Transdiagnostic emotion regulation processes explain how emotion-related factors affect co-occurring PTSD and MDD in relation to trauma

A Predictive Nomogram for Suicide Attempts in Chinese Adolescents With Both Non-Suicidal Self-Injury and Suicidal Ideation

INTRODUCTION

Non-suicidal self-injury (NSSI) and suicidal ideation (SI) are prevalent and co-occurring among adolescents, serving as critical predictors of suicide. This study aimed to develop a predictive model and nomogram for suicide attempts (SA) in Chinese adolescents with mood disorders exhibiting NSSI and SI.

METHODS

Data were collected from 134 participants. Predictors were selected via LASSO regression from data collected using the Self-Injurious Thoughts and Behaviors Interview-Revised and self-report scales, followed by multivariate logistic regression to build the nomogram. Model performance was assessed through discriminatory ability, calibration curves, and clinical decision analysis.

RESULTS

Adolescents with SA history had fewer education years, higher prevalence and future likelihood of self-injurious thoughts and behaviors, earlier NSSI onset, more frequent and severe NSSI, and more intense and persistent SI compared to those without SA. Three key predictors for SA were identified: NSSI emotion regulation scores, average SI persistence duration, and history of interrupted attempts. The developed nomogram exhibited robust predictive accuracy with an AUC of 0.756.

DISCUSSION

This study presents a predictive model for suicide risk in adolescents with mood disorders exhibiting NSSI and SI. The model demonstrates high predictive accuracy and clinical applicability, offering a practical tool for clinicians to prioritize high-risk cases and guide personalized interventions.

The Lack of Neurofeedback Training Regulation Guidance and Process Evaluation May be a Source of Controversy in Post-Traumatic Stress Disorder-Neurofeedback Research: A Systematic Review and Statistical Analysis

Objectives: Neurofeedback (NF) based on brain-computer interface (BCI) is an important direction in adjunctive interventions for post-traumatic stress disorder (PTSD). However, existing research lacks comprehensive methodologies and experimental designs. There are concerns in the field regarding the effectiveness and mechanistic interpretability of NF, prompting this study to conduct a systematic analysis of primary NF techniques and research outcomes in PTSD modulation. The study aims to explore reasons behind these concerns and propose directions for addressing them. Methods: A search conducted in the Web of Science database up to December 1, 2023, yielded 111 English articles, of which 80 were excluded based on predetermined criteria irrelevant to this study. The remaining 31 original studies were included in the literature review. A checklist was developed to assess the robustness and credibility of these 31 studies. Subsequently, these original studies were classified into electroencephalogram-based NF (EEG-NF) and functional magnetic resonance imaging-based NF (fMRI-NF) based on BCI type. Data regarding target brain regions, target signals, modulation protocols, control group types, assessment methods, data processing strategies, and reported outcomes were extracted and synthesized. Consensus theories from existing research and directions for future improvements in related studies were distilled. Results: Analysis of all included studies revealed that the average sample size of PTSD patients in EEG and fMRI NF studies was 17.4 (SD 7.13) and 14.6 (SD 6.37), respectively. Due to sample and neurofeedback training protocol constraints, 93% of EEG-NF studies and 87.5% of fMRI-NF studies used traditional statistical methods, with minimal utilization of basic machine learning (ML) methods and no studies utilizing deep learning (DL) methods. Apart from approximately 25% of fMRI NF studies supporting exploratory psychoregulatory strategies, the remaining EEG and fMRI studies lacked explicit NF modulation guidance. Only 13% of studies evaluated NF effectiveness methods involving signal classification, decoding during the NF process, and lacking in process monitoring and assessment means. Conclusion: In summary, NF holds promise as an adjunctive intervention technique for PTSD, potentially aiding in symptom alleviation for PTSD patients. However, improvements are necessary in the process evaluation mechanisms for PTSD-NF, clarity in NF modulation guidance, and development of ML/DL methods suitable for PTSD-NF with small sample sizes. To address these challenges, it is crucial to adopt more rigorous methodologies for monitoring NF, and future research should focus on the integration of advanced data analysis techniques to enhance the effectiveness and precision of PTSD-NF interventions. Impact Statement The implications of this study are to address the limited application of Neurofeedback training (NFT) in post-traumatic stress disorder (PTSD) research, where a significant portion of the approaches, foundational research, and conclusions lack consensus. There is a notable absence of retrospective statistical analyses on NFT interventions for PTSD. This study provides a comprehensive statistical analysis and discussion of existing research, offering valuable insights for future studies. The findings hold significance for researchers, clinicians, and practitioners in the field, providing a foundation for informed, evidence-based interventions for PTSD treatment.

Coexisting patterns of posttraumatic stress disorder and depression symptoms in college students who experienced childhood maltreatment: Different types of maltreatment exposure

BACKGROUND

Childhood maltreatment is often associated with comorbid posttraumatic stress disorder (PTSD) and depression, but the impact of different types of maltreatment on this comorbidity is not well understood.

METHODS

Using network analysis, we examined differences in comorbidity patterns of PTSD and depression symptoms among college students who experienced different forms of childhood maltreatment. We selected a subsample of 2968 students (Mage = 19.38, SD = ±1.45) who reported exposure to childhood maltreatment from a larger sample of 5231 students.

RESULTS

This study showed that symptoms of negative emotions and cognitive change, intrusive symptoms, and increased alertness might play a significant role in the diagnosis and prognosis of comorbid PTSD and depression. The most central nodes in the network of physical maltreatment were flashbacks, and irritability, whereas the most central nodes in the network of emotional and compound trauma, were low mood and sadness. Moreover, network structure and strength differed significantly between maltreatment types, and differences in specific symptom associations were also observed.

CONCLUSION

Network analysis provides insights into which symptoms contribute to the development of comorbidities in individuals with different childhood maltreatment types, as well as how specific symptoms are interconnected in the network. This information can aid in developing targeted and effective interventions for different maltreatment forms.

Does Trauma Change the Way Individuals with Post-Traumatic Stress Disorder (PTSD) Deal with Positive Stimuli?

INTRODUCTION

Post-Traumatic Stress Disorder (PTSD) is a highly prevalent disorder and a highly debilitating condition. Although current theories focused on depressed mood and intrusion as critical dimensions, the mechanism through which depression increases the risk of PTSD remains unclear. Research usually concentrates on the hyperactive negative valence system (NVS) (e.g., increased fear and threat responses), but some evidence suggests a significant role for the hypoactive positive valence system (PVS) (e.g., less neural activation towards rewards).

METHOD

The main aim of the present research was to investigate whether probable PTSD leads to a different evaluation of the implicit processing in a refugee's sample. Ratings of arousal, dominance, and valence from 60 International Affective Picture System (IAPS) pictures (positive, neutral, and negative) were collected from 42 individuals with probable PTSD, and a group of 26 trauma-exposed individuals (Mage = 28.49 years, SD = ±7.78).

RESULTS

ANOVA results revealed a main group effect (η2p = 0.379) on arousal, dominance, valence dimensions, and pictures' categories (η2p = 0.620), confirming evidence according to which PTSD origins a state of maladaptive hyperarousal and troubles the regulation of emotions, and not supporting the view that such difficulties arise only with negative stimuli. Participants with probable PTSD deemed negative stimuli as more threatening than they really are, reacting to unpleasant images with greater negative emotionality (i.e., enhanced arousal and lower valence ratings) compared with individuals without PTSD. Moreover, they rated positive stimuli as less pleasant. Furthermore, arousal ratings were negatively correlated with valence (r = -0.709, p < 0.01) indicating that pictures with high arousal (negative) were associated with lower valence.

DISCUSSION

Our findings supported evidence according to which PTSD caused a constant state of hyperarousal and difficulties in regulating emotions facing environmental stimuli. Positive stimuli are considered less pleasant, and this inhibits from completely benefiting from them.

CONCLUSION

Our study provides evidence for a differential and potentially complementary involvement of NVS and PVS in PTSD development. Intervention for PTSD may, thus, target both negative and positive valence processing.

Effects of MDMA-assisted therapy for PTSD on self-experience

INTRODUCTION

There is a resurgence of interest in the therapeutic potential of psychedelic substances such as 3,4-methylenedioxymethamphetamine (MDMA). Primary findings from our randomized, double-blind, placebo-controlled, multi-site Phase 3 clinical trial of participants with severe PTSD (NCT03537014) showed that MDMA-assisted therapy induced significant attenuation in the Clinician-Administered PTSD Scale for DSM-5 compared to Therapy with placebo. Deficits in emotional coping skills and altered self-capacities constitute major obstacles to successful completion of available treatments. The current analysis evaluated the differential effects of MDMA-assisted therapy and Therapy with placebo on 3 transdiagnostic outcome measures and explored the contribution of changes in self-experience to improvement in PTSD scores.

METHODS

Participants were randomized to receive manualized therapy with either MDMA or placebo during 3 experimental sessions in combination with 3 preparation and 9 integration therapy visits. Symptoms were measured at baseline and 2 months after the last experimental session using the 20-item Toronto Alexithymia Scale (TAS-20), the 26-item Self Compassion Scale (SCS), and the 63-item Inventory of Altered Self-Capacities (IASC).

RESULTS

90 participants were randomized and dosed (MDMA-assisted therapy, n = 46; Therapy with placebo, n = 44); 84.4% (76/90) had histories of developmental trauma, and 87.8% (79/90) had suffered multiple traumas. MDMA-assisted therapy facilitated statistically significant greater improvement on the TAS-20, the SCS, and most IASC factors of interpersonal conflicts; idealization disillusionment; abandonment concerns; identity impairment; self-awareness; susceptibility to influence; affect dysregulation; affect instability; affect skill deficit; tension reduction activities; the only exception was identity diffusion.

CONCLUSION

Compared with Therapy with placebo, MDMA-assisted therapy had significant positive effects on transdiagnostic mental processes of self-experience which are often associated with poor treatment outcome. This provides a possible window into understanding the psychological capacities facilitated by psychedelic agents that may result in significant improvements in PTSD symptomatology.

Changes in comorbid depression following intensive trauma-focused treatment for PTSD and complex PTSD

BACKGROUND

The extent to which intensive trauma-focused treatment for individuals with post-traumatic stress disorder (PTSD) is also effective in treating comorbid major depressive disorder (MDD) remains unclear.

OBJECTIVE

The purpose of the present study was to test the hypothesis that brief intensive trauma-focused therapy for PTSD is associated with significant reductions in depressive symptoms and loss of diagnostic status of MDD.

METHODS

A total of 334 adult patients with PTSD (189 patients who were also diagnosed with MDD) underwent a brief intensive trauma-focused treatment programme consisting of EMDR therapy, prolonged exposure, physical activity, and psychoeducation. At pre-treatment, post-treatment and 6-month follow-up, severity and diagnostic status of PTSD and MDD were assessed. A linear mixed model was used to analyze changes in the severity of PTSD and depressive symptoms, whereas a generalized linear mixed model was used to determine changes in the MDD diagnostic status.

RESULTS

Treatment resulted in a significant and strong decrease of PTSD and MDD symptoms at post-treatment (d = 2.34 and 1.22, respectively), and at 6-month follow-up (d = 1.67 and 0.73, respectively). The proportion of patients fulfilling the diagnostic status of MDD changed from 57% at pre-treatment to 33% at the 6-month follow-up. Although the initial response to treatment did not differ between patients with and without comorbid MDD, for both groups a significant relapse in depressive symptoms was found after six months, which could be explained almost entirely by the presence of CPTSD at baseline.

CONCLUSIONS

The results support the notion that brief, intensive trauma-focused treatment is highly effective for individuals with PTSD and comorbid MDD. Because patients with CPTSD are vulnerable to relapse in depressive symptoms, this target group may require additional treatment.

"My brain freezes and I am blocked again": The subjective experience of post-migration living difficulties influenced by complex posttraumatic stress disorder of Afghan asylum seekers and refugees in Austria

BACKGROUND

Potentially traumatic experiences and post-migration living difficulties (PMLDs) undoubtedly leave marks on mental health and psychosocial functioning. While PMLDs are recognised as a risk factor for posttraumatic stress disorder and complex posttraumatic stress disorder (described together here as C/PTSD), recent investigations have found that C/PTSD symptoms might also influence the experience of PMLDs. The subjective experience of and coping with PMLDs in the context of C/PTSD symptoms has not yet been explored.

METHODS

Semi-structured, interpreter-assisted interviews exploring the subjective experience of post-migration living difficulties were conducted with treatment-seeking Afghan refugees and asylum seekers (N = 24) and transcribed verbatim. Participants were screened using the International Trauma Questionnaire (ITQ) and allocated to a C/PTSD group or non-C/PTSD group. We analysed the qualitative interviews using content analysis and then compared the results of the two groups.

RESULTS

Over half of the participants (58.3%) met the criteria for C/PTSD. While the two groups addressed numerous similar themes, the C/PTSD group more frequently mentioned themes associated with C/PTSD symptoms (e.g., intrusions, avoidance, sleep disturbances, affective dysregulation) that influenced their responses to PMLDs. The non-C/PTSD group more often experienced positive emotions such as gratitude and optimism, and showed more active, solution-oriented behaviour as well as positive self-verbalisation.

CONCLUSION

To achieve a deeper understanding of PMLDs, post-traumatic psychopathology should be taken into account, as C/PTSD symptoms influence the experience of and coping with PMLDs. The specifics of individual experiences need to be considered in order to promote adaptive coping with PMLDs and to set individual trauma-focused and transdiagnostic treatment targets. In addition, psychological interventions should incorporate psychoeducation to improve the understanding of the impact of C/PTSD on the current experience of PMLDs.

Transdiagnostic factors in symptoms of depression and post-traumatic stress: a systematic review

The current systematic review sought to identify quantitative empirical studies that focused on the transdiagnostic factors of intolerance of uncertainty, emotional dysregulation and rumination, and their relation with depression and post-traumatic stress disorder (PTSD). The overall research aim was to examine the relationship between these transdiagnostic factors and their relation with depression and PTSD symptoms. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Out of the 768 articles initially identified, 55 met the inclusion criteria for the current review. The results determined that intolerance of uncertainty is indirectly related to depression and PTSD symptoms, mainly through other factors including emotion dysregulation and rumination. Additionally, emotional dysregulation is a significant predictor of both depression and PTSD symptoms. Rumination is a robust factor related to depression and PTSD symptoms, this relationship was significant in cross-sectional and longitudinal studies. This review provides evidence on the transdiagnostic factors of intolerance of uncertainty, emotional dysregulation and rumination in the relationship with depression and PTSD symptoms.

Latent profile analysis of post-traumatic stress and post-traumatic growth among firefighters

Background: Due to the job characteristics, firefighters are repeatedly exposed to trauma incidents. However, not all firefighters exhibit the same level of post-traumatic stress disorder (PTSD) or post-traumatic growth (PTG). Despite this, few studies have looked into firefighters' PTSD and PTG.Objective: This study identified subgroups of firefighters based on their PTSD and PTG levels, and investigated the influence of demographic factors and PTSD/PTG-related factors on latent class classification.Method: Latent profile analysis was used to examine the patterns of PTSD and PTG among 483 firefighters in South Korea. Using a cross-sectional design, demographic factors and job factors were examined as group covariates through a three-step approach. PTSD-related factors such as depression and suicide ideation, as well as PTG-related factors such as emotion-based response were analysed as differentiating factors.Results: Four classes were identified and named 'Low PTSD-low PTG (65.2%),' 'Mid PTSD-mid PTG (15.5%),' 'Low PTSD-high PTG (15.3%),' and 'High PTSD-mid PTG (3.9%).' The likelihood of belonging to the group with high trauma-related risks increased with more rotating shift work and years of service. The differentiating factors revealed differences based on the levels of PTSD and PTG in each group.Conclusions: 34.8% of firefighters experienced changes due to traumatic events while on the job, and some required serious attention. Modifiable job characteristics, such as the shift pattern, indirectly affected PTSD and PTG levels. Individual and job factors should be considered together when developing trauma interventions for firefighters.

Internalizing Mental Health Disorders and Emotion Regulation: A Comparative and Mediational Study of Older Adults With and Without a History of Complex Trauma Exposure

Individuals with complex trauma exposure (CTE) in early life (i.e., childhood/adolescence) are at heightened risk for developing problems in various domains of functioning. As such, CTE has repeatedly been linked to internalizing mental health disorders, such as depression and anxiety, as well as emotion dysregulation across the lifespan. While these correlates of CTE are comparatively well studied up to middle adulthood, they are insufficiently studied in older adulthood. Therefore, this study aimed to (a) compare Swiss older adults with and without a CTE history regarding current and lifetime internalizing mental health disorders and emotion regulation strategies; and (b) to examine the potential mediating role of emotion regulation in the mental health disparities between these groups. A total of N = 257 participants (age = 49-95 years; 46.3% female) were assessed in a retrospective, cross-sectional study, using two face-to-face interviews. The CTE group (n = 161; M age = 69.66 years, 48.4% female) presented with significantly more current and lifetime internalizing mental health disorders than the non-affected (nCTE) group (n = 96; M age = 72.49 years, 42.7% female). The CTE group showed significantly higher emotion suppression and lower emotion reappraisal compared to the nCTE group. Mediation analysis revealed that the two emotion regulation strategies were significant mediators between CTE history and internalizing mental health disorders. Findings emphasize the relevance of emotion (dys-)regulation in understanding mental health disparities in older age and deciding about treatment strategies. Research and practice should pay more attention to the needs of this high-risk group of older individuals.

Psychometric Properties of the Korean version of the Emotion Regulation Questionnaire (K-ERQ) in a Clinical Sample

OBJECTIVE

The Emotion Regulation Questionnaire (ERQ) is one of the widely used instruments to assess emotion regulation skills in many countries, including Korea. However, its psychometric properties have not been validated within this population. Also, the ERQ has increasingly been used in studies with psychiatric patients despite a general lack of validation in clinical settings. Therefore, the present study aimed to investigate the psychometric properties of the Korean version of the ERQ (K-ERQ) using a clinical sample in Korea.

METHODS

One hundred and ninety-three psychiatric patients completed a packet of self-report measures, including K-ERQ, K-BDI-II, K-ASI-3, PCL-5-K, AUDIT-K. Confirmatory factor analysis (CFA) was administered to investigate the factor structure of the K-ERQ, and internal reliability and validity were examined.

RESULTS

Results of the CFA supported the two-factor structure, but only after the removal of one item. The K-ERQ showed good internal consistency reliability, and its concurrent validity was also confirmed. Cognitive reappraisal was negatively correlated with depression and alcohol use disorder-related symptoms, and expressive suppression was positively correlated with depression, anxiety sensitivity, posttraumatic stress disorder (PTSD)-related symptoms and alcohol use disorder-related symptoms. Significant group differences were found in the use of emotion regulation strategies; patients with PTSD reported the higher level of cognitive reappraisal than patients with depressive disorders, bipolar disorders, and attention-deficit hyperactivity disorder.

CONCLUSION

The 9-itemed K-ERQ is a reliable and valid tool to assess the emotion regulation strategies in a Korean clinical sample. Our study also adds preliminary evidence on the usefulness of the ERQ in clinical settings.

Trauma-related differences in socio-emotional functioning predict housing and employment outcomes in homeless veterans

RATIONALE

Mental health and substance use disorders are strong risk factors for homelessness. Understanding the role of transdiagnostic factors could help inform efforts to reduce homelessness among veterans with a range of disorders. Homeless veterans have high rates of trauma exposure, which can result in the depletion of social and emotional resources that may contribute to housing and employment stability. In this study, we evaluated the role of problems with emotional lability and interpersonal closeness as transdiagnostic socio-emotional factors that might interfere with efforts to achieve housing and employment stability.

METHODS

The sample consisted of 346 homeless veterans with co-occurring disorders that were admitted to a U.S. Department of Veterans Affairs (VA) residential treatment program between 2004 and 2009. Assessments were conducted at treatment entry (baseline) and two follow-up timepoints (6- and 12-months). Variables used in the current analyses included history of interpersonal trauma exposure, emotional lability and interpersonal closeness at baseline and 6-months, and homelessness and employment problems during follow-up. Data were analyzed using structural equation modeling and counterfactually-defined mediation effects.

RESULTS

Veterans exposed to more trauma types experienced more baseline impairment and less improvement during treatment in emotional lability and interpersonal closeness. Problems with interpersonal closeness mediated 73% of the relationship between exposure to multiple traumas and homelessness, and 32%-61% of the relationship between trauma exposure and employment problems. Emotional lability mediated 36% of the relationship between exposure to multiple traumas and employment problems. Decomposition of indirect pathways revealed that indirect effects were primarily transmitted through changes during treatment, and not baseline levels.

CONCLUSION

Findings support a cumulative effect of trauma on persistence of socio-emotional deficits across treatment, which increased risk of homelessness and employment problems during follow-up. Greater attention and more targeted efforts should be directed at helping trauma-exposed veterans build socio-emotional resources during treatment.