Post-traumatic stress and future substance use outcomes: leveraging antecedent factors to stratify risk

Background

Post-traumatic stress disorder (PTSD) and substance use (tobacco, alcohol, and cannabis) are highly comorbid. Many factors affect this relationship, including sociodemographic and psychosocial characteristics, other prior traumas, and physical health. However, few prior studies have investigated this prospectively, examining new substance use and the extent to which a wide range of factors may modify the relationship to PTSD.

Methods

The Advancing Understanding of RecOvery afteR traumA (AURORA) study is a prospective cohort of adults presenting at emergency departments (N = 2,943). Participants self-reported PTSD symptoms and the frequency and quantity of tobacco, alcohol, and cannabis use at six total timepoints. We assessed the associations of PTSD and future substance use, lagged by one timepoint, using the Poisson generalized estimating equations. We also stratified by incident and prevalent substance use and generated causal forests to identify the most important effect modifiers of this relationship out of 128 potential variables.

Results

At baseline, 37.3% (N = 1,099) of participants reported likely PTSD. PTSD was associated with tobacco frequency (incidence rate ratio (IRR): 1.003, 95% CI: 1.00, 1.01, p = 0.02) and quantity (IRR: 1.01, 95% CI: 1.001, 1.01, p = 0.01), and alcohol frequency (IRR: 1.002, 95% CI: 1.00, 1.004, p = 0.03) and quantity (IRR: 1.003, 95% CI: 1.001, 1.01, p = 0.001), but not with cannabis use. There were slight differences in incident compared to prevalent tobacco frequency and quantity of use; prevalent tobacco frequency and quantity were associated with PTSD symptoms, while incident tobacco frequency and quantity were not. Using causal forests, lifetime worst use of cigarettes, overall self-rated physical health, and prior childhood trauma were major moderators of the relationship between PTSD symptoms and the three substances investigated.

Conclusion

PTSD symptoms were highly associated with tobacco and alcohol use, while the association with prospective cannabis use is not clear. Findings suggest that understanding the different risk stratification that occurs can aid in tailoring interventions to populations at greatest risk to best mitigate the comorbidity between PTSD symptoms and future substance use outcomes. We demonstrate that this is particularly salient for tobacco use and, to some extent, alcohol use, while cannabis is less likely to be impacted by PTSD symptoms across the strata.

The mindful gaze: trait mindful people under an instructed emotion regulation goal selectively attend to positive stimuli

Trait mindfulness confers emotional benefits and encourages skillful emotion regulation, in part because it helps people more deliberately attend to internal experiences and external surroundings. Such heightened attentional control might help skillfully deploy one's attention towards certain kinds of stimuli, which may in turn help regulate emotions, but this remains unknown. Testing how trait mindful people deploy attention when regulating their emotions could help uncover the specific mechanisms of mindfulness that confer its emotional benefits. The present study aimed to determine whether high trait mindfulness is associated with sustained attention biases to (i.e. longer gaze at) emotional scenes, when all participants are given the emotion regulation goal of staying in a positive mood. To measure this, we used eye tracking to assess selective attention to positive, neutral, and negative photographs. Higher trait mindfulness was associated with both a stronger attention bias for positive (vs. neutral and vs. negative) images, as well as greater success staying in a positive mood during viewing. Surprisingly, this attention bias towards the positive images did not mediate the relationship between mindfulness and maintenance of positive mood. Future work should compare visual attention to other emotion regulation strategies that may maximise positive affect for mindful people.

Cognitive predictors of stress-induced mood malleability in depression

BACKGROUND & OBJECTIVES

Basic attentional control, negative biases in attention and interpretation, and rumination are all cognitive processes associated with depression; however, less is known about their predictive role in depressive mood reactivity and -recovery in response to stress, and their relation to severity of depression.

DESIGN & METHODS

We experimentally induced stress based on an autobiographical imagery script in a sample of 92 participants with Major Depressive Disorder with or without comorbid anxiety disorders. We used simple regression analysis for investigating the roles of state- and trait rumination, attentional networks, and attentional and interpretation biases for predicting stress-induced depressive mood reactivity and -recovery, respectively, and whether they in parallel mediated the association between cognitive processes and depression severity.

RESULTS

Stress-induced depressive mood reactivity was predicted by better orienting ability and more state rumination. Better recovery was predicted by better orienting efficiency and lower negative interpretation bias. Furthermore, the relation between state rumination and depression severity was partially mediated by depressive mood reactivity, however limited by the lack of temporal precedence in the analysis.

CONCLUSIONS

We characterized the relation between cognitive processes and mood malleability in response to stress. Findings could refine theoretical models of depression if causality is established.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04137367.

Borderline personality disorder features are associated with inflexible social interpretations

BACKGROUND

Borderline personality disorder (BPD) is thought to involve aberrant social learning, including impaired revision of social interpretations with new evidence (social interpretation inflexibility). However, this topic has received little empirical attention outside of specific literatures, such as moral inference or behavioral economics. Further, the contribution of comorbid depression to BPD-related interpretation inflexibility has not yet been assessed.

METHODS

In two independent samples (Study 1: N = 213; Study 2: N = 210, oversampled for BPD features), we assessed the associations between BPD symptoms, depressive symptoms, and task-based measures of social interpretation flexibility.

RESULTS

We found that BPD symptoms, particularly volatility of identity and relationships, were associated with less revision of social interpretations with both positive and negative evidence. Meanwhile, depressive symptoms were associated with a pattern of less revision of social interpretations with positive versus negative information.

LIMITATIONS

The use of cross-sectional, crowdsourced samples limits causal interpretations. Translation to clinical populations should be assessed in future studies.

CONCLUSIONS

Results suggest that inflexible social interpretations across valences may be a feature of BPD-related pathology, and could be connected to symptoms involving volatility in social contexts. Future studies should investigate whether treatments geared toward increasing the flexibility of social interpretations are effective in treating BPD symptoms, especially those involving interpersonal difficulties.

On the impulsivity path: Examining the unique and conjoint relations between emotion- and non-emotion-related impulsivity, internalizing symptoms, alcohol use, and physical health parameters

BACKGROUND

Researchers have increasingly differentiated trait-like tendencies toward impulsivity occurring during emotional states (emotion-related impulsivity [ERI]) from impulsivity not tied to emotion (non-ERI). Relative to non-ERI, ERI has shown robust correlations with psychopathology and mild to moderate associations with physical health parameters (e.g., physical activity, poor sleep quality, body mass index [BMI]). Therefore, we first aimed to investigate the unique contributions of ERI and non-ERI to psychopathology symptoms while controlling for neuroticism. Second, we sought to explore the combined associations of physical health parameters with several impulsivity forms.

METHODS

German-speaking adults (N = 350, 35.9 ± 14.6 years, 69.1% female, BMI: 24.0 ± 4.8 kg/m2 , mostly students or employees) completed measures of impulsivity, psychopathology symptoms, neuroticism, and physical health. We gathered measures of two ERI forms: Feelings Trigger Action and Pervasive Influence of Feelings. As a control comparison, we gathered a measure of non-ERI, the Lack of Follow-Through scale. We conducted separate path models for Aims 1 and 2.

RESULTS

For Aim 1, Pervasive Influence of Feelings showed strong links with internalizing symptoms. Feelings Trigger Action and Lack of Follow-Through showed small links with alcohol use. For Aim 2, poor sleep quality was related to all three impulsivity factors, while physical activity was only related to Pervasive Influence of Feelings and Lack of Follow-Through. BMI showed a curvilinear association with impulsivity.

CONCLUSIONS

ERI is more directly relevant than non-ERI for psychopathology symptoms, emphasizing the need to differentiate between the two ERI types. The association of ERI and non-ERI with physical activity and poor sleep quality may serve as potential treatment targets for impulsivity-related problems.

Neural Circuit Markers of Familial Risk for Depression Among Healthy Youths in the Adolescent Brain Cognitive Development Study

BACKGROUND

Family history of depression is a robust predictor of early-onset depression, which may confer risk through alterations in neural circuits that have been implicated in reward and emotional processing. These alterations may be evident in youths who are at familial risk for depression but who do not currently have depression. However, the identification of robust and replicable findings has been hindered by few studies and small sample sizes. In the current study, we sought to identify functional connectivity (FC) patterns associated with familial risk for depression.

METHODS

Participants included healthy (i.e., no lifetime psychiatric diagnoses) youths at high familial risk for depression (HR) (n = 754; at least one parent with a history of depression) and healthy youths at low familial risk for psychiatric problems (LR) (n = 1745; no parental history of psychopathology) who were 9 to 10 years of age and from the Adolescent Brain Cognitive Development (ABCD) Study sample. We conducted whole-brain seed-to-voxel analyses to examine group differences in resting-state FC with the amygdala, caudate, nucleus accumbens, and putamen. We hypothesized that HR youths would exhibit global amygdala hyperconnectivity and striatal hypoconnectivity patterns primarily driven by maternal risk.

RESULTS

HR youths exhibited weaker caudate-angular gyrus FC than LR youths (α = 0.04, Cohen's d = 0.17). HR youths with a history of maternal depression specifically exhibited weaker caudate-angular gyrus FC (α = 0.03, Cohen's d = 0.19) as well as weaker caudate-dorsolateral prefrontal cortex FC (α = 0.04, Cohen's d = 0.21) than LR youths.

CONCLUSIONS

Weaker striatal connectivity may be related to heightened familial risk for depression, primarily driven by maternal history. Identifying brain-based markers of depression risk in youths can inform approaches to improving early detection, diagnosis, and treatment.

Associations of alcohol and cannabis use with change in posttraumatic stress disorder and depression symptoms over time in recently trauma-exposed individuals

BACKGROUND

Several hypotheses may explain the association between substance use, posttraumatic stress disorder (PTSD), and depression. However, few studies have utilized a large multisite dataset to understand this complex relationship. Our study assessed the relationship between alcohol and cannabis use trajectories and PTSD and depression symptoms across 3 months in recently trauma-exposed civilians.

METHODS

In total, 1618 (1037 female) participants provided self-report data on past 30-day alcohol and cannabis use and PTSD and depression symptoms during their emergency department (baseline) visit. We reassessed participant's substance use and clinical symptoms 2, 8, and 12 weeks posttrauma. Latent class mixture modeling determined alcohol and cannabis use trajectories in the sample. Changes in PTSD and depression symptoms were assessed across alcohol and cannabis use trajectories via a mixed-model repeated-measures analysis of variance.

RESULTS

Three trajectory classes (low, high, increasing use) provided the best model fit for alcohol and cannabis use. The low alcohol use class exhibited lower PTSD symptoms at baseline than the high use class; the low cannabis use class exhibited lower PTSD and depression symptoms at baseline than the high and increasing use classes; these symptoms greatly increased at week 8 and declined at week 12. Participants who already use alcohol and cannabis exhibited greater PTSD and depression symptoms at baseline that increased at week 8 with a decrease in symptoms at week 12.

CONCLUSIONS

Our findings suggest that alcohol and cannabis use trajectories are associated with the intensity of posttrauma psychopathology. These findings could potentially inform the timing of therapeutic strategies.

Empathy is associated with interpersonal emotion regulation goals in everyday life

Responding to the emotions of the people around us is a phenomenon traversing human lives; however, research has only recently started exploring the predictors of interpersonal emotion regulation (IER). In two ecological momentary assessment studies conducted in 2021 and 2022, we tested whether facets of empathy (i.e., mentalizing, experience sharing, empathic concern, and personal distress) are associated with other-focused IER goals and their attainment in everyday life (Ns = 125 and 204). Study 1 examined associations between mentalizing, experience sharing, and global hedonic and counter-hedonic IER goals (i.e., making others feel better or worse) in a relatively young and predominantly female student sample in Germany. Study 2 expanded these findings to empathic concern, personal distress, and specific types of hedonic and counter-hedonic IER goals (i.e., increasing, decreasing, and/or maintaining others' positive and/or negative emotions) in a more diverse U.S. community sample. Participants primarily endorsed hedonic IER goals, which were associated with higher mentalizing and experience sharing in both studies and higher empathic concern and lower personal distress in Study 2. Counter-hedonic IER goals were positively associated with experience sharing and personal distress in Study 2. Conversely, empathic concern and mentalizing were negatively related to counter-hedonic IER goals. We also found differential associations for state and trait empathy with IER goals. All empathy facets except personal distress were positively associated with goal attainment in Study 2. These findings address a major gap in our knowledge about everyday IER and offer a novel perspective on empathy in social emotion regulation processes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Internal capsule microstructure mediates the relationship between childhood maltreatment and PTSD following adulthood trauma exposure

Childhood trauma is a known risk factor for trauma and stress-related disorders in adulthood. However, limited research has investigated the impact of childhood trauma on brain structure linked to later posttraumatic dysfunction. We investigated the effect of childhood trauma on white matter microstructure after recent trauma and its relationship with future posttraumatic dysfunction among trauma-exposed adult participants (n = 202) recruited from emergency departments as part of the AURORA Study. Participants completed self-report scales assessing prior childhood maltreatment within 2-weeks in addition to assessments of PTSD, depression, anxiety, and dissociation symptoms within 6-months of their traumatic event. Fractional anisotropy (FA) obtained from diffusion tensor imaging (DTI) collected at 2-weeks and 6-months was used to index white matter microstructure. Childhood maltreatment load predicted 6-month PTSD symptoms (b = 1.75, SE = 0.78, 95% CI = [0.20, 3.29]) and inversely varied with FA in the bilateral internal capsule (IC) at 2-weeks (p = 0.0294, FDR corrected) and 6-months (p = 0.0238, FDR corrected). We observed a significant indirect effect of childhood maltreatment load on 6-month PTSD symptoms through 2-week IC microstructure (b = 0.37, Boot SE = 0.18, 95% CI = [0.05, 0.76]) that fully mediated the effect of childhood maltreatment load on PCL-5 scores (b = 1.37, SE = 0.79, 95% CI = [-0.18, 2.93]). IC microstructure did not mediate relationships between childhood maltreatment and depressive, anxiety, or dissociative symptomatology. Our findings suggest a unique role for IC microstructure as a stable neural pathway between childhood trauma and future PTSD symptoms following recent trauma. Notably, our work did not support roles of white matter tracts previously found to vary with PTSD symptoms and childhood trauma exposure, including the cingulum bundle, uncinate fasciculus, and corpus callosum. Given the IC contains sensory fibers linked to perception and motor control, childhood maltreatment might impact the neural circuits that relay and process threat-related inputs and responses to trauma.

Social interpretation inflexibility moderates emotional reactions to social situations in children and adolescents

Interpretation biases and inflexibility (i.e., difficulties revising interpretations) have been linked to increased internalizing symptoms. Although adolescence is a developmental period characterized by novel social situations and increased vulnerability to internalizing disorders, no studies have examined interpretation inflexibility in adolescents. Additionally, no studies (on adolescents or adults) have examined interpretation flexibility as a protective factor against adverse outcomes of interpersonal events. Using a novel task and a 28-day diary we examined relations among interpretation bias and inflexibility, internalizing symptoms, and negative interpersonal events in a sample of children and adolescents (N = 159, ages 9-18). At baseline, negative interpretation bias was positively correlated with social anxiety symptoms, and positive interpretation bias negatively correlated with social anxiety and depressive symptoms. Inflexible positive interpretations were correlated with higher social anxiety and depressive symptoms, while inflexible negative interpretations were correlated with higher social anxiety. Finally, interpretation inflexibility moderated daily associations between negative interpersonal events and depressive symptoms in daily life, such that higher inflexibility was associated with stronger associations between interpersonal events and subsequent depressive symptoms, potentially increasing depressive symptom instability. These results suggest that interpretation biases and inflexibility may act as both risk and protective factors for adolescent anxiety and depression.

Attentional biases in facial emotion processing in individuals at clinical high risk for psychosis

Individuals at clinical high risk (CHR) for psychosis exhibit altered facial emotion processing (FEP) and poor social functioning. It is unclear whether FEP deficits result from attentional biases, and further, how these abnormalities are linked to symptomatology (e.g., negative symptoms) and highly comorbid disorders that are also tied to abnormal FEP (e.g., depression). In the present study, we employed an eye-tracking paradigm to assess attentional biases and clinical interviews to examine differences between CHR (N = 34) individuals and healthy controls (HC; N = 46), as well as how such biases relate to symptoms and functioning in CHR individuals. Although no CHR-HC differences emerged in attentional biases, within the CHR group, symptoms and functioning were related to biases. Depressive symptoms were related to some free-view attention switching biases (e.g., to and from fearful faces, r = .50). Negative symptoms were related to more slowly disengaging from happy faces (r = .44), spending less time looking at neutral faces (r =  - .42), and more time looking at no face (Avolition, r = .44). In addition, global social functioning was related to processes that overlapped with both depression and negative symptoms, including time looking at no face (r =  - .68) and free-view attention switching with fearful faces (r =  - .40). These findings are consistent with previous research, indicating that negative symptoms play a prominent role in the CHR syndrome, with distinct mechanisms relative to depression. Furthermore, the results suggest that attentional bias indices from eye-tracking paradigms may be predictive of social functioning.

Cognitive behavioral therapy following esketamine for major depression and suicidal ideation for relapse prevention: The CBT-ENDURE randomized clinical trial study protocol

In 2020, esketamine received a supplemental indication as a therapy for major depression with suicidal ideation (MDSI), based on protocols enrolling hospitalized patients. Given the high risk of suicide following hospital discharge and the high relapse rates following discontinuation of esketamine, the optimal long-term treatment approach remains unclear. Cognitive behavioral therapy (CBT) is highly effective in relapse prevention and has been shown to prevent suicide attempts in high-risk populations. Here we describe the study protocol for the CBT-ENDURE trial: Cognitive Behavioral Therapy Following Esketamine for Major Depression and SUicidal Ideation for RElapse Prevention. Patients with depression (N = 100) who are admitted to hospital or are outpatients with clinically significant suicidal ideation will be enrolled in the study. All patients will receive esketamine (twice weekly for four weeks) and will be randomly assigned (1:1 ratio) to receive a 16-week course of CBT plus treatment as usual (CBT group) or treatment as usual only (TAU only group). Patients are followed for a total of 6 months. Supported under a funding announcement from NIMH to conduct safety and feasibility trials for patients at high risk for suicide, the primary outcome of the CBT-ENDURE study is feasibility (as measured by recruitment and retention), with a key secondary outcome being relapse among those who experience substantial benefit following two weeks of esketamine.

Cortisol reactivity to a laboratory stressor predicts increases in depressive symptoms in perinatal and nulliparous women during population-level stress

BACKGROUND

Research suggests a link between stress and depression, especially in high-risk groups. The perinatal period is known as a time of increased risk for depression and pregnancy has been associated with alterations in cortisol levels; however, limited research has assessed cortisol reactivity during pregnancy. Finally, no studies have yet examined whether cortisol reactivity predicts later depressive symptoms during a population-level stressor, such as the COVID-19 pandemic.

METHODS

The current study examined whether cortisol reactivity in perinatal and nulliparous women a year before the onset of COVID-19 predicted increases in depressive symptoms during the initial stage of the pandemic. Participants were 68 women (33 pregnant, Mage = 30.6; 35 nulliparous, Mage = 28.4) who, approximately a year before COVID-19, responded to a depressive symptoms questionnaire and completed a psychosocial stress test, during which they provided salivary cortisol samples. Shortly after the onset of pandemic-related closures (April 2020; postpartum for previously pregnant participants), participants completed follow-up questionnaires assessing current depressive symptoms.

RESULTS

Analyses showed that cortisol reactivity at baseline predicted increases in depressive symptoms at follow-up. Perinatal and nulliparous women did not differ in this association.

LIMITATIONS

The present study was limited by a moderate sample size and heterogeneity in terms of gestational week, restricting inferences about specific stages of pregnancy.

CONCLUSIONS

Our findings suggest that cortisol reactivity to a laboratory stressor is a biomarker of risk for increased depressive symptoms during ecological stress in women. Biomarkers like these increase our understanding of depression risk and may help to identify individuals in need of interventions.

Prior Sexual Trauma Exposure Impacts Posttraumatic Dysfunction and Neural Circuitry Following a Recent Traumatic Event in the AURORA Study

Background

Prior sexual trauma (ST) is associated with greater risk for posttraumatic stress disorder after a subsequent traumatic event; however, the underlying neurobiological mechanisms remain opaque. We investigated longitudinal posttraumatic dysfunction and amygdala functional dynamics following admission to an emergency department for new primarily nonsexual trauma in participants with and without previous ST.

Methods

Participants (N = 2178) were recruited following acute trauma exposure (primarily motor vehicle collision). A subset (n = 242) completed magnetic resonance imaging that included a fearful faces task and a resting-state scan 2 weeks after the trauma. We investigated associations between prior ST and several dimensions of posttraumatic symptoms over 6 months. We further assessed amygdala activation and connectivity differences between groups with or without prior ST.

Results

Prior ST was associated with greater posttraumatic depression (F1,1120 = 28.35, p = 1.22 × 10-7, ηp2 = 0.06), anxiety (F1,1113 = 17.43, p = 3.21 × 10-5, ηp2 = 0.05), and posttraumatic stress disorder (F1,1027 = 11.34, p = 7.85 × 10-4, ηp2 = 0.04) severity and more maladaptive beliefs about pain (F1,1113 = 8.51, p = .004, ηp2 = 0.02) but was not related to amygdala reactivity to fearful versus neutral faces (all ps > .05). A secondary analysis revealed an interaction between ST and lifetime trauma load on the left amygdala to visual cortex connectivity (peak Z value: -4.41, corrected p < .02).

Conclusions

Findings suggest that prior ST is associated with heightened posttraumatic dysfunction following a new trauma exposure but not increased amygdala activity. In addition, ST may interact with lifetime trauma load to alter neural circuitry in visual processing regions following acute trauma exposure. Further research should probe the relationship between trauma type and visual circuitry in the acute aftermath of trauma.

The effect of attention bias modification on depressive symptoms in a comorbid sample: a randomized controlled trial

BACKGROUND

Studies investigating the long-term effect of attention bias modification (ABM) in clinical samples are lacking. This study investigates the 6-months follow-up effect of ABM on depressive symptoms in participant with major depressive disorder with and without comorbid disorders.

METHODS

We conducted a double-blind randomized sham-controlled trial in 101 participants between 19 November 2019, and 17 August 2021. Follow-up ended 3 April 2022. Participants were allocated to ABM or sham condition twice daily for 14 consecutive days. Primary outcomes were the total score on the Beck Depression Inventory-II (BDI-II) at 6 months, mean Brief State Rumination Inventory (BSRI) score post-treatment and reduction in BSRI post-treatment. Secondary outcome was change in attentional bias (AB). The trial was preregistered in ClinicalTrials.gov (#NCT04137367).

RESULTS

A total of 118 patients aged 18-65 years were assessed for eligibility, and 101 were randomized and subjected to intention-to-treat analyses. At 6 months, ABM had no effect on depression and anxiety compared to a sham condition. While rumination decreased during the intervention, there was no effect of condition on rumination and AB. Predictor analysis did not reveal differences between participants with ongoing major depressive episode or comorbid anxiety.

CONCLUSION

Compared to sham training, there was no effect of ABM on depressive symptoms at 6-months follow-up. Since the intervention failed at modifying AB, it is unclear whether changes in AB are related to long-term outcomes.

Development of a model to predict antidepressant treatment response for depression among Veterans

BACKGROUND

Only a limited number of patients with major depressive disorder (MDD) respond to a first course of antidepressant medication (ADM). We investigated the feasibility of creating a baseline model to determine which of these would be among patients beginning ADM treatment in the US Veterans Health Administration (VHA).

METHODS

A 2018-2020 national sample of n = 660 VHA patients receiving ADM treatment for MDD completed an extensive baseline self-report assessment near the beginning of treatment and a 3-month self-report follow-up assessment. Using baseline self-report data along with administrative and geospatial data, an ensemble machine learning method was used to develop a model for 3-month treatment response defined by the Quick Inventory of Depression Symptomatology Self-Report and a modified Sheehan Disability Scale. The model was developed in a 70% training sample and tested in the remaining 30% test sample.

RESULTS

In total, 35.7% of patients responded to treatment. The prediction model had an area under the ROC curve (s.e.) of 0.66 (0.04) in the test sample. A strong gradient in probability (s.e.) of treatment response was found across three subsamples of the test sample using training sample thresholds for high [45.6% (5.5)], intermediate [34.5% (7.6)], and low [11.1% (4.9)] probabilities of response. Baseline symptom severity, comorbidity, treatment characteristics (expectations, history, and aspects of current treatment), and protective/resilience factors were the most important predictors.

CONCLUSIONS

Although these results are promising, parallel models to predict response to alternative treatments based on data collected before initiating treatment would be needed for such models to help guide treatment selection.

Cognitive flexibility and emotion regulation: Dual layers of resilience against the emergence of paranoia

Cognitive inflexibility has been linked to difficulties in revising paranoid beliefs, whereas cognitive flexibility may protect against the development and maintenance of paranoid beliefs by allowing for troubleshooting in light of available evidence. While less discussed in the context of paranoia research, better regulation of affective states may reduce the likelihood of biased beliefs developing in the first place, reducing the burden on belief updating mechanisms. The present study hypothesized that high cognitive flexibility and strong emotion regulation ability may act as a reciprocal protective shield against the risk associated with lower ability in the other domain. Participants were recruited from the general population (N = 221) to complete the Ambiguous Interpretation Inflexibility Task, as well as self-report measures for paranoia and emotion regulation ability. The results show an interaction between cognitive flexibility and emotion regulation ability as related to less severe paranoia. Better emotion regulation ability is associated with lower paranoia in individuals with lower cognitive flexibility, whereas higher cognitive flexibility is associated with less severe paranoia in individuals with greater emotion regulation difficulties. These findings highlight the importance of emotion regulation in early interventions of paranoia, especially how emotion regulation relates to known cognitive vulnerabilities such as inflexibility.

Seeing red: Distraction influences visual attention for anger but not for other negative emotions

Emotion regulation is a vital skill that improves psychological well-being and overall functioning. Distraction (the purposeful internal disengagement from an emotional stimulus) and cognitive reappraisal (the process of changing one's thoughts about an emotional event/stimulus) are two well-established regulation strategies that can effectively decrease negative affect. Less understood, however, are the attention allocation strategies that occur when engaging in these emotion regulation strategies-specifically, do people visually scan emotional information differently when distracting vs. reappraising? In the current study, community participants were randomly assigned to either distract, reappraise, or view naturally while watching four emotional film clips that each elicited a different negative emotional state: anger, fear, sadness, and disgust. Eye tracking was used to record total time spent gazing ("dwell time") at faces within the emotion-eliciting film clips. An effect of condition was found for anger-eliciting material only: participants in the distraction condition exhibited shorter dwell times compared with reappraisal and natural viewing. Importantly, this effect was moderated by state anxiety, such that it was found at low but not high levels of state anxiety. These results show that emotion regulation strategies differentially affect attention to emotion-eliciting stimuli and points to the role of current affective states in impacting how distraction is used. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Neural responses to reward valence and magnitude from pre- to early adolescence

BACKGROUND

Neural activation during reward processing is thought to underlie critical behavioral changes that take place during the transition to adolescence (e.g., learning, risk-taking). Though literature on the neural basis of reward processing in adolescence is booming, important gaps remain. First, more information is needed regarding changes in functional neuroanatomy in early adolescence. Another gap is understanding whether sensitivity to different aspects of the incentive (e.g., magnitude and valence) changes during the transition into adolescence. We used fMRI from a large sample of preadolescent children to characterize neural responses to incentive valence vs. magnitude during anticipation and feedback, and their change over a period of two years.

METHODS

Data were taken from the Adolescent Cognitive and Brain DevelopmentSM (ABCD®) study release 3.0. Children completed the Monetary Incentive Delay task at baseline (ages 9-10) and year 2 follow-up (ages 11-12). Based on data from two sites (N = 491), we identified activation-based Regions of Interest (ROIs; e.g., striatum, prefrontal regions, etc.) that were sensitive to trial type (win $5, win $0.20, neutral, lose $0.20, lose $5) during anticipation and feedback phases. Then, in an independent subsample (N = 1470), we examined whether these ROIs were sensitive to valence and magnitude and whether that sensitivity changed over two years.

RESULTS

Our results show that most ROIs involved in reward processing (including the striatum, prefrontal cortex, and insula) are specialized, i.e., mainly sensitive to either incentive valence or magnitude, and this sensitivity was consistent over a 2-year period. The effect sizes of time and its interactions were significantly smaller (0.002≤η2≤0.02) than the effect size of trial type (0.06≤η2≤0.30). Interestingly, specialization was moderated by reward processing phase but was stable across development. Biological sex and pubertal status differences were few and inconsistent. Developmental changes were mostly evident during success feedback, where neural reactivity increased over time.

CONCLUSIONS

Our results suggest sub-specialization to valence vs. magnitude within many ROIs of the reward circuitry. Additionally, in line with theoretical models of adolescent development, our results suggest that the ability to benefit from success increases from pre- to early adolescence. These findings can inform educators and clinicians and facilitate empirical research of typical and atypical motivational behaviors during a critical time of development.

Structural inequities contribute to racial/ethnic differences in neurophysiological tone, but not threat reactivity, after trauma exposure

Considerable racial/ethnic disparities persist in exposure to life stressors and socioeconomic resources that can directly affect threat neurocircuitry, particularly the amygdala, that partially mediates susceptibility to adverse posttraumatic outcomes. Limited work to date, however, has investigated potential racial/ethnic variability in amygdala reactivity or connectivity that may in turn be related to outcomes such as post-traumatic stress disorder (PTSD). Participants from the AURORA study (n = 283), a multisite longitudinal study of trauma outcomes, completed functional magnetic resonance imaging and psychophysiology within approximately two-weeks of trauma exposure. Seed-based amygdala connectivity and amygdala reactivity during passive viewing of fearful and neutral faces were assessed during fMRI. Physiological activity was assessed during Pavlovian threat conditioning. Participants also reported the severity of posttraumatic symptoms 3 and 6 months after trauma. Black individuals showed lower baseline skin conductance levels and startle compared to White individuals, but no differences were observed in physiological reactions to threat. Further, Hispanic and Black participants showed greater amygdala connectivity to regions including the dorsolateral prefrontal cortex (PFC), dorsal anterior cingulate cortex, insula, and cerebellum compared to White participants. No differences were observed in amygdala reactivity to threat. Amygdala connectivity was associated with 3-month PTSD symptoms, but the associations differed by racial/ethnic group and were partly driven by group differences in structural inequities. The present findings suggest variability in tonic neurophysiological arousal in the early aftermath of trauma between racial/ethnic groups, driven by structural inequality, impacts neural processes that mediate susceptibility to later PTSD symptoms.

Interplay between uncertainty intolerance, emotion regulation, cognitive flexibility, and psychopathology during the COVID-19 pandemic: a multi-wave study

The COVID-19 pandemic has created a significant mental health burden on the global population. Studies during the pandemic have shown that risk factors such as intolerance of uncertainty and maladaptive emotion regulation are associated with increased psychopathology. Meanwhile, protective factors such as cognitive control and cognitive flexibility have been shown to protect mental health during the pandemic. However, the potential pathways through which these risk and protective factors function to impact mental health during the pandemic remain unclear. In the present multi-wave study, 304 individuals (18 years or older, 191 Males), residing in the USA during data collection, completed weekly online assessments of validated questionnaires across a period of five weeks (27th March 2020-1st May 2020). Mediation analyses revealed that longitudinal changes in emotion regulation difficulties mediated the effect of increases in intolerance of uncertainty on increases in stress, depression, and anxiety during the COVID-19 pandemic. Further, individual differences in cognitive control and flexibility moderated the relationship between intolerance of uncertainty and emotion regulation difficulties. While intolerance of uncertainty and emotion regulation difficulties emerged as risk factors for mental health, cognitive control and flexibility seems to protect against the negative effects of the pandemic and promote stress resilience. Interventions aimed at enhancing cognitive control and flexibility might promote the protection of mental health in similar global crises in the future.

Emotion regulation and disordered eating behaviour in youths: Two daily-diary studies

OBJECTIVE

Disordered eating cognitions and behaviours in childhood and adolescence have been identified as precursors for the development of eating disorders. Another important contributor to eating disorder risk is maladaptive emotion regulation. However, while the regulation of negative affect has been the focus of much research, the literature on the role of positive emotion regulation in eating pathology is extremely limited. The present study extends previous research by examining the regulation of both positive and negative affect in disordered eating using two waves of a daily diary design.

METHOD

Every evening for 21 days, 139 youths (8-15 years) reported their use of rumination, dampening, and disordered eating cognitions and behaviours. 1 year later, during the onset of the COVID-19 pandemic, 115 of these youths were followed-up.

RESULTS

As predicted, higher levels of rumination and dampening were found to be associated with a higher frequency of weight concerns and restrictive eating on person-level (both Waves) and day-level (Wave 2). Further, a higher frequency of rumination at Wave 1 predicted increases in the frequency of restrictive eating 1 year later.

CONCLUSIONS

Our findings underline the importance of examining regulation of both positive and negative emotion in order to understand eating disorder risk.

Choosing to avoid the positive? Emotion regulation strategy choice in depression

Individuals with major depressive disorder (MDD) are more likely than nondepressed individuals to use emotion regulation strategies that decrease pleasant emotions (e.g., distraction from positive stimuli) and increase unpleasant emotions (e.g., negative rumination). If such strategies are actively chosen, these choices may partly reflect weaker motivation for pleasant emotions or stronger motivation for unpleasant emotions. Therefore, this investigation tested, for the first time, whether such strategies are actively chosen, even when alternatives are available. In Study 1, using a behavioral task, MDD participants (N = 38) were more likely than healthy controls (N = 39) to choose to use distraction over positive rumination in response to pleasant stimuli, resulting in reductions in pleasant affect. When instructed to choose the strategy that would make them feel better, however, MDD participants did not differ from controls in their strategy choices. In Study 2, using ecological momentary assessments, MDD participants (N = 58) were more likely than controls (N = 62) to use distraction from pleasant emotions and to use negative rumination in daily life. This pattern of strategy use was predicted by stronger motivation for unpleasant emotions among MDD participants, compared to controls. Stronger motivation for unpleasant emotions in daily life also predicted increases in unpleasant affect and decreases in pleasant affect. Findings suggest that compared to nondepressed individuals, people with MDD are more likely to choose emotion regulation strategies that decrease pleasant emotions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Prior differences in previous trauma exposure primarily drive the observed racial/ethnic differences in posttrauma depression and anxiety following a recent trauma

BACKGROUND

Racial and ethnic groups in the USA differ in the prevalence of posttraumatic stress disorder (PTSD). Recent research however has not observed consistent racial/ethnic differences in posttraumatic stress in the early aftermath of trauma, suggesting that such differences in chronic PTSD rates may be related to differences in recovery over time.

METHODS

As part of the multisite, longitudinal AURORA study, we investigated racial/ethnic differences in PTSD and related outcomes within 3 months after trauma. Participants (n = 930) were recruited from emergency departments across the USA and provided periodic (2 weeks, 8 weeks, and 3 months after trauma) self-report assessments of PTSD, depression, dissociation, anxiety, and resilience. Linear models were completed to investigate racial/ethnic differences in posttraumatic dysfunction with subsequent follow-up models assessing potential effects of prior life stressors.

RESULTS

Racial/ethnic groups did not differ in symptoms over time; however, Black participants showed reduced posttraumatic depression and anxiety symptoms overall compared to Hispanic participants and White participants. Racial/ethnic differences were not attenuated after accounting for differences in sociodemographic factors. However, racial/ethnic differences in depression and anxiety were no longer significant after accounting for greater prior trauma exposure and childhood emotional abuse in White participants.

CONCLUSIONS

The present findings suggest prior differences in previous trauma exposure partially mediate the observed racial/ethnic differences in posttraumatic depression and anxiety symptoms following a recent trauma. Our findings further demonstrate that racial/ethnic groups show similar rates of symptom recovery over time. Future work utilizing longer time-scale data is needed to elucidate potential racial/ethnic differences in long-term symptom trajectories.

Development of a model to predict combined antidepressant medication and psychotherapy treatment response for depression among veterans

BACKGROUND

Although research shows that more depressed patients respond to combined antidepressants (ADM) and psychotherapy than either alone, many patients do not respond even to combined treatment. A reliable prediction model for this could help treatment decision-making. We attempted to create such a model using machine learning methods among patients in the US Veterans Health Administration (VHA).

METHODS

A 2018-2020 national sample of VHA patients beginning combined depression treatment completed self-report assessments at baseline and 3 months (n = 658). A learning model was developed using baseline self-report, administrative, and geospatial data to predict 3-month treatment response defined by reductions in the Quick Inventory of Depression Symptomatology Self-Report and/or in the Sheehan Disability Scale. The model was developed in a 70 % training sample and tested in the remaining 30 % test sample.

RESULTS

30.0 % of patients responded to treatment. The prediction model had a test sample AUC-ROC of 0.657. A strong gradient was found in probability of treatment response from 52.7 % in the highest predicted quintile to 14.4 % in the lowest predicted quintile. The most important predictors were episode characteristics (symptoms, comorbidities, history), personality/psychological resilience, recent stressors, and treatment characteristics.

LIMITATIONS

Restrictions in sample definition, a low recruitment rate, and reliance on patient self-report rather than clinician assessments to determine treatment response limited the generalizability of results.

CONCLUSIONS

A machine learning model could help depressed patients and providers predict likely response to combined ADM-psychotherapy. Parallel information about potential harms and costs of alternative treatments would be needed, though, to inform optimal treatment selection.

Derivation and Validation of a Brief Emergency Department-Based Prediction Tool for Posttraumatic Stress After Motor Vehicle Collision

STUDY OBJECTIVE

To derive and initially validate a brief bedside clinical decision support tool that identifies emergency department (ED) patients at high risk of substantial, persistent posttraumatic stress symptoms after a motor vehicle collision.

METHODS

Derivation (n=1,282, 19 ED sites) and validation (n=282, 11 separate ED sites) data were obtained from adults prospectively enrolled in the Advancing Understanding of RecOvery afteR traumA study who were discharged from the ED after motor vehicle collision-related trauma. The primary outcome was substantial posttraumatic stress symptoms at 3 months (Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders-5 ≥38). Logistic regression derivation models were evaluated for discriminative ability using the area under the curve and the accuracy of predicted risk probabilities (Brier score). Candidate posttraumatic stress predictors assessed in these models (n=265) spanned a range of sociodemographic, baseline health, peritraumatic, and mechanistic domains. The final model selection was based on performance and ease of administration.

RESULTS

Significant 3-month posttraumatic stress symptoms were common in the derivation (27%) and validation (26%) cohort. The area under the curve and Brier score of the final 8-question tool were 0.82 and 0.14 in the derivation cohort and 0.76 and 0.17 in the validation cohort.

CONCLUSION

This simple 8-question tool demonstrates promise to risk-stratify individuals with substantial posttraumatic stress symptoms who are discharged to home after a motor vehicle collision. Both external validation of this instrument, and work to further develop more accurate tools, are needed. Such tools might benefit public health by enabling the conduct of preventive intervention trials and assisting the growing number of EDs that provide services to trauma survivors aimed at promoting psychological recovery.

"Don't [ruminate], be happy": A cognitive perspective linking depression and anhedonia

Anhedonia, a lack of pleasure in things an individual once enjoyed, and rumination, the process of perseverative and repetitive attention to specific thoughts, are hallmark features of depression. Though these both contribute to the same debilitating disorder, they have often been studied independently and through different theoretical lenses (e.g., biological vs. cognitive). Cognitive theories and research on rumination have largely focused on understanding negative affect in depression with much less focus on the etiology and maintenance of anhedonia. In this paper, we argue that by examining the relation between cognitive constructs and deficits in positive affect, we may better understand anhedonia in depression thereby improving prevention and intervention efforts. We review the extant literature on cognitive deficits in depression and discuss how these dysfunctions may not only lead to sustained negative affect but, importantly, interfere with an ability to attend to social and environmental cues that could restore positive affect. Specifically, we discuss how rumination is associated to deficits in working memory and propose that these deficits in working memory may contribute to anhedonia in depression. We further argue that analytical approaches such as computational modeling are needed to study these questions and, finally, discuss implications for treatment.

Social Interpretation Inflexibility and Functioning: Associations with Symptoms and Stress

Introduction: Interpretation inflexibility has been implicated in a range of mental health problems, including depression, social anxiety, and paranoia. Inflexible interpretation of social situations may be particularly important as it can set the stage for problems in social functioning, a symptom cutting across all three groups of disorders. Methods: This study aimed to examine the interrelations among interpretation inflexibility, social functioning impairment, and affective and psychotic symptoms. The study also explored the potential moderating effects of COVID-related preoccupation, as an example of a major stressor, on these relationships. Results: Based on a sample recruited from the general population (N = 247), interpretation inflexibility was found to be associated with social functioning impairment, with affective symptoms and paranoia as statistical mediators of the association. These relationships were magnified by ambient stress during the COVID-19 pandemic—a moderated mediation that was found only in relation to affective symptoms but not paranoia. A parallel network analysis further confirmed the moderating effects of COVID-related preoccupation on the relation between interpretation inflexibility and depression. Limitations: Measuring ambient stress with a self-report question on COVID-related preoccupation may not be representative of the amount of distress an individual experienced during the pandemic. Also, our mediation models were performed on cross-sectional data, thus not necessarily implying a feed-forward causal mediational relationship. Conclusions: These findings highlight the importance of examining social functioning as a crucial outcome, as well as the differential role of stress in modulating social interpretation flexibility with respect to affective vs. psychotic symptoms.

Use of serial smartphone-based assessments to characterize diverse neuropsychiatric symptom trajectories in a large trauma survivor cohort

The authors sought to characterize adverse posttraumatic neuropsychiatric sequelae (APNS) symptom trajectories across ten symptom domains (pain, depression, sleep, nightmares, avoidance, re-experiencing, anxiety, hyperarousal, somatic, and mental/fatigue symptoms) in a large, diverse, understudied sample of motor vehicle collision (MVC) survivors. More than two thousand MVC survivors were enrolled in the emergency department (ED) and completed a rotating battery of brief smartphone-based surveys over a 2-month period. Measurement models developed from survey item responses were used in latent growth curve/mixture modeling to characterize homogeneous symptom trajectories. Associations between individual trajectories and pre-trauma and peritraumatic characteristics and traditional outcomes were compared, along with associations within and between trajectories. APNS across all ten symptom domains were common in the first two months after trauma. Many risk factors and associations with high symptom burden trajectories were shared across domains. Both across and within traditional diagnostic boundaries, APNS trajectory intercepts, and slopes were substantially correlated. Across all domains, symptom severity in the immediate aftermath of trauma (trajectory intercepts) had the greatest influence on the outcome. An interactive data visualization tool was developed to allow readers to explore relationships of interest between individual characteristics, symptom trajectories, and traditional outcomes ( http://itr.med.unc.edu/aurora/parcoord/ ). Individuals presenting to the ED after MVC commonly experience a broad constellation of adverse posttraumatic symptoms. Many risk factors for diverse APNS are shared. Individuals diagnosed with a single traditional outcome should be screened for others. The utility of multidimensional categorizations that characterize individuals across traditional diagnostic domains should be explored.

Social impression formation and depression: examining cognitive flexibility and bias

Depression is associated with a bias toward negative interpretations of social situations and resistance to integrating evidence consistent with positive interpretations. These features could contribute to social isolation by generating negative expected value for future social interactions. The present study examined potential associations between depressive symptoms and positive (i.e. trust and liking) and negative (i.e. distrust and disliking) social impression formation of individuals who previously appeared in positive or negative contexts. Participants (N = 213) completed the Interpretation Inflexibility Task and were subsequently asked to provide social impression ratings of characters from each scenario type of the task (i.e. positive and negative) as well as characters not previously encountered. In examining social impression formation, higher severity of depressive symptoms was associated with higher negative social impression ratings regardless of scenario outcome, as well as lower positive social impression ratings, but only for characters who previously appeared in positive contexts. Those higher in depression also rated novel characters as significantly more unlikeable and untrustworthy and to an equivalent degree as the characters previously encountered. These findings suggest a role of negative interpretation bias and inflexibility in contributing to negative evaluations of potential social interaction partners in depression.

Individual and environmental correlates of childhood maltreatment and exposure to community violence: Utilizing a latent profile and a multilevel meta-analytic approach

BACKGROUND

Childhood maltreatment (CM) and exposure to community violence (ETV) are correlated with physical/mental health and psychosocial problems. Typically, CM and ETV are examined separately, by subtypes within category, or collapsed across both into one category of adversity. Consequently, research is limited in identifying subgroups of individuals with different amounts of exposure to both CM and ETV. Accordingly, we lack sufficient understanding of the extent to which problems associated with CM and ETV vary based on the amount (i.e. dose) of exposure to both of these experiences.

METHODS

We used 20 samples (28,300 individuals) to estimate person-centered profiles of CM and ETV occurrence and co-occurrence within each sample. An individual data multilevel meta-analytic framework was used to determine the average effect size across samples for different profiles and conditional probability correlations within sociodemographic, neighborhood, health, mental health, and psychosocial domains.

RESULTS

The profile characterized by high levels of CM and high levels of ETV correlated with stressful life events, depression and anxiety symptoms, and general indicators of externalizing behaviors. CM predominant profiles were associated with mental health diagnoses and treatment. ETV predominant profiles associated with risk-taking/violent behavior and neighborhood-level disadvantage. However, nuance based on the dose of CM or ETV was evident.

CONCLUSIONS

It is important to identify subgroups based on the amount of exposure to CM and ETV. These subgroups have differential relationships with correlates across domains. Greater delineation and description of the lived experience will allow for more precision in addressing the burden of childhood adversity.

Anxiety sensitivity as a transdiagnostic risk factor for trajectories of adverse posttraumatic neuropsychiatric sequelae in the AURORA study

Anxiety sensitivity, or fear of anxious arousal, is cross-sectionally associated with a wide array of adverse posttraumatic neuropsychiatric sequelae, including symptoms of posttraumatic stress disorder, depression, anxiety, sleep disturbance, pain, and somatization. The current study utilizes a large-scale, multi-site, prospective study of trauma survivors presenting to emergency departments. Hypotheses tested whether elevated anxiety sensitivity in the immediate posttrauma period is associated with more severe and persistent trajectories of common adverse posttraumatic neuropsychiatric sequelae in the eight weeks posttrauma. Participants from the AURORA study (n = 2,269 recruited from 23 emergency departments) completed self-report assessments over eight weeks posttrauma. Associations between heightened anxiety sensitivity and more severe and/or persistent trajectories of trauma-related symptoms identified by growth mixture modeling were analyzed. Anxiety sensitivity assessed two weeks posttrauma was associated with severe and/or persistent posttraumatic stress, depression, anxiety, sleep disturbance, pain, and somatic symptoms in the eight weeks posttrauma. Effect sizes were in the small to medium range in multivariate models accounting for various demographic, trauma-related, pre-trauma mental health-related, and personality-related factors. Anxiety sensitivity may be a useful transdiagnostic risk factor in the immediate posttraumatic period identifying individuals at risk for the development of adverse posttraumatic neuropsychiatric sequelae. Further, considering anxiety sensitivity is malleable via brief intervention, it could be a useful secondary prevention target. Future research should continue to evaluate associations between anxiety sensitivity and trauma-related pathology.

Which features of repetitive negative thinking and positive reappraisal predict depression? An in-depth investigation using artificial neural networks with feature selection

Emotion regulation habits have long been implicated in risk for depression. However, research in this area traditionally adopts an approach that ignores the multifaceted nature of emotion regulation strategies, the clinical heterogeneity of depression, and potential differential relations between emotion regulation features and individual symptoms. To address limitations associated with the dominant aggregate-level approach, this study aimed to identify which features of key emotion regulation strategies are most predictive and when those features are most predictive of individual symptoms of depression across different time lags. Leveraging novel developments in the field of machine learning, artificial neural network models with feature selection were estimated using data from 460 participants who participated in a 20-wave longitudinal study with weekly assessments. At each wave, participants completed measures of repetitive negative thinking, positive reappraisal, perceived stress, and depression symptoms. Results revealed that specific features of repetitive negative thinking (wondering "why cannot I get going?" and having thoughts or images about feelings of loneliness) and positive reappraisal (looking for positive sides) were important indicators for detecting various depressive symptoms, above and beyond perceived stress. These features had overlapping and unique predictive relations with individual cognitive, affective, and somatic symptoms. Examining temporal fluctuations in the predictive utility, results showed that the utility of these emotion regulation features was stable over time. These findings illuminate potential pathways through which emotion regulation features may confer risk for depression and help to identify actionable targets for its prevention and treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Predicting at-risk opioid use three months after ed visit for trauma: Results from the AURORA study

Objective

Whether short-term, low-potency opioid prescriptions for acute pain lead to future at-risk opioid use remains controversial and inadequately characterized. Our objective was to measure the association between emergency department (ED) opioid analgesic exposure after a physical, trauma-related event and subsequent opioid use. We hypothesized ED opioid analgesic exposure is associated with subsequent at-risk opioid use.

Methods

Participants were enrolled in AURORA, a prospective cohort study of adult patients in 29 U.S., urban EDs receiving care for a traumatic event. Exclusion criteria were hospital admission, persons reporting any non-medical opioid use (e.g., opioids without prescription or taking more than prescribed for euphoria) in the 30 days before enrollment, and missing or incomplete data regarding opioid exposure or pain. We used multivariable logistic regression to assess the relationship between ED opioid exposure and at-risk opioid use, defined as any self-reported non-medical opioid use after initial ED encounter or prescription opioid use at 3-months.

Results

Of 1441 subjects completing 3-month follow-up, 872 participants were included for analysis. At-risk opioid use occurred within 3 months in 33/620 (5.3%, CI: 3.7,7.4) participants without ED opioid analgesic exposure; 4/16 (25.0%, CI: 8.3, 52.6) with ED opioid prescription only; 17/146 (11.6%, CI: 7.1, 18.3) with ED opioid administration only; 12/90 (13.3%, CI: 7.4, 22.5) with both. Controlling for clinical factors, adjusted odds ratios (aORs) for at-risk opioid use after ED opioid exposure were: ED prescription only: 4.9 (95% CI 1.4, 17.4); ED administration for analgesia only: 2.0 (CI 1.0, 3.8); both: 2.8 (CI 1.2, 6.5).

Conclusions

ED opioids were associated with subsequent at-risk opioid use within three months in a geographically diverse cohort of adult trauma patients. This supports need for prospective studies focused on the long-term consequences of ED opioid analgesic exposure to estimate individual risk and guide therapeutic decision-making.

Learned helplessness: expanding on a goal-directed perspective

This commentary reviews a novel model of learned helplessness proposed by Boddez et al. in this issue of Cognition and Emotion. Combining operant and goal-directed perspectives, Boddez et al. suggest that helplessness stems from a lack of reinforcement when striving toward a goal, with the degree of generalisation dependent on subjective perceptions of goal similarity. We begin by reviewing the theoretical model, describe possible expansions from a cognitive perspective, and discuss several considerations. We finish with a brief discussion of possible directions for future work.

Persistent Dissociation and Its Neural Correlates in Predicting Outcomes After Trauma Exposure

OBJECTIVE

Dissociation, a disruption or discontinuity in psychological functioning, is often linked with worse psychiatric symptoms; however, the prognostic value of dissociation after trauma is inconsistent. Determining whether trauma-related dissociation is uniquely predictive of later outcomes would enable early identification of at-risk trauma populations. The authors conducted the largest prospective longitudinal biomarker study of persistent dissociation to date to determine its predictive capacity for adverse psychiatric outcomes following acute trauma.

METHODS

All data were part of the Freeze 2 data release from the Advancing Understanding of Recovery After Trauma (AURORA) study. Study participants provided self-report data about persistent derealization (N=1,464), a severe type of dissociation, and completed a functional MRI emotion reactivity task and resting-state scan 2 weeks posttrauma (N=145). Three-month follow-up reports were collected of posttraumatic stress, depression, pain, anxiety symptoms, and functional impairment.

RESULTS

Derealization was associated with increased ventromedial prefrontal cortex (vmPFC) activation in the emotion reactivity task and decreased resting-state vmPFC connectivity with the cerebellum and orbitofrontal cortex. In separate analyses, brain-based and self-report measures of persistent derealization at 2 weeks predicted worse 3-month posttraumatic stress symptoms, distinct from the effects of childhood maltreatment history and current posttraumatic stress symptoms.

CONCLUSIONS

The findings suggest that persistent derealization is both an early psychological and biological marker of worse later psychiatric outcomes. The neural correlates of trauma-related dissociation may serve as potential targets for treatment engagement to prevent posttraumatic stress disorder. These results underscore dissociation assessment as crucial following trauma exposure to identify at-risk individuals, and they highlight an unmet clinical need for tailored early interventions.

Hippocampal Threat Reactivity Interacts with Physiological Arousal to Predict PTSD Symptoms

Hippo campal impairments are reliably associated with post-traumatic stress disorder (PTSD); however, little research has characterized how increased threat sensitivity may interact with arousal responses to alter hippocampal reactivity, and further how these interactions relate to the sequelae of trauma-related symptoms. In a sample of individuals recently exposed to trauma (N = 116, 76 female), we found that PTSD symptoms at 2 weeks were associated with decreased hippocampal responses to threat as assessed with fMRI. Further, the relationship between hippocampal threat sensitivity and PTSD symptomology only emerged in individuals who showed transient, high threat-related arousal, as assayed by an independently collected measure of fear potentiated startle. Collectively, our finding suggests that development of PTSD is associated with threat-related decreases in hippocampal function because of increases in fear-potentiated arousal.SIGNIFICANCE STATEMENT Alterations in hippocampal function linked to threat-related arousal are reliably associated with post-traumatic stress disorder (PTSD); however, how these alterations relate to the sequelae of trauma-related symptoms is unknown. Prior models based on nontrauma samples suggest that arousal may impact hippocampal neurophysiology leading to maladaptive behavior. Here we show that decreased hippocampal threat sensitivity interacts with fear-potentiated startle to predict PTSD symptoms. Specifically, individuals with high fear-potentiated startle and low, transient hippocampal threat sensitivity showed the greatest PTSD symptomology. These findings bridge literatures of threat-related arousal and hippocampal function to better understand PTSD risk.

Structural covariance of the ventral visual stream predicts posttraumatic intrusion and nightmare symptoms: a multivariate data fusion analysis

Visual components of trauma memories are often vividly re-experienced by survivors with deleterious consequences for normal function. Neuroimaging research on trauma has primarily focused on threat-processing circuitry as core to trauma-related dysfunction. Conversely, limited attention has been given to visual circuitry which may be particularly relevant to posttraumatic stress disorder (PTSD). Prior work suggests that the ventral visual stream is directly related to the cognitive and affective disturbances observed in PTSD and may be predictive of later symptom expression. The present study used multimodal magnetic resonance imaging data (n = 278) collected two weeks after trauma exposure from the AURORA study, a longitudinal, multisite investigation of adverse posttraumatic neuropsychiatric sequelae. Indices of gray and white matter were combined using data fusion to identify a structural covariance network (SCN) of the ventral visual stream 2 weeks after trauma. Participant's loadings on the SCN were positively associated with both intrusion symptoms and intensity of nightmares. Further, SCN loadings moderated connectivity between a previously observed amygdala-hippocampal functional covariance network and the inferior temporal gyrus. Follow-up MRI data at 6 months showed an inverse relationship between SCN loadings and negative alterations in cognition in mood. Further, individuals who showed decreased strength of the SCN between 2 weeks and 6 months had generally higher PTSD symptom severity over time. The present findings highlight a role for structural integrity of the ventral visual stream in the development of PTSD. The ventral visual stream may be particularly important for the consolidation or retrieval of trauma memories and may contribute to efficient reactivation of visual components of the trauma memory, thereby exacerbating PTSD symptoms. Potentially chronic engagement of the network may lead to reduced structural integrity which becomes a risk factor for lasting PTSD symptoms.

Socio-demographic and trauma-related predictors of depression within eight weeks of motor vehicle collision in the AURORA study

BACKGROUND

This is the first report on the association between trauma exposure and depression from the Advancing Understanding of RecOvery afteR traumA(AURORA) multisite longitudinal study of adverse post-traumatic neuropsychiatric sequelae (APNS) among participants seeking emergency department (ED) treatment in the aftermath of a traumatic life experience.

METHODS

We focus on participants presenting at EDs after a motor vehicle collision (MVC), which characterizes most AURORA participants, and examine associations of participant socio-demographics and MVC characteristics with 8-week depression as mediated through peritraumatic symptoms and 2-week depression.

RESULTS

Eight-week depression prevalence was relatively high (27.8%) and associated with several MVC characteristics (being passenger v. driver; injuries to other people). Peritraumatic distress was associated with 2-week but not 8-week depression. Most of these associations held when controlling for peritraumatic symptoms and, to a lesser degree, depressive symptoms at 2-weeks post-trauma.

CONCLUSIONS

These observations, coupled with substantial variation in the relative strength of the mediating pathways across predictors, raises the possibility of diverse and potentially complex underlying biological and psychological processes that remain to be elucidated in more in-depth analyses of the rich and evolving AURORA database to find new targets for intervention and new tools for risk-based stratification following trauma exposure.

Computerized Working Memory Training in Remission From Major Depressive Disorder: Effects on Emotional Working Memory, Processing Speed, Executive Functions, and Associations With Symptoms

Introduction

Remission from major depressive disorder (MDD) is associated with residual symptoms related to reduced functioning, quality of life, and relapse risk. Previous studies have raised questions about mechanisms involved-in and affected by cognitive training. This study investigated the associations and changes among depressive symptoms, rumination, processing speed (PS), executive functioning (EF), and emotional working memory (e-WM) pre- post computerized working memory training (CWMT).

Method

Twenty-nine remitted participants were included in a pre- post pilot study of within-subject effects of online CWMT. A total of 20 participants completed the intervention and pre- post tests of EF and PS, e-WM, in addition to symptom and rumination measures. Associations between changes in symptoms and cognition were investigated pre- post. Associations between improvements in CWMT, depression history, and changes in cognition were explored. Hypotheses and statistics were preregistered before data were analyzed.

Results

Manipulation of negatively valanced stimuli in e-WM showed an inverse association with rumination pre-intervention, but the association disappeared post-intervention. Cognitive functioning improved in most conditions with largest effects in EF. Symptoms did not change in the remitted sample. CWMT improvements were related to improvements in some aspects of EF and PS, but also to worse self-reported attention. Depression history was related to less improvement in EF.

Limitations

Sample size was small and there was dropout from the study. There was no control group, thus precluding practice and placebo effects and causal relationships.

Conclusions

Computerized WM training improves cognitive functions and could influence associations between e-WM and rumination. This could counteract functional impairment following MDD.

A five-factor model of perseverative thought

Like diagnostic status, clinically relevant thought remains overwhelmingly conceptualized in terms of discrete categories (e.g., worry, rumination, obsessions). However, definitions can vary widely. The area of perseverative thought (or clinically relevant thought more broadly) would benefit substantially from a consensus-based, empirically grounded taxonomy similar to the Hierarchical Taxonomy of Psychopathology (Kotov et al., 2017) or the Big Five for personality. This article addresses three major barriers to establishing such a taxonomy: (a) a lack of research explicitly comparing categorical (subtype) versus dimensional models, (b) primary reliance on between-person measures rather than modeling at the level of the thought (within person), and (c) insufficient emphasis on replication and refinement. Participants included an unselected crowdsourced sample (790 observations from 286 participants) and an independent anxious-depressed replication sample (808 observations from 277 participants). Participants made dimensional ratings for three idiographic clinically relevant thoughts on a range of features. Multilevel latent class analysis and multilevel exploratory factor analysis were applied to identify and extract natural patterns of covariation among features at the level of the thought, controlling for person-level tendencies. A consistent five-dimension solution emerged across both samples and reliably outperformed the best-fitting categorical solution in terms of fit, replicability, and explanatory power. Identified dimensions were dyscontrol, self-focus, valence, interpersonal, and uncertainty. Findings support a five-factor latent structure of perseverative thought. Theoretical, empirical, and clinical implications and future directions are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Neurocognition after motor vehicle collision and adverse post-traumatic neuropsychiatric sequelae within 8 weeks: Initial findings from the AURORA study

BACKGROUND

Previous work has indicated that differences in neurocognitive functioning may predict the development of adverse post-traumatic neuropsychiatric sequelae (APNS). Such differences may be vulnerability factors or simply correlates of APNS-related symptoms. Longitudinal studies that measure neurocognitive functioning at the time of trauma are needed to determine whether such differences precede the development of APNS.

METHODS

Here, we present findings from a subsample of 666 ambulatory patients from the AURORA (Advancing Understanding of RecOvery afteR trumA) study. All patients presented to EDs after a motor vehicle collision (MVC). We examined associations of neurocognitive test performance shortly after MVC with peritraumatic symptoms in the ED and APNS (depression, post-traumatic stress, post-concussive symptoms, and pain) 2 weeks and 8 weeks later. Neurocognitive tests assessed processing speed, attention, verbal reasoning, memory, and social perception.

RESULTS

Distress in the ED was associated with poorer processing speed and short-term memory. Poorer short-term memory was also associated with depression at 2 weeks post-MVC, even after controlling for peritraumatic distress. Finally, higher vocabulary scores were associated with pain 2 weeks post-MVC.

LIMITATIONS

Self-selection biases among those who present to the ED and enroll in the study limit generalizability. Also, it is not clear whether observed neurocognitive differences predate MVC exposure or arise in the immediate aftermath of MVC exposure.

CONCLUSIONS

Our results suggest that processing speed and short-term memory may be useful predictors of trauma-related characteristics and the development of some APNS, making such measures clinically-relevant for identifying at-risk individuals.

Prior histories of posttraumatic stress disorder and major depression and their onset and course in the three months after a motor vehicle collision in the AURORA study

BACKGROUND

A better understanding of the extent to which prior occurrences of posttraumatic stress disorder (PTSD) and major depressive episode (MDE) predict psychopathological reactions to subsequent traumas might be useful in targeting posttraumatic preventive interventions.

METHODS

Data come from 1306 patients presenting to 29 U.S. emergency departments (EDs) after a motor vehicle collision (MVC) in the advancing understanding of recovery after trauma study. Patients completed self-reports in the ED and 2-weeks, 8-weeks, and 3-months post-MVC. Associations of pre-MVC probable PTSD and probable MDE histories with subsequent 3-months post-MVC probable PTSD and probable MDE were examined along with mediation through intervening peritraumatic, 2-, and 8-week disorders.

RESULTS

27.6% of patients had 3-month post-MVC probable PTSD and/or MDE. Pre-MVC lifetime histories of these disorders were not only significant (relative risk = 2.6-7.4) but were dominant (63.1% population attributable risk proportion [PARP]) predictors of this 3-month outcome, with 46.6% prevalence of the outcome among patients with pre-MVC disorder histories versus 9.9% among those without such histories. The associations of pre-MVC lifetime disorders with the 3-month outcome were mediated largely by 2- and 8-week probable PTSD and MDE (PARP decreasing to 22.8% with controls for these intervening disorders). Decomposition showed that pre-MVC lifetime histories predicted both onset and persistence of these intervening disorders as well as the higher conditional prevalence of the 3-month outcome in the presence of these intervening disorders.

CONCLUSIONS

Assessments of pre-MVC PTSD and MDE histories and follow-ups at 2 and 8 weeks could help target early interventions for psychopathological reactions to MVCs.

Connections during crisis: Adolescents' social dynamics and mental health during COVID-19

Adolescence is a critical period for social development, which COVID-19 has dramatically altered. Quarantined youths had limited in-person interactions with peers. The present study used an intensive longitudinal design to investigate changes in interpersonal dynamics and mental health during COVID-19. Specifically, we investigated whether the associations between different social contexts-that is, "spillover"-changed during COVID-19 and whether changes in social interactions during COVID-19 was associated with changes in depressive symptoms. Approximately 1 year prior to the onset of COVID-19, 139 youths reported depressive symptoms and daily interactions with parents, siblings, and friends, every day for 21 days via online questionnaires. Shortly after schools closed due to COVID-19, 115 of these youths completed a similar 28-day diary. Analyses included 112 youths (62 girls; 73% Caucasian; Mage = 11.77, range = 8 to 15 in Wave 1) who completed at least 13 diary days in each data wave. Our results show that younger adolescents experienced significant decreases in negative and positive interactions with friends, whereas older adolescents showed significant decreases in negative interactions with friends and significant increases in positive interactions with siblings. As predicted, within-day spillover of positive interactions and person-level association of negative interactions increased within the family during COVID-19, whereas within-day spillover of positive interactions between family and friends decreased. We also found a dramatic increase in depressive symptoms. More negative interactions and fewer positive interactions with family members were associated with changes in depressive symptoms. Our study sheds light on how youths' social development may be impacted by COVID-19. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Depression Predicts Global Functional Outcomes in Individuals at Clinical High Risk for Psychosis

Objectives

While co-morbid depression is associated with poor functional outcome among patients with schizophrenia, whether depression similarly predicts poorer outcomes in individuals at clinical high-risk for psychosis (CHR-P) is not clear. The present study aimed to examine depressive symptoms in relation to long-term global functional outcomes in the North American Prodrome Longitudinal Study cohort (NAPLS2).

Methods

CHR individuals were evaluated clinically at baseline and at 12- and 24-month follow-ups for depressive and prodromal symptom severity as well as general functioning. Regression models were built to investigate whether baseline positive and depressive symptom scores predicted longitudinal improvement in global functioning.

Results

A total of 406 CHR individuals completed the 12-month follow-up assessment and 259 CHR individuals completed the 24-month assessment. Baseline depressive symptoms in the CHR-P population were found to predict better global functional outcomes at 2 years. Furthermore, the degree of recovery of depressive symptoms in the first year following baseline completely mediated the association between depressive symptoms at baseline and functional improvement at 2 years.

Conclusions

Presence of affective symptoms within the CHR-P population has different implications for prognosis compared with patients with schizophrenia. The present findings support the view that among those at risk for psychosis, depressive symptoms at baseline predict a more favorable course of functional recovery, and highlight the potential importance of treating co-occurring depressive symptoms at an early stage of psychosis risk.

Intolerance of uncertainty and physiological responses during instructed uncertain threat: A multi-lab investigation

Individuals with high self-reported Intolerance of uncertainty (IU) tend to interpret uncertainty negatively. Recent research has been inconclusive on evidence of an association between IU and physiological responses during instructed uncertain threat. To address this gap, we conducted secondary analyses of IU and physiology data recorded during instructed uncertain threat tasks from two lab sites (Wisconsin-Madison; n = 128; Yale, n = 95). No IU-related effects were observed for orbicularis oculi activity (auditory startle-reflex). Higher IU was associated with: (1) greater corrugator supercilii activity to predictable and unpredictable threat of shock, compared to the safety from shock, and (2) poorer discriminatory skin conductance response between the unpredictable threat of shock, relative to the safety from shock. These findings suggest that IU-related biases may be captured differently depending on the physiological measure during instructed uncertain threat. Implications of these findings for neurobiological models of uncertainty and anticipation in anxiety are discussed.

Emotion regulation and self-criticism in children and adolescence: Longitudinal networks of transdiagnostic risk factors

Adolescence is a time of heightened risk for the development of psychopathology. Difficulties in emotion regulation and heightened levels of self-criticism are two processes that have been proposed as critical risk factors. Considering the accumulating evidence that risk factors rarely work in isolation, there is a pressing need to examine how self-criticism and emotion regulations strategies interact. The present study utilizes a network analysis approach to address this goal. One-hundred thirty-five children and adolescents (ages 8-15) completed daily-diaries every evening for 21 days (total N of assessments = 2,564), reporting self-criticism and use of emotion regulation strategies focused on negative and positive emotions. Network analysis was applied to estimate contemporaneous, temporal, and between-person networks. Results show that emotion regulation strategies are generally positively associated with each other at the within and between individual levels. As predicted, self-criticism was positively associated with rumination and dampening at the between and within-person networks; unexpectedly, problem-solving also clustered with them in the contemporaneous network. Moreover, problem-solving led to next-day increases in rumination and dampening, whereas self-criticism led to next-day increases in rumination but decreases in dampening. Finally, distraction in response to negative affect was closely tied with strategies that up-regulate positive affect. Collectively, these results shed light on the complex pathways through which self-criticism and emotion regulation interact over time. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Development and Validation of a Model to Predict Posttraumatic Stress Disorder and Major Depression After a Motor Vehicle Collision

IMPORTANCE

A substantial proportion of the 40 million people in the US who present to emergency departments (EDs) each year after traumatic events develop posttraumatic stress disorder (PTSD) or major depressive episode (MDE). Accurately identifying patients at high risk in the ED would facilitate the targeting of preventive interventions.

OBJECTIVES

To develop and validate a prediction tool based on ED reports after a motor vehicle collision to predict PTSD or MDE 3 months later.

DESIGN, SETTING, AND PARTICIPANTS

The Advancing Understanding of Recovery After Trauma (AURORA) study is a longitudinal study that examined adverse posttraumatic neuropsychiatric sequalae among patients who presented to 28 US urban EDs in the immediate aftermath of a traumatic experience. Enrollment began on September 25, 2017. The 1003 patients considered in this diagnostic/prognostic report completed 3-month assessments by January 31, 2020. Each patient received a baseline ED assessment along with follow-up self-report surveys 2 weeks, 8 weeks, and 3 months later. An ensemble machine learning method was used to predict 3-month PTSD or MDE from baseline information. Data analysis was performed from November 1, 2020, to May 31, 2021.

MAIN OUTCOMES AND MEASURES

The PTSD Checklist for DSM-5 was used to assess PTSD and the Patient Reported Outcomes Measurement Information System Depression Short-Form 8b to assess MDE.

RESULTS

A total of 1003 patients (median [interquartile range] age, 34.5 [24-43] years; 715 [weighted 67.9%] female; 100 [weighted 10.7%] Hispanic, 537 [weighted 52.7%] non-Hispanic Black, 324 [weighted 32.2%] non-Hispanic White, and 42 [weighted 4.4%] of non-Hispanic other race or ethnicity were included in this study. A total of 274 patients (weighted 26.6%) met criteria for 3-month PTSD or MDE. An ensemble machine learning model restricted to 30 predictors estimated in a training sample (patients from the Northeast or Midwest) had good prediction accuracy (mean [SE] area under the curve [AUC], 0.815 [0.031]) and calibration (mean [SE] integrated calibration index, 0.040 [0.002]; mean [SE] expected calibration error, 0.039 [0.002]) in an independent test sample (patients from the South). Patients in the top 30% of predicted risk accounted for 65% of all 3-month PTSD or MDE, with a mean (SE) positive predictive value of 58.2% (6.4%) among these patients at high risk. The model had good consistency across regions of the country in terms of both AUC (mean [SE], 0.789 [0.025] using the Northeast as the test sample and 0.809 [0.023] using the Midwest as the test sample) and calibration (mean [SE] integrated calibration index, 0.048 [0.003] using the Northeast as the test sample and 0.024 [0.001] using the Midwest as the test sample; mean [SE] expected calibration error, 0.034 [0.003] using the Northeast as the test sample and 0.025 [0.001] using the Midwest as the test sample). The most important predictors in terms of Shapley Additive Explanations values were symptoms of anxiety sensitivity and depressive disposition, psychological distress in the 30 days before motor vehicle collision, and peritraumatic psychosomatic symptoms.

CONCLUSIONS AND RELEVANCE

The results of this study suggest that a short set of questions feasible to administer in an ED can predict 3-month PTSD or MDE with good AUC, calibration, and geographic consistency. Patients at high risk can be identified in the ED for targeting if cost-effective preventive interventions are developed.

A prospective examination of sex differences in posttraumatic autonomic functioning

BACKGROUND

Cross-sectional studies have found that individuals with posttraumatic stress disorder (PTSD) exhibit deficits in autonomic functioning. While PTSD rates are twice as high in women compared to men, sex differences in autonomic functioning are relatively unknown among trauma-exposed populations. The current study used a prospective design to examine sex differences in posttraumatic autonomic functioning.

METHODS

192 participants were recruited from emergency departments following trauma exposure (Mean age = 35.88, 68.2% female). Skin conductance was measured in the emergency department; fear conditioning was completed two weeks later and included measures of blood pressure (BP), heart rate (HR), and high frequency heart rate variability (HF-HRV). PTSD symptoms were assessed 8 weeks after trauma.

RESULTS

2-week systolic BP was significantly higher in men, while 2-week HR was significantly higher in women, and a sex by PTSD interaction suggested that women who developed PTSD demonstrated the highest HR levels. Two-week HF-HRV was significantly lower in women, and a sex by PTSD interaction suggested that women with PTSD demonstrated the lowest HF-HRV levels. Skin conductance response in the emergency department was associated with 2-week HR and HF-HRV only among women who developed PTSD.

CONCLUSIONS

Our results indicate that there are notable sex differences in autonomic functioning among trauma-exposed individuals. Differences in sympathetic biomarkers (BP and HR) may have implications for cardiovascular disease risk given that sympathetic arousal is a mechanism implicated in this risk among PTSD populations. Future research examining differential pathways between PTSD and cardiovascular risk among men versus women is warranted.