Reexperiencing symptoms, dissociation, and avoidance behaviors in daily life of patients with PTSD and patients with panic disorder with agoraphobia

To sleep or not to sleep, that is the question: A systematic review and meta-analysis on the effect of post-trauma sleep on intrusive memories of analog trauma

Distressing intrusive memories of a traumatic event are one of the hallmark symptoms of posttraumatic stress disorder. Thus, it is crucial to identify early interventions that prevent the occurrence of intrusive memories. Both, sleep and sleep deprivation have been discussed as such interventions, yet previous studies yielded contradicting effects. Our systematic review aims at evaluating existing evidence by means of traditional and individual participant data (IPD) meta-analyses to overcome power issues of sleep research. Until May 16th, 2022, six databases were searched for experimental analog studies examining the effect of post-trauma sleep versus wakefulness on intrusive memories. Nine studies were included in our traditional meta-analysis (8 in the IPD meta-analysis). Our analysis provided evidence for a small effect favoring sleep over wakefulness, log-ROM = 0.25, p < .001, suggesting that sleep is associated with a lower number of intrusions but unrelated to the occurrence of any versus no intrusions. We found no evidence for an effect of sleep on intrusion distress. Heterogeneity was low and certainty of evidence for our primary analysis was moderate. Our findings suggest that post-trauma sleep has the potential to be protective by reducing intrusion frequency. More research is needed to determine the impact following real-world trauma and the potential clinical significance.

Memory representation of aversive social experiences in Social Anxiety Disorder

Aversive social experiences are proposed to be a risk factor for developing Social Anxiety Disorder (SAD). Many patients with SAD report associated daily life symptoms, such as intrusive re-experiencing (e.g., negatively distorted images of oneself), avoidance, alterations in cognitions and mood, as well as hyperarousal, resembling symptom dimensions of Posttraumatic Stress Disorder (PTSD). These PTSD-like symptoms may result from maladaptive processing and representation of the aversive social experiences in memory. Emotional hyperreactivity during memory retrieval of aversive social experiences is another feature of SAD which was found in previous studies. This study aimed to further investigate PTSD-like symptoms and emotional reactivity associated with etiologically relevant aversive social experiences and shed more light on a potential relationship between both. Eighty-five patients with SAD and 85 healthy controls (HC) participated in this cross-sectional study. It comprised an imagination task with self-report and physiological measures to assess emotional reactivity during the cued recall of the aversive social experience and clinical interviews to assess PTSD-like symptoms. We expected increased emotional reactivity and more severe PTSD-like symptoms in response to the aversive social experience in patients with SAD compared to HC, as well as a positive correlation between emotional reactivity and PTSD-like symptoms in patients with SAD. Indeed, patients with SAD showed emotional hyperreactivity (self-report, physiology) during the cued recall of the aversive social experiences, also when compared to two control memory conditions (neutral, negative non-social) and HC. Patients with SAD furthermore reported more severe PTSD-like symptoms compared to HC and intrusive re-experiencing symptoms were positively correlated with distress during imagery of the social aversive event in patients with SAD. These results might point toward a maladaptive representation of aversive social experiences in memory. Similar to PTSD, this maladaptive memory representation might promote the development of PTSD-like symptoms such as intrusive re-experiencing (e.g., in the form of intrusive self-images in patients with SAD), which might finally lead to and maintain symptoms of SAD.

START adolescents: study protocol of a randomised controlled trial to investigate the efficacy of a low-threshold group treatment programme in traumatised adolescent refugees

Introduction

No evaluated therapeutic approaches, that can efficiently be established in routine mental healthcare, are currently available for traumatised adolescent refugees in Germany. This study evaluates the efficacy of the Stress-Traumasymptoms-Arousal-Regulation-Treatment (START) programme to reduce trauma-related symptoms and psychological distress in traumatised adolescent refugees based in Germany.

Methods and analysis

This randomised, waiting-list-controlled, multicentre trial with a 12-week follow-up will include 174 refugee minors with partial or full post-traumatic stress disorder who are fluent in either Arabic, Dari, English, German or Somali. Eligible refugee minors will be randomised to the START or waiting-list control groups. The manualised 8-week START programme is based on techniques of dialectical behaviour therapy (DBT), fosters adaptive coping with emotional distress and traumatic symptoms and comprises eight therapy modules and a booster session. Study assessments are planned at baseline, post-treatment (ie, after programme participation or waiting time), booster session at week 12 or 12-week waiting time, and at the 12-week follow-up. Primary and coprimary outcomes are changes in psychological distress and traumatic symptoms at post-treatment and will be analysed as response variables in linear mixed regression models. Secondary outcomes are changes in further trauma-related and other psychopathological symptoms, emotion regulation and intermediate effects of the programme at follow-up. We will also assess effects of the programme with ecological momentary assessments and on neuroendocrine stress parameters using hair cortisol.

Ethics and dissemination

This study has been approved by the lead ethics committee of Rhineland-Palatinate and the ethics committees of participating sites. The study results will be disseminated through peer-reviewed publications and scientific conferences.

Trial registration number

DRKS00020771.

Emotion Transfer, Emotion Regulation, and Empathy-Related Processes in Physician-Patient Interactions and Their Association With Physician Well-Being: A Theoretical Model

Physicians experience many emotionally challenging situations in their professional lives, influencing their emotional state through emotion contagion or social appraisal processes. Successful emotion regulation is crucial to sustain health, enable well-being, foster resilience, and prevent burnout or compassion fatigue. Despite the alarmingly high rate of stress-related disorders in physicians, affecting not only physician well-being, but also outcomes such as physician performance, quality of care, or patient satisfaction, research on how to deal with emotionally challenging situations in physicians is lacking. Based on extant literature, the present article proposes a theoretical model depicting emotions, emotion regulation, and empathy-related processes and their relation to well-being in provider-client interactions. This model serves as a basis for future research and interventions aiming at improving physician well-being and professional functioning. As a first step, interviews with 21 psychiatrists were conducted. Results of qualitative and initial quantitative analyses provided detailed descriptions of the model's components confirming its usefulness for detecting mechanisms linking emotion regulation and well-being in psychiatrist-patient interactions. Additionally, results lend preliminary support for the validity of the model, suggesting that successful regulation of emotions (i.e., achieving a desired emotional state) elicited by cyclical transfer processes in provider-client interactions is associated with both short- and long-term well-being and resilience. Furthermore, empathy-related emotions and their regulation seem to be linked to well-being. Based on the results of the present study, a prospective longitudinal study is under preparation, which is intended to inform effective interventions targeting emotion transfer, empathy-related processes, and emotion regulation in physicians' professional lives. The model and results are also potentially applicable to other health care and social services providers.

Frequency of Intrusions and Appraisal of Related Distress After Analogue Trauma: A Comparative Ecological Momentary Assessment Methods Study

Intrusive thoughts, images, and their appraisal remain difficult to study despite their clinical relevance. Clinical studies typically used time-based (frequency and distress per observation period), while analogue studies mainly used event-based (report upon occurrence) assessment. A comparison of intrusion frequency, distress appraisal, compliance, and reactivity across different assessments is mostly lacking, particularly with regard to analogue research. Here, intrusions were induced via aversive films and assessed by a smart phone application for 4 days. Three sampling modes were compared by randomizing participants to one of three conditions: either one, or five time-based daily prompts, or event-based assessment. At the end of the study, all participants reported intrusions once again in a retrospective summary assessment. Results indicate that intrusions and their distress decayed over a few days. The three assessments did not differ in intrusion frequency, distress appraisal, compliance (generally high), reactivity (generally low), or retrospective summary assessment. Across groups, the more aversive and arousing participants rated the film clips and the more reactivity to the electronic-diary assessment they reported, the more intrusive memories they had; assessment modes did not differ on this. Thus, no general differences were found between electronic-diary assessment modes for analogue intrusions, giving researchers flexibility for tailoring ecological momentary assessment to specific study aims.

The differences between patients with panic disorder and healthy controls in psychophysiological stress profile

BACKGROUND

Alarming somatic symptoms, in particular, cardiovascular symptoms, are the characteristic feature of panic attacks. Increased cardiac mortality and morbidity have been found in these patients. Power spectral analysis of electrocardiogram R-R intervals is known to be a particularly successful tool in the detection of autonomic instabilities in various clinical disorders. Our study aimed to compare patients with panic disorder and healthy controls in heart rate variation (HRV) parameters (very-low-frequency [VLF], low-frequency [LF], and high-frequency [HF] band components of R-R interval) in baseline and during the response to the mental task.

SUBJECTS AND METHODS

We assessed psychophysiological variables in 33 patients with panic disorder (10 men, 23 women; mean age 35.9±10.7 years) and 33 age- and gender-matched healthy controls (10 men, 23 women; mean age 35.8±12.1 years). Patients were treatment naïve. Heart rate, blood pressure, muscle tension, and HRV in basal conditions and after the psychological task were assessed. Power spectrum was computed for VLF (0.003-0.04 Hz), LF (0.04-0.15 Hz), and HF (0.15-0.40 Hz) bands using fast Fourier transformation.

RESULTS

In the baseline period, the VLF band was significantly lower in panic disorder group compared to controls (p<0.005). In the period of mental task, the LF/HF ratio was significantly higher in panic disorder patients compared to controls (p<0.05). No significant differences were found in the remaining parameters. There was a significant difference in ΔHF and ΔLF/HF ratio between patients and controls, with Δ increasing in patients and decreasing in controls.

CONCLUSION

These findings revealed that patients suffering from panic disorder were characterized by relative sympathetic dominance (reactivity) in response to mental stress compared with healthy controls.

Conditioned responses to trauma reminders: How durable are they over time and does memory integration reduce them?

BACKGROUND AND OBJECTIVES

Stimuli associated with the trauma are important triggers for intrusive memories after a traumatic event. Clinical models assume that fear conditioning for neutral stimuli encountered during traumatic events is a potential cause of these intrusions, and that memory integration has the effect of reducing these associations, thereby also reducing intrusions. This study examines whether conditioned associations lead to intrusive trauma memories and how they are affected by memory integration.

METHODS

Forty-eight healthy participants watched a neutral and a "traumatic" film, both containing neutral sounds, and, on the following day, were randomly allocated to memory integration of either the "traumatic" film or the neutral film. Intrusive memories were monitored for one week. Participants repeatedly completed a memory triggering task, in order to assess how durable conditioned intrusive memories are over time.

RESULTS

Trauma-associated sounds elicited intrusive memories and anxiety when encountered directly after film presentation, as well as one and seven days later. Furthermore, enhanced conditionability predicted subsequent ambulatory trauma intrusions. No evidence was found for the assumption that memory integration of the "traumatic" film reduced conditioned reactions.

LIMITATIONS

The presented film is a relatively mild stressor as compared to a real-life trauma. Further studies are needed to explore the role of conditioned intrusions for real-life trauma.

CONCLUSIONS

This study provides evidence for the assumption that intrusive trauma memories can be explained by conditioned responses to neutral stimuli encountered during the trauma and that these effects are stable over time. Implications for PTSD and its treatment are discussed.

Repeated cortisol administration does not reduce intrusive memories - A double blind placebo controlled experimental study

PTSD is a severe mental disorder, which may develop after exposure to traumatic events and is characterized by intrusive memories. Intrusions are sudden brief sensory memories of the traumatic event, that cause immense distress and impairment in every day functioning. Thus, the reduction of intrusive memories is one of the main aims of PTSD therapy. Recently, the glucocorticoid cortisol has been proposed as a pharmacological option to reduce intrusive memories, because cortisol is known to have memory retrieval inhibiting effects. However, the research on the effects of cortisol administration on intrusive memories is not conclusive. The aim of the present study was to examine if repeated cortisol administration inhibits intrusions and recognition memory in an experimental study using the trauma film paradigm. In a randomized double-blind placebo controlled design participants were exposed to a traumatic film (known to induce intrusions in healthy participants) and received either a low dose of cortisol (20mg) or placebo on the three days following "trauma exposure". Intrusive memories were assessed with an Electronic Diary and an Intrusion Triggering Task. Furthermore, we assessed explicit memory for the traumatic film clip with a recognition test. Contrary to our predictions, the cortisol group did not report fewer intrusions than the placebo group nor did it show diminished performance on the recognition test. Our results show that sole cortisol administration after a traumatic experience cannot reduce intrusive re-experiencing.

Trauma-related memories in PTSD after interpersonal violence: an ambulatory assessment study

Background: Ambulatory assessment (AA) is increasingly recommended for assessing symptoms of posttraumatic stress disorder (PTSD). Previous AA studies provided new insights into the phenomenology of trauma-related memories, but also divergent findings. Notably, the range of trauma-related memories (a major target of psychotherapeutic interventions) reported in AA studies was as wide as 7.3 to 74.5 per week which might result from different methods used in these studies. Objective: We aimed at assessing the frequency of trauma-related memories in PTSD related to interpersonal violence and investigated whether this frequency is dependent upon the method. Method: For each patient trauma-related memories were assessed using two variants of smartphone-based AA: (1) Event-based sampling (EBS), i.e. participants entered data on each intrusive memory as it occurred; (2) Time-based sampling (TBS), i.e. participants reported the number of trauma-related memories they had experienced during the last two hours after they had been alerted by the smartphone. The numbers reported during the TBS-block were either analysed as reported by the participants or restricted to one per hour (rTBS). The impact of smartphone-assessments on trauma-related memories was assessed during a post-monitoring questionnaire. Results: While trauma-related memories were frequent across assessments, the methodology had a huge impact on the numbers: EBS (median = 7) and rTBS (median = 6) yielded significantly lower weekly numbers of intrusive trauma-related memories than TBS (median = 49). Accordingly, the possibility to report unrestricted numbers of trauma-related memories clearly impacted the results. The post-monitoring questionnaire identified another source for the divergent findings: while feeling disrupted by the smartphone-assessments was unrelated to the numbers reported during EBS, feeling disrupted was related to an increase of trauma-related memories during TBS and rTBS. Conclusions: The method clearly impacts the recorded number of trauma-related memories. Future research should clarify whether other variables (e.g. the subjective stress related to intrusive memories) are less dependent on the methodology.

Development and Validation of the Dissociative Symptoms Scale

The Dissociative Symptoms Scale (DSS) was developed to assess moderately severe levels of depersonalization, derealization, gaps in awareness or memory, and dissociative reexperiencing that would be relevant to a wide range of clinical populations. Structural analyses of data from four clinical and five nonclinical samples ( N = 1,600) yielded four factors that reflected the domains of interest and showed good fit with the data. Sample scores were consistent with expectations and showed very good internal consistency and temporal stability. Analyses showed consistent evidence of convergent and divergent validity, and posttrauma elevations in scores and in patients with posttraumatic stress disorder provided additional evidence of construct validity. Item response theory analyses indicated that the items assessed moderately severe dissociative experiences. Overall, the results provide support for the reliability and validity of DSS total and subscale scores in the populations studied. Further work is needed to evaluate the performance of the DSS relative to structured interview measures and in samples of patients with other psychological disorders.

Metabolic decoupling in daily life in patients with panic disorder and agoraphobia

Various studies have assessed autonomic and respiratory underpinnings of panic attacks, yet the psychophysiological functioning of panic disorder (PD) patients has rarely been examined under naturalistic conditions at times when acute attacks were not reported. We hypothesized that emotional activation in daily life causes physiologically demonstrable deviations from efficient metabolic regulation in PD patients. Metabolic coupling was estimated as within-individual correlations between heart rate (HR) and indices of metabolic activity, i.e., physical activity (measured by 3-axial accelerometry, Acc), and minute ventilation (Vm, measured by calibrated inductive plethysmography, as proxy for oxygen consumption). A total of 565 daytime hours were recorded in 19 PD patients and 20 healthy controls (HC). Pairwise cross-correlations of minute-by-minute averages of these metabolic indices were calculated for each participant and then correlated with several indices of self-reported anxiety. Ambulatory HR was elevated in PD (p = .05, d = 0.67). Patients showed reduced HR-Acc (p < .006, d = 0.97) and HR-Vm coupling (p < .009, d = 0.91). Combining Vm and Acc to predict HR showed the strongest group separation (p < .002, d = 1.07). Discriminant analyses, based on the combination of Vm and Acc to predict HR, classified 77% of all participants correctly. In PD, HR-Acc coupling was inversely related to trait anxiety sensitivity, as well as tonic and phasic daytime anxiety. The novel method that was used demonstrates that anxiety in PD may reduce efficient long-term metabolic coupling. Metabolic decoupling may serve as physiological characteristic of PD and might aid diagnostics for PD and other anxiety disorders. This measure deserves further study in research on health consequences of anxiety and psychosocial stress.