Post-traumatic stress disorder – aetiology and treatment

Four papers in the Journal this month focus on post-traumatic stress disorder (PTSD). Attempting to address the complexity of PTSD occurrence in war-exposed individuals, Karam et al (pp. 354–360) examined the relative contributions to PTSD of childhood adversities and environmental sensitivity in a sample of Syrian refugee children and adolescents. War events and childhood adversities were found to be positively correlated and the latter appeared to be the most important predictor of PTSD. At low levels of childhood adversity, children with higher environmental sensitivity were found to be more vulnerable to the impact of war events. The authors highlight the importance of considering factors such as childhood adversity and sensitivity in the development of interventions aimed at improving the mental health of war-exposed refugee groups.

At the other end of the age-group spectrum, Lely et al (pp. 369–377) undertook to test the comparative efficacy of narrative exposure therapy with that of present-centred therapy in older adults with PTSD. In this randomised controlled trial, all symptom levels declined from pre-treatment to post-treatment in both groups but the decline was sharper in the comparison group receiving present-centred therapy and the effects converged at the follow-up point. Both interventions were well tolerated in the participants. The authors comment on the benefits of both trauma-focused and non-trauma-focused therapy approaches for this group and recommend that consideration of patient choice and patient-specific factors should be key to deciding on the right approach at an individual level.

Some occupational groups are at increased risk of exposure to trauma and, in particular, to repeated exposure, but little is known about why only a minority of traumatised workers go on to develop PTSD. Jeong et al (pp. 347–353) sought to understand the neurobiological responses to such repeated traumatic experiences by conducting an functional magnetic resonance imaging (MRI) study of resting-state functional connectivity within fear circuitry brain regions in a group of healthy firefighters. Compared with controls, stronger insular connectivity with the bilateral amygdalae, bilateral hippocampi and ventromedial prefrontal cortex (vmPFC) was identified in the firefighter group. In addition, the insula–amygdala connectivity was positively correlated with trauma-related symptoms, whereas the insula–vmPFC connection was negatively associated with these symptoms.

Finally, Knefel et al (pp. 361–368) consider the new diagnosis of complex PTSD included, in addition to PTSD, in ICD-11. Using data from four nationally representative samples from Germany, Israel, the UK and the USA, the authors identified very similar symptom networks across samples, with the most central symptoms being ‘feelings of worthlessness’ and ‘exaggerated startle response’. The authors comment on the implications for treatment approaches, recommending that targeting of the central symptoms is likely to lead to the best responses to intervention.

Reviews of psychological therapies and in-patient services

In a systematic review and meta-analysis of psychoanalytic/psychodynamic psychotherapy for reducing suicide attempts and self-harm, Briggs et al (pp. 320–328) identified 12 randomised controlled trials. The authors found evidence for a significant reduction in repetition of self-harm at 6 but not 12 months, some evidence for a reduced number of suicide attempts at 12 months and evidence for significant improvement in psychosocial functioning along with a reduction in hospital admissions. They comment, however, on the impact of the small number of studies, moderate quality of evidence and the possibility of publication bias on the extent to which conclusions can be drawn from the current evidence base. Although of relevance to psychological therapies more broadly, an editorial by Holmes & Slade (pp. 318–319) in the Journal this month discusses recent advances in attachment-informed relational neuroscience implicating potential mechanisms underlying the impact of therapy.

Even more broadly, a systematic review by Staniszewska et al (pp. 329–338) has identified key themes for improving experiences of in-patient mental healthcare. From 72 studies across 16 countries, four dimensions were identified – the importance of high-quality relationships, averting negative experiences of coercion, having a healthy, safe and enabling physical and social environment, and authentic experiences of patient-centred care. The authors consider the ways in which such themes can be embedded in the development and evaluation of services. They also highlight the importance of considering the role of staff in delivering high-quality care within the context of a wider system, the latter being neglected in most studies.

Functional connectivity in attention-deficit hyperactivity disorder (ADHD) and autism

Jung et al (pp. 339–344) used machine learning techniques to investigate patterns of surface-based resting-state connectivity in three groups of boys – those with autism spectrum disorder (ASD), those with ADHD and a matched group with typical development. The authors found that children with ASD had increased limbic functional connectivity compared with those with typical development, whereas children with ADHD had increased functional connectivity (frontal and temporal) compared with the other two groups. They also demonstrated the ability of machine learning in this context to distinguish between the three groups. In a linked commentary, Mehra & Absoud (pp. 345–346) highlight the potential for functional connectivity MRI findings to be used as a biomarker for ASD and ADHD, and the extent of overlap between disorders that was identified in the research. In relation to the latter, the authors point to the potential of transdiagnostic treatment approaches informed by research focused on endophenotypes in neurodevelopmental disorders.