A Pilot Study Assessing the Effects of Goal Management Training on Cognitive Functions among Individuals with Major Depressive Disorder and the Effect of Post-Traumatic Symptoms on Response to Intervention.

Recent meta-analyses highlight alterations in cognitive functioning among individuals with major depressive disorder (MDD), with performance deficits observed across multiple cognitive domains including executive functioning, memory, and attention. Moreover, impaired concentration is a formal diagnostic criterion for a major depressive episode. Notably, cognitive impairment is reported frequently in MDD and is associated with poor treatment response. Despite this knowledge, research examining the effectiveness of top-down, adjunctive treatments for cognitive dysfunction in MDD remains in its infancy. The primary aim of the present study was to perform a pilot investigation of the implementation of a standardized cognitive remediation program, Goal Management Training (GMT), among individuals with a primary diagnosis of MDD. A secondary aim was to explore how comorbid symptoms of post-traumatic stress disorder (PTSD) among those MDD patients exposed to trauma may affect treatment response. A final sample of thirty individuals were randomized to either participate in the nine-week GMT program (active group; n = 16) or to complete a nine-week waiting period (waitlist control; n = 14). One participant was excluded from the GMT group analysis following study completion due to meeting an exclusion criteria. In total, 60% of the individuals allocated to the GMT program were trauma exposed (n = 9). Groups were assessed at baseline, post-treatment, and at three-month follow-up. The assessment comprised neuropsychological tasks assessing a variety of cognitive domains, subjective measures of functioning and symptom severity, as well as a clinical interview to establish a primary diagnosis of MDD. Significant gains in processing speed, attention/concentration, and response inhibition were observed for the participants in the GMT condition relative to participants in the waitlist control condition. Individuals in the GMT condition also reported improvements in subjective cognitive functioning from baseline to post-treatment. Heightened PTSD symptom severity was associated with reduced response to treatment with respect to the domain of processing speed. The results of this pilot investigation highlight not only the potential utility of GMT as an augmentative treatment in MDD, but also highlight the contribution of comorbid symptoms of PTSD to diminished treatment response among trauma-exposed individuals with MDD. The study is limited primarily by its small pilot sample and the absence of a program evaluation component to gauge participant opinions and feedback of the treatment protocol.

A Pilot Randomized Controlled Trial of Goal Management Training in Canadian Military Members, Veterans, and Public Safety Personnel Experiencing Post-Traumatic Stress Symptoms.

Post-traumatic stress disorder (PTSD) is a severe psychiatric illness that disproportionately affects military personnel, veterans, and public safety personnel (PSP). Evidence demonstrates that PTSD is significantly associated with difficulties with emotion regulation (ER) and difficulties with cognitive functioning, including difficulties with attention, working memory, and executive functioning. A wide body of evidence suggests a dynamic interplay among cognitive dysfunction, difficulties with ER, and symptoms of PTSD, where numerous studies have identified overlapping patterns of alterations in activation among neuroanatomical regions and neural circuitry. Little work has examined interventions that may target these symptoms collectively. The primary objective of this pilot randomized controlled trial (RCT) with a parallel experimental design was to assess the effectiveness of goal management training (GMT), a cognitive remediation intervention, in reducing difficulties with cognitive functioning, and to determine its effects on PTSD symptoms and symptoms associated with PTSD, including difficulties with ER, dissociation, and functioning among military personnel, veterans, and PSP. Forty-two military personnel, veterans, and PSP between the ages of 18 and 70 with symptoms of PTSD were recruited across Ontario, Canada between October 2017 and August 2019. Participants were randomized to either the waitlist (WL) (n = 18) or the GMT (n = 22) condition. Participants in both conditions received self-report measures and a comprehensive neuropsychological assessment at baseline, post-intervention, and 3-month follow-up. Following their completion of the 3-month follow-up, participants in the WL condition were given the opportunity to participate in GMT. Assessors and participants were blind to intervention allocation during the initial assessment. A series of 2 (time) × 2 (group) ANOVAs were conducted to assess the differences between the WL and GMT conditions from pre- to post-intervention for the self-report and neuropsychological measures. The results demonstrated significant improvements in measures of executive functioning (e.g., verbal fluency, planning, impulsivity, cognitive shifting, and discrimination of targets) and trending improvements in short-term declarative memory for participants in the GMT condition. Participants in the GMT condition also demonstrated significant improvements from pre- to post-testing in measures of subjective cognition, functioning, PTSD symptom severity, difficulties with ER, dissociative symptom severity, and depression and anxiety symptoms. No adverse effects were reported as a result of participating in GMT. The results of this pilot RCT show promise that GMT may be a useful intervention to improve symptoms of cognitive dysfunction, symptoms of PTSD, and symptoms associated with PTSD within military personnel, veterans, and PSP. Future work is needed to address the small sample size and the durability of these findings.

Sensitivity and specificity of the Posttraumatic Stress Disorder Checklist for DSM-5 in a Canadian psychiatric outpatient sample.

The Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) is a widely used, self-report measure that is employed to assess PTSD symptom severity and determine the presence of probable PTSD in various trauma-exposed populations. The PCL-5 is often administered in clinical settings as a screening tool for PTSD, with a suggested cutoff score of 33 indicating a probable PTSD diagnosis. Recent research indicates that a higher cutoff may be required in psychiatric samples. In the present study, we aimed to determine the sensitivity and specificity of the PCL-5 in a Canadian outpatient psychiatric sample and establish an optimal cutoff score for detecting probable PTSD in this sample. Participants were 673 individuals who reported a history of trauma exposure and were assessed using a semistructured interview and self-report measures. Individuals diagnosed with PTSD (N = 193) reported a mean PCL-5 score of 56.57, whereas individuals without PTSD (N = 480) reported a mean score of 33.56. A score of 45 was determined to be the optimal cutoff score in this sample, balancing sensitivity and specificity while detecting a probable diagnosis of PTSD. Consistent with findings in other psychiatric samples, these findings indicate that in an outpatient psychiatric sample with a history of exposure to a variety of trauma types, a higher cutoff score is required to determine probable PTSD. In addition, given the estimated rate of false positives even with a higher cutoff, follow-up diagnostic assessments are recommended.

The relationship between emotion regulation difficulties and PTSD outcomes during group cognitive processing therapy for PTSD.

Emotion regulation difficulties (difficulty regulating the experience, occurrence, and expression of emotions) are associated with the severity of posttraumatic stress disorder (PTSD) symptoms across trauma types (e.g., childhood abuse, sexual assault, combat trauma). Despite emerging research suggesting that evidence-based treatments for PTSD, including cognitive processing therapy (CPT), are effective in improving emotion regulation difficulties, some have argued that these therapies may not be as safe or acceptable to patients compared to non-trauma focused treatments. Accordingly, the current study sought to determine the impact of pre-treatment emotion regulation difficulties on PTSD treatment outcomes and dropout, as well as whether emotion regulation difficulties improve over the course of treatment with group CPT among individuals with PTSD. One hundred and one individuals with PTSD participated in group CPT. Repeated measures t-tests found significant pre- to post-treatment improvements for emotion regulation difficulties (d = .79). Further, hierarchical linear modeling and logistic regression analyses revealed that pre-treatment emotion regulation difficulties were neither significantly associated with changes in PTSD symptoms over the course of treatment (d = -.07) nor with treatment dropout (OR = 1.00). These findings suggest that CPT delivered in a group setting to individuals with PTSD can lead to significant improvement in emotion regulation and that emotion regulation difficulties do not negatively impact treatment outcome or patient retention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Dissociative symptoms predict severe illness presentation in Canadian public safety personnel with presumptive post-traumatic stress disorder (PTSD).

Background: Post-traumatic stress disorder affects 9% of individuals across their lifetime and increases nearly fourfold to 35% in Canadian public safety personnel (PSP). On-the-job experiences of PSP frequently meet criteria for traumatic events, making these individuals highly vulnerable to exposures of trauma and the negative consequences of PTSD. Few studies have reported on the clinical characteristics of Canadian samples of PSP and even fewer have examined the dissociative subtype of PTSD, which is associated with more severe, chronic traumatic experiences, and worse outcomes. Objective: This study aimed to characterize dissociative symptoms, PTSD symptom severity, and other clinical variables among Canadian PSP with presumptive PTSD. Methods: We sampled current and past PSP in Canada from both inpatient and outpatient populations (N = 50) that were enrolled in a psychological intervention. Only baseline testing data (prior to any intervention) were analysed in this study, such as PTSD symptom severity, dissociative symptoms, emotion dysregulation, and functional impairment. Results: In our sample, 24.4% self-reported elevated levels of dissociation, specifically symptoms of depersonalization and derealization. Depersonalization and derealization symptoms were associated with more severe PTSD symptoms, greater emotion dysregulation, and functional impairment. Conclusions: Nearly a quarter of this sample of Canadian PSP reported experiencing elevated levels of PTSD-related dissociation (depersonalization and derealization). These high levels of depersonalization and derealization were consistently positively associated with greater illness severity across clinical measures. It is imperative that dissociative symptoms be better recognized in patient populations that are exposed to chronic traumatic events such as PSP, so that treatment interventions can be designed to target a more severe illness presentation.

Antecedentes: El trastorno de estrés postraumático afecta al 9% de los individuos a lo largo de su vida y se incrementa casi cuatro veces hasta el 35% en el personal de seguridad pública canadiense (PSP). Las experiencias en el trabajo de los PSP cumplen con frecuencia los criterios de eventos traumáticos, lo que hace que estos individuos sean muy vulnerables a la exposición al trauma y a las consecuencias negativas del TEPT. Pocos estudios han informado sobre las características clínicas de las muestras canadienses de PSP y aún menos han examinado el subtipo disociativo del TEPT, que se asocia con experiencias traumáticas más graves y crónicas, y con peores resultados.Objetivo: Este estudio tenía como objetivo caracterizar los síntomas disociativos, la gravedad de los síntomas del TEPT y otras variables clínicas entre los PSP canadienses con presunto TEPT.Métodos: Tomamos una muestra de PSP actuales y pasados en Canadá de poblaciones de pacientes hospitalizados y ambulatorios (N = 50) que se inscribieron en una intervención psicológica. En este estudio sólo se analizaron los datos de las pruebas de referencia (antes de cualquier intervención), como la gravedad de los síntomas del TEPT, los síntomas disociativos, la desregulación de las emociones y el deterioro funcional.Resultados: En nuestra muestra, el 24,4% auto-reportó niveles elevados de disociación, específicamente síntomas de despersonalización y des-realización. Los síntomas de despersonalización y des-realización se asociaron con síntomas de TEPT más graves, mayor desregulación de la emoción y deterioro funcional.Conclusiones: Casi una cuarta parte de esta muestra de PSP canadiense reportó experimentar niveles elevados de disociación relacionada con el TEPT (despersonalización y des-realización). Estos niveles elevados de despersonalización y des-realización se asociaron positivamente de forma consistente con una mayor gravedad de la enfermedad en las medidas clínicas. Es imperativo que se reconozcan mejor los síntomas disociativos en las poblaciones de pacientes que están expuestos a eventos traumáticos crónicos como el PSP, para que las intervenciones de tratamiento puedan ser diseñadas para dirigirse a una presentación de la enfermedad más severa.

The contributions of emotion regulation difficulties and dissociative symptoms to functional impairment among civilian inpatients with posttraumatic stress symptoms.

BACKGROUND: Functional impairment among individuals with posttraumatic stress disorder (PTSD) represents a significant factor in recovery. Critically, functional impairment appears to persist following remission of PTSD symptoms. To date, work investigating functional impairment among individuals with PTSD has focused on PTSD symptom clusters, excluding other relevant symptoms, including emotion regulation difficulties and dissociative symptoms. Emerging work suggests that these symptoms may serve as important predictors of functional impairment among individuals with PTSD. OBJECTIVE AND METHODS: The present study investigated the contributions of difficulties with emotion regulation, dissociative symptoms, and individual PTSD symptom clusters to functional impairment among an inpatient civilian sample who completed self-report assessments of PTSD symptoms, functional impairment, emotion regulation difficulties, and dissociative symptoms, upon admission to the program. Participants met criteria for probable PTSD as per the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) and reported high rates of exposure to childhood abuse and neglect. RESULTS: Emotion regulation difficulties contributed significantly, while dissociative symptoms and PTSD arousal and reactivity symptoms showed a signal toward contributing significantly to a model accounting for variance in functional impairment among individuals with probable PTSD. Differential patterns of contributors emerged for the various domains of functional impairment measured. CONCLUSIONS: These findings add to a growing body of literature highlighting the importance of emotion regulation difficulties, dissociative symptoms, and arousal and reactivity symptoms in contributing to functional impairment in this disorder. Recovery to premorbid functional status in PTSD may require interventions that target directly these symptoms. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The relation between adverse childhood experiences and moral injury in the Canadian Armed Forces.

Background: There is increasing evidence that moral injuries (MIs) may affect the mental health of Canadian Armed Forces (CAF) members and veterans. Despite knowledge suggesting that MIs are related to multiple negative mental health outcomes, including the onset of post-traumatic stress disorder (PTSD), it is unknown whether pre-traumatic variables, including the presence of childhood abuse, are related to MIs. Objective: This study seeks to investigate the potential relationship between adverse childhood experiences and later onset MI in military members. Methods: Thirty-three patients newly admitted to an inpatient unit for treatment of trauma-related disorders received a standardized self-assessment package, including the PTSD Checklist for DSM-5 (PCL-5), the Moral Injury Events Scale (MIES; adapted for the Canadian context), and the Adverse Childhood Experiences Questionnaire (ACE-Q), which is a retrospective measure of childhood abuse. Results: Analyses revealed a significant relation between childhood emotional abuse and the presence of MI in adulthood. Specifically, emotional abuse during childhood was correlated with total score on the MIES (p = 0.006) and with its two subscales, perceived betrayals (p = 0.022) and perceived transgressions (p = 0.016). These correlations remained significant when controlling for age and gender. Conclusions: Among CAF members and veterans, childhood events are related to the presence of MI during adulthood. These preliminary data are provocative in suggesting that emotional abuse during childhood may increase the likelihood of endorsing MI during adult military service. Further work is needed to identify pre-traumatic variables that may serve to increase risk or enhance resilience to the development of MI in military members.

Antecedentes: Existe un aumento de la evidencia que los daños morales (MIs, por sus siglas en inglés) pueden afectar la salud mental de los miembros de las Fuerzas Armadas Canadienses (FAC) y veteranos. A pesar que el conocimiento sugiere que las MIs están relacionadas con múltiples consecuencias negativas en la salud mental, incluyendo el inicio del trastorno de estrés postraumático (TEPT), se desconoce si variables pre-traumáticas, incluyendo la presencia de abuso en la infancia, están relacionadas con MIs. Objetivo: Este estudio busca investigar la relación potencial entre experiencias infantiles adversas y el posterior inicio de MIs entre los miembros militares. Método: Treinta y tres pacientes nuevos admitidos a una unidad hospitalaria para tratamiento de los trastornos relacionados con trauma, recibieron un paquete estandarizado de auto-evaluación, incluyendo la lista de chequeo para TEPT del DSM-5 (PCL-5), la Escala de Eventos de Daño Moral (MIES por sus siglas en inglés, adaptada para el contexto canadiense) y el Cuestionario de Experiencias Adversas Condiciones Infantiles (ACE-Q por sus siglas en inglés). Resultados: Los análisis revelaron una relación significativa entre abuso emocional en la infancia y la presencia de MI en la adultez. Específicamente, el abuso emocional durante la infancia estuvo correlacionado con el puntaje total del MIES (p= 0.006) y con sus dos sub-escalas, percepción de traición (p=0.022) y percepción de transgresiones (p= 0.016). Estas correlaciones permanecen significativas cuando se controlan por edad y sexo. Conclusiones: Entre los miembros y veteranos FAC, los eventos en la infancia están relacionados con la presencia de MI durante la adultez. Estos datos preliminares son provocativos en sugerir que el abuso emocional durante la infancia puede incrementar la posibilidad de refrendar MI durante el servicio militar en la adultez. Es necesaria más investigación para identificar las variables pre-traumáticas que pueden servir para incrementar el riesgo o aumentar la resiliencia a desarrollar MI entre los miembros militares.

An Open-Label Feasibility Trial Examining the Effectiveness of a Cognitive Training Program, Goal Management Training, in Individuals With Posttraumatic Stress Disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with dysfunction across multiple cognitive domains including executive functioning, attention, and verbal memory. This dysfunction is associated with negative impacts on functional outcomes (e.g., work or social functioning) and reduced response to psychotherapy for PTSD. Despite this knowledge, little work has investigated the efficacy of cognitive remediation strategies in improving cognition and functional outcomes among individuals with PTSD. OBJECTIVE: The current study investigated the efficacy of an established cognitive remediation program, Goal Management Training (GMT), in improving cognitive functioning in a pilot sample of individuals with PTSD symptoms in an inpatient treatment setting. METHOD: Thirty-four inpatients with PTSD symptoms participated in either GMT in addition to treatment as usual (TAU; consisting of psychiatric management, group and individual psychotherapy) (TAU+GMT; n = 18) or TAU alone (n = 16). The TAU+GMT group received neuropsychological assessment at baseline and posttreatment, while both the TAU+GMT and TAU groups received assessment with clinical self-report measures at baseline and posttreatment. RESULTS: Paired-sample t-tests revealed significant improvements on measures of executive functioning (e.g., response inhibition, cognitive flexibility), processing speed, sustained attention, and verbal memory in the TAU+GMT group. Mixed-design analyses of variance (ANOVAs) revealed a trend toward an interaction effect indicating potentially greater improvements on a measure of the ability to engage in goal-directed behaviors while highly emotional in the TAU+GMT group as compared to the TAU group. DISCUSSION: The results of this small feasibility investigation of GMT in PTSD point toward the potential efficacy of GMT in ameliorating cognitive difficulties in individuals with PTSD.

A Review of the Neurobiological Basis of Trauma-Related Dissociation and Its Relation to Cannabinoid- and Opioid-Mediated Stress Response: a Transdiagnostic, Translational Approach.

Dissociative experiences have been associated with increased disease severity, chronicity, and, in some cases, reduced treatment response across trauma-related and other psychiatric disorders. A better understanding of the neurobiological mechanisms through which dissociative experiences occur may assist in identifying novel pharmacological and non-pharmacological treatment approaches. Here, we review emerging work on the dissociative subtype of posttraumatic stress disorder (PTSD), and other trauma-related disorders providing evidence for two related overarching neurobiological models of dissociation, the defense cascade model of dissociation and Mobb's threat detection model. In particular, we review neuroimaging studies highlighting alterations in functional connectivity of key brain regions associated with these models, including connectivity between the prefrontal cortex, the amygdala and its complexes, the insula, and the periaqueductal gray. Work implicating the kappa-opioid and endocannabinoid systems in trauma-related dissociative experiences is also reviewed. Finally, we hypothesize mechanisms by which pharmacological modulation of these neurochemical systems may serve as promising transdiagnostic treatment modalities for individuals experiencing clinically significant levels of dissociation. Specifically, whereas kappa-opioid receptor antagonists may serve as a pharmacological vehicle for the selective targeting of dissociative symptoms and associated emotion overmodulation in the dissociative subtype of posttraumatic stress disorder and transdiagnostically, modulation of the endocannabinoid system may reduce symptoms associated with emotional undermodulation of the fight or flight components of the defense cascade model.

Dissociative symptoms mediate the relation between PTSD symptoms and functional impairment in a sample of military members, veterans, and first responders with PTSD.

Background: Posttraumatic Stress Disorder (PTSD) is associated with significant functional impairment in important areas, including interpersonal relationships and occupational or educational roles. Preliminary evidence suggests that the dissociative subtype of PTSD (PTSD+DS), characterized by marked symptoms of depersonalization and derealization, is associated with increased functional impairment and disease severity, including among military members and veterans diagnosed with PTSD. Similarly, first responders (e.g. police, fire, paramedics) have also been found to experience dissociative symptoms. Despite these findings, little work has investigated whether dissociative symptoms are related to heightened functional impairment among these populations. Objective: We examined the relation between functional impairment and symptom level variables, including dissociative symptoms of depersonalization and derealization among military members, veterans, and first responders with probable PTSD. We further investigated the hypothesis that dissociative symptoms mediate the relation between PTSD symptomatology and functional impairment. Method: Eighty-one medical charts of inpatients at a residential PTSD treatment programme were accessed via retrospective review. Sixty-two were included in the present analyses. Comparison of means on symptom measures between first responders and military members/veterans were conducted, followed by correlational and mediation analyses. Results: Compared with first responders, military members and veterans showed higher levels of derealization, functional impairment, alexithymia, anxiety, and depression. Within the total sample, dissociative symptoms emerged as the strongest correlate of functional impairment and, among the dissociative symptom clusters, derealization symptoms demonstrated the strongest relation with impairment. Mediation analyses revealed that total dissociative symptoms and derealization symptoms significantly mediated the relation between PTSD symptoms and functional impairment. Conclusions: These findings highlight the importance of assessing and treating dissociative symptoms, consistent with the dissociative subtype of PTSD, among military members, veterans, and first responders with PTSD. Successful recovery on a functional and symptomatic level may necessitate treatment of dissociative symptoms, particularly derealization.

Planteamiento: El trastorno por estrés postraumático (TEPT) se asocia con un deterioro funcional significativo en áreas importantes, incluidas las relaciones interpersonales y los roles ocupacionales o educativos. La evidencia preliminar sugiere que el subtipo disociativo de TEPT (TEPT + SD), caracterizado por síntomas marcados de despersonalización y desrealización, se asocia con mayor deterioro funcional y gravedad de la enfermedad, incluso entre miembros militares y veteranos diagnosticados con TEPT. Del mismo modo, también se ha encontrado que los profesionales en intervención inmediata (por ejemplo, policías, bomberos, paramédicos) también experimentan síntomas disociativos. A pesar de estos hallazgos, pocos han investigado si los síntomas disociativos están relacionados con una mayor deficiencia funcional entre estas poblaciones.Objetivo: Examinamos la relación entre el deterioro funcional y las variables de nivel de síntomas, incluyendo síntomas disociativos de despersonalización, desrealización entre miembros militares, veteranos y profesionales en intervención inmediata con un probable TEPT. Además investigamos la hipótesis de que los síntomas disociativos median la relación entre la sintomatología del TEPT y el deterioro funcional.Método: Se accedió a ochenta y un historiales clínicos de pacientes hospitalizados en un programa residencial de tratamiento de TEPT mediante un análisis retrospectivo. Sesenta y dos fueron incluidos en el presente análisis. Se realizó una comparación de los medios de medición de síntomas entre los profesionales en intervención inmediata y los militares y veteranos, seguida de análisis de correlación y mediación.Resultados: En comparación con los profesionales en intervención inmediata los miembros del ejército y los veteranos mostraron niveles más altos de desrealización, deterioro funcional, alexitimia, ansiedad y depresión.Dentro de la muestra total, los síntomas disociativos surgieron como el correlato más fuerte del deterioro funcional y, entre los grupos de síntomas disociativos, los síntomas de desrealización mostraron la relación más fuerte con el deterioro. Los análisis de mediación revelaron que los síntomas disociativos totales y los síntomas de desrealización mediaban significativamente en la relación entre los síntomas de TEPT y el deterioro funcional.Conclusiones: Estos hallazgos resaltan la importancia de evaluar y tratar los síntomas disociativos, coincidentes con el subtipo disociativo del TEPT, entre los militares, los veteranos y los profesionales en intervención inmediata con TEPT. El éxito de su recuperación a nivel funcional y sintomático puede requerir el tratamiento de los síntomas disociativos, en particular, la desrealización.

Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence.

Mindfulness-based treatments for posttraumatic stress disorder (PTSD) have emerged as promising adjunctive or alternative intervention approaches. A scoping review of the literature on PTSD treatment studies, including approaches such as mindfulness-based stress reduction, mindfulness-based cognitive therapy and metta mindfulness, reveals low attrition with medium to large effect sizes. We review the convergence between neurobiological models of PTSD and neuroimaging findings in the mindfulness literature, where mindfulness interventions may target emotional under- and overmodulation, both of which are critical features of PTSD symptomatology. Recent emerging work indicates that mindfulness-based treatments may also be effective in restoring connectivity between large-scale brain networks among individuals with PTSD, including connectivity between the default mode network and the central executive and salience networks. Future directions, including further identification of the neurobiological mechanisms of mindfulness interventions in patients with PTSD and direct comparison of these interventions to first-line treatments for PTSD are discussed.

The innate alarm system in PTSD: conscious and subconscious processing of threat.

The innate alarm system (IAS), comprised of functionally connected brain regions including the brainstem, amygdala, pulvinar, and frontotemporal cortex, is a fast subcortical brain network facilitating rapid responses to threat. Post-traumatic stress disorder (PTSD) features subconscious and conscious threat detection, together contributing to hyperarousal symptoms. Emerging literature identifies aberrant threat-related neurocircuitry involved in subconscious and conscious threat processing in PTSD. We review this literature, focusing on subconscious threat processing and its relation to the IAS. Available evidence indicates increased neural activity and functional connectivity between IAS brain regions (e.g. locus coeruleus, superior colliculus, amygdala, and prefrontal cortex). These alterations are observed during both subconscious threat processing and at rest, suggesting increased defensive posturing, maintained in the absence of overt threat.

A review of the relation between dissociation, memory, executive functioning and social cognition in military members and civilians with neuropsychiatric conditions.

Dissociative experiences, involving altered states of consciousness, have long been understood as a consequence or response to traumatic experiences, where a reduced level of consciousness may aid in survival during and after a traumatic event. Indeed, the dissociative subtype of post-traumatic stress disorder (PTSD-DS) was added recently to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Dissociative symptoms are present across a host of neuropsychiatric conditions, including PTSD, psychotic spectrum illnesses, anxiety and mood disorders. Transdiagnostically, the presence of dissociative symptoms is associated with a greater illness burden and reduced treatment outcomes. Critically, dissociative symptoms are related to impaired performance on measures of attention, executive functioning, memory, and social cognition and may contribute to the widespread cognitive dysfunction observed across psychiatric illnesses. Despite this knowledge, the relation between dissociative symptoms and reduced cognitive function remains poorly understood. Here, we review the evidence linking dissociative symptoms to cognitive dysfunction across neuropsychiatric disorders. In addition, we explore two potential neurobiological mechanisms that may underlie the relation between dissociative symptoms and cognitive dysfunction in trauma-related neuropsychiatric conditions. Specifically, we hypothesize that: 1) functional sensory deafferentation at the level of the thalamus, as observed in the defence cascade model of dissociation, may underlie reduced attention and arousal leading to progressive cognitive dysfunction and; 2) altered functional connectivity between key brain networks implicated in cognitive functioning may represent a critical neurobiological mechanism linking dissociative symptoms and cognitive dysfunction in patients with PTSD-DS and transdiagnostically.

Test-retest reliability of N400 event-related brain potential measures in a word-pair semantic priming paradigm in patients with schizophrenia.

The N400 event-related brain potential (ERP), a negative voltage deflection occurring approximately 400ms after onset of any meaningful stimulus, is reduced in amplitude when the stimulus is preceded by related context. Previous work has found this N400 semantic priming effect to be decreased in schizophrenia, suggesting impairment in using meaningful context to activate related concepts in semantic memory. Thus, N400 amplitude may be a useful biomarker of abnormal semantic processing and its response to treatment in schizophrenia. To help assess the validity of N400 amplitude as a longitudinal measure in schizophrenia, we evaluated its test-retest reliability. ERPs were recorded in sixteen schizophrenia patients who viewed prime words, each followed at 300- or 750-ms stimulus-onset asynchrony (SOA) by a target that was either a related or unrelated word, or nonword. Participants' task was to indicate whether or not the target was a real word. They were retested on the same procedure one week later. Test-retest reliability was assessed by calculating Pearson's r and intraclass correlation coefficients (ICCs) across timepoints for N400 amplitudes for related and unrelated targets, at each SOA. Consistent with previous results, there were no significant differences between patients' N400 amplitudes for related and unrelated targets, at any SOA/timepoint combination. Pearson's r and ICCs for N400 amplitudes at Fz across timepoints were significant for both target types at each SOA (ranges: r 0.52-0.64, ICC 0.52-0.63; all p<.04). The results suggest potential utility of N400 amplitude as a longitudinal neurophysiological biomarker of semantic processing abnormalities in schizophrenia.