measures of demographic and clinical details were collected to characterise the sample and verify themes.

RESULTS

Eight people with later-onset functional seizures participated in the study. Illness representations relating to all domains of the CSM as well as an additional theme of 'Triggers' were identified. Functional seizures were characterised as a mysterious brain disorder analogous to a computer malfunction and involving involuntary movements associated with alterations in consciousness. Perceptions of duration were indefinite, and triggers were unknown or at the extremes of autonomic arousal. Half of the sample identified health-related events/trauma as causal. Opinions were divided on 'cumulative life stress' as a causal factor. Most perceived themselves to have limited or no control but having 'control' over seizures was conceptualised as different to reducing their likelihood, frequency, or impact. Later-onset functional seizures were viewed as being more detrimental for caring and financial responsibilities but to have advantages for acceptance.

CONCLUSIONS

This is the first study to assess the illness representations of people with later-onset functional seizures. Many themes were similar to those identified in samples including people with earlier-onset functional seizures. Health-related trauma or events were the most strongly endorsed perceived causal factor, but with the exception of 'consequences', all representations were characterised by uncertainty. Clinicians should hold in mind the interaction between life stage and the consequences of later-onset functional seizures.

Adverse events and contradictory effects of benzodiazepine in a case with intellectual disability and challenging behaviour

This study aims to contribute to the knowledge about lacking or contradictory effects of benzodiazepine on hyperaroused or aggressive behaviour in persons with intellectual disability (ID). We conducted a retrospective and natural case study in a person with mild ID and multiple adverse childhood experiences (ACE), using routine diary data consisting of 275 days including 113 consecutive days under benzodiazepine medication. The medication effects were documented as "calm / relaxed", "fretful / distressed" and "sleep / doze". Transitions between these were modelled using Markov chains. Differences in transitions were analysed using Chi-Square test for homogeneity. The results show a significantly reduced stability of mood and increased distressed behaviour under benzodiazepine. This is in line with reports about the effects of psychotropic medication in patients with ID and challenging behaviour. Besides other influences on unexpected medication effects, a possible dissociative identity disorder is discussed as an additional explanation.

Relationships Between Violent Sexual Victimization and Muscle-Building Exercise among Adolescents from the 2019 Youth Risk Behavior Survey

BACKGROUND

This study aimed to investigate the association between violent sexual victimization and muscle-building exercise among adolescents.

METHODS

Cross-sectional data from the 2019 National Youth Risk Behavior Survey (N = 8408) were analyzed. Two indicators of non-dating-related sexual violence (lifetime, past 12 months), along with one indicator of adolescent sexual violence (past 12 months), were assessed. Days of muscle-building in the past week were reported. Multinomial logistic regression analyses were conducted to determine the associations between the three violent sexual victimization variables and muscle-building exercise.

RESULTS

Among the sample (50.3% girls), lifetime violent sexual victimization (relative risk ratio [RRR] 1.87, 95% confidence interval [CI] 1.29 to 2.72), past 12-month violent sexual victimization (RRR 1.60, 95% CI 1.15 to 2.22), and past 12-month sexual dating violence (RRR 1.60, 95% CI 1.03 to 2.51) were associated greater relative risk of high engagement (ie, 6 to 7 days) in muscle-building exercise relative to no engagement.

CONCLUSIONS

A history of violent sexual victimization is associated with greater involvement in muscle-building exercise, particularly among adolescent girls. Engagement in muscle-building exercise in relation to violent sexual victimization may be a means of emotion regulation and occur due to body dissatisfaction resulting from experiencing violence.

Potential Benefits of a 'Trauma-Informed Care' Approach to Improve the Assessment and Management of Dogs Presented with Anxiety Disorders

Dog caregiver reporting on the spectrum of fearful-aggressive behaviours often describes 'unpredictable' or 'exaggerated' responses to a situation/animal/person. A possible explanation for these behavioural responses considers that the dog is reacting to triggered memories for which the dog has a negative association. For many dogs undergoing veterinary behavioural treatment or rehabilitation through a canine rescue organisation, the assessing clinician relies on "proxy" reporting of the history/background by a caregiver (dog owner, foster carer, or shelter personnel). Detailed information on the event or circumstances resulting in this negative association may be limited or absent altogether. Consideration of a trauma-informed care (TIC) approach, currently applied in a wide range of human psychology and social care fields, may be helpful in guiding the clinical approach taken. The literature relating to adverse early experience (AEE) and trauma-informed care (TIC) in puppies/dogs compared to children/adults was evaluated to identify common themes and conclusions identified across both species. In the absence of known/identifiable trauma, behavioural assessment and management should consider that a 'problem' dog may behave as it does, as the result of previous trauma. The dog can then be viewed through a lens of empathy and understanding, often lacking for dogs presenting with impulsive, reactive, or aggressive behaviours. Assessment must avoid re-traumatising the animal through exposure to triggering stimuli and, treatment options should include counselling of caregivers on the impact of adverse early experiences, consideration of the window of tolerance, and TIC behavioural modification techniques.

Impact of dissociation on exposure therapy for PTSD outcomes and Adherence among U.S. Military service members

Emotional engagement is necessary for successful exposure therapy for posttraumatic stress disorder (PTSD), but dissociation is considered a barrier to emotional engagement. Virtual reality exposure therapy (VRE) uses multi-sensory virtual environments to increase emotional engagement during exposure therapy, and average treatment outcomes are comparable to traditional exposure therapy. However, individual factors (e.g., depression) can predict differential responses to VRE. Studies have yet to investigate whether VRE would be more effective in treating patients with dissociation compared to traditional PE. This secondary analysis of a randomized clinical trial explores whether dissociation predicts treatment outcomes to exposure therapy among active-duty soldiers (N = 108) diagnosed with PTSD. We also examine whether individuals reporting dissociative symptoms demonstrated differential treatment responses to VRE and PE. Results indicated a significant two-way interaction between dissociation and time in treatment, such that dissociation blunted the negative relationship between time and PTSD symptoms. Dissociation was not associated with treatment session attendance or drop out. Results also revealed no significant effect of treatment group (PE or VRE) on the relationship between dissociation and PTSD symptoms. Findings contribute to a body of literature supporting the potential clinical and research utility of a dissociative subtype of PTSD.

Psychedelic-Assisted Therapy in Military and Veterans Healthcare Systems: Clinical, Legal, and Implementation Considerations

PURPOSE OF REVIEW

This review discusses the current and projected landscape of psychedelic-assisted therapy (PAT), with a focus on clinical, legal, and implementation considerations in Department of Defense (DoD) and Department of Veterans Affairs (VA) healthcare systems.

RECENT FINDINGS

3,4-Methylenedioxymethamphetamine (MDMA)- and psilocybin-assisted therapy have shown promising outcomes in efficacy, safety, tolerability, and durability for PTSD and depression, respectively. MDMA-assisted therapy is already approved by the Food and Drug Administration (FDA) on an Expanded Access ("compassionate use") basis for PTSD, with full approval projected for 2024. Psilocybin-assisted therapy is projected to be FDA-approved for depression soon thereafter. Other psychedelics are in earlier stages of development. The VA is currently conducting PAT clinical trials. Although there are clear legal pathways for the VA and DoD to conduct PAT trials, a number of implementation barriers exist, such as the very high number of clinical hours necessary to treat each patient, resource requirements to support treatment infrastructure, military-specific considerations, and the high level of evidence necessary for PAT to be recommended in clinical practice guidelines. Ongoing considerations are whether and how PAT will be made available to VA and DoD beneficiaries, feasibility and cost-effectiveness, and ethical safeguards that must be implemented to prioritize access to PAT given the likelihood of extremely limited initial availability. However, with imminent FDA approval of PATs and considerable national interest in these treatments, DoD and VA policymakers must be prepared with clearly delineated policies and plans for how these healthcare systems will approach PAT.

Trauma-informed care (TIC) best practices for improving patient care in the emergency department

A patient's current or previous experience of trauma may have an impact on their health and affect their ability to engage in health care. Every year, millions of patients who have experienced physically or emotionally traumatic experiences present to emergency departments (ED) for care. Often, the experience of being in the ED itself can exacerbate patient distress and invoke physiological dysregulation. The physiological reactions that lead to fight, flight, or freeze responses can make providing care to these patients complex and can even lead to harmful encounters for providers. There is a need to improve the care provided to the vast number of patients in the ED and create a safer environment for patients and healthcare workers. One solution to this complex challenge is understanding and integrating trauma-informed care (TIC) into emergency services. The federal Substance Abuse and Mental Health Service Administration's (SAMHSA) six guiding principles of TIC offer a universal precaution framework that ensures quality care for all patients, providers, and staff in EDs. While there is growing evidence that TIC quantitatively and qualitatively improves ED care, there is a lack of practical, emergency medicine-specific guidance on how to best operationalize TIC. In this article, using a case example, we outline how emergency medicine providers can integrate TIC into their practice.

How past trauma impacts emotional intelligence: Examining the connection

Backed by both research and practice, the organizational psychology field has come to value emotional intelligence (EI) as being vital for leader and employee effectiveness. While this field values EI, it has paid little attention to the antecedents of emotional intelligence, leaving the EI domain without clarity on (1) why EI might vary across individuals, and (2) how to best develop EI. In this article, we rely on neuroscience and psychology research to make the case that past psychological trauma impacts later EI capabilities. Specifically, we present evidence that psychological trauma impairs the brain areas and functions that support EI. Establishing psychological trauma has valuable theoretical and practical implications that include providing an explanation of why EI might vary across individuals and providing a focus for improving EI: healing from past trauma. Further theoretical and practical implications for the field of organizational psychology are provided.

Depression as a cardiovascular disorder: central-autonomic network, brain-heart axis, and vagal perspectives of low mood

If depressive symptoms are not caused by the physiological effects of a substance or other medical or neurological conditions, they are generally classified as mental disorders that target the central nervous system. However, recent evidence suggests that peripheral neural dynamics on cardiovascular control play a causal role in regulating and processing emotions. In this perspective, we explore the dynamics of the Central-Autonomic Network (CAN) and related brain-heart interplay (BHI), highlighting their psychophysiological correlates and clinical symptoms of depression. Thus, we suggest that depression may arise from dysregulated cardiac vagal and sympathovagal dynamics that lead to CAN and BHI dysfunctions. Therefore, treatments for depression should target the nervous system as a whole, with particular emphasis on regulating vagal and BHI dynamics.

Trauma-related dissociation and the autonomic nervous system: a systematic literature review of psychophysiological correlates of dissociative experiencing in PTSD patients

Background: Neurophysiological models link dissociation (e.g. feeling detached during or after a traumatic event) to hypoarousal. It is currently assumed that the initial passive reaction to a threat may coincide with a blunted autonomic response, which constitutes the dissociative subtype of post-traumatic stress disorder (PTSD). Objective: Within this systematic review we summarize research which evaluates autonomic nervous system activation (e.g. heart rate, blood pressure) and dissociation in PTSD patients to discern the validity of current neurophysiological models of trauma-related hypoarousal. Method: Of 553 screened articles, 28 studies (N = 1300 subjects) investigating the physiological response to stress provocation or trauma-related interventions were included in the final analysis. Results: No clear trend exists across all measured physiological markers in trauma-related dissociation. Extracted results are inconsistent, in part due to high heterogeneity in experimental methodology. Conclusion: The current review is unable to provide robust evidence that peri- and post-traumatic dissociation are associated with hypoarousal, questioning the validity of distinct psychophysiological profiles in PTSD.

The reasons dissociative disorder patients self-injure

BACKGROUND

Most individuals with dissociative disorders (DDs) report engaging in self-injury.

OBJECTIVE

The present study aimed to understand the reasons for self-injury among a clinical sample of 156 DD patients enrolled in the TOP DD Network study.

METHOD

Participants answered questions about self-injury, including a prompt asking how often they are aware of the reasons they have urges to self-injure, as well as a prompt asking them to list three reasons they self-injure.

RESULTS

Six themes of reasons for self-injury, each with subthemes, were identified in the qualitative data: (1) Trauma-related Cues, (2) Emotion Dysregulation, (3) Stressors, (4) Psychiatric and Physical Health Symptoms, (5) Dissociative Experiences, and (6) Ineffective Coping Attempts. Participants reported that they were able to identify their reasons for self-injuring sometimes (60.26%) or almost always (28.85%), with only 3.20% unable to identify any reasons for their self-injury.

CONCLUSION

Results suggest that the vast majority of DD patients (92.31%) reported being at least partially unaware of what leads them to have self-injury urges, and many individuals with DDs experience some reasons for self-injury that are different from those with other disorders. The treatment implications of these findings are discussed.

Effectiveness of game-based meditation therapy on neurobiological stress systems in adolescents with posttraumatic symptoms: a randomized controlled trial

Many adolescents in residential care have experienced traumatic events and suffer from posttraumatic stress. Prolonged activation of neurobiological stress systems as the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis can result in long-lasting maladaptive alternations. This study investigated the effectiveness of Muse, a game-based meditation intervention, on the sympathetic nervous system (SNS), parasympathetic nervous system (PNS), and cortisol basal activity and reactivity to acute stress among adolescents with posttraumatic symptoms in residential care. The intervention consisted of two gameplay sessions a week, for 6 consecutive weeks. Seventy-seven adolescents with clinical levels of posttraumatic symptoms (10-18 years old) received either Muse as an addition to treatment as usual (n = 40) or treatment as usual alone (n = 37). We expected reduced basal activity for the SNS and cortisol and increased basal activity for the PNS. As for the response to acute stress, we expected decreased PNS and increased HPA axis reactivity. The Muse group exhibited lower basal activity for the SNS and increased HPA reactivity to acute stress. There were no differences between conditions on SNS and HPA axis activity during rest and on SNS and PNS reactivity to acute stress. Game-based meditation therapy is a promising intervention for the treatment of adolescents with posttraumatic symptoms in residential care. Implications for clinical relevance and trauma-focused treatment purposes are discussed.

Alterations of autonomic nervous system and HPA axis basal activity and reactivity to acute stress: a comparison of traumatized adolescents and healthy controls

Alterations in neurobiological stress systems such as the autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis contribute to the development and maintenance of psychological and behavioral problems after traumatic experiences. Investigating neurobiological parameters and how these relate to each other may provide insight into the complex mechanisms at play. Whereas the preponderance of studies focuses on either the ANS or the HPA axis separately, the current study is the first to evaluate relations between posttraumatic stress and both basal activity during rest and stress reactivity of the ANS as well as the HPA axis in a sample of traumatized adolescents and healthy controls. The traumatized sample (n = 77), based on clinical levels of posttraumatic stress, was a convenience sample that was recruited within residential institutions, was compared to a healthy control sample (n = 48) recruited within the general community. For the ANS, we expected increased SNS and decreased PNS activity during rest and increased SNS and decreased PNS reactivity to social stress among traumatized adolescents compared to healthy controls. Regarding the HPA axis, we expected increased basal cortisol levels and decreased cortisol reactivity to stress in the traumatized sample. Compared to healthy controls, traumatized adolescents exhibited significantly higher sympathetic and lower parasympathetic activation during rest and increased sympathetic reactivity to acute stress (ANS parameters). Outcomes on the HPA axis (i.e. cortisol) indicated that traumatized adolescents showed increased cortisol levels during rest and blunted cortisol reactivity to acute stress. Implications for clinical relevance and trauma-focused treatment purposes are discussed.

Mindfulness and Behavior Change

Initiating and maintaining behavior change is key to the prevention and treatment of most preventable chronic medical and psychiatric illnesses. The cultivation of mindfulness, involving acceptance and nonjudgment of present-moment experience, often results in transformative health behavior change. Neural systems involved in motivation and learning have an important role to play. A theoretical model of mindfulness that integrates these mechanisms with the cognitive, emotional, and self-related processes commonly described, while applying an integrated model to health behavior change, is needed. This integrative review (1) defines mindfulness and describes the mindfulness-based intervention movement, (2) synthesizes the neuroscience of mindfulness and integrates motivation and learning mechanisms within a mindful self-regulation model for understanding the complex effects of mindfulness on behavior change, and (3) synthesizes current clinical research evaluating the effects of mindfulness-based interventions targeting health behaviors relevant to psychiatric care. The review provides insight into the limitations of current research and proposes potential mechanisms to be tested in future research and targeted in clinical practice to enhance the impact of mindfulness on behavior change.

More than just a dental practitioner: A realist evaluation of a dental anxiety service in Norway

Patients with dental phobia or a history of trauma tend to avoid dental services, which may, over time, lead to poor oral health. In Norway, a specific service targets these patients by providing exposure therapy to treat their fear of attendance and subsequently enable oral restoration. Dental practitioners deliver the exposure therapy, which requires a role change that deviates from their traditional practice. This paper explores how - and under what circumstances - dental practitioners manage this new role of alleviating dental anxiety for patients with a history of trauma or dental phobia. Using a realist evaluation approach, this paper develops theory describing which contexts promote mechanisms that allow practitioners to alleviate dental anxiety for patients with trauma or dental phobia. A multi-method approach, comprising service documents (n = 13) and stakeholder interviews (n = 12), was applied. The data were then analysed through a content analysis and context-mechanism-outcome heuristic tool. Our findings reveal that dental practitioners must adopt roles that enable trust, a safe space, and gradual desensitisation of the patient to their fear triggers. Adopting these roles requires time and resources to develop practitioners' skills - enabling them to adopt an appropriate communication style and exposure pace for each patient.

How Memory Switches Brain Responses of Patients with Post-traumatic Stress Disorder

To characterize the brain responses to traumatic memories in post-traumatic stress disorder (PTSD), we conducted task-employed functional magnetic resonance imaging and, in the process, devised a simple but innovative approach-correlation computation between task conditions. A script-driven imagery task was used to compare the responses with a script of the patients' own traumatic memories and with that of tooth brushing as a daily activity and to evaluate how eye movement desensitization and reprocessing (EMDR), an established therapy for PTSD, resolved the alterations in patients. Nine patients with PTSD (seven females, aged 27-50 years) and nine age- and gender-matched healthy controls participated in this study. Six patients underwent the second scan under the same paradigm after EMDR. We discovered intense negative correlations between daily and traumatic memory conditions in broad areas, including the hippocampus; patients who had an intense suppression of activation during daily recognition showed an intense activation while remembering a traumatic memory, whereas patients who had a hyperarousal in daily recognition showed an intense suppression while remembering a traumatic memory as a form of "shut-down." Moreover, the magnitude of the discrepancy was reduced in patients who remitted after EMDR, which might predict an improved prognosis of PTSD.

Imagery Rehearsal Based Art Therapy: Treatment of Post-traumatic Nightmares in Art Therapy

Imagery Rehearsal Therapy (IRT) is effective for trauma-related nightmares and is also a challenge to patients in finding access to their traumatic memories, because these are saved in non-verbal, visual, or audiovisual language. Art therapy (AT) is an experiential treatment that addresses images rather than words. This study investigates the possibility of an IRT-AT combination. Systematic literature review and field research was conducted, and the integration of theoretical and practice-based knowledge resulted in a framework for Imagery Rehearsal-based Art Therapy (IR-AT). The added value of AT in IRT appears to be more readily gaining access to traumatic experiences, living through feelings, and breaking through avoidance. Exposure and re-scripting take place more indirectly, experientially and sometimes in a playlike manner using art assignments and materials. In the artwork, imagination, play and fantasy offer creative space to stop the vicious circle of nightmares by changing theme, story line, ending, or any part of the dream into a more positive and acceptable one. IR-AT emerges as a promising method for treatment, and could be especially useful for patients who benefit least from verbal exposure techniques. This description of IR-AT offers a base for further research.

The terror of the good: working the edge of experience

This paper considers the topic of the 'good' within the literature and in clinical work. Milder forms of the good which arise on the personal level generate defences against personal vulnerability. More powerful forms of the good, which the author calls the 'truly good', arise on an archetypal level and overwhelm the ego, generating fear, even terror. The 'truly good' invokes defences against the dissolution of an intact sense of self. In both mild and intense forms, the good will arise in every analysis, will challenge boundaries of both client and analyst, and touch the core of the analytic relationship. It demands acknowledgement. Within these two categories, the author identifies five forms of the good that may arise in containable and uncontainable intensities: beauty, intimacy, becoming, love, and encounters with the divine. Exploring encounters with the good in its various forms expands the range of tolerable human experience - one of the fundamental goals of analysis. Living the good, or at times suffering the truly good, furthers individuation as it enlarges access to experiences of profound meaning, including the divine or the numinous.

Game-Based Meditation Therapy to Improve Posttraumatic Stress and Neurobiological Stress Systems in Traumatized Adolescents: Protocol for a Randomized Controlled Trial

BACKGROUND

Many adolescents in residential care have been exposed to prolonged traumatic experiences such as violence, neglect, or abuse. Consequently, they suffer from posttraumatic stress. This not only negatively affects psychological and behavioral outcomes (eg, increased anxiety, depression, and aggression) but also has adverse effects on physiological outcomes, in particular on their neurobiological stress systems. Although current evidence-based treatment options are effective, they have their limitations. An alternative to traditional trauma treatment is meditation-based treatment that focuses on stress regulation and relaxation. Muse is a game-based meditation intervention that makes use of adolescents' intrinsic motivation. The neurofeedback element reinforces relaxation abilities.

OBJECTIVE

This paper describes the protocol for a randomized controlled trial in which the goal is to examine the effectiveness of Muse (InteraXon Inc) in reducing posttraumatic stress and normalizing neurobiological stress systems in a sample of traumatized adolescents in residential care.

METHODS

This will be a multicenter, multi-informant, and multimethod randomized controlled trial. Participants will be adolescents (N=80), aged 10 to 18 years, with clinical levels of posttraumatic symptoms, who are randomized to receive either the Muse therapy sessions and treatment as usual (intervention) or treatment as usual alone (control). Data will be collected at 3 measurement instances: pretest (T1), posttest (T2), and at 2-month follow-up. Primary outcomes will be posttraumatic symptoms (self-report and mentor report) and stress (self-report) at posttest. Secondary outcomes will be neurobiological stress parameters under both resting and acute stress conditions, and anxiety, depression, and aggression at posttest. Secondary outcomes also include all measures at 2-month follow-up: posttraumatic symptoms, stress, anxiety, depression aggression, and neurobiological resting parameters.

RESULTS

The medical-ethical committee Arnhem-Nijmegen (NL58674.091.16) approved the trial on November 15, 2017. The study was registered on December 2, 2017. Participant enrollment started in January 2018, and the results of the study are expected to be published in spring or summer 2021.

CONCLUSIONS

Study results will demonstrate whether game-based meditation therapy improves posttraumatic stress and neurobiological stress systems, and whether it is more effective than treatment as usual alone for traumatized adolescents.

TRIAL REGISTRATION

Netherlands Trial Register NL6689 (NTR6859); https://www.trialregister.nl/trial/6689.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19881.

A novel approach to improve stress regulation among traumatized youth in residential care: Feasibility study testing three game-based meditation interventions

AIM

Many youth in residential care suffer from post-traumatic symptoms that have adverse effects on a range of psychological, behavioural and physiological outcomes. Although current evidence-based treatment options are effective, they have their limitations. Meditation interventions are an alternative to traditional trauma-focused treatment. This pilot study aimed to evaluate three game-based meditation interventions in a sample of traumatized youth in residential care.

METHODS

Fifteen participants were randomly divided over three conditions (Muse, DayDream and Wild Divine) that all consisted of twelve 15-minute game-play sessions. Physiological measurements (heart rate variability) were conducted at baseline, post-treatment and during each intervention session. Post-traumatic symptoms, stress, depression, anxiety and aggression were assessed at baseline, post-treatment and 1-month follow-up.

RESULTS

Physiological stress regulation was improved during the meditation sessions of all three interventions. User evaluations were in particular high for Muse with a rating of 8.42 out of 10 for game evaluation. Overall, outcomes on psychopathology demonstrated the most robust effect on stress. Muse performed best, with all participants showing reliable improvements (reliable change indexes [RCIs]) in post-traumatic symptoms, stress and anxiety. Participants who played Daydream or Wild Divine showed inconsistent progression: some participants improved, whereas others remained stable or even deteriorated based on their RCIs.

CONCLUSIONS

Preliminary findings show promising outcomes on physiology, psychopathology and user evaluations. All indicate the potential of this innovative form of stress regulation intervention, and the potential of Muse in particular, although findings should be considered preliminary due to our small sample size. Further studies are warranted to assess intervention effectiveness effects of Muse or other game-based meditation interventions for traumatized youth.

Oxytocin-enhanced group therapy for methamphetamine use disorder: Randomized controlled trial

BACKGROUND

Methamphetamine (METH) use is a public health crisis that disproportionately affects men who have sex with men (MSM). There are currently no FDA-approved pharmacological interventions to treat methamphetamine use disorder (MUD). MUD is associated with social impairments and extremely high treatment attrition rates. Administration of oxytocin, a neuropeptide involved in social attachment, may be a novel approach to addressing these issues. Moreover, oxytocin administration has shown promise for reducing METH-related addictive behavior in animal models, but has not yet been investigated in clinical trials for MUD. Last, oxytocin is known to modulate stress responsivity via regulation of the autonomic nervous system, which is dysregulated in METH users. We hypothesize that oxytocin, in combination with group psychotherapy, will increase treatment engagement, reduce addiction behavior, and mitigate stress hyperreactivity.

METHODS

This is a randomized, double blind trial of oxytocin 40-IU (n = 24) or placebo (n = 24) administered intranasally prior to each of six weekly motivational interviewing group therapy (MIGT) sessions for MUD in MSM.

PRIMARY OUTCOME

(a) session attendance.

SECONDARY OUTCOMES

(b) group cohesion, (c) anxiety, (d) METH craving, (e) METH use, and (f) in-session cardiac physiology.

RESULTS

Participants receiving oxytocin had significantly higher group therapy attendance than those receiving placebo, OR 3.26, 95% CI [1.27-8.41], p = .014. There was a small effect of oxytocin on group cohension, but not anxiety or craving. METH use did not change over the six-week MIGT course in either treatment arm. Participants receiving oxytocin had lower average heart rates during MIGT sessions and higher heart rate variability. There were positive main effects of MIGT over Time regardless of study drug.

CONCLUSIONS

This evidence, and the lack of any serious adverse events, suggests that oxytocin may safely increase treatment attendance. One possible mechanism by which it may do so is its modulation of the autonomic nervous system. Further investigation is warranted.

Neuroscience of Adolescent Anorexia Nervosa: Implications for Family-Based Treatment (FBT)

Over the past 20 years significant progress has been made to elucidate some of the neurobiological underpinnings of the development and maintenance of anorexia nervosa and their possible implications for treatment. There is increasing evidence supporting the notion that anorexia nervosa shares neurobehavioral patterns with anxiety disorders and involves reward processing aberrations and habit formation. There is consensus for the need of early intervention to ameliorate the effects of starvation on the adolescent brain and the effects of illness duration on neurodevelopment. Family-based treatment (FBT) is the first line evidence-based treatment for adolescents with anorexia nervosa achieving sustainable full remission rates of over 40%. FBT has an agnostic treatment approach and its mechanisms of change have until now not been fully understood. To help fill this gap in theoretical understanding, this paper will provide a review of the treatment model of FBT through a neuroscientific lens. It argues that FBT is well designed to address the implications of current key findings of the neuroscience of anorexia nervosa and that it is also well aligned with the current understanding of neuroscience principles underpinning therapeutic change. The paper supports the perspective that FBT utilizes principles of parent facilitated exposure response prevention. It concludes that an integration of a neuroscience perspective to the provision of FBT will assist the clinician in their practice of FBT.

Practitioner perspectives on the nexus between acquired brain injury and family violence

Family violence has been highlighted by the World Health Organization as a major public health concern. Although family violence occurs to all genders, a higher prevalence of victims are female. Estimates report around 30% of all women experience intimate partner violence worldwide. Experiencing assault in the family violence context can lead to an acquired brain injury (ABI); however, the connection between these two phenomena has not been well established. The aim of this qualitative study was to explore the extent of, and factors contributing to, ABI and family violence. We conducted 22 semi-structured interviews and one focus group (n = 4) with practitioners working with family violence victims and/or perpetrators. Thematic data analysis utilised inductive and deductive coding approaches. The Social Determinants of Health Framework was used to guide analysis. Practitioners estimated 30%-40% of the clients on their caseloads had a suspected or diagnosed ABI. They identified that contributing factors were extremely complex. These included acquiring an ABI through assault (past family violence or other criminal act), and transport crashes. Complicating factors of ABI were identified as mental health conditions, alcohol and drug use, and post-traumatic stress disorder. Additional factors contributing to family violence were recognised as biological (age of parent, twin births, pregnancy, premature births, and children with congenital abnormalities), relationships (intimate partner, father, boyfriend, mother and siblings), previous trauma (family violence), and life stressors (unemployment, financial, and lack of housing). Social determinants of health included cultural (ethnicity, societal attitudes, values, and beliefs) and organisational (legislation and policy) factors which influenced behaviours and outcomes across all sectors. A model of Brain injury Family violence Nexus (BFN) was created to understand the interaction between these phenomena. Utilising the BFN model to understand the interaction can enhance the methods used within health and social services for a more efficacious approach.

The effects of trauma on brain and body: A unifying role for the midbrain periaqueductal gray

Post-traumatic stress disorder (PTSD), a diagnosis that may follow the experience of trauma, has multiple symptomatic phenotypes. Generally, individuals with PTSD display symptoms of hyperarousal and of hyperemotionality in the presence of fearful stimuli. A subset of individuals with PTSD; however, elicit dissociative symptomatology (i.e., depersonalization, derealization) in the wake of a perceived threat. This pattern of response characterizes the dissociative subtype of the disorder, which is often associated with emotional numbing and hypoarousal. Both symptomatic phenotypes exhibit attentional threat biases, where threat stimuli are processed preferentially leading to a hypervigilant state that is thought to promote defensive behaviors during threat processing. Accordingly, PTSD and its dissociative subtype are thought to differ in their proclivity to elicit active (i.e., fight, flight) versus passive (i.e., tonic immobility, emotional shutdown) defensive responses, which are characterized by the increased and the decreased expression of the sympathetic nervous system, respectively. Moreover, active and passive defenses are accompanied by primarily endocannabinoid- and opioid-mediated analgesics, respectively. Through critical review of the literature, we apply the defense cascade model to better understand the pathological presentation of defensive responses in PTSD with a focus on the functioning of lower-level midbrain and extended brainstem systems.

Adverse Childhood Experiences and Trauma-Informed Care in Rehabilitation Clinical Practice

Adverse childhood experiences (ACEs) contribute to physical, behavioral, and mental health issues throughout the lifespan and, because of their prevalence, constitute a significant public health issue. Practitioners in all health care disciplines need to be knowledgeable about ACEs and prepared to address them. ACEs can contribute to conditions that lead patients to seek rehabilitation care, and therefore a framework is needed that enables rehabilitation professionals to understand the effects of ACEs and how to discuss them with patients. This article summarizes ACE research and its clinical relevance, presents an overview of the related topic of trauma-informed care, and introduces rehabilitation professionals to practical tools for incorporating ACE- and trauma-informed care into clinical practice.

There is growing acknowledgement across all health care disciplines of the impact of ACEs. ACEs are understood as stressful, potentially traumatic events that may have lasting negative effects on health and well-being. Since the 1990s, when landmark research found striking associations between early life stress and adversity and a wide range of chronic physical, behavioral, and mental health issues, international attention to ACEs as a major public health issue has grown.1, 2 ACE-related research has identified strong correlations between chronic disease, stress, and prior experience. Eighty-six percent of health care dollars in the United States are spent on chronic diseases, and a population health strategy should include empowering, person-centered, low-risk, low-cost, self-management skill-building practices to help patients manage the stress response.³

Though a relevant consideration for all care provision, the biopsychosocial framework may be particularly important for understanding and working with chronic health conditions.4, 5, 6, 7 For example, chronic pain affects 116 million in the United States⁸ and may be a key force in driving patients to seek rehabilitation services. Patients need their providers to skillfully and comprehensively navigate the intersection of mental, emotional, and physical components of their healing process. Given the prevalence of ACEs and their potential contribution to chronic pain, among other conditions, rehabilitation professionals should be prepared to address ACEs in the clinical setting as a possible underlying contributor to the condition for which treatment is sought. This article provides an overview of ACEs research and the health effects that can result from ACEs and introduces a trauma-informed practical guide for rehabilitation professionals to use in clinical encounters.

•

Adverse childhood experiences (ACEs) contribute to a broad spectrum of health challenges across the lifespan and constitute a significant public health issue.

•

Rehabilitation professionals routinely work with individuals experiencing health challenges that may be linked to ACEs.

•

Models of trauma-informed care and resilience-building approaches assist rehabilitation professionals in contributing to a solution to the prevalence of ACEs and chronic stress in the population.

•

A novel schema is presented to assist rehabilitation professionals in navigating the topic of ACEs in clinical care.

The Threatful Self: Midbrain Functional Connectivity to Cortical Midline and Parietal Regions During Subliminal Trauma-Related Processing in PTSD

BACKGROUND

The innate alarm system consists of a subcortical network of interconnected midbrain, lower brainstem, and thalamic nuclei, which together mediate the detection of evolutionarily-relevant stimuli. The periaqueductal gray is a midbrain structure innervated by the innate alarm system that coordinates the expression of defensive states following threat detection. In participants with post-traumatic stress disorder, the periaqueductal gray displays overactivation during the subliminal presentation of trauma-related stimuli as well as altered resting-state functional connectivity. Aberrant functional connectivity is also reported in post-traumatic stress disorder for the default-mode network, a large-scale brain network recruited during self-referential processing and autobiographical memory. Here, research lacks investigation on the extent to which functional interactions are displayed between the midbrain and the large-scale cortical networks in post-traumatic stress disorder.

METHODS

Using a subliminal threat presentation paradigm, we investigated psycho-physiological interactions during functional neuroimaging in participants with post-traumatic stress disorder (n = 26) and healthy control subjects (n = 20). Functional connectivity of the periaqueductal gray was investigated across the whole-brain of each participant during subliminal exposure to trauma-related and neutral word stimuli.

RESULTS

As compared to controls during subliminal threat presentation, the post-traumatic stress disorder group showed significantly greater periaqueductal gray functional connectivity with regions of the default-mode network (i.e., angular gyrus, precuneus, superior frontal gyrus). Moreover, multiple regression analyses revealed that the functional connectivity between the periaqueductal gray and the regions of the default-mode network correlated positively to symptoms of avoidance and state dissociation in post-traumatic stress disorder.

CONCLUSION

Given that the periaqueductal gray engages the expression of defensive states, stronger midbrain functional coupling with the default-mode network may have clinical implications to self-referential and trauma-related processing in participants with post-traumatic stress disorder.

Evidence establishing a link between prenatal and early-life stress and asthma development

PURPOSE OF REVIEW

The objective of this review is to provide an update on our evolving understanding of the effects of stress in pregnancy and during early development on the onset of asthma-related phenotypes across childhood, adolescence, and into early adulthood.

RECENT FINDINGS

Accumulating evidence over the past 2 decades has established that prenatal and early-life psychological stress and stress correlates (e.g., maternal anxiety or depression) increase the risk for childhood respiratory disorders. Recent systematic reviews and meta-analyses including numerous prospective epidemiological and case-control studies substantiate a significant effect of prenatal stress and stress in early childhood on the development of wheeze, asthma, and other atopic-related disorders (eczema and allergic rhinitis), with many studies showing an exposure-response relationship. Offspring of both sexes are susceptible to perinatal stress, but effects differ. The impact of stress on child wheeze/asthma can also be modified by exposure timing. Moreover, coexposure to prenatal stress can enhance the effect of chemical stressors, such as prenatal traffic-related air pollution, on childhood respiratory disease risk. Understanding complex interactions among exposure dose, timing, child sex, and concurrent environmental exposures promises to more fully characterize stress effects and identify susceptible subgroups. Although the link between perinatal stress and childhood asthma-related phenotypes is now well established, pathways by which stress predisposes children to chronic respiratory disorders are not as well delineated. Mechanisms central to the pathophysiology of wheeze/asthma and lung growth and development overlap and involve a cascade of events that include disrupted immune, neuroendocrine, and autonomic function as well as oxidative stress. Altered homeostatic functioning of these integrated systems during development can enhance vulnerability to asthma and altered lung development.

SUMMARY

Mechanistic studies that more comprehensively assess biomarkers reflecting alterations across interrelated stress response systems and associated regulatory processes, in both pregnant women and young children, could be highly informative. Leveraging high-throughput systems-wide technologies to include epigenomics (e.g., DNA methylation, microRNAs), transcriptomics, and microbiomics as well as integrated multiomics are needed to advance this field of science. Understanding stress-induced physiological changes occurring during vulnerable life periods that contribute to chronic respiratory disease risk could lead to the development of preventive strategies and novel therapeutic interventions.

The enemy in the mirror: self-perception-induced stress results in dissociation of psychological and physiological responses in patients with dissociative disorder

Background: Patients suffering from dissociative disorders (DD) are characterized by an avoidance of aversive stimuli. Clinical experience has shown that DD patients typically avoid the confrontation with their own faces in a mirror (CFM). Objective: To investigate potential CFM-associated self-reported and psychophysiological stress reactions of DD patients, which most likely inform on the still unknown pathophysiology of dysfunctional self-perception in DD. Method: Eighteen DD patients and 18 healthy controls (HCs) underwent CFM. They were assessed for CFM-induced subjective self-reported stress, acute dissociative symptoms and sympathetic and parasympathetic drive using impedance cardiography. Results: DD patients experienced more subjective stress and acute dissociation than HCs upon CFM. Their psychological stress response did not activate the sympathetic and parasympathetic nervous system. Conclusions: In DD patients, CFM constitutes serious self-reported stress and is associated with a blunted autonomic reactivity. Therapeutic approaches promoting self-perception and self-compassion, in particular by using CFM, might serve as goal-oriented diagnostic and therapeutic tools in DD.

If we build it, will they come? Issues of engagement with digital health interventions for trauma recovery

Exposure to traumatic events is extremely common with nearly 75% reported to have experienced one or more traumatic events worldwide. A significant number of those exposed will develop posttraumatic stress disorder (PTSD) along with depression, anxiety, and substance use disorders. Globally, trauma-related mental health disorders are the leading cause of global disability burden, and many of these disorders are caused, or worsened, by exposure to wars, natural and human-caused disasters, and other traumatic events. Significant barriers to treatment exist including logistical, geographical, financial, stigma, and other attitudinal challenges. One opportune approach to overcoming these barriers is the provision of mental health interventions via technology that can be readily standardized for wide dissemination of evidence-based care. However, engagement with technology-based interventions is a concern and limited participation and high attrition rates are common. This may be especially true for trauma survivors who often experience symptoms of avoidance and hyperarousal. Engagement is regarded as an essential component of intervention efficacy and has been demonstrated to be associated with more positive clinical outcomes, yet theoretically based research in this area is sparse. This review focuses on the complex issue of engagement with digital health interventions (DHIs). Specifically, we review the conceptualization and measurement of engagement, predictors of engagement, and importantly, the relationship of engagement with intervention effectiveness. Finally, a theoretically based model of engagement is proposed that considers the unique challenges of trauma recovery. This review is not intended to provide a systematic or exhaustive set of recommendations, rather it is intended to highlight the challenges of engagement research including its definition, measurement, and modeling. Future engagement research that includes valid and reliable measures of engagement will enable consistent exploration of engagement predictors that can then inform methods for increasing engagement and, ultimately, intervention effectiveness.

Mindfulness and Emotion Regulation: Insights from Neurobiological, Psychological, and Clinical Studies

There is increasing interest in the beneficial clinical effects of mindfulness-based interventions (MBIs). Research has demonstrated their efficacy in a wide range of psychological conditions characterized by emotion dysregulation. Neuroimaging studies have evidenced functional and structural changes in a myriad of brain regions mainly involved in attention systems, emotion regulation, and self-referential processing. In this article we review studies on psychological and neurobiological correlates across different empirically derived models of research, including dispositional mindfulness, mindfulness induction, MBIs, and expert meditators in relation to emotion regulation. From the perspective of recent findings in the neuroscience of emotion regulation, we discuss the interplay of top-down and bottom-up emotion regulation mechanisms associated with different mindfulness models. From a phenomenological and cognitive perspective, authors have argued that mindfulness elicits a "mindful emotion regulation" strategy; however, from a clinical perspective, this construct has not been properly differentiated from other strategies and interventions within MBIs. In this context we propose the distinction between top-down and bottom-up mindfulness based emotion regulation strategies. Furthermore, we propose an embodied emotion regulation framework as a multilevel approach for understanding psychobiological changes due to mindfulness meditation regarding its effect on emotion regulation. Finally, based on clinical neuroscientific evidence on mindfulness, we open perspectives and dialogues regarding commonalities and differences between MBIs and other psychotherapeutic strategies for emotion regulation.

The hierarchical basis of neurovisceral integration

The neurovisceral integration (NVI) model was originally proposed to account for observed relationships between peripheral physiology, cognitive performance, and emotional/physical health. This model has also garnered a considerable amount of empirical support, largely from studies examining cardiac vagal control. However, recent advances in functional neuroanatomy, and in computational neuroscience, have yet to be incorporated into the NVI model. Here we present an updated/expanded version of the NVI model that incorporates these advances. Based on a review of studies of structural/functional anatomy, we first describe an eight-level hierarchy of nervous system structures, and the contribution that each level plausibly makes to vagal control. Second, we review recent work on a class of computational models of brain function known as "predictive coding" models. We illustrate how the computational dynamics of these models, when implemented within our proposed vagal control hierarchy, can increase understanding of the relationship between vagal control and both cognitive performance and emotional/physical health. We conclude by discussing novel implications of this updated NVI model for future research.

Impact of Maternal Lifetime Interpersonal Trauma on Children's Asthma: Mediation Through Maternal Active Asthma During Pregnancy

OBJECTIVE

Traumatic stressors, including child abuse and/or interpersonal violence over a woman's lifecourse, can affect the health of her children. This study examines the associations between maternal lifetime interpersonal trauma (IPT) and children's asthma by age 6 years (n = 857).

METHODS

Pregnant women completed the Revised Conflict Tactics Scale; IPT exposure was categorized as unexposed (55%), early (childhood and/or teen years only, 25%), late (adulthood and/or index pregnancy, 7%), and chronic (early and late, 13%). Clinician-diagnosed asthma in children was reported by mothers at each follow-up visit until the child reached age 6 years. We examined the effects of maternal IPT categories and child's asthma using logistic regression. Using structural equation models, we also examined indirect relationships between maternal chronic IPT and child asthma operating through active asthma in pregnancy, prepregnancy BMI, prenatal smoking, and/or increased exposure to other adverse life events or environmental toxins prenatally. Effect modification by the child's sex was examined.

RESULTS

Mothers were primarily Hispanic (55%) or black (30%) with less than high school education (62%). In logistic regression models, chronic maternal IPT (compared with unexposed) was associated with asthma in boys (odds ratio = 2.87, 95% confidence interval = 1.48-5.57) but not girls (odds ratio = 0.69, 95% confidence interval = 0.23-2.12; pinteraction = .042). In structural equation models, chronic IPT was associated with maternal active asthma in pregnancy (β = 0.59, p < .001), maternal active asthma was associated with children's asthma (β = 0.20, p = .009), and the total indirect effect for this path was significant (β = 0.12, p = .031). Associations were most evident among boys.

CONCLUSIONS

Mothers' history of chronic IPT was associated with asthma in boys. This association was mediated through active maternal asthma in pregnancy.

fMRI functional connectivity of the periaqueductal gray in PTSD and its dissociative subtype

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with hyperarousal and active fight or flight defensive responses. By contrast, the dissociative subtype of PTSD, characterized by depersonalization and derealization symptoms, is frequently accompanied by additional passive or submissive defensive responses associated with autonomic blunting. Here, the periaqueductal gray (PAG) plays a central role in defensive responses, where the dorsolateral (DL-PAG) and ventrolateral PAG (VL-PAG) are thought to mediate active and passive defensive responses, respectively.

METHODS

We examined PAG subregion (dorsolateral and ventrolateral) resting-state functional connectivity in three groups: PTSD patients without the dissociative subtype (n = 60); PTSD patients with the dissociative subtype (n = 37); and healthy controls (n = 40) using a seed-based approach via PickAtlas and SPM12.

RESULTS

All PTSD patients showed extensive DL- and VL-PAG functional connectivity at rest with areas associated with emotional reactivity and defensive action as compared to controls (n = 40). Although all PTSD patients demonstrated DL-PAG functional connectivity with areas associated with initiation of active coping strategies and hyperarousal (e.g., dorsal anterior cingulate; anterior insula), only dissociative PTSD patients exhibited greater VL-PAG functional connectivity with brain regions linked to passive coping strategies and increased levels of depersonalization (e.g., temporoparietal junction; rolandic operculum).

CONCLUSIONS

These findings suggest greater defensive posturing in PTSD patients even at rest and demonstrate that those with the dissociative subtype show unique patterns of PAG functional connectivity when compared to those without the subtype. Taken together, these findings represent an important first step toward identifying neural and behavioral targets for therapeutic interventions that address defensive strategies in trauma-related disorders.

Substance use to regulate intense posttraumatic shame in individuals with childhood abuse and neglect

Childhood abuse and neglect (CAN) is considered as a risk factor for substance use disorder (SUD). Based on the drinking to cope model, this study investigated the association of two trauma-relevant emotions (shame and sadness) and substance use. Using ecological momentary assessment we compared real-time emotion regulation in situations with high and low intensity of shame and sadness in currently abstinent patients with CAN and lifetime SUD (traumaSUD group), healthy controls with CAN (traumaHC group), and without CAN (nontraumaHC group). Multilevel analysis showed a positive linear relationship between high intensity of both emotions and substance use for all groups. The traumaSUD group showed heightened substance use in low, as well as in high, intensity of shame and sadness. In addition, we found an interaction between type of emotion, intensity, and group: the traumaHC group exhibited a fourfold increased risk for substance use in high intense shame situations relative to the traumaSUD group. Our findings provide evidence for the drinking to cope model. The traumaSUD group showed a reduced distress tolerance for variable intensity of negative emotions. The differential effect of intense shame for the traumaHC group emphazises its potential role in the development of SUD following CAN. In addition, shame can be considered a relevant focus for therapeutic preinterventions and interventions for SUD after CAN.

Young children's experiences of participating in group treatment for children exposed to intimate partner violence: A qualitative study

The risk of exposure to intimate partner violence (IPV) between caregivers is increased during early childhood. The adverse effects on the health and development of the youngest children may be severe. Effective and promising interventions for children who have experienced IPV have been developed and evaluated. However, there is a lack in knowledge about how the children themselves experience the interventions. The aim of this study was to contribute to the evaluation of group treatment designed to improve the psychological health of young children in the aftermath of family violence by elucidating the children's experiences of participating. Nine children, aged 4 to 6 years, were interviewed after participating in group programmes specifically designed for children who have been exposed to intimate partner violence. A semi-structured interview guide with open-ended questions was used. The interviews were transcribed and analysed using interpretative phenomenological analysis, to ensure a focus on the children's own views and experiences. Five master themes embracing the children's experiences were identified: joy - positive emotional experience of participation; security - feeling safe; relatedness - relationships within the group; to talk - externalised focus on the violence; and competence - new knowledge and skills. Theoretical and clinical implications and the benefit of including very young children's views and experiences in research are discussed.

Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and nonepileptic attacks

OBJECTIVE

The objective was to compare a brief interdisciplinary psychotherapeutic intervention to standard care as treatments for patients recently diagnosed with severe motor conversion disorder or nonepileptic attacks.

METHODS

This randomized controlled trial of 23 consecutive patients compared (a) an interdisciplinary psychotherapeutic intervention group receiving four to six sessions by a consultation liaison psychiatrist, the first and last sessions adding a neurological consultation and a joint psychiatric and neurological consultation, and (b) a standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dissociation Questionnaire (SDQ-20), Clinical Global Impression scale, Rankin scale, use of medical care, global mental health [Montgomery and Asberg Depression Rating Scale, Beck Depression Inventory, mental health component of Short Form (SF)-36] and quality of life (SF-36). We calculated linear mixed models.

RESULTS

Our intervention brought a statistically significant improvement of physical symptoms [as measured by the SDQ-20 (P<.02) and the Clinical Global Impression scale (P=.02)] and psychological symptoms [better scores on the mental health component of the SF-36 (P<.05) and on the Beck Depression Inventory (P<.05)] and a reduction in new hospital stays after intervention (P<.05).

CONCLUSION

A brief psychotherapeutic intervention taking advantage of a close collaboration with neurology consultants in the setting of consultation liaison psychiatry appears effective.

The integrated memory model: A new framework for understanding the mechanisms of change in psychotherapy

In this response to commentaries on our target article, we highlight and clarify a variety of issues and respond to several comments, challenges, and misconceptions. Topics covered include the mechanisms of enduring change, the nature of memory, the conditions in which memories are updated, the role of emotional arousal in change, and current limitations in our understanding of the neural basis of change in psychotherapy. It is our hope that through research stimulated by this exchange the latter may be advanced.

Neglect of the complex: why psychotherapy for post-traumatic clinical presentations is often ineffective

Evidence of efficacy in studies of post-traumatic conditions is largely derived from studies in which variables are kept to a minimum. Extrapolation of treatments from uncomplicated disorders to complex conditions may therefore be called evidence-based without being evidenced. Complex conditions with polysymptomatic presentations and extensive comorbidity are being denied proper evaluation, and patients most severely traumatised from the early stages of their development are not provided with rigorously evaluated psychotherapies because they are more difficult to study in the manner approved by research protocols. Such evidence as there is suggests that the simple extension of treatments for uncomplicated disorders is seriously inadequate. This has significant implications for health services responsible for the provision of the most efficacious treatments to those whose disorders arise from severe trauma, often very early in their life.

Dopamine in the nucleus accumbens modulates the memory of social defeat in Syrian hamsters (Mesocricetus auratus)

Conditioned defeat (CD) is a behavioral response that occurs in Syrian hamsters after they experience social defeat. Subsequently, defeated hamsters no longer produce territorial aggression but instead exhibit heightened levels of avoidance and submission, even when confronted with a smaller, non-aggressive intruder. Dopamine in the nucleus accumbens is hypothesized to act as a signal of salience for both rewarding and aversive stimuli to promote memory formation and appropriate behavioral responses to significant events. The purpose of the present study was to test the hypothesis that dopamine in the nucleus accumbens modulates the acquisition and expression of behavioral responses to social defeat. In Experiment 1, bilateral infusion of the non-specific D1/D2 receptor antagonist cis(z)flupenthixol (3.75 μg/150 nl saline) into the nucleus accumbens 5 min prior to defeat training significantly reduced submissive and defensive behavior expressed 24h later in response to a non-aggressive intruder. In Experiment 2, infusion of 3.75 μg cis-(Z)-flupenthixol 5 min before conditioned defeat testing with a non-aggressive intruder significantly increased aggressive behavior in drug-infused subjects. In Experiment 3, we found that the effect of cis-(Z)-flupenthixol on aggression was specific to defeated animals as infusion of drug into the nucleus accumbens of non-defeated animals did not significantly alter their behavior in response to a non-aggressive intruder. These data demonstrate that dopamine in the nucleus accumbens modulates both acquisition and expression of social stress-induced behavioral changes and suggest that the nucleus accumbens plays an important role in the suppression of aggression that is observed after social defeat.

Lost among the trees? The autonomic nervous system and paediatrics

The autonomic nervous system (ANS) has been strikingly neglected in Western medicine. Despite its profound importance for regulation, adjustment and coordination of body systems, it lacks priority in training and practice and receives scant attention in numerous major textbooks. The ANS is integral to manifestations of illness, underlying familiar physical and psychological symptoms. When ANS activity is itself dysfunctional, usual indicators of acute illness may prove deceptive. Recognising the relevance of the ANS can involve seeing the familiar through fresh eyes, challenging assumptions in clinical assessment and in approaches to practice. Its importance extends from physical and psychological well-being to parenting and safeguarding, public services and the functioning of society. Exploration of its role in conditions ranging from neurological, gastrointestinal and connective tissue disorders, diabetes and chronic fatigue syndrome, to autism, behavioural and mental health difficulties may open therapeutic avenues. The ANS offers a mechanism for so-called functional illnesses and illustrates the importance of recognising that 'stress' takes many forms, physical, psychological and environmental, desirable and otherwise. Evidence of intrauterine and post-natal programming of ANS reactivity suggests that neonatal care and safeguarding practice may offer preventive opportunity, as may greater understanding of epigenetic change of ANS activity through, for example, accidental or psychological trauma or infection. The aim of this article is to accelerate recognition of the importance of the ANS throughout paediatrics, and of the potential physical and psychological cost of neglecting it.