Evidence Based Care for Iraqi, Kurdish, and Syrian Asylum Seekers and Refugees of the Syrian Civil War: A Systematic Review

A systematic review of literature reporting on the prevalence of assessment measures, treatments, and biomarkers used in the diagnosis and treatment of PTSD in Iraqi, Kurdish, and Syrian refugees was undertaken. A search of medical, psychological, and sociological databases was conducted on all relevant literature published between January 2011 and March 2016. Seventeen manuscripts met the study inclusion criteria. Seven assessment measures were used in more than one study, four of which were clinically administered (Vivo checklist of war, detention, and torture; Clinically Administered PTSD Scale (CAPS); Mini International Neuropsychiatric Interview; and Hamilton Depression Scale) and three of which were self-report measures (Harvard Trauma Questionnaire (HTQ); Hopkins Symptom Checklist-25 (HSCL-25); Post Migrational Living Difficulties (PMLD). Two studies reported on psychological treatment, both of which administered Narrative Exposure Therapy (NET); no other systematic psychological treatments were identified. Several biomarkers were investigated but only in a single study each, including MRI of lateral prefrontal regions, right inferior parietal cortex, and bilateral isthmus of the cingulate, EEG event-related potentials, hypercortisolemia, and elevated heart rate. Based on these findings, we advocate the use of the HTQ, HSCL-25 and PMLD to exclude PTSD non-cases, and the CAPS for diagnosis of PTSD in Iraqi, Kurdish, and Syrian refugees in Canada. We further suggest NET as the psychological treatment currently with the strongest evidence-base in this population. Finally, we advocate continued research into biomarkers as a means of improving and objectifying psychological assessment and treatment of PTSD in Canadian refugee populations

Neuroimaging studies of psychological interventions for mood and anxiety disorders: empirical and methodological review.

This article reviews the methods and results of published neuroimaging studies of the effects of structured psychological interventions for mood and anxiety disorders. The results are consistent with neural models of improved affective- and self-regulation, as evidenced by psychotherapeutic modulation of brain metabolic activity within the dorsolateral, ventrolateral, and medial prefrontal cortices, the anterior cingulate, the posterior cingulate/precuneus, and the insular cortices. Specific recommendations for future studies are outlined, and the clinical and theoretical significance of this research is discussed

Mind over chatter: plastic up-regulation of the fMRI alertness network by EEG neurofeedback

EEG neurofeedback (NFB) is a brain-computer interface (BCI) approach used to shape brain oscillations by means of real-time feedback from the electroencephalogram (EEG), which is known to reflect neural activity across cortical networks. Although NFB is being evaluated as a novel tool for treating brain disorders, evidence is scarce on the mechanism of its impact on brain function. In this study with 34 healthy participants, we examined whether, during the performance of an attentional auditory oddball task, the functional connectivity strength of distinct fMRI networks would be plastically altered after a 30-min NFB session of alpha-band reduction (n=17) versus a sham-feedback condition (n=17). Our results reveal that compared to sham, NFB induced a specific increase of functional connectivity within the alertness/salience network (dorsal anterior and mid cingulate), which was detectable 30 minutes after termination of training. Crucially, these effects were significantly correlated with reduced mind-wandering 'on-task' and were coupled to NFB-mediated resting state reductions in the alpha-band (8-12 Hz). No such relationships were evident for the sham condition. Although group default-mode network (DMN) connectivity was not significantly altered following NFB, we observed a positive association between modulations of resting alpha amplitude and precuneal connectivity, both correlating positively with frequency of mind-wandering. Our findings demonstrate a temporally direct, plastic impact of NFB on large-scale brain functional networks, and provide promising neurobehavioral evidence supporting its use as a noninvasive tool to modulate brain function in health and disease

Trauma-Related Altered States of Consciousness: Exploring the 4-D Model

22 pagesFrewen and Lanius (in press) recently articulated a 4-D model as a framework for classifying symptoms of posttraumatic stress into those that potentially occur within normal waking consciousness (NWC) versus those that intrinsically represent dissociative experiences of trauma-related altered states of consciousness (TRASC). Four dimensions were specified: time-memory, thought, body, and emotion. The 4-D model further hypothesizes that in traumatized persons, symptoms of TRASC, compared with NWC forms of distress, will be (a) observed less frequently; (b) less intercorrelated, especially as measured as moment-to-moment states; (c) observed more frequently in people with high dissociative symptomatology as measured independently; and (d) observed more often in people who have experienced repeated traumatization, particularly early developmental trauma. The aim of the present research was to begin to evaluate these 4 predictions of the 4-D model. Within a sample of 74 women with posttraumatic stress disorder (PTSD) primarily due to histories of childhood trauma, as well as within a 2nd sample of 504 undergraduates (384 females), the 1st 2 hypotheses of the 4-D model were supported. In addition, within the PTSD sample, the 3rd hypothesis was supported. However, inconsistent with the 4th hypothesis, severity of childhood trauma history was not strongly associated with TRASC. We conclude that the hypotheses articulated by the 4-D model were generally supported, although further research in different trauma-related disorders is needed, and the role of childhood trauma history in the etiology of TRASC requires further research

Letting Go: Mindfulness and Negative Automatic Thinking

Cognitive theorists describe mindfulness as a form of attention-awareness in which thoughts can be observed in non-judging, de-centered, and non-attached ways. However, empirical research has not examined associations between mindfulness and responses to negative automatic thoughts, such as the ability to let go of negative cognition. In the first study reported in this article, measures of dispositional mindfulness were negatively correlated with negative thought frequency and perceptions of the ability to let go of negative thoughts in an unselected student sample. In the second study reported, these associations were replicated in a treatment-seeking student sample, where participation in a mindfulness meditation-based clinical intervention was shown to be associated with decreases in both frequency and perceptions of difficulty in letting-go of negative automatic thoughts. Theoretical and clinical implications are discussed

Meta-analysis of alexithymia in posttraumatic stress disorder.

The authors present a meta-analysis investigating the prevalence of alexithymia in 12 studies encompassing 1,095 individuals with posttraumatic stress disorder (PTSD). A large effect size was found associating PTSD with alexithymia. Effect sizes were higher in studies of male combat PTSD samples in comparison with studies of other PTSD samples. Clinical and research directions are discussed

Restoring large-scale brain networks in PTSD and related disorders: a proposal for neuroscientifically-informed treatment interventions

Background: Three intrinsic connectivity networks in the brain, namely the central executive, salience, and default mode networks, have been identified as crucial to the understanding of higher cognitive functioning, and the functioning of these networks has been suggested to be impaired in psychopathology, including posttraumatic stress disorder (PTSD). Objective: 1) To describe three main large-scale networks of the human brain; 2) to discuss the functioning of these neural networks in PTSD and related symptoms; and 3) to offer hypotheses for neuroscientificallyinformed interventions based on treating the abnormalities observed in these neural networks in PTSD and related disorders. Methods: Literature relevant to this commentary was reviewed. Results: Increasing evidence for altered functioning of the central executive, salience, and default mode networks in PTSD has been demonstrated. We suggest that each network is associated with specific clinical symptoms observed in PTSD, including cognitive dysfunction (central executive network), increased and decreased arousal/interoception (salience network), and an altered sense of self (default mode network). Specific testable neuroscientifically-informed treatments aimed to restore each of these neural networks and related clinical dysfunction are proposed. Conclusions: Neuroscientifically-informed treatment interventions will be essential to future research agendas aimed at targeting specific PTSD and related symptoms

Selective attention to threat versus reward: meta-analysis and neural-network modeling of the dot-probe task.

Two decades of research conducted to date has examined selective visual attention to threat and reward stimuli as a function of individual differences in anxiety using the dot-probe task. The present study tests a connectionist neural-network model of meta-analytic and key individual-study results derived from this literature. Attentional bias for threatening and reward-related stimuli is accounted for by connectionist model implementation of the following clinical psychology and affective neuroscience principles: 1) affective learning and temperament, 2) state and trait anxiety, 3) intensity appraisal, 4) affective chronometry, 5) attentional control, and 6) selective attention training. Theoretical implications for the study of mood and anxiety disorders are discussed

The Threatful Self: Midbrain Functional Connectivity to Cortical Midline and Parietal Regions During Subliminal Trauma-Related Processing in PTSD.

BACKGROUND: The innate alarm system consists of a subcortical network of interconnected midbrain, lower brainstem, and thalamic nuclei, which together mediate the detection of evolutionarily-relevant stimuli. The periaqueductal gray is a midbrain structure innervated by the innate alarm system that coordinates the expression of defensive states following threat detection. In participants with post-traumatic stress disorder, the periaqueductal gray displays overactivation during the subliminal presentation of trauma-related stimuli as well as altered resting-state functional connectivity. Aberrant functional connectivity is also reported in post-traumatic stress disorder for the default-mode network, a large-scale brain network recruited during self-referential processing and autobiographical memory. Here, research lacks investigation on the extent to which functional interactions are displayed between the midbrain and the large-scale cortical networks in post-traumatic stress disorder. METHODS: Using a subliminal threat presentation paradigm, we investigated psycho-physiological interactions during functional neuroimaging in participants with post-traumatic stress disorder (n = 26) and healthy control subjects (n = 20). Functional connectivity of the periaqueductal gray was investigated across the whole-brain of each participant during subliminal exposure to trauma-related and neutral word stimuli. RESULTS: As compared to controls during subliminal threat presentation, the post-traumatic stress disorder group showed significantly greater periaqueductal gray functional connectivity with regions of the default-mode network (i.e., angular gyrus, precuneus, superior frontal gyrus). Moreover, multiple regression analyses revealed that the functional connectivity between the periaqueductal gray and the regions of the default-mode network correlated positively to symptoms of avoidance and state dissociation in post-traumatic stress disorder. CONCLUSION: Given that the periaqueductal gray engages the expression of defensive states, stronger midbrain functional coupling with the default-mode network may have clinical implications to self-referential and trauma-related processing in participants with post-traumatic stress disorder

The hijacked self: Disrupted functional connectivity between the periaqueductal gray and the default mode network in posttraumatic stress disorder using dynamic causal modeling.

Self-related processes define assorted self-relevant or social-cognitive functions that allow us to gather insight and to draw inferences related to our own mental conditions. Self-related processes are mediated by the default mode network (DMN), which, critically, shows altered functionality in individuals with posttraumatic stress disorder (PTSD). In PTSD, the midbrain periaqueductal gray (PAG) demonstrates stronger functional connectivity with the DMN [i.e., precuneus (PCN), medial prefrontal cortex (mPFC)] as compared to healthy individuals during subliminal, trauma-related stimulus processing. Here, we analyzed the directed functional connectivity between the PAG and the PCN, as well as between the PAG and the mPFC to more explicitly characterize the functional connectivity we have observed previously on the corresponding sample and paradigm. We evaluated three models varying with regard to context-dependent modulatory directions (i.e., bi-directional, bottom-up, top-down) among individuals with PTSD (n = 26) and healthy participants (n = 20), where Bayesian model selection was used to identify the most optimal model for each group. We then compared the effective connectivity strength for each parameter across the models and between our groups using Bayesian model averaging. Bi-directional models were found to be favoured across both groups. In PTSD, we revealed the PAG to show stronger excitatory effective connectivity to the PCN, as well as to the mPFC as compared to controls. In PTSD, we further demonstrated that PAG-mediated effective connectivity to the PCN, as well as to the mPFC were modulated more strongly during subliminal, trauma-related stimulus conditions as compared to controls. Clinical disturbances towards self-related processes are reported widely by participants with PTSD during trauma-related stimulus processing, where altered functional connectivity directed by the PAG to the DMN may elucidate experiential links between self- and trauma-related processing in traumatized individuals