Living with uncertainty
Plus: Brain changes in PTSD; intersecting risks and domestic violence; and predicting postnatal depression
Living with uncertainty
A new paper in JMIR Mental Health proposes “intolerance of uncertainty” as a potential factor impacting on mental health: individuals who find uncertainty hard to cope with are, they state, “more likely to experience heightened levels of stress when confronted with uncertain or unpredictable circumstances, such as wartime”. Moreover, the digital media ecosystem provides a superficially appealing, but ultimately maladaptive, way for such individuals to cope with their uncertainty:
“People in uncertain situations, such as disaster events or pandemics, seek information via media to alleviate negative feelings, yet extensive media exposure perpetuates stress and is associated with symptoms of psychopathology, and this pattern is particularly characteristic of the use of social media”.
In other words: people doomscroll to manage distressing uncertainty, but the doomscrolling just induces further distressing uncertainty. Another approach is to seek refuge in conspiracy theories, of which there is no shortage on the internet; but people who try this strategy “do not succeed…and may even experience short-term increases in uncertainty aversion, anxiety, and existential dread”.
The authors propose a number of potential interventions, from managing media consumption to increasing tolerance and cognitive flexibility through methods such as Acceptance and Commitment Therapy.
This is one of those ideas that sounds intuitively appealing, but it’s worth pausing to recognise that the data out there is messy: there’s no consistent definition or measurement of intolerance of uncertainty, and many of the studies cited (eg, around COVID) are self-report and cross-sectional. Still, it’s an interesting paper and I’ll be interested to read further developments in this field.
Is it over now? Brain changes in PTSD
A new Nature paper looks at the effect of psychological trauma on the brain by examining molecular changes in the prefrontal cortex in postmortem samples from people with PTSD (n=36; 19 female, 17 male individuals) compared with major depressive disorder (n=36; 18 female, 18 male) and healthy controls (n=39; 18 female, 21 male).
As will all papers of this sort, it’s quite heavy-going; fortunately, the journal has also published a clear explainer; best to start with that. In brief, the authors found changes in gene expression post-trauma; for example, protein FKBP5 was upregulated, which might give us a mechanistic clue as it interacts with the glucocorticoid receptor that mediates the stress response. Interestingly, this change was concentrated around blood vessels, which are implicated in stress-related pathology. Other findings were consistent with an alteration in the normal excitatory-inhibitory balance of neurons in PTSD.
The hope is that as many of these changes were specific to PTSD, figuring out markers for detection in vivo will help to develop and target new and specific treatments for the condition.
Domestic violence and suicide
An important paper for clinicians in The Lancet Regional Health Europe. This study from the ever-reliable Manchester group analysed data from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) database on women who had died by suicide while under the care of UK mental health services between 2015 and 2021.
They found that 3908 women who had been under the care of services in the past 12 months died by suicide during this time. Data on the presence or absence of domestic violence was available on 2416 women; according to records, 630 (26%) of these women were known to have experienced domestic violence. Compared as a group with those with no history of experiencing domestic violence, these women were younger, and had histories of adverse life events, housing, employment, and financial problems, and diagnoses of PTSD, self-harm, and alcohol misuse, as well as a history of violence as a perpetrator
Two notes of caution: first, the reliance on clinician report means that this study likely underestimated the number of women who had experienced domestic violence. And second, the nature of this study means that we can’t trace a clear path of causation. However, the authors note that they have identified a group with “intersecting disadvantages” putting them at risk of both domestic violence and suicide. “Mental health clinicians”, they conclude, “have a responsibility to enquire about domestic violence and address its impacts as an integral part of suicide prevention.”
Predicting postnatal depression (and more)
The BJPsych has just published this useful review of potential biomarkers for “female reproductive psychiatric disorders”—that is, mental health problems relating to menstruation, pregnancy, parturition and perimenopause. There’s a lot of detail in here, so I’d suggest going to table 1 first: this summarises the various hormonal, epigenetic, immune, and neuroimaging biomarkers relating to specific conditions.
As with other fields of mental health, nothing here is in clinical use just yet. And there are both methodological issues we need to fix (eg, not lumping pregnancy- and postpartum data together in studies), and classification problems (how does “postnatal depression” differ from non-pregnancy-related depression?).
Overall, though, if we’re trying to improve precision in mental health care, as well as understand more about underlying mechanisms, this paper suggests that these conditions are a good place to start.
Thought Formation is taking a short break and will be back soon.