'I am afraid you will see the stain on my soul': Direct gaze neural processing in individuals with PTSD after moral injury recall.

Direct eye contact is essential to understanding others' thoughts and feelings in social interactions. However, those with post-traumatic stress disorder (PTSD) and exposure to moral injury (MI) may exhibit altered theory-of-mind (ToM)/mentalizing processes and experience shame which precludes one's capacity for direct eye contact. We investigated blood oxygenation level-dependent (BOLD) responses associated with direct vs averted gaze using a virtual reality paradigm in individuals with PTSD (n = 28) relative to healthy controls (n = 18) following recall of a MI vs a neutral memory. Associations between BOLD responses and clinical symptomatology were also assessed. After MI recall, individuals with PTSD showed greater activation in the right temporoparietal junction as compared to controls (T = 4.83; pFDR < 0.001; k = 237) during direct gaze. No significant activation occurred during direct gaze after neutral memory recall. Further, a significant positive correlation was found between feelings of distress and right medial superior frontal gyrus activation in individuals with PTSD (T = 5.03; pFDR = 0.049; k = 123). These findings suggest that direct gaze after MI recall prompts compensatory ToM/mentalizing processing. Implications for future interventions aimed at mitigating the effects of PTSD on social functioning are discussed.

A systematic review of the neural correlates of sexual minority stress: towards an intersectional minority mosaic framework with implications for a future research agenda.

BACKGROUND: Systemic oppression, particularly towards sexual minorities, continues to be deeply rooted in the bedrock of many societies globally. Experiences with minority stressors (e.g. discrimination, hate-crimes, internalized homonegativity, rejection sensitivity, and microaggressions or everyday indignities) have been consistently linked to adverse mental health outcomes. Elucidating the neural adaptations associated with minority stress exposure will be critical for furthering our understanding of how sexual minorities become disproportionately affected by mental health burdens.Following PRISMA-guidelines, we systematically reviewed published neuroimaging studies that compared neural dynamics among sexual minority and heterosexual populations, aggregating information pertaining to any measurement of minority stress and relevant clinical phenomena. RESULTS: Only 1 of 13 studies eligible for inclusion examined minority stress directly, where all other studies focused on investigating the neurobiological basis of sexual orientation. In our narrative synthesis, we highlight important themes that suggest minority stress exposure may be associated with decreased activation and functional connectivity within the default-mode network (related to the sense-of-self and social cognition), and summarize preliminary evidence related to aberrant neural dynamics within the salience network (involved in threat detection and fear processing) and the central executive network (involved in executive functioning and emotion regulation). Importantly, this parallels neural adaptations commonly observed among individuals with posttraumatic stress disorder (PTSD) in the aftermath of trauma and supports the inclusion of insidious forms of trauma related to minority stress within models of PTSD. CONCLUSIONS: Taken together, minority stress may have several shared neuropsychological pathways with PTSD and stress-related disorders. Here, we outline a detailed research agenda that provides an overview of literature linking sexual minority stress to PTSD and insidious trauma, moral affect (including shame and guilt), and mental health risk/resiliency, in addition to racial, ethnic, and gender related minority stress. Finally, we propose a novel minority mosaic framework designed to inform future directions of minority stress neuroimaging research from an intersectional lens.

Antecedentes: La opresión sistémica, en particular hacia las minorías sexuales, sigue estando profundamente arraigada en los cimientos de muchas sociedades a nivel mundial. Las experiencias con los factores de estrés de las minorías (por ejemplo, la discriminación, los delitos de odio, la homonegatividad interiorizada, la sensibilidad al rechazo y las microagresiones o humillaciones cotidianas) se han relacionado sistemáticamente con resultados adversos para la salud mental. La elucidación de las adaptaciones neuronales asociadas con la exposición al estrés de las minorías será fundamental para avanzar en nuestra comprensión de cómo las minorías sexuales se ven afectadas de manera desproporcionada por las cargas de salud mental.Métodos: Siguiendo las directrices PRISMA, revisamos sistemáticamente los estudios de neuroimagen publicados que comparaban la dinámica neural entre las poblaciones de minorías sexuales y heterosexuales, agregando la información relativa a cualquier medición del estrés de minorías y los fenómenos clínicos relevantes.Resultados: Sólo 1 de los 13 estudios elegibles para su inclusión examinó directamente el estrés de las minorías, mientras que todos los demás estudios se centraron en investigar las bases neurobiológicas de la orientación sexual. En nuestra síntesis narrativa, destacamos temas importantes que sugieren que la exposición al estrés de las minorías puede estar asociada con la disminución de la activación y la conectividad funcional dentro de la red del modo por defecto (relacionada con el sentido del yo y la cognición social), y resumimos la evidencia preliminar relacionada con la dinámica neuronal aberrante dentro de la red de saliencia (involucrada en la detección de amenazas y el procesamiento del miedo) y la red ejecutiva central (involucrada en el funcionamiento ejecutivo y la regulación de las emociones). Es importante destacar que esto es paralelo a las adaptaciones neuronales comúnmente observadas entre los individuos con trastorno de estrés postraumático (TEPT) después del trauma y apoya la inclusión de formas insidiosas de trauma relacionadas con el estrés de las minorías dentro de los modelos de TEPT.Conclusiones: En conjunto, el estrés de las minorías puede tener varias vías neuropsicológicas compartidas con el TEPT y los trastornos relacionados con el estrés. Aquí, esbozamos una agenda de investigación detallada que proporciona una visión general de la literatura que vincula el estrés de las minorías sexuales con el TEPT y el trauma insidioso, el afecto moral (incluyendo la vergüenza y la culpa), y el riesgo/resiliencia de la salud mental, además del estrés de las minorías relacionadas con la raza, la etnia y el género. Por último, proponemos un marco de mosaico de minorías novedoso diseñado para informar sobre las futuras direcciones de la investigación de neuroimagen del estrés de las minorías desde una perspectiva interseccional.

Moral wounds run deep: exaggerated midbrain functional network connectivity across the default mode network in posttraumatic stress disorder.

BACKGROUND: A moral injury occurs when a deeply held moral code has been violated, and it can lead to the development of symptoms of posttraumatic stress disorder (PTSD). However, the neural correlates that differentiate moral injury and PTSD remain largely unknown. Intrinsic connectivity networks such as the default mode network (DMN) appear to be altered in people with PTSD who have experienced moral injury. However, brainstem, midbrain and cerebellar systems are rarely integrated into the intrinsic connectivity networks; this is a critical oversight, because these systems display marked differences in people with PTSD and are thought to underlie strong moral emotions such as shame, guilt and betrayal. METHODS: We conducted an independent component analysis on data generated during script-driven memory recall of moral injury in participants with military- or law enforcement-related PTSD (n = 28), participants with civilian-related PTSD (n = 28) and healthy controls exposed to a potentially morally injurious event (n = 18). We conducted group-wise comparisons of functional network connectivity differences across a DMN-correlated independent component, with a particular focus on brainstem, midbrain and cerebellar systems. RESULTS: We found stronger functional network connectivity in the midbrain periaqueductal grey (t 71 = 4.95, p FDR = 0.028, k = 39) and cerebellar lobule IX (t 71 = 4.44, p FDR = 0.046, k = 49) in participants with civilian-related PTSD as compared to healthy controls. We also found a trend toward stronger functional network connectivity in the midbrain periaqueductal grey (t 71 = 4.22, p FDR = 0.076, k = 60) in participants with military- or law enforcement-related PTSD as compared to healthy controls. LIMITATIONS: The significant clusters were large, but resolution is generally lower for subcortical structures. CONCLUSION: In PTSD, the DMN appears to be biased toward lower-level, midbrain systems, which may drive toxic shame and related moral emotions that are common in PTSD, highlighting the depth at which moral injuries are represented neurobiologically.

Mental health symptoms in Public Safety Personnel: Examining the effects of adverse childhood experiences and moral injury.

BACKGROUND: Adverse Childhood Experiences (ACEs) increase risk for negative mental health outcomes in adulthood; however, the mechanisms through which ACEs exert their influence on adult mental health are poorly understood. This is particularly true for Public Safety Personnel (PSP; e.g., police, firefighters, paramedics, etc.), a group with unique vulnerability to negative psychiatric sequalae given their chronic exposure to potentially traumatic, work-related events. OBJECTIVES: To examine the role of moral injury (MI) and emotion regulation in the relation between ACEs and adult mental health symptoms in adulthood. PARTICIPANTS AND SETTING: Participants (N = 294) included a community sample of Canadian and American PSP members aged 22 to 65. METHODS: The current study uses cross-sectional data collection via retrospective self-report questionnaires administered between November, 2018 and November, 2019 to assess level of ACEs (ACE-Q), emotion regulation difficulties (DERS) and symptoms of post-traumatic stress (PCL-5), dissociation (MDI), depression, stress, and anxiety (DASS-21). Additionally, participants completed the Moral Injury Assessment for Public Safety Personnel, the first measure of MI developed specifically for PSP. RESULTS: Path analysis revealed that ACEs significantly predicted adverse mental health symptoms in adulthood; this effect was mediated by symptoms of MI and moderated by difficulties with emotion regulation. CONCLUSIONS: This study is the first to identify MI as a mechanism involved in the relation between ACEs and adult psychopathology and highlights the protective role of emotion regulation skills. These findings can inform the development of future research and clinical interventions in PSP populations.

Mapping alexithymia: Level of emotional awareness differentiates emotion-specific somatosensory maps.

BACKGROUND: Emotions have been associated with culturally universal and distinct bodily sensation "maps". Despite this knowledge, to date few studies have explored emotion-specific topography along clinically relevant dimensions, such as alexithymia. OBJECTIVE: We aimed to investigate emotion-specific topographies among individuals exposed to childhood maltreatment or neglect with absent (n = 51) or with probable (n = 46) alexithymia in adulthood, as defined by scores on the Toronto Alexithymia Scale (TAS-20). PARTICIPANTS AND SETTING: Ninety eight adult participants with exposure to childhood maltreatment or neglect were recruited to complete an online survey. METHODS: Using the well-validated emBODY tool (Nummenmaa et al., 2014), participants reported on their somatic experience of 17 emotions. RESULTS: Random effects analyses revealed topographically distinct bodily sensation t-maps that differentiated participants who endorsed probable alexithymia from those who did not (p-FDR < .05). Consistent with our a priori hypothesis, the probable alexithymia group reported a muted, diffuse and undifferentiated pattern of emotion-specific bodily sensation, whereas the non-alexithymia group reported a more distinct and localized pattern. CONCLUSIONS: These results suggest that difficulty identifying and labeling emotions, as observed in alexithymia, may arise, in part, from an altered perception of somatic activation. It is well-established that childhood maltreatment predicts the development of alexithymia symptoms. The preliminary findings presented here expand our working understanding of the physical markers of childhood trauma, which may be used in practice to aid detection and to monitor treatment outcomes.

Shame on the brain: Neural correlates of moral injury event recall in posttraumatic stress disorder.

BACKGROUND: Moral injury (MI) is consistently associated with adverse mental health outcomes, including the development of posttraumatic stress disorder (PTSD) and suicidality. METHODS: We investigated neural activation patterns associated with MI event recall using functional magnetic resonance imaging in participants with military and public safety-related PTSD, relative to civilian MI-exposed controls. RESULTS: MI recall in the PTSD as compared to control group was associated with increased neural activation among salience network nodes involved in viscerosensory processing and hyperarousal (right posterior insula, dorsal anterior cingulate cortex; dACC), regions involved in defensive responding (left postcentral gyrus), and areas responsible for top-down cognitive control of emotions (left dorsolateral prefrontal cortex; dlPFC). Within the PTSD group, measures of state and trait shame correlated negatively with activity among default mode network regions associated with self-related processing and moral cognition (dorsomedial prefrontal cortex; dmPFC) and salience network regions associated with viscerosensory processing (left posterior insula), respectively. CONCLUSIONS: These findings suggest that MI event processing is altered in military and public safety-related PTSD, relative to MI-exposed controls. Here, it appears probable that as individuals with PTSD recall their MI event, they experience a surge of blame-related processing of bodily sensations within salience network regions, including the right posterior insula and the dACC, which in turn, prompt regulatory strategies at the level of the left dlPFC aimed at increasing cognitive control and inhibiting emotional affect. These results are consistent with previous findings showing enhanced sensory processing and altered top-down control in PTSD samples during autobiographical memory recall.

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.

Assessing Post-Traumatic Tonic Immobility Responses: The Scale for Tonic Immobility Occurring Post-Trauma.

BACKGROUND: Peri-traumatic tonic immobility has been associated with the development and course of post-traumatic stress disorder. Despite serving as an adaptive late-stage defense response, tonic immobility that continues in response to post-traumatic reminders may lead to reduced functioning and a diminished sense of well-being. At present, no validated self-report measures assess post-traumatic tonic immobility responses specifically. METHODS: The primary objective of the present study was to evaluate the Scale for Tonic immobility Occurring Post-trauma (STOP), the first self-report measure developed to assess for the presence and severity of tonic immobility responses that persist following trauma exposure as part of post-traumatic symptomatology. Trauma-exposed clinical and non-clinical participants (N = 462) with a history of tonic immobility completed a demographic questionnaire, the STOP, and measures of post-traumatic symptoms, dissociation, anxiety, and depression. RESULTS: STOP assessed four latent constructs, which were interpreted following the human defense cascade model. Together, these factors capture the sensorimotor and perceptual alterations, and dissociative experiences, associated with post-traumatic tonic immobility as a trauma-related altered state. Residual symptoms and the experience of negative affect following this response (including guilt and shame) are also represented. STOP scores demonstrated excellent reliability, as well as good construct and convergent validity, with other measures of dissociation and post-traumatic stress disorder. Results from the present study suggest tonic immobility is most consistent with other dissociative post-traumatic symptomatology. CONCLUSIONS: STOP demonstrates excellent preliminary psychometric properties and may be useful for researchers and clinicians wishing to assess chronic forms of tonic immobility across trauma-exposed, clinical and community samples.

Youth-focused group mindfulness-based intervention in individuals with early psychosis: A randomized pilot feasibility study.

AIM: To assess the feasibility of a randomized pilot trial that evaluated the acceptability and potential clinical utility of the Mindfulness Ambassador Program (MAP), a unique, standardized 12-session facilitated group mindfulness-based intervention (MBI) for youth experiencing early psychosis. METHODS: Twenty-one patients of an early psychosis intervention program were randomized to receive MAP (n = 11) or treatment as usual (n = 10). Acceptability was measured by group attendance rate and client satisfaction; feasibility of the study design was measured by the recruitment and retention rate. The means, standard deviations, and 95% confidence intervals were described for outcomes of interest. RESULTS: MAP is associated with a high degree of acceptability and has beneficial effects for depression and fatigue. The randomized trial design is feasible. CONCLUSIONS: This study provides important pilot data supporting a larger randomized trial of effectiveness for MAP as a group MBI for early psychosis. Details of MAP and study limitations are discussed.

Altered Sense of Body Ownership and Agency in Posttraumatic Stress Disorder and Its Dissociative Subtype: A Rubber Hand Illusion Study.

Traumatic experiences have been linked to the development of altered states of consciousness affecting bodily perception, including alterations in body ownership and in sense of agency, the conscious experience of the body as one's own and under voluntary control. Severe psychological trauma and prolonged distress may lead to posttraumatic stress disorder (PTSD). Together, symptoms of derealization and, related specifically to the sense of body ownership and agency, of depersonalization (where parts of the body or the entire body itself is perceived as detached and out of control), constitute the dissociative subtype (PTSD+DS). In this study, we explored the Rubber Hand Illusion, an experimental paradigm utilized to manipulate sense of body ownership in PTSD (n = 4) and PTSD+DS (n = 6) as compared to healthy controls (n = 7). Perceived finger location and self-report questionnaires were used as behavioral and subjective measures of the illusion, respectively. In addition, the correlation between the illusion's effect and sense of agency as a continuous feeling of controlling one's own body movements was explored. Here, a lower illusion effect was observed in the PTSD as compared to the control group after synchronous stimulation for both the proprioceptive drift and subjectively perceived illusion. Moreover, by both proprioceptive drift and by subjective ratings, the PTSD+DS group showed a response characterized by high variance, ranging from a very strong to a very weak effect of the illusion. Finally, sense of agency showed a trend toward a negative correlation with the strength of the illusion as subjectively perceived by participants with PTSD and PTSD+DS. These findings suggest individuals with PTSD may, at times, maintain a rigid representation of the body as an avoidance strategy, with top-down cognitive processes weakening the impact of manipulation of body ownership. By contrast, the response elicited in PTSD+DS appeared to be driven by either an increased vulnerability to manipulation of embodiment or by a dominant top-down cognitive representation of the body, with disruption of multisensory integration processes likely in both cases. Taken together, these findings further our understanding of bodily consciousness in PTSD and its dissociative subtype and highlight the supportive role played by sense of agency for the maintenance of body ownership.