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Burback L, Brémault-Phillips S, Nijdam MJ, McFarlane A, Vermetten E. Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review. Curr Neuropharmacol 2024; 22:557-635. [PMID: 37132142 PMCID: PMC10845104 DOI: 10.2174/1570159x21666230428091433] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/19/2023] [Accepted: 02/23/2023] [Indexed: 05/04/2023] Open
Abstract
This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.
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Affiliation(s)
- Lisa Burback
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | | | - Mirjam J. Nijdam
- ARQ National Psychotrauma Center, Diemen, The Netherlands
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Department of Psychiatry, New York University Grossman School of Medicine, New York, USA
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Andrews K, Lloyd CS, Densmore M, Kearney BE, Harricharan S, McKinnon MC, Théberge J, Jetly R, Lanius RA. 'I am afraid you will see the stain on my soul': Direct gaze neural processing in individuals with PTSD after moral injury recall. Soc Cogn Affect Neurosci 2023; 18:nsad053. [PMID: 37897804 PMCID: PMC10612569 DOI: 10.1093/scan/nsad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/20/2023] [Accepted: 10/19/2023] [Indexed: 10/30/2023] Open
Abstract
Direct eye contact is essential to understanding others' thoughts and feelings in social interactions. However, those with post-traumatic stress disorder (PTSD) and exposure to moral injury (MI) may exhibit altered theory-of-mind (ToM)/mentalizing processes and experience shame which precludes one's capacity for direct eye contact. We investigated blood oxygenation level-dependent (BOLD) responses associated with direct vs averted gaze using a virtual reality paradigm in individuals with PTSD (n = 28) relative to healthy controls (n = 18) following recall of a MI vs a neutral memory. Associations between BOLD responses and clinical symptomatology were also assessed. After MI recall, individuals with PTSD showed greater activation in the right temporoparietal junction as compared to controls (T = 4.83; pFDR < 0.001; k = 237) during direct gaze. No significant activation occurred during direct gaze after neutral memory recall. Further, a significant positive correlation was found between feelings of distress and right medial superior frontal gyrus activation in individuals with PTSD (T = 5.03; pFDR = 0.049; k = 123). These findings suggest that direct gaze after MI recall prompts compensatory ToM/mentalizing processing. Implications for future interventions aimed at mitigating the effects of PTSD on social functioning are discussed.
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Affiliation(s)
- Krysta Andrews
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8N 3K7, Canada
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
| | - Chantelle S Lloyd
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
- Department of Psychiatry, Western University, London, ON N6C 0A7, Canada
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Maria Densmore
- Department of Psychiatry, Western University, London, ON N6C 0A7, Canada
- Imaging Division, Lawson Health Research Institute, London, ON N6A 4V2, Canada
| | - Breanne E Kearney
- Department of Neuroscience, Western University, London, ON N6A 3K7, Canada
| | - Sherain Harricharan
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8N 3K7, Canada
| | - Margaret C McKinnon
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON L8N 3K7, Canada
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, Hamilton, ON L8N 3K7, Canada
| | - Jean Théberge
- Department of Psychiatry, Western University, London, ON N6C 0A7, Canada
- Imaging Division, Lawson Health Research Institute, London, ON N6A 4V2, Canada
- Department of Medical Biophysics, Western University, London, ON N6A 5C1, Canada
| | - Rakesh Jetly
- Canadian Forces, Health Services, Ottawa, ON K1A 0S2, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Ruth A Lanius
- Homewood Research Institute, Guelph, ON N1E 6K9, Canada
- Department of Psychiatry, Western University, London, ON N6C 0A7, Canada
- Imaging Division, Lawson Health Research Institute, London, ON N6A 4V2, Canada
- Department of Neuroscience, Western University, London, ON N6A 3K7, Canada
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Cahill JM, Moyse AJ, Dugdale LS. "Ruptured selves: moral injury and wounded identity". MEDICINE, HEALTH CARE, AND PHILOSOPHY 2023; 26:225-231. [PMID: 36780060 DOI: 10.1007/s11019-023-10138-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 05/13/2023]
Abstract
Moral injury is the trauma caused by violations of deeply held values and beliefs. This paper draws on relational philosophical anthropologies to develop the connection between moral injury and moral identity and to offer implications for moral repair, focusing particularly on healthcare professionals. We expound on the notion of moral identity as the relational and narrative constitution of the self. Moral identity is formed and forged in the context of communities and narrative and is necessary for providing a moral horizon against which to act. We then explore the relationship between moral injury and damaged moral identities. We describe how moral injury ruptures one's sense of self leading to moral disorientation. The article concludes with implications for moral repair. Since moral identity is relationally formed, moral repair is not primarily an individual task but requires the involvement of others to heal one's identity. The repair of moral injury requires the transformation of a moral identity in community.
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Affiliation(s)
- Jonathan M Cahill
- Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Ashley J Moyse
- Center for Clinical Medical Ethics, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - Lydia S Dugdale
- Department of Medicine, Center for Clinical Medical Ethics, Columbia University, Vagelos College of Physicians & Surgeons, 622 W 168th St, PH 8E-105, 10032-3784, New York, NY, USA.
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