Should we keep some distance from distancing? Regulatory and post-regulatory effects of emotion downregulation.

Emotion regulation is an indispensable part of mental health and adaptive behavior. Research into emotion regulation processes has largely focused on the concurrent effects of volitional emotion regulation. However, there is scarce evidence considering post-regulatory effects with regard to neural mechanisms and emotional experiences. Therefore, we compared concurrent effects of cognitive emotion regulation with effects at different (immediate, short- and long-term) time intervals. In an fMRI study with N = 46 (N = 30 at re-exposure) young healthy adults, we compared neuronal responses to negative and neutral pictures while participants had to distance themselves from or to actively permit emotions in response to these pictures. We investigated the temporal dynamics of activation changes related to regulation in cognitive control brain networks as well as in the amygdala during stimulation (concurrent effects, timepoint 1) and post-stimulation (immediate, timepoint 2), as well as during re-exposure with the same pictures after short (10 minutes, timepoint 3) and long (1 week, timepoint 4) time intervals. At timepoint 1, negative pictures (versus neutral pictures) elicited a strong response in regions of affective processing, including the amygdala. Distancing (as compared to permit) led to a decrease of this response, and to an increase of activation in the right middle frontal and inferior parietal cortex. We observed an interaction effect of time (stimulation vs. post-stimulation) and regulation (distance vs. permit), indicating a partial reversal of regulation effects during the post-stimulation phase (timepoint 2). Similarly, after 10 minutes (timepoint 3) and after 1 week (timepoint 4), activation in the amygdala was higher during pictures that participants were previously instructed to distance from as compared to permit. These results show that the temporal dynamics are highly variable both within experimental trials and across brain regions. This can even take the form of paradoxical aftereffects at immediate and persistent effects at prolonged time scales.

Lifetime Trauma History and Cognitive Functioning in Major Depression and Their Role for Cognitive-Behavioral Therapy Outcome.

Background: While cognitive-behavioral therapy (CBT) is the gold-standard psychological treatment for major depression (MD), non-response and lacking stability of treatment gains are persistent issues. Potential factors influencing treatment outcome might be lifetime trauma history and possibly associated primarily prefrontal-cortex- and hippocampus-dependent cognitive alterations. Method: We investigated MD and healthy control participants with (MD+T+, n = 37; MD-T+, n = 39) and without lifetime trauma history (MD+T-, n = 26; MD-T-, n = 45) regarding working memory, interference susceptibility, conflict adaptation, and autobiographical memory specificity. Further, MD+T+ (n = 21) and MD+T- groups (n = 16) were re-examined after 25 CBT sessions, with MD-T- individuals (n = 34) invited in parallel in order to explore the stability of cognitive alterations and the predictive value of lifetime trauma history, cognitive functioning, and their interaction for treatment outcome. Results: On a cross-sectional level, MD+T+ showed the highest conflict adaptation, but MD+T- the lowest autobiographical memory specificity, while no group differences emerged for working memory and interference susceptibility. Clinical improvement did not differ between groups and cognitive functioning remained stable over CBT. Further, only a singular predictive association of forward digit span, but no other facets of baseline cognitive functioning, lifetime trauma history, or their interaction with treatment outcome emerged. Discussion: These results indicate differential roles of lifetime trauma history and psychopathology for cognitive functioning in MD, and add to the emerging literature on considering cognitive, next to clinical remission as a relevant treatment outcome.

Cognitive functioning in posttraumatic stress disorder before and after cognitive-behavioral therapy.

Although substantial evidence suggests altered executive functioning and autobiographical memory in posttraumatic stress disorder (PTSD), the clinical significance of these findings remains unclear. Here, we investigated the effects of cognitive-behavioral therapy (CBT) on different aspects of cognitive functioning (working memory, interference susceptibility, conflict adaptation, autobiographical memory) in PTSD patients in a pre-post control group design with a nested cross-sectional element. Cross-sectional analyses at baseline were conducted on 58 PTSD patients, 39 traumatized (TC), and 45 non-traumatized controls (NTC). Intervention effects were investigated before and after 25 CBT sessions in 25 PTSD and 34 untreated NTC individuals assessed in parallel. At baseline, PTSD patients showed higher conflict adaptation than the NTC group and less autobiographical memory specificity than both control groups, suggesting particularly the latter to be a correlate of PTSD. No consistent evidence for treatment-induced improvements in cognitive functioning emerged on the group level or from associations between intra-individual clinical and cognitive changes. Analyses on the role of cognitive functioning on subsequent treatment effects revealed a predictive effect of backward digit span on CBT-induced reductions of depressiveness, but no other significant effects. Our findings highlight the need for further research to identify more relevant predictors of differential treatment response.

Is repetitive negative thinking a transdiagnostic process? A comparison of key processes of RNT in depression, generalized anxiety disorder, obsessive-compulsive disorder, and community controls.

BACKGROUND AND OBJECTIVES: The transdiagnostic view of repetitive negative thinking (RNT) claims that different forms of RNT are characterized by identical processes that are applied to disorder-specific content. The purpose of the study was to test whether the processes of RNT differ across major depression disorder (MDD), generalized anxiety disorder (GAD), and obsessive-compulsive disorder (OCD). METHODS: Forty-two individuals diagnosed with MDD, 35 individuals with GAD, 41 individuals with OCD, and 35 community controls were asked to think of a typical RNT episode and to rate its processes (core processes; use of mental capacity, unproductivity, abstractness, verbal quality, duration). Ratings were compared across groups using planned contrasts and analysis of variance. RESULTS: All individuals with a clinical diagnosis rated the key processes of RNT and avoidance function of RNT as higher than healthy controls. There were no differences between individuals diagnosed with MDD, GAD or OCD on key processes and avoidance function of RNT. LIMITATIONS: Results are based on retrospective self-reports, which might restrict validity of the measurements. CONCLUSIONS: Data support the transdiagnostic hypothesis of RNT. Transdiagnostic prevention and intervention techniques seem highly recommendable given these findings.

Cognitive emotion regulation and personality: an analysis of individual differences in the neural and behavioral correlates of successful reappraisal.

A common and mostly effective emotion regulation strategy is reappraisal. During reappraisal, activity in cognitive control brain regions increases and activity in brain regions associated with emotion responding (e.g., the amygdala) diminishes. Immediately after reappraisal, it has been observed that activity in the amygdala increases again, which might reflect a paradoxical aftereffect. While there is extensive empirical evidence for these neural correlates of emotion regulation, only few studies targeted the association with individual differences in personality traits. The aim of this study is to investigate these associations more thoroughly. Seventy-six healthy participants completed measures of broad personality traits (Big Five, Positive and Negative Affect) as well as of more narrow traits (habitual use of emotion regulation) and performed an experimental fMRI reappraisal task. Participants were instructed to either permit their emotions or to detach themselves from the presented negative and neutral pictures. After each picture, a relaxation period was included. Reappraisal success was determined by arousal ratings and activity in the amygdala. During reappraisal, we found activation in the prefrontal cortex and deactivation in the left amygdala. During the relaxation period, an immediate aftereffect was found in occipital regions and marginally in the amygdala. Neither personality traits nor habitual use of emotion regulation predicted reappraisal success or the magnitude of the aftereffect. We replicated typical activation and deactivation patterns during intentional emotion regulation and partially replicated the immediate aftereffect in the amygdala. However, there was no association between personality traits and emotion regulation success.

Posttraumatic Stress Disorder and Autobiographical Memories in Everyday Life.

Evidence from self-reports and laboratory studies suggests that recall of nontrauma autobiographical memories may be disturbed in posttraumatic stress disorder (PTSD), but investigations in everyday life are sparse. This study investigated unintentional nontrauma and trauma memories in trauma survivors with and without PTSD (N = 52), who kept an autobiographical memory diary for a week. We investigated whether unintentional nontrauma memories show an overgeneral memory bias and further memory abnormalities in people with PTSD, and whether unintentional trauma memories show distinct features. Compared to the no-PTSD group, the PTSD group recorded fewer nontrauma memories, which were more overgeneral, more often from before the trauma or related to the trauma, were perceived as distant, and led to greater dwelling. Trauma memories were more vivid, recurrent, and present and led to greater suppression and dwelling. Within the PTSD group, the same features distinguished trauma and nontrauma memories. Results are discussed regarding theories of autobiographical memory and PTSD.

ATTENTIONAL BIAS TEMPORAL DYNAMICS PREDICT POSTTRAUMATIC STRESS SYMPTOMS: A PROSPECTIVE-LONGITUDINAL STUDY AMONG SOLDIERS.

BACKGROUND: Attentional bias (AB) to threat is thought to play a key role in the development and maintenance of posttraumatic stress symptomatology (PTS). Empirical evidence though is inconsistent. Some studies report associations between AB towards, threat and PTS; other studies report associations between AB away from threat and PTS; yet other studies fail to find any association. We propose that prospective-longitudinal study of AB as a dynamic process, expressed from moment to moment in time, may help to understand these mixed findings and the role of AB in PTS. METHODS: We tested cross-sectional and prospective-longitudinal associations between AB and PTS among German soldiers from pre- to post-deployment in Afghanistan (n = 144). AB to threat and positive emotion stimuli (angry/happy faces) was measured using the dot-probe task. PTS was assessed by the PTSD Checklist. The number of traumatic experiences was assessed using CIDI-traumatic experience lists for military. RESULTS: We found that AB dynamics (i.e., towards, away, temporal variability) at pre- and post-deployment, with respect to angry and happy faces, predicted higher levels of PTS after deployment as a function of number of intermediate traumatic experiences. Traditional aggregated mean bias scores did not similarly prospectively predict PTS post deployment. CONCLUSIONS: Findings indicate that AB to emotionally arousing stimuli may play an important function in the development and maintenance of PTS. We argue that mixed and null findings appear to be due to failure to model the within-subject temporal variability in AB expression. Theoretical, empirical, and clinical implications of these findings are discussed.

Hair cortisol concentrations and cortisol stress reactivity predict PTSD symptom increase after trauma exposure during military deployment.

BACKGROUND: Previous evidence on endocrine risk markers for posttraumatic stress disorder (PTSD) has been inconclusive. Here, we report results of the first prospective study to investigate whether long-term hair cortisol levels and experimentally-induced cortisol stress reactivity are predictive of the development of PTSD symptomatology in response to trauma during military deployment. METHODS: Male soldiers were examined before deployment to Afghanistan and at a 12-month post-deployment follow-up using dimensional measures for psychopathological symptoms. The predictive value of baseline (i) hair cortisol concentrations (HCC, N=90) and (ii) salivary cortisol stress reactivity (measured by the Trier Social Stress Test, N=80) for the development of PTSD symptomatology after being exposed to new-onset traumatic events was analyzed. RESULTS: Baseline cortisol activity significantly predicted PTSD symptom change from baseline to follow-up upon trauma exposure. Specifically, our results consistently revealed that lower HCC and lower cortisol stress reactivity were predictive of a greater increase in PTSD symptomatology in soldiers who had experienced new-onset traumatic events (explaining 5% and 10.3% of variance, respectively). Longitudinal analyses revealed an increase in HCC from baseline to follow-up and a trend for a negative relationship between HCC changes and the number of new-onset traumatic events. Additional pre-deployment analyses revealed that trauma history was reflected in lower HCC (at trend level) and that HCC were negatively related to stressful load. CONCLUSIONS: Our data indicate that attenuated cortisol secretion is a risk marker for subsequent development of PTSD symptomatology upon trauma exposure. Future studies are needed to confirm our findings in other samples.

Is trait resilience characterized by specific patterns of attentional bias to emotional stimuli and attentional control?

BACKGROUND AND OBJECTIVES: Attentional processes have been suggested to play a crucial role in resilience defined as positive adaptation facing adversity. However, research is lacking on associations between attentional biases to positive and threat-related stimuli, attentional control and trait resilience. METHODS: Data stem from the follow-up assessment of a longitudinal study investigating mental health and related factors among German soldiers. Trait resilience was assessed with the Connor-Davidson Resilience Scale and attentional control with the Attentional Control Scale. A subset of n = 198 soldiers also completed a dot probe task with happy, neutral and threatening faces. RESULTS: Attentional control was positively related to trait resilience. Results revealed no associations between both attentional biases and trait resilience. However, there was a negative association between attentional bias to threat and trait resilience when attentional control was low and a positive association between attentional bias to threat and trait resilience when attentional control was high. No such associations were found for attentional bias to positive stimuli. LIMITATIONS: Generalizability to other populations may be limited since we exclusively focused on male soldiers. Also, the cross-sectional design does not allow for causal conclusions. CONCLUSIONS: Findings suggest that attentional processing may promote trait resilience. Future research on preventive interventions should consider these findings.

Stress exposure and the risk for the onset of alcohol use disorders and nicotine dependence in deployed military personnel: the role of prior internalizing disorders.

OBJECTIVE: This prospective study aimed to investigate whether prior internalizing disorders (PIDs) moderate the relationship between stress exposure (SE) and the onset of alcohol use disorders (AUDs) and nicotine dependence (ND) in deployed military personnel. METHODS: 358 male soldiers were examined directly before and 12months after return from deployment using standardized interviews. Combat experiences, concerns about family disruptions, and difficult living and working environment were assessed as different aspects of SE. PID diagnoses (mood disorders (PMDs), anxiety disorders (PADs)) and substance use disorders were defined according to the DSM-IV-TR. RESULTS: PMDs were related to a stronger association between concerns about family disruptions and the risk of AUD onset (OR=7.7, 95% CI 1.8-32.8, p=0.006). The number of PID diagnoses (OR per diagnosis: 1.7, 95% CI 1.0-2.8, p=0.036) and PADs (OR: 2.6, 95% CI 1.1-6.3, p=0.038) were further related to a stronger association between difficult living and working environment and the risk of AUD onset. With regard to ND, PMDs were related to a weaker association between difficult living and working environment and the risk of ND onset (OR=0.4, 95% CI 0.2-0.8, p=0.013). CONCLUSIONS: PIDs might be related to an increased risk for the onset of AUDs but not ND following SE. This effect is probably restricted to specific constellations of PADs, PMDs, comorbid PIDs and specific aspects of SE. These critical constellations of PIDs and SE might be a promising target for future research and could contribute to the development of preventive measures to reduce the risk of AUDs following SE.

Instructions matter: a comparison of baseline conditions for cognitive emotion regulation paradigms.

The choice of a meaningful baseline condition is a crucial issue for each experimental design. In the case of cognitive emotion regulation, it is common to either let participants passively view emotional stimuli without any further specific instructions or to instruct them to actively attend to and permit any arising emotions, and to contrast one of these baseline conditions with a regulation condition. While the "view" strategy can be assumed to allow for a more spontaneous emotional response, the "permit" strategy may result in a more pronounced affective and cognitive response. As these conceptual differences may be associated with differences both in subjective emotional experience and neural activation, we compared these two common control conditions within a single functional magnetic resonance imaging (fMRI) experiment, during which participants were instructed to either passively view a set of unpleasant and neutral pictures or to actively permit any emotions arising in response to the unpleasant pictures. Trial-by-trial ratings confirmed that participants perceived the unpleasant pictures as more arousing than the neutral pictures, but also indicated higher subjective arousal during the "permit negative" as compared to the "view negative" and "view neutral" conditions. While both the "permit negative" and "view negative" conditions led to increased activation of the bilateral amygdala when contrasted with the passive viewing of neutral pictures, activation in the left amygdala was increased in response to the "permit" instruction as compared to the "view" instruction for unpleasant pictures. The increase in amygdala activation in both the "permit" and "view" conditions renders both strategies as suitable baseline conditions for studies of cognitive emotion regulation. Conceptual and activation differences, however, indicate that these two variants are not exchangeable and should be chosen depending on the experimental context.

Hair cortisol as a biomarker of traumatization in healthy individuals and posttraumatic stress disorder patients.

BACKGROUND: Previous evidence on endocrine correlates of posttraumatic stress disorder (PTSD) has been rather inconsistent. The analysis of cortisol in hair is a recent methodological development that may increase the quality of long-term cortisol assessments in such research. Here, we use this method to closely assess hair cortisol relationships with trauma-related characteristics and PTSD symptom patterns. METHODS: Hair cortisol concentrations (HCC), diurnal salivary cortisol, and relevant psychometric data were assessed in matched groups of 28 PTSD patients and 27 traumatized and 32 nontraumatized healthy control subjects. Cortisol levels were quantified by liquid chromatography tandem mass spectrometry. RESULTS: Posttraumatic stress disorder patients and traumatized control subjects exhibited 59% and 51% lower HCC than nontraumatized control subjects, respectively. Hair cortisol concentrations were found to be negatively related to the severity of intrusion symptoms, the number of different lifetime traumatic events, the frequency of traumatization, and the time interval since traumatization. The overall pattern of HCC associations was not reflected in short-term salivary cortisol findings. CONCLUSIONS: Our results indicate that trauma exposure per se, either in the absence or presence of PTSD, is a crucial correlate of long-term basal cortisol levels. Particularly, the experience of multiple events with a longer time since traumatization and an increased severity of intrusion symptoms may be related to hypocortisolism. The fact that HCC findings were not consistently seen in salivary cortisol data underscores the importance of the method of cortisol assessment and highlights the utility of hair cortisol analyses for future biological psychiatry research.

Traumatic experiences and posttraumatic stress disorder in soldiers following deployment abroad: how big is the hidden problem?

BACKGROUND: Little is known about the frequency of traumatic event exposure and the development of post-traumatic stress disorder (PTSD) among German soldiers serving in Afghanistan. METHODS: We studied a random sample consisting of 1599 soldiers who had served in the 2009/2010 ISAF mission in Afghanistan, stratified by deployment location and unit. Twelve months after their return to Germany, the soldiers were assessed with a Composite International Diagnostic Interview (CIDI) to establish the diagnoses of mental disorders and PTSD according to the DSM-IV. 889 similar soldiers who had not been deployed abroad were assessed in the same way. RESULTS: 49.2% (95% confidence interval [CI]: 46.4 to 52.1) of the deployed soldiers experienced at least one traumatic event during their deployment, and 13% experienced more than three. The 12-month prevalence of PTSD among returning soldiers was 2.9% (95% CI: 2.1 to 4.1), while the service-related incidence after deployment was 0.9% (95% CI: 0.5 to 1.6). These figures imply a two- to fourfold elevation of the risk of PTSD. The risk of PTSD was highest among soldiers who had served in Kunduz (Afghanistan) and in combat units. Only half of all soldiers with PTSD sought professional help. CONCLUSION: Deployment abroad is associated with a high frequency of traumatic experiences and a two- to fourfold elevation of the risk of PTSD. Each year, about 300 cases of PTSD develop for every 10 000 soldiers who return to Germany; thus, the cumulative number of returnees with PTSD from the beginning of German deployment abroad may currently run into the thousands. 45% of all PTSD cases, or about one in two, are neither diagnosed nor treated. Deployment abroad also substantially increases the risk of developing a number of other mental disorders.

Prevalence, incidence and determinants of PTSD and other mental disorders: design and methods of the PID-PTSD+3 study.

Investigation of the prevalence, incidence, and determinants of post-traumatic stress disorders (PTSD) and other mental disorders associated with military deployment in international missions poses several methodological and procedural challenges. This paper describes the design and sampling strategies, instruments, and experimental procedures applied in a study programme aimed to examine military deployment-related mental health and disorders (prevalence and trajectories) and to identify vulnerability and risk factors (e.g. age, gender, type of mission, rank, and duration of deployment and a wide range of neurobiological, psychological, social, and behavioural factors). The study comprised two components. The first component, a cross-sectional study, included 1483 deployed and 889 non-deployed German soldiers (response rate, 93%) who served during the 2009 International Security Assistance Force (ISAF) mission. A standardized diagnostic instrument (Composite International Diagnostic Interview, CIDI) coupled with established questionnaires was administered to detect and diagnose PTSD and a broad spectrum of mental disorders and mental health problems. The second component, a prospective-longitudinal study, included 621 soldiers examined before (2011) and after return (2012) from the ISAF mission. In addition to the CIDI and questionnaires, several experimental behavioural tests and biological markers were implemented to probe for incident mental disorders, mental health problems and risk factors. Our methods are expected to provide greater precision than previous studies for estimating the risk for incident deployment-related and non-deployment-related disorders and their risk factors. We expect the findings to advance our understanding of a wide spectrum of adverse mental health outcomes beyond PTSD.

Differences and similarities between obsessive and ruminative thoughts in obsessive-compulsive and depressed patients: a comparative study.

Repetitive, intrusive cognitive phenomena are central both to obsessive-compulsive patients - typically as obsessive thoughts - and to depressed patients - typically as ruminative thoughts. The objective of the present study is to compare obsessive and ruminative thoughts in non-depressed obsessive-compulsive and depressed patients. Thirty-four patients diagnosed with obsessive-compulsive disorder and 34 patients diagnosed with major depression disorder were asked to identify both a personally relevant obsessive and a personally relevant ruminative thought and to subsequently evaluate these thoughts on a modified version of the Cognitive Intrusions Questionnaire (CIQ) developed by Freeston, Ladouceur, Thibodeau, and Gagnon (1991). The CIQ assesses general descriptors, emotional reactions, appraisal and coping strategies on a nine-point Likert scale. A mixed-model ANOVA demonstrated that obsessive and ruminative thoughts are distinct cognitive processes, clearly distinguishable in form, appraisal and temporal orientation across disorders. In obsessive-compulsive patients, ruminative thoughts were more common and more emotionally distressing than predicted. In depressed patients, obsessive thoughts occurred infrequently and were not associated with high negative emotions. Clarifying similarities and differences between ruminative and obsessive thoughts and understanding their interaction might ultimately help to expand on the role of cognitive vulnerability factors in obsessive-compulsive and major depression disorder.

The Perseverative Thinking Questionnaire (PTQ): validation of a content-independent measure of repetitive negative thinking.

Repetitive negative thinking (RNT) has been found to be involved in the maintenance of several types of emotional problems and has therefore been suggested to be a transdiagnostic process. However, existing measures of RNT typically focus on a particular disorder-specific content. In this article, the preliminary validation of a content-independent self-report questionnaire of RNT is presented. The 15-item Perseverative Thinking Questionnaire was evaluated in two studies (total N = 1832), comprising non-clinical as well as clinical participants. Results of confirmatory factor analyses across samples supported a second-order model with one higher-order factor representing RNT in general and three lower-order factors representing (1) the core characteristics of RNT (repetitiveness, intrusiveness, difficulties with disengagement), (2) perceived unproductiveness of RNT and (3) RNT capturing mental capacity. High internal consistencies and high re-test reliability were found for the total scale and all three subscales. The validity of the Perseverative Thinking Questionnaire was supported by substantial correlations with existing measures of RNT and associations with symptom levels and clinical diagnoses of depression and anxiety. Results suggest the usefulness of the new measure for research into RNT as a transdiagnostic process.

Posttraumatic stress disorder: diagnostic and epidemiological perspectives.

We reviewed epidemiological findings for the diagnosis of posttraumatic stress disorder (PTSD) and its core diagnostic features, focusing on whether epidemiology has been helpful in clarifying some of the critical diagnostic issues relevant to the revision of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases. Though epidemiology has provided increasingly rich data and knowledge regarding prevalence and incidence, patterns of onset and course, comorbidity, and risk factors for traumatic experiences and posttraumatic stress, little systematic research has been performed specifically addressing such critical diagnostic issues. Particularly, unresolved concerns remain regarding the definition of trauma, duration and impairment/distress criteria, the distinctiveness of the PTSD-syndrome, and even the position of PTSD in the classification system of mental disorders. A further exploitation of the existing data, and an improvement of existing epidemiological methods, strategies, and assessments are likely to substantially contribute to the clarification of unresolved diagnostic issues.

Overgeneral memory and suppression of trauma memories in post-traumatic stress disorder.

The study investigated the relationship between the suppression of trauma memories and overgeneral memory in 42 assault survivors with and without PTSD. Overgeneral memory (OGM) was assessed with a standard autobiographical memory test (AMT). Participants completed two further AMTs under the instructions to either suppress or not suppress assault memories, in counterbalanced order. Participants with PTSD retrieved fewer and more general memories when following the suppression instruction than participants without PTSD, but not under the control instruction. OGM correlated with PTSD symptom severity, and measures of cognitive avoidance. The results are discussed with reference to current theories of overgeneral memory and its possible relationship with PTSD.