Heparin as a Potential Therapeutic Substance for Post-Traumatic Stress Disorder.

In sexually mature male Wistar rats with modeled post-traumatic stress disorder, personalized characteristics of neurobiological reactions in the population of predator-induced stress-resilient and stress-susceptible heparinized animals were determined. Characteristics of the systemic response of immune mechanisms, hypothalamic-pituitary-adrenal axis, behavioral manifestations, as well as basic properties of the CNS (excitation/inhibition) are presented. The study demonstrated encouraging positive results of the course administration of unfractionated heparin at a dose below the therapeutic and prophylactic doses. The inclusion of heparin drugs into the clinical practice for the treatment of post-traumatic stress disorder will not require large-scale clinical trials, because many effects of heparin as a nonspecific adaptogen are well studied. Moreover, these properties were confirmed at a higher technological level during the COVID-19 pandemic.

Corrigendum: Artemisinin reduces PTSD-like symptoms, improves synaptic plasticity, and inhibits apoptosis in rats subjected to single prolonged stress.

[This corrects the article DOI: 10.3389/fphar.2024.1303123.].

Analysis of risk factors and construction of a prediction model for posttraumatic stress disorder among Chinese college students during the COVID-19 pandemic.

BACKGROUND: To explore the risk factors of post-traumatic stress disorder (PTSD) among Chinese college students during the COVID-19 pandemic and the construction and validation of risk prediction models. METHODS: A total of 10,705 university students were selected for the study. The questionnaire included the Generalized Anxiety Disorder 7 (GAD-7), Patient Health Questionnaire 9 (PHQ-9), PTSD Checklist for DSM-5 (PCL-5), and self-designed questionnaire. These assessments were conducted to facilitate the survey, construct the predictive model and validate the model's validity. RESULTS: Sex, left-behind experience, poverty status, anxiety score, and depression score were identified as independent risk factors influencing psychological trauma among Chinese college students during the COVID-19 pandemic, while COVID-19 infection emerged as a protective factor against psychological trauma. A column chart was constructed to visualize the six independent risk factors derived from logistic regression analysis. The Hosmer-Lemeshow test results (χ2 = 13.021, P = 0.111) indicated that the risk prediction model fitted well. The receiver operating characteristic (ROC) curve showed an area under the curve (AUC) of 0.864 in the model group and 0.855 in the validation group. The calibration curves of the model closely resembled the ideal curve. Decision curve analysis (DCA) revealed that the model provided net benefit and demonstrated good clinical utility. LIMITATIONS: The validation of the model is currently restricted to internal assessments. However, further confirmation through larger sample sizes, multicenter investigations, and prospective studies is necessary. CONCLUSIONS: The model effectively predicted PTSD risk among Chinese college students during the COVID-19 pandemic, indicating strong clinical applicability.

Case report: "Scared to deaf": medical-legal evaluation of a suspected post -traumatic stress disorder".

The case concerns the alleged failure by the resisting administration to fulfill obligations arising from the contract and employment relationship, as well as the violation of safety regulations leading to the workplace accident reported by an Airforce Sergeant. Following the accident, the soldier complains of developing barotraumatic hearing loss with tinnitus and reactive post-traumatic stress disorder to the traumatic event. The case provides an opportunity to analyze the relevance of forensic medical assessment and its integration with psychodiagnostic examination for the correct nosographic classification aimed at evaluating and quantifying biological damage.

Psychological interventions to pregnancy-related complications in patients with post-traumatic stress disorder: a scoping review.

OBJECTIVE: This scoping review sought to investigate the association between pregnancy-related complications and post-traumatic stress disorder (PTSD) among postpartum women, then summarize effective psychological interventions for pregnancy-related PTSD or sub-PTSD. METHOD: Publications in English and Chinese were searched in PubMed, Embase, Cochrane, ISI Web of Science, China National Knowledge Infrastructure (CNKI), and WanFang databases using the subject headings of "Stress Disorders, Post-Traumatic", "Pregnant Women", and "psychotherapy". To ensure that as many relevant studies are incorporated as possible, free terms such as prenatal, postnatal, perinatal and gestation were also used. Intervention studies and related cases published by July 1st, 2023, were also searched. RESULTS: Twenty-one articles (including 3,901 mothers) were included in this review. Evidence showed that typical psychological interventions exhibited great effect, and family support programs, peer support, online yoga, and music therapy were also effective in reducing risk and improving the psychological well-being of the studied population. CONCLUSION: Fetal abnormalities, miscarriage, premature birth, infants with low birth weights, hypertension, pre-eclampsia, HELLP syndrome, and hyperemesis gravidarum are associated with an increased risk of PTSD. Moreover, high-risk pregnant women may benefit from psychological interventions such as cognitive behavioral therapy (CBT). It may also be feasible and well-accepted for music therapy and exposure therapy to lessen the intensity of PTSD in mothers.

Mental Health Outcomes of Arab and Jewish Populations in Israel a Month after the Mass Trauma Events of October 7, 2023: A Cross-Sectional Survey of a Representative Sample.

On October 7, 2023, a war erupted in Israel following a mass terror attack including mass shootings, violent events, civilian abductions, and numerous fatalities, ranking as the third most deadliest terror attack. This cross-sectional, population-based study evaluated the impact on the mental health and utilization of mental health services in the Arab and Jewish populations. Conducted through a virtual platform, the study compared demographic factors, exposure to war-related events, anxiety, and post-traumatic stress symptoms among 517 participants in a representative sample of the adult population in Israel (79.1% Jewish, 20.9% Arab). Jews reported higher exposure to war-related events, but a majority expressed a lack of interest in mental help. In contrast, more Arabs desired mental help but faced barriers like stigma and scarce resources. Arabs showed a greater preference for group therapy and medical treatment. Trust in official bodies was consistently higher among Jews. Both populations exhibited similar levels (12-15.4%) of probable post-traumatic stress disorder (PTSD). This study equips clinicians, researchers and policymakers with real-time insights into improving mental health support for the culturally diverse needs of Jewish and Arab communities following exposure to mass trauma.

Astroglial Dysfunctions in Mood Disorders and Rodent Stress Models: Consequences on Behavior and Potential as Treatment Target.

Astrocyte dysfunctions have been consistently observed in patients affected with depression and other psychiatric illnesses. Although over the years our understanding of these changes, their origin, and their consequences on behavior and neuronal function has deepened, many aspects of the role of astroglial dysfunction in major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) remain unknown. In this review, we summarize the known astroglial dysfunctions associated with MDD and PTSD, highlight the impact of chronic stress on specific astroglial functions, and how astroglial dysfunctions are implicated in the expression of depressive- and anxiety-like behaviors, focusing on behavioral consequences of astroglial manipulation on emotion-related and fear-learning behaviors. We also offer a glance at potential astroglial functions that can be targeted for potential antidepressant treatment.

A network meta-analysis of psychological interventions for children and adolescents after natural and man-made disasters.

INTRODUCTION: Children and adolescents, after natural and man-made disasters, often exhibit various psychological, emotional, and behavioral issues, showing a range of clinical symptoms related to post-traumatic stress disorder (PTSD) and depression. This review used a network meta-analysis (NMA) approach to compare and rank psychological interventions for PTSD and depression in children and adolescents after exposure to natural and man-made disasters. METHODS: Randomized studies of psychosocial interventions for PTSD and depression in children and adolescents exposed to natural and man-made disasters were identified. PTSD and depression symptoms at postintervention and 1-12 month follow-up are the outcomes. The standardized mean differences (SMDs) between pairs of interventions at postintervention and follow-up were pooled. Mean effect sizes with 95% credible intervals (CI) were calculated, and the ranking probabilities for all interventions were estimated using the surface under the cumulative ranking curve. Study quality was assessed with version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). RESULTS: In total, 26 studies with 4331 participants were included in this NMA. Eye movement desensitization and reprocessing therapy (EMDR) (SMD = - 0.67; 95% CI - 1.17 to - 0.17), exposure therapy (ET) (SMD = - 0.66; 95% CI - 1.11 to - 0.22), and cognitive behavioral therapy (CBT) (SMD = - 0.62; 95% CI - 0.90 to - 0.34) were significantly more effective for PTSD at postintervention than inactive intervention. EMDR (SMD = - 0.72; 95% CI - 1.11 to - 0.33) and ET (SMD = - 0.62; 95% CI - 0.97 to - 0.27) were associated with a higher reduction in PTSD symptoms at follow-up than inactive intervention. EMDR (SMD = - 0.40; 95% CI - 0.78 to - 0.03) and play therapy (PT) (SMD = - 0.37; 95% CI - 0.62 to - 0.12) were significantly more effective for depression at postintervention than inactive intervention. For all psychological interventions in reducing depression symptoms at follow-up compared with inactive intervention, the differences were not significant. CONCLUSION: EMDR appears to be most effective in reducing PTSD and depression in children and adolescents exposed to natural and man-made disasters. In addition, ET and CBT are potentially effective in reducing PTSD symptoms at postintervention, while PT is beneficial in managing depression symptoms at the treatment endpoint.

Post-traumatic Stress Disorder in Veterans: A Concept Analysis.

Post-traumatic stress disorder (PTSD) occurs when an individual experiences a traumatic event that exceeds the limits of psychological endurance. Many veterans experience PTSD. PTSD can negatively impact veterans' quality of life, functioning, life satisfaction, and overall well-being. It is important to analyze the concept of PTSD in the veteran population. This concept analysis aimed to investigate the defining attributes, a model case, antecedents, consequences, and empirical referents related to the concept of PTSD among veterans. Walker and Avant's method was used to guide this concept analysis of PTSD. The results showed that three attributes were determined from the analysis: intrusive memories of traumatic events, feelings of isolation and estrangement, and negative cognitions. PTSD is conceptualized as a collection of symptoms that arise from highly traumatic experiences. The military environment predisposes veterans to traumatic events that should be identified or acknowledged. A better understanding of the concept of PTSD can facilitate the development of effective interventions for the veteran population and enhance their mental health.

Pain neuroscience education improves post-traumatic stress disorder, disability, and pain self-efficacy in veterans and service members with chronic low back pain: Preliminary results from a randomized controlled trial with 12-month follow-up.

Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain neuroscience education (PNE) is more effective than traditional education in reducing PTSD, disability, pain, and maladaptive beliefs in patients with CLBP. Participants with CLBP and possible PTSD/PTSD-symptoms were recruited for this study. Participants were randomly allocated to a PNE group or a traditional education group. The intervention included 30 minutes of education followed by a standardized exercise program once a week for 4-weeks with a 4 and 8-week follow-up and healthcare utilization assessed at 12-months. Forty-eight participants consented for this research study with 39 allocated to treatment (PNE n = 18, traditional n = 21). PNE participants were more likely to achieve a clinically meaningful reduction in PTSD symptoms and disability at short-term follow-up. At 12-months, the PNE group utilized healthcare with 76% lower costs. In participants with CLBP, PNE may reduce hypervigilance toward pain and improve PTSD symptoms. Participants who received PNE were more confident body-tissues were safe to exercise. These beliefs about pain could contribute to a decrease in perceived disability and healthcare consumption for CLBP.

Traumatic stress-enhanced alcohol drinking: Sex differences and animal model perspectives.

Purpose of review: Stress is associated with alcohol drinking, and epidemiological studies document the comorbidity of alcohol use disorder (AUD) and post-traumatic stress disorder (PTSD), with higher comorbid prevalence in females than in males. The aim of this paper is to highlight information related to sex differences in stress-enhanced alcohol drinking from clinical studies and from preclinical studies utilizing an animal model of traumatic stress. Recent findings: Stress is associated with alcohol drinking and relapse in males and females, but there are sex differences in the alcohol-related adaptation of stress pathways and in the association of different prefrontal regions with stress-induced anxiety. The predator stress model of traumatic stress produced enhanced alcohol drinking in a subgroup of stress-sensitive male and female animals, which could be associated with sex and subgroup differences in stress axis responsivity, behavioral responses to predator odors, and epigenetic mechanisms engaged by traumatic experiences. Summary: While additional studies in females are necessary, existing clinical and preclinical evidence suggests that biological mechanisms underlying stress-enhanced drinking likely differ between males and females. Thus, effective treatment strategies may differ between the sexes.

Post-traumatic stress disorder and associated factors among inpatients at Eastern Command Referral Hospital in Dire Dawa, Eastern Ethiopia.

Background: Post-traumatic stress disorder (PTSD) is characterized by heightened stress and anxiety after experiencing a traumatic event. While numerous studies have been conducted to investigate the magnitude and factors associated with PTSD, there is limited evidence available on specific study populations of military personnel. Objective: The study aimed to determine the magnitude of post-traumatic stress disorder and associated factors among military personnel admitted to the Eastern Command Referral Hospital in Eastern Ethiopia from May 1 to 30, 2023. Methods and materials: A cross-sectional study was carried out at an institution. Face-to-face interviews were conducted to collect data using the post-traumatic stress disorder military version checklist for the Diagnostic and Statistical Manual, Fifth Edition. Data were entered and analyzed using EpiData version 3.1 and STATA version 14. Descriptive statistics were employed to summarize the information. To investigate factors linked with outcome variables, bivariate and multivariate logistic regression analyses were conducted. The results were presented using odds ratios with 95% confidence intervals, with statistical significance given at a p-value of 0.05. Results: This study found that approximately 23.6% (95% CI = 19.9-27.8) of admitted military members fulfilled the diagnostic criteria for PTSD. Participants' history of mental illness [adjusted odds ratio (AOR) = 5.73, 95% CI = 2.66-12.31], family history of mental illness (AOR = 10.38, 95% CI = 5.36-20.10), current chewing of khat (AOR = 2.21, 95% CI = 1.13-4.32), physical trauma (AOR = 2.03, 95% CI = 1.00-4.13), moderate social support (AOR = 0.27, 95% CI = 0.1-4.53), strong social support (AOR = 0.09, 95% CI = 0.02-0.35), and severe depression (AOR = 2.06, 95% CI = 1.74-5.71) were factors significantly associated with post-traumatic stress disorder. Conclusions: The magnitude of post-traumatic stress disorder is high among military personnel. Factors such as participants' history of mental illness, family history of mental illness, depression, lack of social support, current use of khat, and physical trauma are significantly associated with PTSD. It is crucial to identify and intervene early in individuals with these risk factors to address PTSD effectively.

Findings of PTSD-specific deficits in default mode network strength following a mild experimental stressor.

Reductions in default mode (DMN) connectivity strength have been reported in posttraumatic stress disorder (PTSD). However, the specificity of DMN connectivity deficits in PTSD compared to major depressive disorder (MDD), and the sensitivity of these alterations to acute stressors are not yet known. 52 participants with a primary diagnosis of PTSD (n = 28) or MDD (n = 24) completed resting-state functional magnetic resonance imaging immediately before and after a mild affective stressor. A 2 × 2 design was conducted to determine the effects of group, stress, and group*stress on DMN connectivity strength. Exploratory analyses were completed to identify the brain region(s) underlying the DMN alterations. There was significant group*stress interaction (p = 0.03), reflecting stress-induced reduction in DMN strength in PTSD (p = 0.02), but not MDD (p = 0.50). Nodal exploration of connectivity strength in the DMN identified regions of the ventromedial prefrontal cortex and the precuneus potentially contributing to DMN connectivity deficits. The findings indicate the possibility of distinct, disease-specific, patterns of connectivity strength reduction in the DMN in PTSD, especially following an experimental stressor. The identified dynamic shift in functional connectivity, which was perhaps induced by the stressor task, underscores the potential utility of the DMN connectivity and raises the question whether these disruptions may be inversely affected by antidepressants known to treat both MDD and PTSD psychopathology.

To study any differences between PTSD and depression in the way the brain talks with itself in its default mode when not doing any particular thing, we did MRI brain scans with 52 people with Depression, but only some had PTSD. We found that mild emotional stress may briefly reduce default mode strength in PTSD, but not in depression. This might help researchers better understand the impact of stress and trauma on the brain.

The relationship between post-traumatic stress disorder and gastrointestinal disease in United States Military Veterans.

Background: This study examined the relationship between gastrointestinal disease and post-traumatic stress disorder in U.S. military Veterans. Based on literature and clinical practice data sources from the U.S. Veterans Administration, gastrointestinal disease and post-traumatic stress disorder were hypothesized to be positively correlated in Veterans. Objectives: This study aimed to determine the frequency with which gastrointestinal disease and post-traumatic stress disorder are diagnosed comorbidities, a diagnosis of gastrointestinal disease accompanies a diagnosis of post-traumatic stress disorder, and a diagnosis of post-traumatic stress disorder accompanies a diagnosis of a gastrointestinal disease. Methods: The methodology was a retrospective, correlational design using data collected from the U.S. Department of Veterans Affairs patient database. Results: The results were that post-traumatic stress disorder is bi-directionally correlated with the gastrointestinal diseases of gastroesophageal reflux disease, peptic ulcer disease, functional dyspepsia, Crohn's disease, diverticular disease, irritable bowel syndrome, and the symptoms of constipation and nausea/vomiting within Veterans who served during wartime periods. The study also found that post-traumatic stress disorder is not correlated with ulcerative colitis in Veterans. Conclusions: The conclusions are that clinicians who see a presentation of post-traumatic stress disorder should be screening for gastrointestinal disease, while primary care and gastroenterology providers treating gastrointestinal disease should be screening for a history of trauma, as improved diagnosis rates may lead to improved treatment.

Validating the Spanish translation of the posttraumatic stress disorder checklist (PCL-5) in a sample of individuals with traumatic brain injury.

Introduction: There is controversy regarding the comorbidity of posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI). The present study translated the PTSD Checklist for DSM-5 (PCL-5) to Spanish and validated it in a sample of patients with TBI 6 months after the injury. Methods: The study included 233 patients (162 males and 71 females) recruited from four Spanish hospitals within 24 h of traumatic brain injury. A total of 12.2% of the sample met the provisional PTSD diagnostic criteria, and the prevalence was equal between male and female participants. Results: The analysis confirmed the internal consistency of the translated instrument (α = 0.95). The concurrent validity of the instrument was confirmed based on high correlation coefficients of 0.7 and 0.74 with the General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire (PHQ-9), respectively. Exploratory factor analysis also confirmed that the items on the PCL-5 can be differentiated from the GAD-7 and PHQ-9 items. Confirmatory factor analysis (CFA) was used to examine the structural validity of the Spanish translation of the PCL-5 with three different models. CFA partially confirmed the four-factor PTSD model, whereas both the six-factor anhedonia model and the seven-factor hybrid model showed adequate fit. However, the difference between the anhedonia and hybrid models was not statistically significant; moreover, both models showed signs of overfitting. Therefore, the utility of these models should be reexamined in future studies. Conclusion: Overall, the results suggest that the Spanish translation of the PCL-5 is a reliable and valid instrument for screening PTSD symptoms among Spanish TBI patients. The Spanish translation of the PCL-5 is also presented in the manuscript.

Post-traumatic stress disorder in children after discharge from the pediatric intensive care unit: a scoping review.

As the prevalence of post-traumatic stress disorder (PTSD) among children discharged from pediatric intensive care unit (PICU) continues to rise, corresponding research efforts have also increased. This scoping review aimed to review the PTSD prevalence, influencing factors, and tools used for PTSD measurements in children discharged from the PICU. This review employed the five-stage framework proposed by Arksey and O'Malley. The data sources included PubMed, Web of Science, Ovid, ScienceDirect, Springer, Scopus, CNKI, and WANFANG. Studies in English or Chinese published up to September 2023 were eligible for inclusion. The search yielded a total of 3536 results, with 31 articles meeting the inclusion criteria. The included studies reported that the prevalence of PTSD ranged from a minimum of 13% to a maximum of 84.6%. Risk factors for PTSD included medical interventions, child-related factors, and family environment. A total of 17 assessment tools for PTSD in PICU patients were reported. Given the significance of PTSD in this pediatric population, further attention, research, and intervention are warranted to help alleviate the burden of PTSD.

Cognitive emotion regulation strategies as a mediator between cyber dating violence and post-traumatic stress disorder symptoms among college students.

Objective: Cyber dating violence (CDV) is prevalent among emerging adults and could lead to post-traumatic stress disorder (PTSD) symptoms. However, limited research has been conducted on potential mitigating (or exacerbating) factors, such as the use of cognitive emotion regulation strategies (CER). The present study examined whether CER strategies mediate the relationship between CDV and PTSD. Participants: Among a sample of 598 college students, the present study focuses on those who reported past-year CDV (56%; N = 335). Methods: An online survey was completed by college students to assess CDV, CER, and PTSD using validated self-report measures. Results: CDV was bivariately correlated with PTSD symptoms as well as adaptive and maladaptive CER. Within a mediation model, maladaptive (but not adaptive) CER mediated the relationship between CDV and PTSD. Conclusions: CDV is common among college students. Targeting maladaptive CER, such as self-blame and rumination, could lead to reductions in PTSD symptoms.

Transdiagnostic and transtherapeutic strategies for optimising autobiographical memory.

Our memories for past personally experienced autobiographical events play an important role in therapy, irrespective of presenting issue, diagnoses or therapeutic modality. Here, we summarise evidence for how autobiographical memory abilities can influence our mental health and the relevance of this for the treatment of mental health problems. We then guide the reader through principles and strategies for optimising autobiographical memory within treatment. We ground these recommendations within research for stand-alone interventions for improving autobiographical memory and from studies of how to support the formation and retrieval of therapeutic memories. Options are given for clinicians to guide clients in improving retrieval of autobiographical memories within treatment, for improving autobiographical memory for the therapeutic experience itself, and for creating improvements in autobiographical memory that endure post-treatment. We also provide worksheets for clinicians to use within treatment.

Pain and psychopathology after intensive care unit admission.

Pain and psychopathology are observed in 18% and 55% of patients, respectively, 1 year after intensive care unit (ICU) admission. It is well known that chronic pain and psychopathology have a bidirectional relation in the general population, but it is not known whether this holds true for ICU survivors. The aim of this study was to investigate whether pain before, during and after ICU admission is related to psychopathology in ICU survivors 1 year after discharge. We performed a cohort study in a mixed ICU in the Netherlands between 2013 and 2016. At 1-year follow-up, patients completed the Hospital Anxiety and Depression Scale, the Impact of Event Scale/Impact of Event Scale-Revised, and answered standardised questions regarding pain. Psychopathology was defined as having anxiety, depressive and/or post-traumatic stress disorder symptoms. We used multivariable logistic regression analysis to evaluate the association of pain before, during and after ICU admission with psychopathology at 1 year follow-up. We included 1105 patients of whom 558 (50%) (95% confidence interval (CI) 0.48 to 0.54) had psychopathology at 1 year follow-up. Pain before ICU admission (odds ratio (OR) 1.18; 95% CI 1.10 to 1.26) and pain after ICU admission (OR 2.38; 95% CI 1.68 to 3.35) were associated with psychopathology. Pain during ICU stay was not associated with psychopathology, but the memory of insufficient pain management during ICU stay was (OR 2.19; 95% CI 1.39 to 3.45). Paying attention to pain and pain treatment experiences related to ICU admission may therefore contribute to early identification of ICU survivors at risk of psychopathology development.

A roadmap to understanding interoceptive awareness and post-traumatic stress disorder: a scoping review.

The concept of interoception has existed since the beginning of the 1900s. It is suggested that humans can observe feelings arising from the body that allows them to develop a sense of their emotional status and physical condition. The term interoceptive awareness appears to originate with clinicians working with individuals who had experienced trauma, in particular Post Traumatic Stress Disorder (PTSD). The purpose of this scoping review was to provide an overview of the existing literature surrounding the combination of these two themes: interoceptive awareness and PTSD. A total of 226 articles were initially screened and 52 articles were retained for comprehensive review. Nine articles were excluded, resulting in 43 studies included in the review. The review aimed to answer: (a) how is interoceptive awareness defined? (b) how is interoceptive awareness measured? (c) what is the function of interoceptive awareness? (d) is there/what is the relationship between interoceptive awareness and PTSD? The scoping review identified nine terms that are used synonymously throughout the literature surrounding interoceptive awareness and PTSD, and three primary ways in which interoceptive awareness is measured in relation to PTSD. The primary function documented was the role interoceptive awareness played in an individual's ability to regulate their emotions, and the most common and compelling function emerging was the association with emotion regulation. The evidence supports the utilisation of a definition of interoceptive awareness to include one that includes the quality of cognitive appraisal and focuses on the adaptive mindful approach to internal physical sensations as opposed to the heightened ruminative self-focus. Limitations and future research are suggested.