Cognitive Behavior Therapy vs Mindfulness in Treatment of Prolonged Grief Disorder: A Randomized Clinical Trial

Importance

Although grief-focused cognitive behavior therapies are the most empirically supported treatment for prolonged grief disorder, many people find this treatment difficult. A viable alternative for treatment is mindfulness-based cognitive therapy.

Objective

To examine the relative efficacies of grief-focused cognitive behavior therapy and mindfulness-based cognitive therapy to reduce prolonged grief disorder severity.

Design, Setting, and Participants

A single-blind, parallel, randomized clinical trial was conducted among adults aged 18 to 70 years with prolonged grief disorder, as defined in the International Classification of Diseases, 11th Revision, and assessed by clinical interview based on the Prolonged Grief-13 (PG-13) scale. Those with severe suicidal risk, presence of psychosis, or substance dependence were excluded. Between November 2012 and November 2022, eligible participants were randomized 1:1 to eleven 90-minute sessions of grief-focused cognitive behavior therapy or mindfulness-based cognitive therapy at a traumatic stress clinic in Sydney, Australia, with follow-up through 6 months.

Interventions

Both groups received once-weekly 90-minute individual sessions for 11 weeks. Grief-focused cognitive behavior therapy comprised 5 sessions of recalling memories of the deceased, plus cognitive restructuring and planning future social and positive activities. Mindfulness-based cognitive therapy comprised mindfulness exercises adapted to tolerate grief-related distress.

Main Outcomes and Measures

The primary outcome was change in prolonged grief disorder severity measured by the PG-13 scale assessed at baseline, 1 week posttreatment, and 6 months after treatment (primary outcome time point), as well as secondary outcome measures of depression, anxiety, grief-related cognition, and quality of life.

Results

The trial included 100 participants (mean [SD] age, 47.3 [13.4] years; 87 [87.0%] female), 50 in the grief-focused cognitive behavior therapy condition and 50 in the mindfulness-based cognitive therapy condition. Linear mixed models indicated that at the 6-month assessment, participants in the grief-focused cognitive behavior therapy group showed greater reduction in PG-13 scale score relative to those in the mindfulness-based cognitive therapy group (mean difference, 7.1; 95% CI, 1.6-12.5; P = .01), with a large between-group effect size (0.8; 95% CI, 0.2-1.3). Participants in the grief-focused cognitive behavior therapy group also demonstrated greater reductions in depression as measured on the Beck Depression Inventory than those in the mindfulness-based cognitive therapy group (mean difference, 6.6; 95% CI, 0.5-12.9; P = .04) and grief-related cognition (mean difference, 14.4; 95% CI, 2.8-25.9; P = .02). There were no other significant differences between treatment groups and no reported adverse events.

Conclusions and Relevance

In this study, grief-focused cognitive behavior therapy conferred more benefit for core prolonged grief disorder symptoms and associated problems 6 months after treatment than mindfulness-based cognitive therapy. Although both treatments may be considered for prolonged grief disorder, grief-focused cognitive behavior therapy might be the more effective choice, taking all factors into consideration.

Trial Registration

anzctr.org.au Identifier: ACTRN12612000307808.

Genome-wide association analyses identify 95 risk loci and provide insights into the neurobiology of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) genetics are characterized by lower discoverability than most other psychiatric disorders. The contribution to biological understanding from previous genetic studies has thus been limited. We performed a multi-ancestry meta-analysis of genome-wide association studies across 1,222,882 individuals of European ancestry (137,136 cases) and 58,051 admixed individuals with African and Native American ancestry (13,624 cases). We identified 95 genome-wide significant loci (80 new). Convergent multi-omic approaches identified 43 potential causal genes, broadly classified as neurotransmitter and ion channel synaptic modulators (for example, GRIA1, GRM8 and CACNA1E), developmental, axon guidance and transcription factors (for example, FOXP2, EFNA5 and DCC), synaptic structure and function genes (for example, PCLO, NCAM1 and PDE4B) and endocrine or immune regulators (for example, ESR1, TRAF3 and TANK). Additional top genes influence stress, immune, fear and threat-related processes, previously hypothesized to underlie PTSD neurobiology. These findings strengthen our understanding of neurobiological systems relevant to PTSD pathophysiology, while also opening new areas for investigation.

Relationship between trauma, psychological distress and help-seeking among corrective service workers

BACKGROUND

Corrective service workers (CSWs) are at high risk of post-traumatic stress disorder (PTSD) and other mental health problems. Prevalence rates and help-seeking behaviours are under-researched within this population.

AIMS

To assess rates of PTSD and distress, and identify predictors of intention to seek help, among workers at an Australian corrective service agency.

METHODS

A cross-sectional online survey was used to collect data on staff demographics, employment, PTSD symptoms and current distress. Participants received a tailored feedback report including referral to relevant mental health services (where applicable) and were asked to indicate their likelihood of seeking help. Prevalence data are reported. Binary logistic regression was used to examine relationships between participant characteristics and help-seeking for those with probable PTSD and/or high psychological distress.

RESULTS

Participants (n=1001) were predominantly men (56.8%) with a mean age of 46.72 (SD=11.00). Over half (58.0%) were classified as probable PTSD cases, and one-third (33.0%) were experiencing high psychological distress. Around a third (34.3%) of participants with probable PTSD and/or elevated distress indicated they were likely to seek help. Older age and fewer years of service were associated with increased help-seeking intentions.

CONCLUSIONS

CSWs were found to be experiencing probable PTSD at higher rates than reported in previous studies. Relatively few intended to seek help from mental health services, despite being provided with personalised screening and feedback along with access to specialised care. Future research should investigate the potential role of organisational support as a facilitator of help-seeking within this population.

Yoga resilience training to prevent the development of posttraumatic stress disorder in active-duty first responders: A cluster randomized controlled trial

OBJECTIVE

Evidence on effective prevention of posttraumatic stress disorder (PTSD) is sparse, particularly among first responders. This study evaluated the effectiveness of a Tactical Mind-Body Resilience Training program on PTSD symptoms in first responders.

METHOD

Active-duty first responders (n = 80; Mage = 41.8 years, 82.5% men) were randomized to the intervention group or the waitlist control condition. PTSD symptoms as measured by the PTSD-8 were the primary outcome assessed at postintervention and at 3-month follow-up. Secondary outcomes were cognitive and emotional coping strategies, resilience, somatic symptoms, work performance, and sickness absence.

RESULTS

At postintervention, the intervention group had significantly reduced PTSD symptoms compared to the control group (d = -0.26, difference = -2.52, 95% confidence interval [CI] [-4.93, -0.11], p = .040); however, this difference was attenuated at 3-month follow-up (d = -0.07, difference = -1.41, 95% CI [-3.83, 1.01], p = .248). The intervention group had significant improvements in cognitive reappraisal and resilience at postintervention compared to the control group, which were sustained at 3 months. The remaining secondary outcomes had statistically nonsignificant improvements.

CONCLUSIONS

This workplace-delivered intervention shows potential in preventing the development of PTSD in first responders. Further research is needed on maintaining long-term benefits of this training. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Trajectory of adjustment difficulties following disaster: 10-year longitudinal cohort study

BACKGROUND

Although much is known about psychopathology such as post-traumatic stress disorder (PTSD) and depression following bushfire (also known as wildfire), little is known about prevalence, trajectory and impacts for those experiencing general adjustment difficulties following exposure to these now-common events.

AIMS

This was an exploratory analysis of a large cohort study that examined the prevalence, trajectory and risk factors of probable adjustment disorder over a 10-year period following bushfire exposure.

METHOD

The Beyond Bushfires study assessed individuals exposed to a large and deadly bushfire across three time points spanning 10 years. Self-report survey data from participants from areas with moderate and high levels of fire-affectedness were analysed: n = 802 participants at Wave 1 (3-4 years post-fires), n = 596 at Wave 2 (5 years post-fires) and n = 436 at Wave 3 (10 years post-fires). Surveys indexed fire-related experiences and post-fire stressors, and comprised the six-item Kessler Psychological Distress Scale (probable adjustment disorder index), four-item Posttraumatic Stress Disorder Checklist (probable fire-related PTSD) and nine-item Patient Health Questionnaire (probable major depressive episode).

RESULTS

Prevalence of probable adjustment disorder was 16% (Wave 1), 15% (Wave 2) and 19% (Wave 3). Probable adjustment disorder at 3-4 years post-fires predicted a five-fold increase in risk for escalating to severe psychiatric disorder (i.e. probable fire-related PTSD/major depressive episode) at 10 years post-fires, and was associated with post-fire income and relationship stressors.

CONCLUSIONS

Adjustment difficulties are prevalent post-disaster, many of which are maintained and exacerbated over time, resulting in increased risk for later disorder and adaptation difficulties. Psychosocial interventions supporting survivors with adjustment difficulties may prevent progression to more severe disorder.

Efficacy and moderators of efficacy of cognitive behavioural therapies with a trauma focus in children and adolescents: an individual participant data meta-analysis of randomised trials

BACKGROUND

Existing clinical trials of cognitive behavioural therapies with a trauma focus (CBTs-TF) are underpowered to examine key variables that might moderate treatment effects. We aimed to determine the efficacy of CBTs-TF for young people, relative to passive and active control conditions, and elucidate putative individual-level and treatment-level moderators.

METHODS

This was an individual participant data meta-analysis of published and unpublished randomised studies in young people aged 6-18 years exposed to trauma. We included studies identified by the latest UK National Institute of Health and Care Excellence guidelines (completed on Jan 29, 2018) and updated their search. The search strategy included database searches restricted to publications between Jan 1, 2018, and Nov 12, 2019; grey literature search of trial registries ClinicalTrials.gov and ISRCTN; preprint archives PsyArXiv and bioRxiv; and use of social media and emails to key authors to identify any unpublished datasets. The primary outcome was post-traumatic stress symptoms after treatment (<1 month after the final session). Predominantly, one-stage random-effects models were fitted. This study is registered with PROSPERO, CRD42019151954.

FINDINGS

We identified 38 studies; 25 studies provided individual participant data, comprising 1686 young people (mean age 13·65 years [SD 3·01]), with 802 receiving CBTs-TF and 884 a control condition. The risk-of-bias assessment indicated five studies as low risk and 20 studies with some concerns. Participants who received CBTs-TF had lower mean post-traumatic stress symptoms after treatment than those who received the control conditions, after adjusting for post-traumatic stress symptoms before treatment (b=-13·17, 95% CI -17·84 to -8·50, p<0·001, τ2=103·72). Moderation analysis indicated that this effect of CBTs-TF on post-traumatic stress symptoms post-treatment increased by 0·15 units (b=-0·15, 95% CI -0·29 to -0·01, p=0·041, τ2=0·03) for each unit increase in pre-treatment post-traumatic stress symptoms.

INTERPRETATION

This is the first individual participant data meta-analysis of young people exposed to trauma. Our findings support CBTs-TF as the first-line treatment, irrespective of age, gender, trauma characteristics, or carer involvement in treatment, with particular benefits for those with higher initial distress.

FUNDING

Swiss National Science Foundation.

Neuroimaging-based classification of PTSD using data-driven computational approaches: A multisite big data study from the ENIGMA-PGC PTSD consortium

BACKGROUND

Recent advances in data-driven computational approaches have been helpful in devising tools to objectively diagnose psychiatric disorders. However, current machine learning studies limited to small homogeneous samples, different methodologies, and different imaging collection protocols, limit the ability to directly compare and generalize their results. Here we aimed to classify individuals with PTSD versus controls and assess the generalizability using a large heterogeneous brain datasets from the ENIGMA-PGC PTSD Working group.

METHODS

We analyzed brain MRI data from 3,477 structural-MRI; 2,495 resting state-fMRI; and 1,952 diffusion-MRI. First, we identified the brain features that best distinguish individuals with PTSD from controls using traditional machine learning methods. Second, we assessed the utility of the denoising variational autoencoder (DVAE) and evaluated its classification performance. Third, we assessed the generalizability and reproducibility of both models using leave-one-site-out cross-validation procedure for each modality.

RESULTS

We found lower performance in classifying PTSD vs. controls with data from over 20 sites (60 % test AUC for s-MRI, 59 % for rs-fMRI and 56 % for d-MRI), as compared to other studies run on single-site data. The performance increased when classifying PTSD from HC without trauma history in each modality (75 % AUC). The classification performance remained intact when applying the DVAE framework, which reduced the number of features. Finally, we found that the DVAE framework achieved better generalization to unseen datasets compared with the traditional machine learning frameworks, albeit performance was slightly above chance.

CONCLUSION

These results have the potential to provide a baseline classification performance for PTSD when using large scale neuroimaging datasets. Our findings show that the control group used can heavily affect classification performance. The DVAE framework provided better generalizability for the multi-site data. This may be more significant in clinical practice since the neuroimaging-based diagnostic DVAE classification models are much less site-specific, rendering them more generalizable.

Effectiveness of a scalable, remotely delivered stepped-care intervention to reduce symptoms of psychological distress among Polish migrant workers in the Netherlands: study protocol for the RESPOND randomised controlled trial

BACKGROUND

The COVID-19 pandemic has negatively affected the mental health of international migrant workers (IMWs). IMWs experience multiple barriers to accessing mental health care. Two scalable interventions developed by the World Health Organization (WHO) were adapted to address some of these barriers: Doing What Matters in times of stress (DWM), a guided self-help web application, and Problem Management Plus (PM +), a brief facilitator-led program to enhance coping skills. This study examines whether DWM and PM + remotely delivered as a stepped-care programme (DWM/PM +) is effective and cost-effective in reducing psychological distress, among Polish migrant workers with psychological distress living in the Netherlands.

METHODS

The stepped-care DWM/PM + intervention will be tested in a two-arm, parallel-group, randomized controlled trial (RCT) among adult Polish migrant workers with self-reported psychological distress (Kessler Psychological Distress Scale; K10 > 15.9). Participants (n = 212) will be randomized into either the intervention group that receives DWM/PM + with psychological first aid (PFA) and care-as-usual (enhanced care-as-usual or eCAU), or into the control group that receives PFA and eCAU-only (1:1 allocation ratio). Baseline, 1-week post-DWM (week 7), 1-week post-PM + (week 13), and follow-up (week 21) self-reported assessments will be conducted. The primary outcome is psychological distress, assessed with the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS). Secondary outcomes are self-reported symptoms of depression, anxiety, posttraumatic stress disorder (PTSD), resilience, quality of life, and cost-effectiveness. In a process evaluation, stakeholders' views on barriers and facilitators to the implementation of DWM/PM + will be evaluated.

DISCUSSION

To our knowledge, this is one of the first RCTs that combines two scalable, psychosocial WHO interventions into a stepped-care programme for migrant populations. If proven to be effective, this may bridge the mental health treatment gap IMWs experience.

TRIAL REGISTRATION

Dutch trial register NL9630, 20/07/2021, https://www.onderzoekmetmensen.nl/en/trial/27052.

Opponent intrinsic brain network connectivity profiles associated with posttraumatic fear and dysphoria symptoms in trauma-exposed refugees

OBJECTIVE

Resting-state functional magnetic resonance imaging (rsfMRI) studies report functional alterations in the connectivity between intrinsic brain networks in posttraumatic stress disorder (PTSD), but PTSD heterogeneity is rarely considered. Evidence points to fear (e.g., reexperiencing) and dysphoria (e.g., withdrawal) symptom factors as important in PTSD presentations, including relating to variable emotion dysregulation patterns. This study, therefore, tested how fear and dysphoria posttraumatic symptoms were differentially associated with core network connectivity and emotion dysregulation behaviors in a large group of trauma-exposed refugees.

METHOD

A final sample of 77 trauma-exposed participants completed a rsfMRI scan. Independent component analysis identified active networks and functional network connectivity (FNC) between networks was assessed. Fear and dysphoria posttraumatic symptoms were partially correlated with FNCs, and linear regression models examined relationships with self-reported difficulties in emotion regulation.

RESULTS

Twenty-three active networks were identified, eight being in the networks of interest (p < .05 false discovery rate-corrected). Fear and dysphoria symptoms were specifically related to connectivity patterns between two subnetworks of the default mode network (DMN). Fear symptoms were negatively associated with anterior dorsomedial DMN (admDMN) and temporoparietal DMN (tpDMN) connectivity; whereas dysphoria symptoms were positively associated with admDMN-tpDMN connectivity. Additionally, admDMN-tpDMN connectivity was positively predicted by goal-directed emotion dysregulation but negatively predicted by poor emotional clarity.

CONCLUSIONS

Fear and dysphoria posttraumatic symptoms showed opponent associations with admDMN and tpDMN connectivity, potentially reflecting patterns of under- and overemotion dysregulation associated with these symptom profiles respectively. Findings highlight the importance of considering posttraumatic heterogeneity when constructing neural models of PTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The effect of a low-level psychological intervention (PM+) on post-migration living difficulties - Results from two studies in Switzerland and in the Netherlands

AIMS OF THE STUDY

After arriving in host countries, most refugees are confronted with numerous post-migration stressors (e.g., separation from family, discrimination, and employment difficulties). Post-migration living difficulties (PMLDs) significantly contribute to the development and persistence of mental disorders. Effective treatment approaches focusing on reducing post-migration stress are urgently needed. The aim of the present study was to examine the effect of a brief psychological intervention, Problem Management Plus (PM+), on PMLDs among Syrian refugees in two European countries.

METHODS

We merged data from two single-blind feasibility trials with Syrian refugees experiencing elevated levels of psychological distress and impaired functioning in Switzerland (N = 59) and the Netherlands (N = 60). Participants were randomised to receive either five sessions of PM+ or an enhanced care-as-usual control condition. PMLDs were assessed at baseline and 3 months after the intervention. To estimate treatment effect on PMLD, linear mixed model analysis was performed.

RESULTS

Three months after the intervention, participants in the PM+ condition reported significantly fewer PMLDs compared to the control condition. Further analyses at item-level showed that interpersonal and family related PMLDs, such as "worries about family back home" significantly improved over time in the PM+ condition.

CONCLUSIONS

This exploratory study suggests that brief psychological interventions have the potential to reduce PMLDs in refugees and asylum seekers. The reduction of post-migration stress in turn may subsequently lead to an overall reduction in psychological distress.

CLINICAL TRIAL NUMBERS

BASEC Nr. 2017-0117 (Swiss trial) and NL61361.029.17, 7 September 2017 (Dutch trial).

The mental health effects of changing from insecure to secure visas for refugees

OBJECTIVE

In response to growing numbers of refugees worldwide, host governments are increasingly implementing temporary protection policies; however, little is known regarding the mental health impact of these policies. This online longitudinal study investigated whether refugees who transitioned from low visa security (e.g. short-term transient visas) to medium (e.g. temporary protection visas) or high visa (e.g. permanent visas) security showed changes in depression symptoms, social difficulties and immigration-related fears.

METHODS

Participants were 1,201 refugees and asylum-seekers from Arabic, Farsi, Tamil or English-speaking backgrounds. Study variables were measured prior to and after change in visa status (6 months apart).

RESULTS

Refugees who transitioned from low to medium security visas showed reduced immigration-related fear (B = -0.09, 95% confidence interval = -0.29 to -0.06), but no change in depression symptoms or social difficulties compared to those who retained low visa security. Refugees who transitioned from low to high security visas showed reduced depression symptoms (B = -0.02, 95% confidence interval = -0.04 to -0.01), social difficulties (B = -0.04, 95% confidence interval = -0.05 to -0.01) and immigration-related fear (B = -0.03, 95% confidence interval = -0.06 to -0.01) compared to those who retained low visa security.

CONCLUSION

Findings indicate that the increased security afforded by temporary protection policies (vs short-term transient visas) did not translate into improved mental health and social outcomes for refugees. In contrast, permanent protection was associated with significant improvements in psychological and social functioning. These results have important policy implications for countries who have committed to protect and facilitate improved mental health among refugees.

Discovery of 95 PTSD loci provides insight into genetic architecture and neurobiology of trauma and stress-related disorders

Posttraumatic stress disorder (PTSD) genetics are characterized by lower discoverability than most other psychiatric disorders. The contribution to biological understanding from previous genetic studies has thus been limited. We performed a multi-ancestry meta-analysis of genome-wide association studies across 1,222,882 individuals of European ancestry (137,136 cases) and 58,051 admixed individuals with African and Native American ancestry (13,624 cases). We identified 95 genome-wide significant loci (80 novel). Convergent multi-omic approaches identified 43 potential causal genes, broadly classified as neurotransmitter and ion channel synaptic modulators (e.g., GRIA1, GRM8, CACNA1E ), developmental, axon guidance, and transcription factors (e.g., FOXP2, EFNA5, DCC ), synaptic structure and function genes (e.g., PCLO, NCAM1, PDE4B ), and endocrine or immune regulators (e.g., ESR1, TRAF3, TANK ). Additional top genes influence stress, immune, fear, and threat-related processes, previously hypothesized to underlie PTSD neurobiology. These findings strengthen our understanding of neurobiological systems relevant to PTSD pathophysiology, while also opening new areas for investigation.

Functional connectivity of amygdala subnuclei in PTSD: a narrative review

While the amygdala is often implicated in the neurobiology of posttraumatic stress disorder (PTSD), the pattern of results remains mixed. One reason for this may be the heterogeneity of amygdala subnuclei and their functional connections. This review used PRISMA guidelines to synthesize research exploring the functional connectivity of three primary amygdala subnuclei, basolateral (BLA), centromedial (CMA), and superficial nuclei (SFA), in PTSD (N = 331) relative to trauma-exposed (N = 155) and non-trauma-exposed controls (N = 210). Although studies were limited (N = 11), preliminary evidence suggests that in PTSD compared to trauma-exposed controls, the BLA shows greater connectivity with the dorsal anterior cingulate, an area involved in salience detection. In PTSD compared to non-trauma-exposed controls, the BLA shows greater connectivity with the middle frontal gyrus, an area involved in attention. No other connections were replicated across studies. A secondary aim of this review was to outline the limitations of this field to better shape future research. Importantly, the results from this review indicate the need to consider potential mediators of amygdala subnuclei connectivity, such as trauma type and sex, when conducting such studies. They also highlight the need to be aware of the limited inferences we can make with such small samples that investigate small subcortical structures on low field strength magnetic resonance imaging scanners. Collectively, this review demonstrates the importance of exploring the differential connectivity of amygdala subnuclei to understand the pathophysiology of PTSD and stresses the need for future research to harness the strength of ultra-high field imaging to gain a more sensitive picture of the neural connectivity underlying PTSD.

Workplace mental health screening: a systematic review and meta-analysis

Workplaces are an important location for population mental health interventions. Screening to detect employees at risk of or experiencing mental ill health is increasingly common. This systematic review and meta-analysis examined the efficacy of workplace mental health screening programmes on employee mental health, work outcomes, user satisfaction, positive mental health, quality of life, help-seeking and adverse effects. PubMed, PsycINFO, EMBASE, CENTRAL, Global Index Medicus, Global Health and SciELO were searched (database inception-10 November 2022) and results screened by two independent reviewers. Controlled trials evaluating screening of workers' mental health as related to their employment were included. Random effects meta-analysis was performed to calculate pooled effect sizes for each outcome of interest. Grading of Recommendations Assessment, Development and Evaluation was conducted to evaluate the certainty of findings. Of the 12 328 records screened, 11 were included. These reported 8 independent trials collectively assessing 2940 employees. Results indicated screening followed by advice or referral was ineffective in improving employee mental health symptoms (n=3; d=-0.07 (95% CI -0.29 to 0.15)). Screening followed by facilitated access to treatment interventions demonstrated a small improvement in mental health (n=4; d=-0.22 (95% CI -0.42 to -0.02)). Limited effects were observed for other outcomes. Certainty ranged from low to very low. The evidence supporting workplace mental health screening programmes is limited and available data suggest mental health screening alone does not improve worker mental health. Substantial variation in the implementation of screening was observed. Further research disentangling the independent effect of screening alongside the efficacy of other interventions to prevent mental ill health at work is required.

The Lingering Impact of Resolved PTSD on Subsequent Functioning

This study investigated whether impairment persists after posttraumatic stress disorder (PTSD) has resolved. Traumatically injured patients (N = 1,035) were assessed during hospital admission and at 3 (85%) and 12 months (73%). Quality of life prior to traumatic injury was measured with the World Health Organization Quality of Life-BREF during hospitalization and at each subsequent assessment. PTSD was assessed using the Clinician-Administered PTSD Scale at 3 and 12 months. After controlling for preinjury functioning, current pain, and comorbid depression, patients whose PTSD symptoms had resolved by 12 months were more likely to have poorer quality of life in psychological (OR = 3.51), physical (OR = 10.17), social (OR = 4.54), and environmental (OR = 8.83) domains than those who never developed PTSD. These data provide initial evidence that PTSD can result in lingering effects on functional capacity even after remission of symptoms. Reprinted from Clin Psychol Sci 2016; 4:493-498, with permission from Sage. Copyright © 2016.

Views and experiences of migrants and stakeholders involved in social and health care for migrants in Italy during the COVID-19 pandemic: a qualitative study

BACKGROUND

The COVID-19 pandemic has had major and potentially long-lasting effects on mental health and wellbeing across populations worldwide. However, these impacts were not felt equally, leading to an exacerbation of health inequalities, especially affecting vulnerable populations such as migrants, refugees and asylum seekers. Aiming to inform the adaptation and implementation of psychological intervention programmes, the present study investigated priority mental health needs in this population group.

METHODS

Participants were adult asylum seekers, refugees and migrants (ARMs) and stakeholders with experience in the field of migration living in Verona, Italy, and fluent in Italian and English. A two-stage process was carried out to examine their needs using qualitative methods including free listing interviews and focus group discussions, according to Module One of the DIME (Design, Implementation, Monitoring, and Evaluation) manual. Data were analyzed using an inductive thematic analyses approach.

RESULTS

A total of 19 participants (12 stakeholders, 7 ARMs) completed the free listing interviews and 20 participants (12 stakeholders and 8 ARMs) attended focus group discussions. Salient problems and functions that emerged during free listing interviews were discussed during the focus group discussions. During the COVID-19 pandemic, ARMs struggled with many everyday living difficulties in their resettlement country due to social and economic issues, revealing a strong influence of contextual factors in determining mental health. Both ARMs and stakeholders highlighted a mismatch between needs, expectations and interventions as factors that may hamper proper implementation of health and social programmes.

CONCLUSIONS

The present findings could help in the adaptation and implementation of psychological interventions targeting the needs of asylum seekers, refugees and migrants aiming to find a match between needs, expectations, and the corresponding interventions.

TRIAL REGISTRATION

Registration number 2021-UNVRCLE-0106707, February 11 2021.

Changes in neural responses during affective and non-affective tasks and improvement of posttraumatic stress disorder symptoms following trauma-focused psychotherapy

At least one-third posttraumatic stress disorder (PTSD) patients do not respond to trauma-focused psychotherapy (TF-psychotherapy), which is the treatment of choice for PTSD. To clarify the change mechanisms that may be associated with treatment response, this study examined changes in neural activations during affective and non-affective processing that occur with improvement of symptoms after TF-psychotherapy. This study assessed PTSD treatment-seeking patients (n = 27) prior to and after TF-psychotherapy using functional magnetic resonance imaging when they completed three tasks: (a) passive viewing of affective faces, (b) cognitive reappraisal of negative images, and (c) non-affective response inhibition. Patients then underwent 9 sessions of TF-psychotherapy, and were assessed on the Clinician-Administered PTSD Scale following treatment. Changes in neural responses in affect and cognitive processing regions-of-interest for each task were correlated with reduction of PTSD severity from pretreatment to posttreatment in the PTSD cohort. Data from 21 healthy controls was used for comparison. Improvement of symptoms in PTSD were associated with increased activation of left anterior insula, reductions in the left hippocampus and right posterior insula during viewing of supraliminally presented affective images, and reduced connectivity between the left hippocampus with the left amygdala and rostral anterior cingulate. Treatment response was also associated with reduced activation in the left dorsolateral prefrontal cortex during reappraisal of negative images. There were no associations between response and activation change during response inhibition. This pattern of findings indicates that improvement of PTSD symptoms following TF-psychotherapy is associated with changes in affective rather than non-affective processes. These findings accord with prevailing models that TF-psychotherapy promotes engagement and mastery of affective stimuli.Clinical Trials Registration: Trial Registration: Prospectively registered at Australian and New Zealand Clinical Trials Registry, ACTRN12612000185864 and ACTRN12609000324213. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=83857.

Posttraumatic Stress Disorder in Refugees

The number of refugees and internally displaced people in 2022 is the largest since World War II, and meta-analyses demonstrate that these people experience elevated rates of mental health problems. This review focuses on the role of posttraumatic stress disorder (PTSD) in refugee mental health and includes current knowledge of the prevalence of PTSD, risk factors, and apparent differences that exist between PTSD in refugee populations and PTSD in other populations. An emerging literature on understanding mechanisms of PTSD encompasses neural, cognitive, and social processes, which indicate that these factors may not function exactly as they have functioned previously in other PTSD populations. This review recognizes the numerous debates in the literature on PTSD in refugees, including those on such issues as the conceptualization of mental health and the applicability of the PTSD diagnosis across cultures, as well as the challenge of treating PTSD in low- and-middle-income countries that lack mental health resources to offer standard PTSD treatments. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 19 is May 2023. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Study protocol for a controlled trial of a resilience program on psychological distress in correctional officers in Australia

BACKGROUND

The mental health impacts of workers within correctional settings has been of increasing focus over the past number of years. This paper outlines the study protocol for a trial that tests the efficacy of a brief resilience program, relative to a no intervention control in reducing general psychological distress and absenteeism in a cohort of correctional personnel in NSW, Australia.

METHODS

A, parallel, randomized controlled trial will be carried out in a small group format. Following informed consent, corrective personnel within prisons across NSW will volunteer to either attend a clinician delivered resilience program on stress management skills or not (N = 600). The primary outcome will be change in psychological distress including anxiety and depression at 2-months post intervention. Secondary outcomes include help-seeking behaviours and absenteeism.

DISCUSSION

This prevention focused treatment trial will assess whether a brief clinician delivered resilience program will reduce absenteeism and mitigate psychological distress in a cohort of corrective personnel within NSW, Australia. This study will yield insights into the role of a brief psychological program in mitigating the psychological distress reported by personnel in correctional settings.

TRIAL REGISTRATION

This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12622000029796).

ETHICS AND DISSEMINATION

Ethics approval has been obtained from University of New South Wales Human Research Ethics Committee. Results of the trial will be submitted for publication in peer reviewed journals and findings presented at scientific conferences and to key service providers and policy makers.

Patterns of acute stress disorder in a sample of blast-injured military service members: A latent profile analysis

OBJECTIVE

The primary aims of this study were to identify latent profiles of acute stress disorder (ASD) symptoms and to evaluate postconcussive symptom differences across the identified profiles as measured by the Acute Stress Disorder Scale and the Military Acute Concussion Evaluation, respectively.

METHOD

Participants (N = 315) in the current study were predominantly active-duty (75.0%), enlisted (97.8%) males (97.4%) serving in the U.S. Army (87.8%). Approximately, half of the sample reported being married or engaged (51.1%) and was on average 25.94 (SD = 6.31) years old. Participants were referred to the Air Force Theater Hospital, 332nd Air Expeditionary Wing, Joint Base Balad, Iraq, to be evaluated as part of routine clinical assessment for neurocognitive and psychological symptoms following exposure to a blast.

RESULTS

A 3-profile solution was identified as the most parsimonious and best-fitting model based on statistical model fit indices. Blast injured service members in Profile 3 had greater ASD total and subscale severity compared to the other 2 subgroups, with effect size estimates largely differing by hyperarousal and reexperiencing symptoms. Furthermore, Profiles 2 and 3 were more likely to demonstrate postconcussive symptoms compared to Profile 1.

CONCLUSIONS

Findings provide novel information on heterogenous ASD symptom profiles during the acute phase following a blast injury and highlight the relationship between psychological and physical symptoms. Classification of blast-injured service members may help identify at-risk individuals who would benefit from further clinical care and mitigate long-term psychological and neurocognitive issues. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Attachment processes in posttraumatic stress disorder: A review of mechanisms to advance theories and treatments

Current conceptualisations of posttraumatic stress disorder (PTSD) are driven by biological, learning, and cognitive models that have shaped current treatments of the disorder. The strong influence of these models has resulted in a relative neglect of social mechanisms that can influence traumatic stress. There is abundant evidence from experimental, observational, and clinical studies that social factors can moderate many of the mechanisms articulated in prevailing models of PTSD. In this review it is proposed that attachment theory provides a useful framework to complement existing models of PTSD because it provides explanatory value for social factors can interact with biological, learning, and cognitive processes that shape traumatic stress response. The review provides an overview of attachment theory in the context of traumatic stress, outlines the evidence for how attachment factors can moderate stress responses and PTSD, and considers how harnessing attachment processes may augment recovery from and treatment of PTSD. This review emphasizes that rather than conceptualizing attachment theory as an independent theory of traumatic stress, there is much to gain by integrating attachment mechanisms into existing models of PTSD to accommodate the interactions between cognitive, biological, and attachment processes.

Web-Based Mind-Body Tactical Resilience Training Program for First Responders: Pre-Post Study Assessing Feasibility, Acceptability, and Usability

BACKGROUND

First responders report elevated rates of mental disorders, including posttraumatic stress disorder (PTSD), yet many are reluctant to seek care. Preventative resilience training programs attempt to proactively address this issue, and there is evidence showing promise for programs targeting cognitive processes. However, these programs rarely address the physical health conditions associated with PTSD. There is emerging evidence of mind-body exercise training improving PTSD symptoms as well as its associated physical health symptoms. However, the feasibility and acceptability of delivering a web-based mind-body resilience training among first responders are not yet known.

OBJECTIVE

This study aimed to evaluate the feasibility, usability, and acceptability of a web-based mind-body tactical resilience training program designed for first responders. In addition, we explored the preliminary effectiveness of the training program on mental health outcomes, adaptive cognitive strategies, and work productivity.

METHODS

A total of 42 first responders based in the United States enrolled in the web-based training program. Participants were administered web-based surveys before enrolling in the 6-week web-based program and at the end of the program. The primary outcomes of feasibility were measured using the number of training hours, program adherence rates, and self-reported data on frequency of practice. Acceptability and usability were measured using self-reported data. Secondary outcomes were symptoms of PTSD, psychological distress, emotion regulation, stress mindset, psychological preparedness, and work performance.

RESULTS

Overall, the training program was feasible based on the median number of training hours spent on the web-based program (7.57 hours out of an expected total of 6 to 9 hours), and 55% (23/42) of the enrolled participants completed more than half of the program. Although acceptability, usability, and frequency of practice were rated as high, this was based on only 29% (12/42) of the respondents who provided follow-up data. Secondary outcomes showed a significant improvement in the adaptive cognitive strategy of the stress mindset, with a mean difference of -5.42 (SD 4.81; 95% CI -8.475 to -2.358; t₁₁=-3.898; P=.002). All other secondary outcomes were not significant. However, the secondary outcomes were exploratory only, and this study was neither designed nor powered to adequately assess efficacy.

CONCLUSIONS

These findings suggest that a mind-body tactical resilience training program delivered in a web-based format is feasible and acceptable among first responders; however, further refinements may be required to improve adherence rates. Further research using a larger, more rigorous trial design is warranted to examine the effectiveness of this type of training as a possible prevention or treatment strategy for this population.

The Heterogeneity of Posttraumatic Stress Disorder in DSM-5

This diagnostic study reports patterns of DSM-5 posttraumatic stress disorder diagnostic presentations from multiple cohorts.

Effectiveness of a stepped-care programme of WHO psychological interventions in migrant populations resettled in Italy: Study protocol for the RESPOND randomized controlled trial

Introduction

Migrant populations, including workers, undocumented migrants, asylum seekers, refugees, internationally displaced persons, and other populations on the move, are exposed to a variety of stressors and potentially traumatic events before, during, and after the migration process. In recent years, the COVID-19 pandemic has represented an additional stressor, especially for migrants on the move. As a consequence, migration may increase vulnerability of individuals toward a worsening of subjective wellbeing, quality of life, and mental health, which, in turn, may increase the risk of developing mental health conditions. Against this background, we designed a stepped-care programme consisting of two scalable psychological interventions developed by the World Health Organization and locally adapted for migrant populations. The effectiveness and cost-effectiveness of this stepped-care programme will be assessed in terms of mental health outcomes, resilience, wellbeing, and costs to healthcare systems.

Methods and analysis

We present the study protocol for a pragmatic randomized study with a parallel-group design that will enroll participants with a migrant background and elevated level of psychological distress. Participants will be randomized to care as usual only or to care a usual plus a guided self-help stress management guide (Doing What Matters in Times of Stress, DWM) and a five-session cognitive behavioral intervention (Problem Management Plus, PM+). Participants will self-report all measures at baseline before random allocation, 2 weeks after DWM delivery, 1 week after PM+ delivery and 2 months after PM+ delivery. All participants will receive a single-session of a support intervention, namely Psychological First Aid. We will include 212 participants. An intention-to-treat analysis using linear mixed models will be conducted to explore the programme's effect on anxiety and depression symptoms, as measured by the Patient Health Questionnaire-Anxiety and Depression Scale summary score 2 months after PM+ delivery. Secondary outcomes include post-traumatic stress disorder symptoms, resilience, quality of life, resource utilization, cost, and cost-effectiveness.

Discussion

This study is the first randomized controlled trial that combines two World Health Organization psychological interventions tailored for migrant populations with an elevated level of psychological distress. The present study will make available DWM/PM+ packages adapted for remote delivery following a task-shifting approach, and will generate evidence to inform policy responses based on a more efficient use of resources for improving resilience, wellbeing and mental health.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT04993534.

A proof-of-concept randomized controlled trial of follow-up mental health care for traumatic injury patients following hospital discharge

INTRODUCTION

Traumatic injuries account for a huge burden of disease. Many patients develop persistent mental health problems in the months following hospital discharge. This proof-of-concept trial investigated whether Stepped Care comprising follow-up assessment telephone calls and appropriate referral information would lead to better mental health and functioning in traumatic injury patients.

METHODS

Patients admitted to the Trauma Service at Royal North Shore Hospital were randomized to either Stepped Care (n = 84) or Treatment as Usual (n = 90). All patients were assessed for anxiety, depression, and posttraumatic stress prior to hospital discharge. Those in Stepped Care received a telephone call at 1-month and 3-months after hospital discharge in which they were administered a brief assessment; patients who reported mental health or pain difficulties were provided with information for local specialists to address their specific problem. All patients were independently assessed by telephone interview 9- months after hospital discharge for posttraumatic stress disorder (PTSD) (primary outcome), as well as for anxiety, depression, disability, and pain.

RESULTS

There were 58 (73%) patients that could be contacted at either the 1-month or 3-month assessments. Of those contacted, 28 patients (48% of those contacted) were referred for specialist assistance. There were no differences between treatment arms on PTSD symptoms at follow-up [F_1,95 = 0.55, p = 0.46]. At the 9-month assessment, patients in the Stepped Care condition reported significantly less anxiety [F_1,95 = 5.07, p = 0.03] and disability [F_1,95 = 4.37, p = 0.04] relative to those in Treatment as Usual. At 9 months there was no difference between conditions on depression [F_1,95 = 1.03, p = 0.31]. There were no differences between conditions on self-reported pain difficulties.

CONCLUSIONS

This proof-of-concept trial suggests that brief screening assessments of traumatic injury patients following hospital discharge, combined with appropriate referral information, may lead to better functional outcomes. Further research is needed with larger sample sizes and greater verification of referral uptake to validate this finding.

Association of Neural Connectome With Early Experiences of Abuse in Adults

IMPORTANCE

More than 10% of children experience sexual, physical, or emotional abuse, and abuse experienced during sensitive neurodevelopmental periods is associated with a greater risk of psychiatric disorders.

OBJECTIVE

To investigate the extent to which a history of abuse is associated with alterations in the intrinsic functional connectome of the adult brain independent from the restriction of associated psychiatric conditions.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study assessed data from 768 adult participants from the greater Sydney, Australia, area who were included in the study without diagnostic restrictions and categorized based on a history of childhood sexual, physical, and/or emotional abuse. Data were collected from January 1, 2009, to December 31, 2015; data analysis was performed from October 1, 2020, to March 31, 2022.

MAIN OUTCOMES AND MEASURES

Outcomes were structured psychiatric interview responses, self-report of the frequency and extent of various types of negative experiences in childhood and adolescence, and intrinsic functional connectivity derived from 5 functional magnetic resonance imaging tasks and estimated among 436 brain regions, comprising intranetwork and internetwork connectivity of 8 large-scale brain networks.

RESULTS

Among the 647 individuals with usable data (330 female [51.0%]; mean [SD] age, 33.3 [12.0] years; age range, 18.2-69.2 years), history of abuse was associated with greater likelihood of a current psychiatric illness (odds ratio, 4.55; 95% CI, 3.07-6.72; P < .001) and with greater depressive, anxiety, and stress symptoms (mean difference, 20.4; 95% CI, 16.1-24.7; P < .001). An altered connectome signature of higher connectivity within somatomotor, dorsal, and ventral attention networks and between these networks and executive control and default mode networks was observed in individuals with a history of abuse experienced during childhood (n = 127) vs those without a history of abuse (n = 442; mean difference, 0.07; 95% CI, 0.05-0.08; familywise, Bonferroni-corrected P = .01; Cohen d = 0.82) and compared with those who experienced abuse in adolescence (n = 78; mean difference, 0.06; 95% CI, 0.04-0.08]; familywise, Bonferroni-corrected P < .001; Cohen d = 0.68). Connectome alterations were not observed for those who experienced abuse in adolescence. Connectivity of this signature was transdiagnostic and independent of the nature and frequency of abuse, sex, or current symptomatic state.

CONCLUSIONS AND RELEVANCE

Findings highlight the associations of exposure to abuse before and during adolescence with the whole-brain functional connectome. The experience of child abuse was found to be associated with physiologic changes in intrinsic connectivity, independent of psychopathology, in a way that may affect functioning of systems responsible for perceptual processing and attention.

Is Fear Extinction Impairment Central to Psychopathology?

As discussed in this chapter, there have been enormous advances in our understanding of how anxiety disorders develop, are maintained, and can be treated. Many of these advances have been the result of translational studies using fear conditioning and extinction models. Despite these successes, we recognize, as a field, that there are important limitations in the extent to which extinction can explain how anxiety disorders and behaviors remit. Clinically speaking, the outstanding challenge for treatment of anxiety disorders is to improve the current suboptimal success rates. Over the past 30 years, we have not improved our treatment success rates despite employing many pharmacological and pharmacological strategies. While extinction and related fear circuitry mechanisms most certainly appear to play a role in treatment of anxiety disorders, they are also apparently insufficient to fully accommodate the varied responses individuals exhibit with this treatment approach. Increasingly diverse and innovative approaches are needed that accommodate the multitude of change mechanisms involved in treating anxiety. However, this is not to suggest ignoring the key role that extinction and memory updating processes play in overcoming anxiety.

Augmenting trauma-focused psychotherapy for post-traumatic stress disorder with brief aerobic exercise in Australia: a randomised clinical trial

BACKGROUND

Although exposure therapy is central in most front-line psychotherapies of post-traumatic stress disorder (PTSD), many patients do not respond to this treatment. We aimed to investigate the effects of brief aerobic exercise on the efficacy of exposure therapy in reducing the severity of PTSD.

METHODS

We did a single-blind, parallel, randomised controlled trial in Sydney, NSW, Australia. We included adults (aged ≥18 years) with clinician-diagnosed PTSD. We excluded participants aged 70 years or older, with imminent suicidal risk (reporting suicidal plan), presence of psychosis or substance dependence, history of moderate-to-severe traumatic brain injury, or presence of a physical disorder or impairment that might be exacerbated by aerobic exercise (eg, back pain). We randomly assigned participants (1:1) to nine 90-min weekly sessions of exposure therapy for PTSD with 10 min aerobic exercise or to the control group of exposure therapy with 10 min passive stretching. The primary outcome was PTSD severity measured by the clinician-administered PTSD scale 2 (CAPS-2), independently assessed at baseline, 1 week after treatment, and 6 months after treatment (primary outcome timepoint).

FINDINGS

Between Dec 12, 2012, and July 25, 2018, we enrolled 130 participants with PTSD, with 65 (50%) participants randomly assigned to exposure therapy with exercise and 65 (50%) to exposure therapy with passive stretching, including 79 (61%) women and 51 (39%) men, with a mean age of 39·1 years (SD 14·4; range 18-69). 99 (76%) participants were White, 14 (11%) were Asian, and 17 (13%) were listed as other. At the 6-month follow-up assessment, participants in the exposure therapy with exercise group showed greater reductions in CAPS-2 scores relative to those in the exposure therapy with stretching group (mean difference 12·1 [95% CI 2·4-21·8]; p=0·023), which resulted in a moderate effect size of 0·6 (0·1-1·1). No adverse events associated with the intervention were reported. The trial was prospectively registered on the Australian and New Zealand Clinical Trials Registry, ACTRN12612000185864.

INTERPRETATION

Brief aerobic exercise has the potential to augment long-term gains of exposure therapy for PTSD, which accords with evidence from studies in animals and humans on the role of exercise in modulating the extinction learning processes. This strategy might offer a simple and affordable means to augment treatment gains for exposure therapy in people with PTSD.

FUNDING

Australian National Health and Medical Research Council.

Habituation of distress during exposure and its relationship to treatment outcome in post-traumatic stress disorder and prolonged grief disorder

Background: Reliving distressing memories is a core component of treatments for post-traumatic stress disorder (PTSD) and prolonged grief disorder (PGD). There is little understanding of how reliving these memories functions in the treatment of these disorders.Objective: This study investigated whether reliving functions comparably in the treatment of PTSD and PGD, and whether it is comparably related to treatment outcome.Method: This study conducted a reanalysis of patients with either PTSD (n = 55) or PGD (n = 45) who underwent treatments that comprised at least four sessions of reliving memories of either their traumatic experience or the loss of the deceased person.Results: PTSD participants displayed greater habituation of distress across sessions during reliving than PGD participants. Between-session reduction in distress during reliving was associated with symptom remission in PTSD, but this pattern was not observed in PGD.Conclusion: This pattern of findings indicates that although reliving appears to be a useful strategy for treating both PTSD and PGD, this strategy does not function comparably in the two conditions and may involve distinct mechanisms.

Refugee visa insecurity disrupts the brain's default mode network

BACKGROUND

Research has largely focused on the psychological consequences of refugee trauma exposure, but refugees living with visa insecurity face an uncertain future that also adversely affects psychological functioning and self-determination.

OBJECTIVE

This study aimed to examine how refugee visa insecurity affects the functional brain.

METHOD

We measured resting state brain activity via fMRI in 47 refugees with insecure visas (i.e. temporary visa status) and 52 refugees with secure visas (i.e. permanent visa status) residing in Australia, matched on key demographic, trauma exposure and psychopathology. Data analysis comprised independent components analysis to identify active networks and dynamic functional causal modelling tested visa security group differences in network connectivity.

RESULTS

We found that visa insecurity specifically affected sub-systems within the default mode network (DMN) - an intrinsic network subserving self-referential processes and mental simulations about the future. The insecure visa group showed less spectral power in the low frequency band in the anterior ventromedial DMN, and reduced activity in the posterior frontal DMN, compared to the secure visa group. Using functional dynamic causal modelling, we observed positive coupling between the anterior and posterior midline DMN hubs in the secure visa group, while the insecure visa group displayed negative coupling that correlated with self-reported fear of future deportation.

CONCLUSIONS

Living with visa-related uncertainty appears to undermine synchrony between anterior-posterior midline components of the DMN responsible for governing the construction of the self and making mental representations of the future. This could represent a neural signature of refugee visa insecurity, which is marked by a perception of living in limbo and a truncated sense of the future.

An fMRI examination of the neural basis of suicide attempts: The role of mentalizing in the context of mood

OBJECTIVES

Facial emotion recognition (FER) deficits in depressed mood disorder patients contribute to suicidality. Prior research shows that intrinsic brain activity patterns are altered by attempting suicide. Therefore, we investigated in depressed patients whether differences in FER contribute to their clinical symptoms of suicide.

METHODS

Neural activity in response to an FER task was compared across three groups: healthy controls (HCs, N = 66), suicide non-attempter (SNA, N = 50), suicide attempter (SA, N = 25). Modulation of brain networks by the task and functional connectivity (FC) within (using spatial map, spectral power) and between (using functional network connectivity; FNC) were examined. The contribution of these differences to suicidal symptoms in each group was also examined.

RESULTS

Patient groups displayed impaired FC both within and between networks but differed in nature and networks involved. They also showed differential modulation of networks by task, such that compared with both HC and SNA, SA displayed impaired FC within the default-mode network (DMN) and also its task modulation. In the SA group, FC within the DMN and FNC between two lateral prefrontal networks, and its interaction with the basal ganglia network contributed significantly to the clinical symptoms of suicide.

CONCLUSIONS

This study affirms differences between SA and SNA brain activity patterns and suggests that suicidal activity probably emanates via different mechanisms in these patient groups. Perhaps, over-attribution of emotion impairs one's self-referential thought processes and coupled with diminished emotional control this makes depressed individuals vulnerable to suicide.

Rare copy number variation in posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a heritable (h2 = 24-71%) psychiatric illness. Copy number variation (CNV) is a form of rare genetic variation that has been implicated in the etiology of psychiatric disorders, but no large-scale investigation of CNV in PTSD has been performed. We present an association study of CNV burden and PTSD symptoms in a sample of 114,383 participants (13,036 cases and 101,347 controls) of European ancestry. CNVs were called using two calling algorithms and intersected to a consensus set. Quality control was performed to remove strong outlier samples. CNVs were examined for association with PTSD within each cohort using linear or logistic regression analysis adjusted for population structure and CNV quality metrics, then inverse variance weighted meta-analyzed across cohorts. We examined the genome-wide total span of CNVs, enrichment of CNVs within specified gene-sets, and CNVs overlapping individual genes and implicated neurodevelopmental regions. The total distance covered by deletions crossing over known neurodevelopmental CNV regions was significant (beta = 0.029, SE = 0.005, P = 6.3 × 10-8). The genome-wide neurodevelopmental CNV burden identified explains 0.034% of the variation in PTSD symptoms. The 15q11.2 BP1-BP2 microdeletion region was significantly associated with PTSD (beta = 0.0206, SE = 0.0056, P = 0.0002). No individual significant genes interrupted by CNV were identified. 22 gene pathways related to the function of the nervous system and brain were significant in pathway analysis (FDR q < 0.05), but these associations were not significant once NDD regions were removed. A larger sample size, better detection methods, and annotated resources of CNV are needed to explore this relationship further.

A comparison of methods to harmonize cortical thickness measurements across scanners and sites

Results of neuroimaging datasets aggregated from multiple sites may be biased by site-specific profiles in participants' demographic and clinical characteristics, as well as MRI acquisition protocols and scanning platforms. We compared the impact of four different harmonization methods on results obtained from analyses of cortical thickness data: (1) linear mixed-effects model (LME) that models site-specific random intercepts (LMEINT), (2) LME that models both site-specific random intercepts and age-related random slopes (LMEINT+SLP), (3) ComBat, and (4) ComBat with a generalized additive model (ComBat-GAM). Our test case for comparing harmonization methods was cortical thickness data aggregated from 29 sites, which included 1,340 cases with posttraumatic stress disorder (PTSD) (6.2-81.8 years old) and 2,057 trauma-exposed controls without PTSD (6.3-85.2 years old). We found that, compared to the other data harmonization methods, data processed with ComBat-GAM was more sensitive to the detection of significant case-control differences (Χ2(3) = 63.704, p < 0.001) as well as case-control differences in age-related cortical thinning (Χ2(3) = 12.082, p = 0.007). Both ComBat and ComBat-GAM outperformed LME methods in detecting sex differences (Χ2(3) = 9.114, p = 0.028) in regional cortical thickness. ComBat-GAM also led to stronger estimates of age-related declines in cortical thickness (corrected p-values < 0.001), stronger estimates of case-related cortical thickness reduction (corrected p-values < 0.001), weaker estimates of age-related declines in cortical thickness in cases than controls (corrected p-values < 0.001), stronger estimates of cortical thickness reduction in females than males (corrected p-values < 0.001), and stronger estimates of cortical thickness reduction in females relative to males in cases than controls (corrected p-values < 0.001). Our results support the use of ComBat-GAM to minimize confounds and increase statistical power when harmonizing data with non-linear effects, and the use of either ComBat or ComBat-GAM for harmonizing data with linear effects.

Anxiety and depression symptoms during the COVID-19 pandemic in European countries and Australia

Background

Studies on mental health changes during the COVID-19 pandemic report no change or increasing prevalence of mental health problems in general, but less is known on changes in potentially disadvantaged groups over time. We investigated changes in anxiety and depression symptoms during the first year of the pandemic in France, Germany, Italy, the Netherlands, Spain, Sweden, and Australia by prior mental disorders and migration status.

Methods

Overall, 4,674 adults answered a web-based survey in May-June 2020 and were followed by three repeated surveys up to February 2021 in these countries. Information on socio-demographic, living conditions, psychosocial factors, diagnosis of mental disorders before, depression and anxiety symptoms during the pandemic and migration status (being a resident or not) was collected. Weighted general estimation equations modelling was used to investigate the association between prior mental disorders, migration status, and symptoms over time.

Results

Most participants were &lt;40 years old (48%), women (78%), and highly educated (62%) with some variations across countries. The baseline prevalence of depressive and anxiety symptoms ranged between 19%-45% and 13%-35% respectively. In most countries, prevalence remained unchanged throughout the pandemic and was higher among people with prior mental disorder than without even after adjustment for socioeconomic, psychosocial, living and health factors. We observed interactions between previous mental disorders and symptoms of anxiety or depression over time in Germany (p = 0.01) and in Spain (p = 0.04). No prevalence difference was noted by migration status.

Conclusions

Depression and anxiety symptoms were worse among individuals with prior mental disorders than without, but there was no clear trend of mental health worsening in the observed groups during the first year of the pandemic. Still, monitoring mental health should be continued in the long-term, with special focus on vulnerable groups.

Key messages

• Depression and anxiety symptoms were higher in individuals with prior mental disorders during the first year of the pandemic in an international sample of six European countries and Australia.

• There were no clear trends of mental health worsening in any of the observed groups in neither of the countries between May-June 2020 and February 2021.

A comparison of the functional connectome in mild traumatic brain injury and post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) often co-occur in the context of threat to one's life. These conditions also have an overlapping symptomatology and include symptoms of anxiety, poor concentration and memory problems. A major challenge has been articulating the underlying neurobiology of these overlapping conditions. The primary aim of this study was to compare intrinsic functional connectivity between mTBI (without PTSD) and PTSD (without mTBI). The study included functional MRI data from 176 participants: 42 participants with mTBI, 67 with PTSD and a comparison group of 66 age and sex-matched healthy controls. We used network-based statistical analyses for connectome-wide comparisons of intrinsic functional connectivity between mTBI relative to PTSD and controls. Our results showed no connectivity differences between mTBI and PTSD groups. However, we did find that mTBI had significantly reduced connectivity relative to healthy controls within an extensive network of regions including default mode, executive control, visual and auditory networks. The mTBI group also displayed hyperconnectivity between dorsal and ventral attention networks and perceptual regions. The PTSD group also demonstrated abnormal connectivity within these networks relative to controls. Connectivity alterations were not associated with severity of PTSD or post-concussive symptoms in either clinical group. Taken together, the similar profiles of intrinsic connectivity alterations in these two conditions provide neural evidence that can explain, in part, the overlapping symptomatology between mTBI and PTSD.

Effectiveness of a stepped-care programme of internet-based psychological interventions for healthcare workers with psychological distress: Study protocol for the RESPOND healthcare workers randomised controlled trial

Background and aims

The coronavirus disease 2019 pandemic has challenged health services worldwide, with a worsening of healthcare workers' mental health within initial pandemic hotspots. In early 2022, the Omicron variant is spreading rapidly around the world. This study explores the effectiveness and cost-effectiveness of a stepped-care programme of scalable, internet-based psychological interventions for distressed health workers on self-reported anxiety and depression symptoms.

Methods

We present the study protocol for a multicentre (two sites), parallel-group (1:1 allocation ratio), analyst-blinded, superiority, randomised controlled trial. Healthcare workers with psychological distress will be allocated either to care as usual only or to care as usual plus a stepped-care programme that includes two scalable psychological interventions developed by the World Health Organization: A guided self-help stress management guide (Doing What Matters in Times of Stress) and a five-session cognitive behavioural intervention (Problem Management Plus). All participants will receive a single-session emotional support intervention, namely psychological first aid. We will include 212 participants. An intention-to-treat analysis using linear mixed models will be conducted to explore the programme's effect on anxiety and depression symptoms, as measured by the Patient Health Questionnaire - Anxiety and Depression Scale summary score at 21 weeks from baseline. Secondary outcomes include post-traumatic stress disorder symptoms, resilience, quality of life, cost impact and cost-effectiveness.

Conclusions

This study is the first randomised trial that combines two World Health Organization psychological interventions tailored for health workers into one stepped-care programme. Results will inform occupational and mental health prevention, treatment, and recovery strategies.

Registration details

ClinicalTrials.gov Identifier: NCT04980326.

Using an ecological momentary assessment protocol to understand problem anger in veterans

BACKGROUND AND OBJECTIVES

Problem anger is highly destructive, and is one of the most commonly reported issues in military and veteran populations. The goal of this study was to use ecological momentary assessment (EMA) to explore and characterize moment-to-moment experiences of problem anger in a sample of Australian veterans.

METHODS

Sixty veterans with problem anger (measured on the Dimensions of Anger Reactions Scale) completed measures of anger and anger rumination, before and after a 10-day EMA period which assessed the frequency, intensity, and expression of momentary anger experiences.

RESULTS

Findings showed that 75% of respondents indicated some level of anger during EMA monitoring. In 25% of cases, anger was reported as severe. Moreover, anger was expressed verbally in 43% of cases, and expressed physically in 27% of cases. While anger fluctuated frequently during the day, more severe anger was more likely to be reported in the late afternoon/early evening. Problem anger symptoms decreased significantly over time, from pre-EMA to post EMA (p < .001).

LIMITATIONS

The generalizability of findings is limited to a predominantly male sample, with low levels of risk of harm or violence. The study was also limited in the selection of outcome variables assessed and the lack of a control group; other momentary factors could influence experience of problem anger and provide further explanation of study results.

CONCLUSIONS

EMA is a valuable assessment tool for individuals with problem anger, and the potential for EMA as an intervention needs to be explored further.

The longitudinal association between moral injury appraisals and psychological outcomes in refugees

BACKGROUND

Refugees report a diverse array of psychological responses following persecution and displacement. Little is known, however, regarding the mechanisms that underlie differential psychological reactions in refugees. This study investigated the longitudinal impact of negative moral appraisals about one's own actions [i.e. moral injury-self (MI-self) appraisals] and others' actions [i.e. moral injury-other (MI-others) appraisals] on a variety of psychological symptoms over a period of 6 months.

METHODS

Participants were 1085 Arabic, Farsi, Tamil, or English-speaking refugees who completed a survey at baseline and 6 months later either on-line or via pen-and-paper. The survey indexed demographic factors, exposure to potentially traumatic events (PTEs), exposure to ongoing stressors, MI-other appraisals, MI-self appraisals, re-experiencing and arousal symptoms, and feelings of sadness, anger and shame.

RESULTS

Findings indicated that, after controlling for demographics, PTE exposure and ongoing stressors, MI-other appraisals predicted increased re-experiencing and hyperarousal symptoms, and feelings of sadness and shame. MI-self appraisals predicted decreased feelings of shame, and decreased re-experiencing symptoms. In contrast, psychological symptoms at baseline did not as strongly influence MI appraisals 6 months later.

CONCLUSIONS

These findings highlight the important role that cognitive appraisals of adverse events play in the longitudinal course of psychological symptoms. These results thus have important implications for the development of tailored psychological interventions to alleviate the mental health burden held by refugees.

Remodeling of the Cortical Structural Connectome in Posttraumatic Stress Disorder: Results From the ENIGMA-PGC Posttraumatic Stress Disorder Consortium

BACKGROUND

Posttraumatic stress disorder (PTSD) is accompanied by disrupted cortical neuroanatomy. We investigated alteration in covariance of structural networks associated with PTSD in regions that demonstrate the case-control differences in cortical thickness (CT) and surface area (SA).

METHODS

Neuroimaging and clinical data were aggregated from 29 research sites in >1300 PTSD cases and >2000 trauma-exposed control subjects (ages 6.2-85.2 years) by the ENIGMA-PGC (Enhancing Neuro Imaging Genetics through Meta Analysis-Psychiatric Genomics Consortium) PTSD working group. Cortical regions in the network were rank ordered by the effect size of PTSD-related cortical differences in CT and SA. The top-n (n = 2-148) regions with the largest effect size for PTSD > non-PTSD formed hypertrophic networks, the largest effect size for PTSD < non-PTSD formed atrophic networks, and the smallest effect size of between-group differences formed stable networks. The mean structural covariance (SC) of a given n-region network was the average of all positive pairwise correlations and was compared with the mean SC of 5000 randomly generated n-region networks.

RESULTS

Patients with PTSD, relative to non-PTSD control subjects, exhibited lower mean SC in CT-based and SA-based atrophic networks. Comorbid depression, sex, and age modulated covariance differences of PTSD-related structural networks.

CONCLUSIONS

Covariance of structural networks based on CT and cortical SA are affected by PTSD and further modulated by comorbid depression, sex, and age. The SC networks that are perturbed in PTSD comport with converging evidence from resting-state functional connectivity networks and networks affected by inflammatory processes and stress hormones in PTSD.

Symptoms of anxiety and depression during the COVID-19 pandemic in six European countries and Australia - Differences by prior mental disorders and migration status

BACKGROUND

Little is known about changes of mental health during the COVID-19 pandemic in potentially disadvantaged groups. We investigated changes in anxiety and depression symptoms during the first year of the pandemic in six European countries and Australia by prior mental disorders and migration status.

METHODS

Overall, 4674 adults answered a web-based survey in May-June 2020 and were followed by three repeated surveys up to February 2021. Information on psychosocial, financial and demographic, living conditions, prior mental disorders, depression and anxiety symptoms during the pandemic and migration status was collected. Weighted general estimation equations modelling was used to investigate the association between prior mental disorders, migration status, and symptoms over time.

RESULTS

Most participants were <40 years old (48%), women (78%) and highly educated (62%). The baseline prevalence of depressive and anxiety symptoms ranged between 19%-45% and 13%-35%, respectively. In most countries, prevalence rates remained unchanged throughout the pandemic and were higher among people with prior mental disorders than without even after adjustment for several factors. We observed interactions between previous mental disorders and symptoms of anxiety or depression over time in two countries. No difference by migration status was noted.

LIMITATIONS

Convenience sampling limits generalizability. Self-assessed symptoms of depression and anxiety might involve some misclassification.

CONCLUSIONS

Depression and anxiety symptoms were worse among individuals with prior mental disorders than without, but there was no clear trend of worsening mental health in the observed groups during the observed period.

Effectiveness of a brief group behavioural intervention on psychological distress in young adolescent Syrian refugees: A randomised controlled trial

BACKGROUND

Millions of young adolescents in low- and middle-income countries (LMICs) affected by humanitarian crises experience elevated rates of poor mental health. There is a need for scalable programs that can improve the mental health of young adolescents. This study evaluated the effectiveness of a nonspecialist delivered group-based intervention (Early Adolescent Skills for Emotions (EASE)) to improve young adolescents' mental health.

METHODS AND FINDINGS

In this single-blind, parallel, controlled trial, Syrian refugees aged 10 to 14 years in Jordan were identified through screening of psychological distress as defined by scores ≥15 on the Paediatric Symptom Scale. Participants were randomised to either EASE or enhanced usual care (EUC) involving referral to local psychosocial services (on a 1:1.6 ratio). Participants were aware of treatment allocation but assessors were blinded. Primary outcomes were scores on the Paediatric Symptom Checklist (PSC; internalising, externalising, and attentional difficulty scales) assessed at week 0, 9 weeks, and 3 months after treatment (primary outcome time point). It was hypothesised that EASE would result in greater reductions on internalising symptoms than EUC. Secondary outcomes were depression, posttraumatic stress, well-being, functioning, school belongingness, and caregivers' parenting and mental health. Between June 2019 and January 2020, 1,842 young adolescent refugees were screened for eligibility on the basis of psychological distress. There were 520 adolescents (28.2%) who screened positive, of whom 471 (90.6%) agreed to enter the trial. Overall, 185 were assigned to EASE and 286 to EUC, and 169 and 254 were retained at 3 months for EASE and EUC, respectively. Intent-to-treat analyses indicated that at 3 months, EASE resulted in greater reduction on the PSC-internalising scale than EUC (estimated mean difference 0.69, 95% CI 0.19 to 1.19; p = 0.007; effect size, 0.38) but there were no differences for PSC-externalising (estimated mean difference 0.24, 95% CI -0.43 to 0.91; p = 0.49; effect size, -0.10), PSC-attentional problem (estimated mean difference -0.01, 95% CI -0.51 to 0.54; p = 0.97; effect size, -0.01) scores, or on depression, posttraumatic stress, well-being, functioning, or school belongingness. Relative to EUC, caregivers in EASE had less psychological distress (estimated mean difference 1.95, 95% CI 0.71 to 3.19; p = 0.002) and inconsistent disciplinary parenting (mean difference 1.54, 95% CI 1.03 to 2.05; p < 0.001). Secondary analyses that (a) focused on adolescents with probable internalising disorders; (b) completed the 3-month assessment; and (c) controlled for trauma exposure did not alter the primary results. Mediation analysis indicated that for caregivers in the EASE condition, reduction in inconsistent disciplinary parenting was associated with reduced attentional (β = 0.11, SE 0.07; 95% CI 0.003, 0.274) and internalising (β = 0.11, SE 0.07; 95% CI 0.003, 0.274) problems in their children. No adverse events were attributable to the intervention. A limitation was that EUC was not matched to EASE in terms of facilitator attention or group involvement.

CONCLUSIONS

EASE led to reduced internalising problems in young refugee adolescents and was associated with reduced distress and less inconsistent disciplinary parenting in caregivers. This intervention has the potential as a scalable intervention to mitigate young adolescents' emotional difficulties in LMIC.

TRIAL REGISTRATION

Prospectively registered at Australian and New Zealand Clinical Trials Registry: ACTRN12619000341123.

Attention-control training as an early intervention for veterans leaving the military: A pilot randomized controlled trial

Transitioning out of the military can be a time of change and challenge. Research indicates that altered threat monitoring in military populations may contribute to the development of psychopathology in veterans, and interventions that adjust threat monitoring in personnel leaving the military may be beneficial. Australian Defence Force personnel (N = 59) transitioning from the military were randomized to receive four weekly sessions of either attention-control training or a placebo attention training. The primary outcome was symptoms of posttraumatic stress disorder (PTSD), as measured using the PTSD Checklist for DSM-5 (PCL-5) at posttreatment. Following training, participants who received attention-control training reported significantly lower levels of PTSD symptoms, Hedges' g = 0.86, 95% CI [0.37, 1.36], p = .004, and significantly improved work and social functioning, Hedges' g = 0.93, 95% CI [0.46, 1.39], p = .001, relative to those in the placebo condition. Moreover, no participants who received attention-control training worsened with regard to PTSD symptoms, whereas 23.8% of those who received the placebo attention training experienced an increase in PTSD symptoms. The preliminary findings from this pilot study add to a small body of evidence supporting attention-control training as a viable indicated early intervention approach for PTSD that is worthy of further research.

Mental health problems and needs of frontline healthcare workers during the COVID-19 pandemic in Spain: A qualitative analysis

Background

Healthcare workers (HCWs) from COVID-19 hotspots worldwide have reported poor mental health outcomes since the pandemic's beginning. The virulence of the initial COVID-19 surge in Spain and the urgency for rapid evidence constrained early studies in their capacity to inform mental health programs accurately. Here, we used a qualitative research design to describe relevant mental health problems among frontline HCWs and explore their association with determinants and consequences and their implications for the design and implementation of mental health programs.

Materials and methods

Following the Programme Design, Implementation, Monitoring, and Evaluation (DIME) protocol, we used a two-step qualitative research design to interview frontline HCWs, mental health experts, administrators, and service planners in Spain. We used Free List (FL) interviews to identify problems experienced by frontline HCWs and Key informant (KI) interviews to describe them and explore their determinants and consequences, as well as the strategies considered useful to overcome these problems. We used a thematic analysis approach to analyze the interview outputs and framed our results into a five-level social-ecological model (intrapersonal, interpersonal, organizational, community, and public health).

Results

We recruited 75 FL and 22 KI interviewees, roughly balanced in age and gender. We detected 56 themes during the FL interviews and explored the following themes in the KI interviews: fear of infection, psychological distress, stress, moral distress, and interpersonal conflicts among coworkers. We found that interviewees reported perceived causes and consequences across problems at all levels (intrapersonal to public health). Although several mental health strategies were implemented (especially at an intrapersonal and interpersonal level), most mental health needs remained unmet, especially at the organizational, community, and public policy levels.

Conclusions

In keeping with available quantitative evidence, our findings show that mental health problems are still relevant for frontline HCWs 1 year after the COVID-19 pandemic and that many reported causes of these problems are modifiable. Based on this, we offer specific recommendations to design and implement mental health strategies and recommend using transdiagnostic, low-intensity, scalable psychological interventions contextually adapted and tailored for HCWs.

Sustained Negative Mental Health Outcomes Among Healthcare Workers Over the First Year of the COVID-19 Pandemic: A Prospective Cohort Study

Objective: To characterize the evolution of healthcare workers' mental health status over the 1-year period following the initial COVID-19 pandemic outbreak and to examine baseline characteristics associated with resolution or persistence of mental health problems over time. Methods: We conducted an 8-month follow-up cohort study. Eligible participants were healthcare workers working in Spain. Baseline data were collected during the initial pandemic outbreak. Survey-based self-reported measures included COVID-19-related exposures, sociodemographic characteristics, and three mental health outcomes (psychological distress, depression symptoms, and posttraumatic stress disorder symptoms). We examined three longitudinal trajectories in mental health outcomes between baseline and follow-up assessments (namely asymptomatic/stable, recovering, and persistently symptomatic/worsening). Results: We recruited 1,807 participants. Between baseline and follow-up assessments, the proportion of respondents screening positive for psychological distress and probable depression decreased, respectively, from 74% to 56% and from 28% to 21%. Two-thirds remained asymptomatic/stable in terms of depression symptoms and 56% remained symptomatic or worsened over time in terms of psychological distress. Conclusion: Poor mental health outcomes among healthcare workers persisted over time. Occupational programs and mental health strategies should be put in place.

Cognitive mechanisms underlying the association between trauma exposure, mental health and social engagement in refugees: A longitudinal investigation

BACKGROUNDS

Refugees and asylum-seekers are at heightened risk for developing psychological symptoms following exposure to trauma and displacement. Despite this, relatively little is known about the cognitive mechanisms that underlie common mental disorders in refugees.

METHODS

In this study, we investigated the associations between self-efficacy, beliefs about others (relating to benevolence and trust) and psychological and social outcomes in 1079 refugees from Arabic, Farsi, Tamil or English-speaking backgrounds who were residing in Australia. Participants completed an online survey assessing exposure to potentially traumatic events (PTEs), at baseline (T1), and self-efficacy, beliefs about others, PTSD symptoms, depression symptoms, anger and social engagement at baseline (T1) and six months later (T2).

RESULTS

A path analysis revealed that greater PTE exposure was associated with lower self-efficacy and lower positive beliefs about others at T1. Self-efficacy at T1 was negatively associated with depression and anger at T2, while positive beliefs about others at T1 were positively associated with social engagement and greater depression symptoms at T2.

LIMITATIONS

Limitations of this study included the fact that the study sample was not necessarily representative of the broader refugee population, and in particular may have overrepresented those with higher education levels.

CONCLUSIONS

Findings point to the critical role that cognitive variables play in the maintenance of psychological symptoms in forcibly displaced persons, and highlight the importance of targeting these in psychological interventions to promote positive posttraumatic mental health.

Emerging experience with selected new categories in the ICD-11: complex PTSD, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder

Among the important changes in the ICD-11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD-11 implementation. This paper focuses on four disorders: complex post-traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD-11 represents a different decision than was made for the DSM-5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD-11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD-11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD-11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.

Neural processes during response inhibition in complex posttraumatic stress disorder

BACKGROUND

A common feature of complex posttraumatic stress disorder (CPTSD) is impulsivity. Despite the importance of this characteristic in functional difficulties in CPTSD, little is known about its mechanisms. The aim of this study was to identify the distinctive neural profile of CPTSD during attempted inhibition.

METHODS

The present study examined functional alterations in neural networks involved in inhibitory control across functional magnetic resonance imaging (fMRI) and electroencephalogram (EEG) paradigms in CPTSD (n = 30), PTSD (n = 40), and healthy control (n = 40) participants who completed a Go/NoGo response inhibition task during separate fMRI and EEG sessions. Brain activations were calculated during the NoGo trials relative to the baseline to evaluate response inhibition functioning.

RESULTS

There was reduced bilateral thalamic activation in participants with CPTSD relative to PTSD and controls during inhibition trials, but no activation differences between PTSD and controls for this brain region. There were no differences in functional connectivity between the thalamus and other regions involved in cognitive control between groups. No differences were observed between groups on EEG responses.

CONCLUSIONS

These findings provide initial evidence of aberrant functioning in the neurocircuitry of inhibitory control, involving the thalamus, in CPTSD. This evidence suggests that CPTSD is distinguished from PTSD by impaired neural processes implicated in response inhibition.