Nijenhuis, E.R.S. (2017). The trinity of trauma: Ignorance, fragility, and control. Volume III, Enactive trauma therapy. Göttingen: Vandenhoeck & Ruprecht. See About/Publications.
Nijenhuis, E.R.S. (2018). Die Trauma-Trinität: Ignoranz-Fragilität-Kontrolle, Band III, Enaktive Traumatherapie. Göttingen: Vandenhoeck & Ruprecht.
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Functional reorganization of neural networks involved in emotion regulation following trauma therapy for complex trauma disorders
Yolanda R. Schlumpf, Ellert R.S. Nijenhuis, Carina Klein, Lutz Jäncke, & Silke Bachmann (2019). Neuroimage: Clinical, 23, 101807. The article can also be downloaded for free at Neuroimage: Clinical’s website.
Objectives: We investigated whether patients with complex interpersonal trauma engage neural networks that are commonly activated during cognitive reappraisal and responding naturally to affect-laden images. In this naturalistic study, we examined whether trauma treatment not only reduces symptoms but also changes neural networks involved in emotional control.
Methods: Before and after eight weeks of phase-oriented inpatient trauma treatment, patients (n=28) with complex posttraumatic stress disorder (cPTSD) and complex dissociative disorders (CDD) performed a cognitive reappraisal task while electroencephalography (EEG) was registered. Patients were measured as a prototypical dissociative part that aims to fulfill daily life goals while avoiding traumatic memories and associated dissociative parts. Matched healthy controls (n=38) were measured twice as well. We examined task-related functional connectivity and assessed self-reports of clinical symptoms and emotion regulation skills.
Results: Prior to treatment and compared to controls, patients showed hypoconnectivity within neural networks involved in emotional downregulation while reappraising affect-eliciting pictures as well as viewing neutral and affect-eliciting pictures. Following treatment, connectivity became normalized in these networks comprising regions associated with cognitive control and memory. Additionally, patients showed a treatment-related reduction of negative but not of positive dissociative symptoms.
Conclusions: This is the first study demonstrating that trauma-focused treatment was associated with favorable changes in neural networks involved in emotional control. Emotional overregulation manifesting as negative dissociative symptoms was reduced but not emotional underregulation, manifesting as positive dissociative symptoms.
Multiple first-person perspectives in PTSD
Aiding the diagnosis of dissociative identity disorder: A pattern recognition study of brain biomarkers
Antje A.T.S. Reinders, Andre F. Marquand, Yolanda R. Schlumpf, Sima Chalavi, Eline M. Vissia, Ellert R.S. Nijenhuis, Paola Dazzan, Lutz Jäncke, Dick J. Veltman (2018). British Journal of Psychiatry. (Article available for members)
Background: A diagnosis of dissociative identity disorder (DID) is controversial and prone to under- and misdiagnosis. From the moment of seeking treatment for symptoms to the time of an accurate diagnosis of DID individuals received an average of four prior other diagnoses and spent 7 years, with reports of up to 12 years, in mental health services.
Aim: To investigate whether data-driven pattern recognition methodologies applied to structural brain images can provide bio- markers to aid DID diagnosis.
Method: Structural brain images of 75 participants were included: 32 female individuals with DID and 43 matched healthy controls. Individuals with DID were recruited from psychiatry and psy- chotherapy out-patient clinics. Probabilistic pattern classifiers were trained to discriminate cohorts based on measures of brain morphology.
Results: The pattern classifiers were able to accurately discriminate between individuals with DID and healthy controls with high sensitivity (72%) and specificity (74%) on the basis of brain structure. These findings provide evidence for a biological basis for distinguishing between DID-affected and healthy individuals.
Conclusions: We propose a pattern of neuroimaging biomarkers that could be used to inform the identification of individuals with DID from healthy controls at the individual level. This is important and clinically relevant because the DID diagnosis is controversial and individuals with DID are often misdiagnosed. Ultimately, the application of pattern recognition methodologies could prevent unnecessary suffering of individuals with DID because of an earlier accurate diagnosis, which will facilitate faster and targeted interventions.
Neurodevelopmental origins of abnormal cortical morphology in dissociative identity disorder
Reinders, A., Chalavi, S., Schlumpf, Y. R., Vissia, E. M., Nijenhuis, E. R. S., Jancke, L., . . . Ecker, C. (2018). Neurodevelopmental origins of abnormal cortical morphology in dissociative identity disorder. Acta Psychiatr Scand, 137(2), 157-170.
OBJECTIVE: To examine the two constitutes of cortical volume (CV), that is, cortical thickness (CT) and surface area (SA), in individuals with dissociative identity disorder (DID) with the view of gaining important novel insights into the underlying neurobiological mechanisms mediating DID. METHODS: This study included 32 female patients with DID and 43 matched healthy controls. Between-group differences in CV, thickness, and SA, the degree of spatial overlap between differences in CT and SA, and their relative contribution to differences in regional CV were assessed using a novel spatially unbiased vertex-wise approach. Whole-brain correlation analyses were performed between measures of cortical anatomy and dissociative symptoms and traumatization. RESULTS: Individuals with DID differed from controls in CV, CT, and SA, with significantly decreased CT in the insula, anterior cingulate, and parietal regions and reduced cortical SA in temporal and orbitofrontal cortices. Abnormalities in CT and SA shared only about 3% of all significantly different cerebral surface locations and involved distinct contributions to the abnormality of CV in DID. Significant negative associations between abnormal brain morphology (SA and CV) and dissociative symptoms and early childhood traumatization (0 and 3 years of age) were found. CONCLUSIONS: In DID, neuroanatomical areas with decreased CT and SA are in different locations in the brain. As CT and SA have distinct genetic and developmental origins, our findings may indicate that different neurobiological mechanisms and environmental factors impact on cortical morphology in DID, such as early childhood traumatization.
Article on Enactive Trauma Theory and Practice
Nijenhuis, E.R.S. (2017). From Passion to Action: A Synopsis of the Theory and Practice of Enactive Trauma Therapy. Frontiers in the Psychotherapy of Trauma and Dissociation, 1(1):65–89, 2017.
Enactive trauma therapy is influenced by the philosophy of enactivism, among other sources of inspiration. Enactivism holds that, like anyone else, traumatized individuals (1) are embodied and embedded in their environment; (2) are goal-oriented human organism-environment systems that primarily long and strive to preserve their existence; (3) are primordial affective systems oriented toward making sense of things; (4) bring forth, i.e., enact a mental and phenomenal self, world, and self-as-a-part-of-this-world, and (5) primarily gain knowledge on the basis of their goal-oriented sensorimotor and affect-laden actions. In this light, trauma is an injury to a whole human organism-environment system. Its core is a lack of integration of various dynamic modes of longing and striving: those that concern longings to live daily life and to avoid perceived threat (notably including traumatic memories) and those that involve longings to defend the integrity of the body. In dissociative disorders, these modes take the form of two or more conscious and self-conscious dissociative subsystems that enact their own mental and phenomenal self, world, and self-as-a-part-of-this-world. Enactive trauma therapy is the endeavor to mend the integrative deficit. It is comprised of the patient and the therapist as two organism-environment systems that enact a common world and that long and strive to achieve common results. Together they spawn new actions and meaning. Their collaboration and communication resembles dancing: It takes pacing, attunement, timing, a sensitivity to balance, movement and rhythm, and courage, as well as the ability and willingness to follow and lead. I propose and illustrate several principles for the progression from passions to actions. Individuals engage in passions and experience sorrow the more they are mostly acted on, that is, influenced by external causes. The more they are their own master, the more they act, and the more they act, the more they experience joy.