Toward a possible trauma subtype of functional neurological disorder: Impact on symptom severity and physical health

Neuroscience in pictures: Functional neurological disorder

Functional neurological disorder (FND) is a biopsychosocially-complex, prevalent, and potentially disabling neuropsychiatric condition. In this pictorial review, we explore the complexity of FND, from its diagnosis and conceptualization to current mechanistic understandings. We highlight advances in neuroimaging research that have revealed structural and functional brain alterations in FND and discuss a variety of factors that may serve as predisposing vulnerabilities for the development of this condition and/or perpetuate symptoms. This overview is designed as an initial teaching resource to educate trainees, clinicians, and researchers, highlighting core concepts in the literature on FND. Given that mechanistic research in FND is at a relatively early stage and is rapidly evolving, the interested reader should aim to continue updating their mechanistic understanding of FND as research further advances in this area.

Positive signs from the history as an aid for early diagnosis in functional movement disorders: The prospective TASMAN study

BACKGROUND AND PURPOSE

There has been a concerted move in recent times to shift from an exclusionary to a positive diagnosis of functional movement disorders (FMDs). To date, most of the focus has been on defining positive physical signs. Here the focus was on the diagnostic specificity of specific symptoms and patient characteristics.

METHODS

For this prospective cohort study, newly referred patients in the Netherlands and Australia were recruited before their first neurology appointment. Participants completed questionnaires within 2 months prior to their visit at one of the six different clinics. Directly following the first consultation, physicians received a questionnaire about their diagnostic process. Patients were excluded if the diagnosis was not a movement disorder. Univariate and multivariate regression analyses were conducted to identify predictors of FMDs. Subsequently, a predictive model was constructed and assessed using the area under the receiver operating curve.

RESULTS

Between 1 March 2021 and 1 March 2023, 465 patients were eligible for inclusion, of whom 171 (37%) had an FMD and 294 (63%) a non-FMD. Distinguishing factors amongst these groups included age at onset, gender, history or family history of a functional and psychiatric disorder, sudden onset, specific triggers, fluctuation patterns throughout the day and over an extended period, pain, fatigue, depression, anxiety and dissociation. Using these, a predictive model was developed, yielding a discriminative accuracy of 88%.

CONCLUSION

Specific symptoms and patient characteristics have high diagnostic discriminative value between FMDs and non-FMDs, providing an additional tool in positive diagnosis.

Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study

BACKGROUND

Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions.

METHODS

International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter-rater agreement analyses were undertaken.

RESULTS

Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%-88% of the FCD diagnoses were attributed to non-neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%-92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD.

CONCLUSIONS

Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence-based interventions.

Functional Neurological Disorder and Autism Spectrum Disorder: A Complex and Potentially Significant Relationship

INTRODUCTION

Functional neurological disorder (FND) and autism spectrum disorder (ASD) are two complex neuropsychiatric conditions that have been historically classified within psychiatric domains, resulting in a lack of extensive research, insufficient clinical recognition, and persistent societal stigma. In recent years, there has been an increasing recognition among professionals and affected individuals of their possible overlap. This review explores the potential clinical and mechanistic overlap between FND and ASD, with particular attention to shared symptoms across sensory, motor, and psychiatric domains.

METHODS

We conducted a narrative analysis utilizing the PubMed, CINAHL, MEDLINE, and ScienceDirect databases from inception to June 2024. The search employed specific MeSH terms related to ASD and FND. Given the limited data availability, we included all relevant articles that explored the potential connections between FND and ASD, focusing on established findings and theoretical hypotheses areas.

RESULTS

Scientific evidence indicates that FND and ASD may co-occur more frequently than previously acknowledged and with notable overlaps in their clinical presentations and pathophysiology. Theoretical models that have been applied to FND and ASD, such as the Bayesian brain theory and the tripartite model of autism, may provide valuable insights into the intersection of these conditions. Although much of the current evidence remains speculative, it underscores the need for hypothesis-driven research to investigate these potential connections further.

CONCLUSION

ASD and FND are heterogeneous conditions that appear to co-occur in a subset of individuals, with overlapping symptomatology and possibly shared underlying mechanisms. This hypothesis-generating review emphasizes the need for further research to better understand these links, ultimately aiming to improve clinical recognition and develop targeted interventions that enhance the quality of life for affected individuals.

Measurement Properties of the Patient Health Questionnaire-15 and Somatic Symptom Scale-8: A Systematic Review and Meta-Analysis

Importance

The subjective experience of somatic symptoms is a key concern throughout the health care system. Valid and clinically useful instruments are needed.

Objective

To evaluate the measurement properties of 2 widespread patient-reported outcomes: the Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Scale-8 (SSS-8).

Data Sources

Medline, PsycINFO, and Web of Science were last searched February 1, 2024.

Study Selection

English-language studies reporting estimates pertaining to factor analysis, taxometric analysis, internal consistency, construct validity, mean scores in relevant groups, cutoffs, areas under the receiver operating characteristic curves (AUROCs), minimal clinically important difference, test-retest reliability, or sensitivity to change.

Data Extraction and Synthesis

Search hits were reviewed by independent raters. Cronbach α, Pearson r, means, and between-group effect sizes indicative of sensitivity to change were pooled in random-effects meta-analysis. Study quality was assessed using 3 instruments. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 reporting guideline.

Main Outcomes and Measures

Comprehensive overview of evidence pertaining to the measurement properties of the PHQ-15 and SSS-8.

Results

A total of 305 studies with 361 243 participants were included. Most concerned routine care (178 studies) and the general population (27 studies). In factor analyses, both scales reflected a combination of domain-specific factors (cardiopulmonary, fatigue, gastrointestinal, pain) and a general symptom burden factor. The pooled PHQ-15 α was 0.81 (95% CI, 0.80-0.82), but with low item-total correlations for items concerning menstrual problems, fainting spells, and sexual problems (item-total correlations <0.40), and the SSS-8 α was 0.80 (0.77-0.83). Pooled correlations with other measures of somatic symptom burden were 0.71 (95% CI, 0.64-0.78) for the PHQ-15 and 0.82 (95% CI, 0.72-0.92) for the SSS-8. Reported AUROCs for identification of somatoform disorders ranged from 0.63 (95% CI, 0.50-0.76) to 0.79 (95% CI, 0.73-0.85) for the PHQ-15 and from 0.71 (95% CI, 0.66-0.77) to 0.73 (95% CI, 0.69-0.76) for the SSS-8. The minimal clinically important difference on both scales was 3 points. Test-retest reliability could not be pooled and was inconsistent for the PHQ-15 (PHQ-15: r = 0.65-0.93; ICC, 0.87; SSS-8: r = 0.996, ICC = 0.89). The PHQ-15 showed tentative sensitivity to change (g = 0.32; 95% CI, 0.08-0.56), but data for the SSS-8 were lacking.

Conclusions and Relevance

In this systematic review and meta-analysis, findings supported use of the PHQ-15 and SSS-8 for the assessment of symptom burden, but users should be aware of the complex, multifactorial structures of these scales. More evidence is needed concerning longitudinal measurement properties.

Trauma-Based Sexually Dimorphic Changes in the Connectome and Its Association with Central Sensitization Syndromes-A Systematic Review

BACKGROUND/OBJECTIVES

Chronic pain syndromes pose a significant global health challenge to patients and physicians with a complex relationship of biological and psychosocial factors that are only partly understood. Emerging research suggests an association between prenatal and childhood adversity and the development of somatic syndromes, particularly in females. This study aims to explore the relationship between sexual dimorphic epigenetic changes in the connectome and prenatal and early life adversity (ELA).

METHODS

A review of the existing literature was conducted, examining studies utilizing MRI to identify critical periods of environmental influence on neural phenotypes.

RESULTS

The findings indicate a significant association between prenatal and childhood adversity and the emergence of central sensitization syndromes, particularly among females. Notably, alterations in grey matter volume and neural connectivity patterns were observed, suggesting that early adverse experiences can influence pain signaling mechanisms.

CONCLUSIONS

Understanding the role of sex differences in brain circuitry is crucial for developing personalized pain management strategies. This study highlights the importance of considering both biological and psychosocial factors in addressing chronic pain, as interventions based predominantly on male subjects may be less effective for females. Further research is warranted to explore these differences and refine therapeutic approaches.

Illness perceptions, experiences of stigma and engagement in functional neurological disorder (FND): exploring the role of multidisciplinary group education sessions

Background

A critical first step in managing functional neurological disorder (FND) is a positive diagnosis and clear explanation using an understandable illness model. Multidisciplinary group education sessions are one way to achieve this, with some evidence they improve understanding, confidence in diagnosis and outcomes with further treatment. In many conditions, illness perceptions and stigma affect distress, functioning, quality of life and engagement. Exploring relationships between these factors could lead to deeper understanding of the impact of education.

Methods

Questionnaires assessing illness perceptions, quality of life, mood, anxiety, comorbidities, treatment engagement and stigma (both experienced and anticipated) were completed before, immediately and 1 month after a multidisciplinary online group education session for FND at a regional neurosciences centre. Free-text data on causal attributions and needs were also collected.

Results

166 patients attended online education sessions from January 2022 to July 2023; 61 (37%) completed presession surveys, 42 (25%) completed postsession and 35 (21%) completed 1 month postsession surveys. Patients reported multiple comorbidities, poor quality of life, functioning and high levels of stigma. Illness perception scores indicated FND as threatening, mysterious and unpredictable, with low personal or treatment control over symptoms. Illness coherence/understanding (mean difference 2.27, p<0.01, 95% CI 1.22 to 4.23) and engagement (mean difference 2.42, p<0.01, 95% CI 0.46 to 4.36) increased after the session. There were no significant changes in stigma, distress, sense of control or anticipated discrimination. Free-text analysis revealed stress and trauma as the most common causal attributions, followed by physical illnesses. Patients requested personalised formulations, practical disability advice, help with explaining the condition to others (eg, employers), peer support and treatment.

Conclusion

Multidisciplinary group FND education sessions potentially improve patient understanding and engagement. Clinicians should consider the possible benefits of personalised formulations and linking to practical and peer support. Further work assessing illness perceptions is needed, such as adapting measures for FND.

Case report: Dissociative neurological symptom disorder with gait disturbance: taking after the father?

Dissociative neurological symptoms disorder (DNSD), or conversion disorder, frequently manifests with unexplained neurological symptoms, necessitating referral to psychiatry following preliminary diagnosis in neurology. We present a case of an adolescent female patient with gait disturbance as the predominant clinical presentation, and delve into the diagnosis and interdisciplinary intervention process. Given neuroimaging deviations detected and familial similar presentations, the organic etiology was confirmed. However, the aberrant gait remained unexplained ultimately prompting psychiatric consultation resulting in the diagnosis of DNSD. Interventions consisting of health education, suggestive therapy, and physiotherapy notably improved gait disturbance. However, at follow-up, the patient presented with a depressive episode. It was deduced that undiagnosed psychosocial factors, notably familial dynamics, likely contributed to this decline. Eventually, transformed relation patterns among family members as well as antidepressant treatment were instrumental in attaining symptom remission.

Predictive Processing and the Pathophysiology of Functional Neurological Disorder

The contemporary neuroscience understanding of the brain as an active inference organ supports that our conscious experiences, including sensorimotor perceptions, depend on the integration of probabilistic predictions with incoming sensory input across hierarchically organized levels. As in other systems, these complex processes are prone to error under certain circumstances, which may lead to alterations in their outcomes (i.e., variations in sensations and movements). Such variations are an important aspect of functional neurological disorder, a complex disorder at the interface of brain-mind-body interactions. Thus, predictive processing frameworks offer fundamental mechanistic insights into the pathophysiology of functional neurological disorder. In recent years, many of the aspects relevant to the neurobiology of functional neurological disorder - e.g., aberrant motor and sensory processes, symptom expectation, self-agency, and illness beliefs, as well as interoception, allostasis, and emotion - have been investigated through the lens of predictive processing frameworks. Here, we provide an overview of the current state of research on predictive processing and the pathophysiology of functional neurological disorder.

Unravelling the influence of affective stimulation on functional neurological symptoms: a pilot experiment examining potential mechanisms

BACKGROUND

Differences in affective processing have previously been shown in functional neurological disorder (FND); however, the mechanistic relevance is uncertain. We tested the hypotheses that highly arousing affective stimulation would result in elevated subjective functional neurological symptoms (FNS), and this would be associated with elevated autonomic reactivity. The possible influence of cognitive detachment was also explored.

METHOD

Individuals diagnosed with FND (motor symptoms/seizures; n=14) and healthy controls (n=14) viewed Positive, Negative and Neutral images in blocks, while passively observing the stimuli ('Watch') or detaching themselves ('Distance'). The FND group rated their primary FNS, and all participants rated subjective physical (arousal, pain, fatigue) and psychological states (positive/negative affect, dissociation), immediately after each block. Skin conductance (SC) and heart rate (HR) were monitored continuously.

RESULTS

FNS ratings were higher after Negative compared with Positive and Neutral blocks in the FND group (p=0.002, ηp 2=0.386); however, this effect was diminished in the Distance condition relative to the Watch condition (p=0.018, ηp 2=0.267). SC and/or HR correlated with FNS ratings in the Negative-Watch and Neutral-Distance conditions (r values=0.527-0.672, p values=0.006-0.035). The groups did not differ in subjective affect or perceived arousal (p values=0.541-0.919, ηp 2=<0.001-0.015).

CONCLUSIONS

Emotionally significant events may exert an influence on FNS which is related to autonomic activation rather than altered subjective affect or perceived arousal. This influence may be modulated by cognitive detachment. Further work is needed to determine the relevance and neural bases of these processes in specific FND phenotypes.

Neuropsychological evaluation of functional cognitive disorder: A narrative review

Objective: To critically review contemporary theoretical models, diagnostic approaches, clinical features, and assessment findings in Functional Cognitive Disorder (FCD), and make recommendations for neuropsychological evaluation of this condition. Method: Narrative review. Results: FCD is common in neuropsychological practice. It is characterized by cognitive symptoms that are not better explained by another medical or psychiatric disorder. The cognitive symptoms are associated with distress and/or limitations in daily functioning, but are potentially reversible with appropriate identification and treatment. Historically, a variety of diagnostic frameworks have attempted to capture this condition. A contemporary conceptualization of FCD positions it as a subtype of Functional Neurological Disorder, with shared and unique etiological factors. Patients with FCD tend to perform normally on neuropsychological testing or demonstrate relatively weak memory acquisition (e.g. list learning trials) in comparison to strong attention and delayed recall performance. Careful history-taking and behavioral observations are essential to support the diagnosis of FCD. Areas of ongoing controversy include operationalizing "internal inconsistencies" and the role of performance validity testing. Evidence for targeted interventions remains scarce. Conclusions: Neuropsychologists familiar with FCD can uniquely contribute to the care of patients with this condition by improving diagnostic clarity, richening case formulation, communicating effectively with referrers, and leading clinical management. Further research is needed to refine diagnosis, prognosis, and treatment.

The Impact of Depression, Anxiety and Personality Disorders on the Outcome of Patients with Functional Limb Weakness - Individual Patient Data Meta-Analysis

OBJECTIVE

Psychiatric comorbidities such as depression, anxiety, and personality disorders are common in patients with functional limb weakness/paresis (FND-par). The impact of these conditions on the prognosis of FND-par has not been systematically reviewed. The aim of this study was to identify a potential prognostic effect of comorbid depression, anxiety, and/or personality disorder on prognosis in patients with FND-par.

METHODS

A systematic review was performed to identify studies that reported measures of baseline depression, anxiety, and/or personality disorder, and physical disability. An individual patient data meta-analysis was subsequently performed.

RESULTS

Eight studies comprising 348 individuals were included (7 prospective cohorts; 1 case-control study). There was heterogeneity in sample size, follow-up duration, and treatment modality. Depression and anxiety were present in 51.4% and 53.0% of FND-par patients, respectively. In individuals whose FND-par improved, there was no significant difference between those with versus without depression (52.6% vs 47.4%, p = 0.69) or those with versus without anxiety (50.3% vs 49.7%, p = 0.38). Meta-analysis showed no clear impact of baseline depression or anxiety per se [pooled OR for depression 0.85 (95%CI 0.50-1.45; p = 0.40) and anxiety 0.84 (95%CI 0.51-1.38; p = 0.91)]; and of depression or anxiety severity [pooled OR for depression 1.23 (95%CI 0.63-2.39; p = 0.91) and anxiety 1.40 (95%CI 0.70-2.78; p = 0.58)] on FND-par outcome. Insufficient data were available to assess the impact of personality disorders.

CONCLUSION

We found no evidence that depression or anxiety influenced outcome in FND-par. Large-scale, prospective studies in FND-par, and other FND subtypes, are needed to fully contextualize the impact of concurrent mental health concerns on outcomes.

Psychogenic Nonepileptic Seizures Associated with an Eating Disorder and PTSD Are Responsive to Cognitive Processing Therapy

Objective

Eating disorders (EDs) are often associated with prior histories of trauma, subsequent PTSD and related psychiatric comorbidities. There is a paucity of information about their relationship to somatic symptom disorders, specifically psychogenic nonepileptic seizures (PNES), a type of functional neurological symptom disorder or conversion disorder.

Methods

We report a case of a 39-year-old bisexual female with bulimia nervosa (BN), PTSD, recurrent major depressive disorder (MDD), cannabis use disorder, and PNES who responded to integrated trauma-focused treatment during residential ED treatment using cognitive processing therapy (CPT). Symptoms of ED, PTSD, major depression, and state-trait anxiety were measured using validated assessment instruments.

Results

During the course of CPT treatment, the patient's total scores on the PTSD Symptom Checklist for DSM-5 (PCL-5) went from 59 to 26, which is below the diagnostic threshold for PTSD. In addition, she demonstrated improvements in the Eating Disorder Examination Questionnaire (EDE-Q) Global Severity score, the Eating Disorder Inventory (EDI-2) total score, the Patient Health Questionnaire (PHQ-9) total score, the Spielberger State and Trait Anxiety Inventory scores, and the Eating Disorder Quality of Life (EDQOL) total score. Furthermore, her PNES also abated, and she remained seizure free for ∼1 year following discharge with the exception of one short seizure, per report of the patient.

Conclusion

The use of CPT as part of an integrated trauma-informed treatment approach during residential ED treatment was successful in a woman with PNES, BN, PTSD, MDD, and cannabis use disorder.

Adverse life events in patients with functional seizures: Assessment in clinical practice and association with long-term outcome

BACKGROUND

A history of adverse life events (ALE) is a risk factor for functional seizures (FS). Their influence on long-term outcome remains unclear. International guidelines recommend assessing ALE in patients presenting with associated disorders. It is not clear to what extent patients evaluated for FS are regularly asked about ALE.

OBJECTIVES

We hypothesised that the presence of ALE would relate to worse outcome at follow-up and, that the rate of detection of ALE in clinical work-up would be inferior to that based on self-report questionnaires.

METHODS

53 patients with FS from the National Centre for Epilepsy in Norway, aged 16-62 years were included. Symptom severity, health-related quality of life (HRQoL), and antecedent ALE were assessed at baseline. Medical records were examined for disclosure of ALE. At a mean of 70.45 (SD 29.0, range 22-130) months after inclusion, participants were inquired about FS status, FS-related health care utilization and HRQoL.

FINDINGS

A history of emotional abuse documented in the medical record was an independent risk factor for worse HRQoL at follow-up. Prevalence of ALE documented in medical records was lower compared with rates measured by a self-report questionnaire.

CONCLUSIONS

These findings indicate an association between antecedent ALE and HRQoL years after diagnosis. A substantial proportion of the adverse life events by a self-report questionnaire had not been documented in the clinical records.

CLINICAL IMPLICATIONS

The supplemental use of a self-report questionnaire in the diagnostic work-up of patients with FS may be valuable for detecting ALE.

Functional Neurological Disorder: Diagnostic Pitfalls and Differential Diagnostic Considerations

Functional neurologic disorder (FND) is a "rule-in" diagnosis, characterized by positive examination signs or semiological features. Similar to other clinical diagnoses, providers should ideally see robustly present features, including if possible the identification of multiple features consistent with FND for the diagnosis to be made with a high degree of certainty. Diagnostic pitfalls need to be guarded against and vary depending on FND symptom subtype and the specific patient presentation. This perspective article aims to review pitfalls based on an FND symptom subtype, as well as discuss differential diagnostic considerations with respect to both neurologic and psychiatric entities.

MODIFI: protocol for randomised feasibility study of eye-movement desensitisation and reprocessing therapy (EMDR) for functional neurological disorder (FND)

INTRODUCTION

Functional neurological disorder (FND) refers to an involuntary loss of control over and/or aberrant perception of the body. Common presenting symptoms are functional (non-epileptic) seizures, and functional motor disorder, for example, walking difficulties, weakness or tremor. Greater access to effective treatments would lead to reduced distress and disability; and reduce unnecessary healthcare costs.This study will examine eye-movement desensitisation and reprocessing therapy (EMDR) as a treatment for FND. EMDR is an evidence-based treatment for post-traumatic stress disorder (PTSD), but its use for other conditions is growing. An FND-specific EMDR protocol will be tested, and if the intervention proves feasible with promising clinical outcomes, progression to a substantive study could take place.

METHODS AND ANALYSIS

Fifty adult patients diagnosed with FND will be recruited. It will be a single-blind randomised controlled trial with two arms: EMDR (plus standard neuropsychiatric care; NPC) and standard NPC. The two groups will be compared at baseline (T0), 3 months (T1), 6 months (T2) and 9 months (T3). Measures of feasibility include safety, recruitment, retention, treatment adherence and acceptability. Clinical outcome measures will assess health-related functioning/quality of life, ratings of FND symptoms and severity, depression, anxiety, PTSD, dissociation, service utilisation and other costs. Improvement and satisfaction ratings will also be assessed. Feasibility outcomes will be summarised using descriptive statistics. Exploratory analyses using (linear/logistic) mixed-effect models will examine the rate of change in the groups' clinical outcome measures across the four time-points.After the intervention period, a sample of participants, and clinicians, will be invited to attend semistructured interviews. The interviews will be analysed using reflexive thematic analysis.

ETHICS AND DISSEMINATION

This study has been approved by the NHS West Midlands-Edgbaston Research Ethics Committee. Study findings will be published in open access peer-reviewed journals, presented at conferences, and communicated to participants and other relevant stakeholders.

TRIAL REGISTRATION

NCT05455450 (www.

CLINICALTRIALS

gov).

Socioemotional self- and co-regulation in functional seizures: comparing high and low posttraumatic stress

Functional seizures (FS) are seizure-like symptoms without electroencephalogram (EEG)-based epileptic activity. Those with FS often show emotion-related dysfunction and disrupted interpersonal relationships, in which posttraumatic stress disorder symptoms (PTS) may play a role. We sought to better understand trauma comorbidities and socioemotional processes in FS, including affectionate touch, a form of social connection linked to emotion regulation and awareness. We administered questionnaires online to a community sample of 89 trauma-exposed FS participants (FS diagnoses were self-reported), 51 with and 38 without clinical-level PTS (FS-PTShi, FS-PTSlo) and 216 seizure-free matched trauma-exposed controls (TCs), 91 with and 125 without clinical-level PTS (TC-PTShi, TC-PTSlo) per the Posttraumatic Stress Disorder Symptom Checklist (PCL). As hypothesized, both FS-PTShi and FS-PTSlo reported more emotional avoidance (Brief Experiential Avoidance Questionnaire), more emotion regulation difficulties (Difficulties in Emotion Regulation Scale), and more perceived stress (Perceived Stress Scale) than PTS-matched counterparts. FS-PTShi also reported less reappraisal (Emotion Regulation Questionnaire), more loneliness (UCLA Loneliness Scale), and less frequent affectionate touch (Physical Affection Scale) during waking and surrounding sleep than TC-PTShi, whereas FS-PTSlo and TC-PTSlo did not differ. Neither FS group differed from PTS-matched controls in emotion suppression (Emotion Regulation Questionnaire) or comfort with social touch (Social Touch Questionnaire). Among FS, FS-PTShi reported more difficulties than FS-PTSlo on nearly all measures (non-significant trend for social support). Findings underscore potential synergistic effects of FS and PTS clinical symptoms in shaping experiences of one's emotions and social world, suggesting fostering meaningful connections with others, including via affectionate touch, is an important treatment target.