BackgroundThe relationship between adverse childhood experiences (ACEs) and personality disorders (PDs) has attracted sustained attention in psychiatry, psychology, and public health. Existing studies have mainly examined epidemiological associations, specific PDs diagnoses, or mechanisms, whereas bibliometric evidence mapping the field’s knowledge structure and thematic evolution remains limited. This study aimed to characterize trends, contributors, collaboration networks, core themes, and frontiers in ACEs–PDs research.MethodsEnglish-language publications on ACEs and PDs were retrieved from Web of Science Core Collection, Scopus, and PubMed from inception to December 31, 2025. After year screening, document-type filtering, and deduplication, 5,084 records were included. Bibliometric analyses were performed using R, VOSviewer, and CiteSpace. The merged dataset was used to examine annual trends, countries/regions, institutions, authors, journals, and keyword co-occurrence, while WoSCC records were used for co-citation analysis, keyword clustering, and burst detection.ResultsACEs–PDs research showed sustained growth, with a marked increase after 2000. The United States occupied a central position in publication output, citation impact, and international collaboration, while the United Kingdom, Germany, Canada, the Netherlands, and Australia also showed strong influence. Harvard University, the University of London, and Ruprecht Karls University Heidelberg were leading institutions; Zanarini M, Fonagy P, Schmahl C, Paris J, and Kleindienst N were key contributors. Influential journals mainly covered psychiatry, personality disorders, child maltreatment, trauma, and developmental psychopathology. Keyword analyses identified childhood adversity, personality disorder, borderline personality disorder, depression, childhood sexual abuse, and post-traumatic stress disorder as core themes. VOSviewer and CiteSpace analyses indicated that hotspots have expanded from childhood abuse, PDs diagnosis, and psychiatric comorbidity to emotion dysregulation, non-suicidal self-injury, social support, functional connectivity, early intervention, and mechanism validation. Highly cited publications revealed a knowledge base centered on childhood abuse/trauma, borderline personality disorder, psychiatric comorbidity, emotion regulation, and neurobiological mechanisms.ConclusionThis study maps development and knowledge structure of ACEs–PDs research. Findings suggest a shift from exposure–outcome association studies toward comorbidity, intermediate phenotypes, neurobiological mechanisms, and clinical translation. Future research should strengthen longitudinal and cross-cultural designs, consider ACE type, timing, duration, and severity, and integrate neuroimaging, inflammatory, epigenetic, and clinical-course phenotypes.
Awakening from the Trance
This blog was originally posted by the TLC Foundation for BFRBs
Trichotillomania touches on all levels of human experience, from the neurological to the spiritual. It represents the interactions of brain chemistry, but also habituated physiological responses, sensory processing, behavior patterns, characteristic emotional states, perceptual styles and beliefs, and the sense of interconnectedness with others and the experience of faith. It is more than just a behavior, although it is most apparent when it manifests itself in that way.
Trichotillomania can be treated at all of these levels through different treatment approaches: medication, relaxation and response prevention, behavior modification, hypnotherapy, psychotherapy, cognitive therapy and visualization, group therapy and spiritual practices. The most effective approach will depend on the specific needs and circumstances of each individual at specific times, as well as on the compatibility of the personalities of the treatment provider and patient/participant.
In this article I will present my own view of treatment with a particular focus on how to understand and address the aspect of trance.
“Trance” is not a clinical term, but it is one which most pullers seem to recognize immediately as a significant part of the hair pulling experience: particularly when reading or watching TV. However, I believe that any time one is pulling, one has entered a trance state and that trance states occur with great frequency even at other times. To look at how to make use of this concept I will first describe what I think treatment needs to address.
Trichotillomania as a symptom: My approach is to look at what the behavior of pulling means to a particular person, and what it means about them. I view pulling as a symptom which indicates something about what is going on in that person’s life and can be best understood if we look at the context in which it occurs – both over time (how did it evolve), and ecologically (how does it fit into the network of the person’s relationships, commitments, self-perceptions, experiences of their own body and emotional states, etc.).
Symptoms are an indication of the existence of some other process. Just as a fever may reflect a viral infection, a repetitive behavior reflects an underlying mental activity. The symptom develops in response to the activity and one of its functions is to achieve some control over the consequences of that mental activity. I believe that trichotillomania indicates an attempted solution to a psychological challenge (or opportunity) one is facing in one’s life. However, it is an ineffective solution for two reasons. Firstly, it doesn’t alter the situation which has become challenging, and so the underlying causes remain unchanged. Secondly, by drawing attention onto itself it obscures those underlying causes. It distracts attention from them.
But the behavior, none the less, does have some purpose and utility. It relieves the anxiety of becoming too aware that there are challenges and opportunities which one feels unprepared to confront.
The role of emotions:
The mechanism which could be drawing one’s attention to these challenges and opportunities is the experience of emotional reaction. Emotions serve to amplify our perceptions of situations by making the good seem better and the bad seem worse. In that way, they lead us to focus on what is important to us so that we will take action. Being able to notice and interpret our emotions is something we learn as we grow up. Emotions represent a kind of language for helping us make meaningful choices as we engage with life.
But if these emotions were felt to be too overwhelming – if what they indicated felt too bad to be tolerated because we did not learn how to resolve the situations they drew attention to – then we eliminated them from our emotional vocabulary and we restricted our awareness of them. Now, when those situations reoccur, rather than notice our feelings of hopelessness and helplessness, we may turn to other mechanisms, more basic ones rooted in physical sensations, to occupy ourselves and restore some sense of order to the world.
So, in this model, the behavior of hair pulling is not an indicator of psychological inadequacy, but rather a lack of awareness. It reflects a split between awareness/thoughts and sensations/feelings. It is the result of an unknown mental process, something one has not been able to assimilate into one’s conscious thought, for which no words or language have been developed.
If this could be understood then I believe there would be less justification for feelings of shame connected with Trichotillomania, because Trichotillomania represents an underlying process outside of personal awareness, and thus is not something voluntarily chosen. (It would also answer the following disturbing statement frequently made to hair pullers: “You could stop if you really wanted to.”)
I have so far described how emotional activity and unconscious thoughts affect us in ways which we do not recognize. Despite this lack of recognition, we still need to adjust to them and regulate or organize ourselves. A good example of this is the way in which a fussy baby, if not picked up or fed when it wants to be, learns to get its thumb into its mouth and suck on it. It is finding a way to organize its reactions to its world by retreating into an attitude of self-sufficiency. In this way it solves the problems of the conflict it experiences between the emotions it feels and the lack of a way to take effective action about them in the outside world. It restores order by returning to a sensation-based activity which it has control over. It has learned to retreat into a trance.
The similarities between this example and the experience of hair pulling are striking. So how is Trichotillomania like a trance, exactly?
Trance:
The (Oxford) dictionary defines “trance” in these ways: a suspension of consciousness; a state of mental abstraction from external things; absorption, exaltation, rapture, ecstasy. Going into a trance is turning away from the world, suspending engagement with it, and entering a twilight zone of self-enchantment. The experience is one of being in between states: neither in one’s own mind, nor aware of one’s body. One has turned away, both from the rest of the world and from the rest of oneself.
It is a state in which one doesn’t think about what one feels, and doesn’t act on what one feels. One has turned away from the parts of the self which are concerned with action and purposefulness. In the trance state, a part of the personality takes over which doesn’t care about anything (except the act of pulling) and ignores the existence of time or consequences to one’s actions. It is the opposite of the perfectionist attitude so common to many hair pullers. Becoming entranced in the act of reading, for example, one detaches from the here and now, and allows this part of the personality to “come out”: while the cat’s away, the mouse plays. It is a secure, dependable, magical place in which one can avoid dealing with the stimulation of one’s spontaneous emotional responses to life.
If we look again at the role of emotions as amplifiers of perceptions, we see that what is happening in this state is that one is neither thinking about, nor acting on, what the emotions could be indicating. And as they indicate what is important so that action can be taken, the trance state eliminates the possibility of taking the action required.
How does this detaching process become chronic?
I believe it is the result of repeated experiences of failing to take effective action on what one’s emotions tell one is important. This failure can have many causes, but the result is that these important situations become perceived as challenging and threatening because they are felt as over stimulating. To protect oneself from discomfort, one disassociates from the situation. The part of oneself which perceives or feels what is going on is split off from consciousness. What remains conscious is the part which doesn’t feel and which preserves a sense of order and calm. Gradually, a gap develops between this external presentation of the self – as coherent, caring, positive – and an inner state of feeling confused, frustrated, and overwhelmed.
A false self develops, a self which appears to be more in control than is actually felt, and which one tries to believe in. The fear of having this façade penetrated adds greatly to the level of stress felt by hair pullers. Because this false self cannot be dropped when one’s gut reactions tell one to, one becomes trapped in a vicious circle that leaves one over stimulated (including the times when one merely seems to be bored), detaching from one’s body, and trying to regain control. A strong need is felt to reconnect to the body and feel grounded.
Trichotillomania as a return to the body:
The route to feeling in one’s body again is through becoming hyperaware and hypersensitive to sensation. This is a more basic and elementary experience of oneself: one cannot think or feel what is happening, so one uses a physical behavior to establish a link between unconscious inner experience and being in the real, physical world. This provides a solution to the twilight state of feeling detached. The sensation-focused behavior provides a substitute sense of being connected, and its ritualistic aspect creates a sense of soothing order rather than chaos.
So, looked at in this way, the act of pulling a hair actually represents the second stage of entering into a trance. The trance is triggered by the habitual reaction of disassociating rather than facing a situation which one perceives as overwhelming. But while an attitude of order and calm is being adopted (a state of “mental abstraction”), the experience of being detached from the feelings in the body becomes disorienting and the urgent need is felt to focus on the sensation of touching, playing with, and pulling hair. This provides the experience of concreteness and connectedness which allows the trance to continue.
Awakening:
What is needed is a process for regaining consciousness and turning back to engaging with life. How does one wake up? How can one build a sort of observational platform from which to watch the process of entering into a trance; one which can be separate from the process itself? I would suggest that rather than start with the ultimate goal of avoiding trance states altogether (which may be unreachable), a more pragmatic approach would be to learn how to wake up once one starts.
When we drive long distances on freeways and our attention wanders, we sometimes find ourselves drifting over into the next lane. If there were raised lane markers on the road, they would then alert us by causing a noise and a vibration as the car drove over them. That is the kind of alarm system we are looking for. It doesn’t prevent our minds from wandering, but it brings us back to the here-and-now experience before we get into trouble.
Such a system does exist: it is the sensation of a hair being pulled out. Once one hair is pulled, the opportunity exists to break the trance. That hair can be a signal to come back to the here and now rather than getting into the trouble of starting a pulling binge. (The goal of stopping at one hair pulled would also very likely include the benefit of making it much easier to commit to a realistic process of bringing the behavior within tolerable limits.)
How can one learn to stop at just one? Setting such a goal becomes much more possible if one understands one’s reasons for avoiding the goal until now. I have discussed in this article how Trichotillomania is a process which provides an attempted solution to an underlying tension. There is an inevitable anxiety about relinquishing a familiar, dependable behavior. A part of oneself therefore resists changing it and depends on the benefits it brings. This part has no intention of allowing any changes to occur unless one is prepared for the emotional experiences that follow, and it protects one from them.
A way to understand this resistance to change would be to think of the patterns of our behavior as a balanced mobile hanging from the ceiling. All its parts are interconnected and form a stable pattern. If we remove one of the parts, all of the others start to swing wildly until they settle into a new, substantially different formation. The intermediate stage of unbalanced, indeterminate movement could be likened to the feeling of overstimulation from one’s emotions when the ritualistic trance is denied.
To prepare for this change, an expanded awareness of emotional experience and what it teaches is indispensable. The remainder of this article offers some suggestions for work that can be done alone to expand this ability. This task is made much easier and more effective, however, when it is done in the context of a healing dialogue: either in individual or group therapy, or in a support group. This option deserves serious consideration because the act of communicating to another person helps bring one’s inner experiences into focus. Additionally, when there is the trust that the other person is willing not only to listen but to actively attempt to grasp what the speaker means from the speaker’s own point of view, the feeling of validation and recognition received makes awareness of the emotional states more bearable.
Reading the signals:
Part of the personal preparation which can be done is to establish intent to learn from what is found when one tries to read the signals. This would require a willingness to recognize that there are good reasons for what one feels rather than prejudging emotions as wrong, inappropriate, or proof of all the “bad” things one has come to believe about oneself. It also requires a willingness to feel discomfort, hurt, and vulnerability so that there can be a return to wholeness and the sense of being fully alive.
1. The most direct step is simply to ask yourself questions such as: What am I feeling? What is on my mind? Is something bothering me? What do I want right now? Is there something I should be doing? Special attention should be paid to the first answer that comes to mind, even if it very quickly disappears or seems insignificant. You should have an open mind and be prepared to be surprised. Before asking yourself these questions, stop the activity you are doing, if possible. If answers do not emerge the following techniques can be tried.
2. Let your body speak. Allow yourself to become aware of where you feel tension or discomfort. Imagine that that part of you has a voice and can answer the questions in Step One. Try asking follow-up questions to learn more.
3. Try exaggerating the physical state that you are in. That is, whatever movement your body is making or would like to make, take it to an extreme as if you were a very melodramatic actor or dancer who had no inhibitions. Again, think about how your body is expressing answers to the questions in Step One.
4. Visualize yourself as a child of about five and ask the questions of her or him. The answers should seem to be in the language of a 5-year-old. It might help to hold an object such as a cushion or stuffed animal to you as you try to make contact with yourself in this way. It also might help to combine this with some exaggeration of body expression. Additional questions you might ask could be: What do you need from me? Is somebody upsetting you? (See Reference 1.)
5. Write a question to the child, then switch your pen to your other hand and write the answer with that hand. You should write very quickly and with no attempt to make the writing more legible. Then switch your pen back to your original hand for a further question. Continue the dialogue, and the switching of hands, until no further clarification is necessary. The purpose of this technique is to facilitate the spontaneous flow of ideas. (See Reference 2.)
6. Write out the questions as complete sentences to be completed and complete the same question five times as quickly as possible. The questions would be rewritten as follows: Right now, I want….; or: I am upset because…. Allow any response to come forward. Often, a few unrevealing responses will be followed by one unexpected and more valuable one. (See Reference 3.)
7. Hold the hair which has just been pulled out and ask yourself: What did this hair give itself up for? A significant reason for the failure to stop hair pulling is the frequent presence of trance states, which enable one to deny the consequences of the behavior. Additionally, the experience of trance encourages one to focus on physical sensations such as the feeling of a hair being pulled, so as to achieve a greater sense of being connected to reality.
I have described how one enters a trance when certain situations trigger a habituated expectation of becoming overwhelmed. In self-defense one suspends consciousness of the challenge and retreats into a state of emotional detachment. The alternative to the trance, then, is to identify and assimilate the emotional cues about the situation so that appropriate action can be taken. The sensation of the first hair being pulled can serve as an alarm to awaken one from the trance and begin this process of self-evaluation and a return to an alert engagement with life.
Reference 1: Margaret Paul. Inner Bonding. San Francisco: Harper Collins, 1990.Reference 2: Lucia Cappachione. The Power of Your Other Hand. North Hollywood, CA: Newcastle Publishing, 1988.Reference 3: Nathaniel Branden. How to Raise Your Self-Esteem. New York: Bantam, 1987.
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Detection of Self-Harm in Electronic Mental Health Records Using Privacy-Preserving Local Language Models: Methodological Study
Background: Self-harm is the strongest risk factor for suicide and an important outcome for mental health care. Although prevalent in clinical populations, it is often imprecisely captured in routinely collected clinical data, where it is often recorded and stored as unstructured free text. Contemporary language models, such as GPT (OpenAI) and Gemini (Google), can analyze free-text clinical notes, but such models may violate data governance of processing sensitive patient data. Objective: This study aimed to evaluate whether a privacy-preserving language model running entirely within an institution’s secure computing infrastructure (here, the UK National Health Service [NHS]) could accurately identify the presence and timing of self-harm using electronic health records from secondary mental health care. Methods: Clinical notes were drawn from Oxford Health NHS Foundation Trust using a multistage workflow: (1) a random sample of 1000 patients with a psychiatric diagnosis, defined according to the (; codes F00–F99); (2) candidate-note identification using a Gemma3-4b language model to flag notes containing self-harm content; and (3) from those candidates, 1352 randomly sampled notes were selected for expert annotation, resulting in gold-standard corpus enriched for self-harm content. Clinical notes were annotated for the presence of self-harm and its timing (≤90 days, >90 days, or unknown). A privacy-preserving locally served 27-billion-parameter Gemma 3 language model (“Gemma3-27b”) was used as the core model. Prompts were systematically developed and refined using a labeled development set to identify self-harm and generate a structured output per clinical record. Gemma3-27b performance was compared against a strong baseline multilabel text classification model based on robustly optimized BERT pretraining approach (RoBERTa), a transformer-based language model architecture. Model performance was evaluated using precision, recall, and the -score (harmonic mean of precision and recall), with 95% CIs estimated from 1000 bootstrap samples with replacement. Results: Gemma3-27b outperformed the RoBERTa classifier across all categories, achieving Precision=0.92, Recall=0.92 (sensitivity), and -score=0.92 for notes containing self-harm, and Precision=0.97, Recall=0.97 (specificity), and -score=0.97 for notes without self-harm. For the 51 notes labeled as recent self-harm in the held-out test set, Gemma3-27b achieved Precision=0.84, Recall=0.75, and -score=0.79. The global weighted -score of Gemma3-27b across all categories was 0.88, compared to 0.85 for RoBERTa. Conclusions: With systematic prompt development on a labeled development set, but no gradient-based fine-tuning, the current Gemma3-27b language model matched or exceeded a fine-tuned RoBERTa classifier for ascertaining self-harm events and their timing. Aggregate gains were modest, while improvements were largest in the most challenging, lower-frequency timing categories. On a simplified binary recent-versus-other task, RoBERTa performed marginally better, indicating that supervised classifiers remain highly effective when the task is simplified and sufficient labeled data exist. This work demonstrates the technical feasibility of privacy-preserving self-harm detection within a secure NHS research environment.
Validation of a criterion-based screening and triage pathway for adult ADHD: a prospective observational study of safety and operational efficiency
BackgroundThe increasing demand for adult attention-deficit hyperactivity disorder (ADHD) assessments has required the development of efficient triage pathways. This study provides a formal assessment of a criterion-based screening model designed to prioritise patient safety and operational efficiency within a National Health Service (NHS) specialist secondary care setting.MethodsA prospective observational validation design was employed, involving 49 consecutive adults referred for ADHD assessment none of whom had a previous ADHD diagnosis. The Comprehensive ADHD Screening Questionnaire (CASQ), a clinician-administered instrument based on DSM-5 criteria, was utilised by four trained Physician Assistants. To ensure an assessment of triage safety, a universal assessment model was adopted: all participants received a blinded, gold-standard diagnostic assessment (NICE-compliant) regardless of the initial triage recommendation thereby eliminating verification bias. The primary outcome measure was the Number Needed to Harm (NNH), defined as the number of people screened before a single false-negative result occurs.ResultsOf the 48 participants who completed the diagnostic process, six (12.5%) received an ADHD diagnosis. The triage pathway correctly identified all six cases, resulting in a sensitivity of 100.0% (95% CI: 61.0%–100.0%) and an infinite NNH. Specificity was 45.2% (95% CI: 31.2%–59.9%), with a positive predictive value of 20.7%. The pathway permitted 39.6% (n = 19) of referrals to be triaged to alternative pathways rather than full ADHD assessment, potentially saving significant specialist clinician time. Exploratory analyses indicated that score magnitude did not reliably distinguish between true and false positives within the group triaged as appropriate for further assessment.ConclusionsThese preliminary findings suggest that criterion-based screening conducted by appropriately trained non-specialist clinicians can achieve high levels of safety whilst improving service efficiency. The findings support the feasibility of task-shifting models in adult ADHD services, provided that triage thresholds are calibrated to prioritise sensitivity. These results require replication in adequately powered multi-site studies before firm conclusions regarding pathway safety can be drawn. Further research is required to establish inter-rater reliability and cost-effectiveness across diverse clinical settings.
Adoption of Digital Mental Health Interventions in National Health Service England, Scotland, and Wales: Freedom of Information Questionnaire Study
<strong>Background:</strong> Digital mental health interventions (DMHIs) have been widely promoted to improve access to mental health care within the UK National Health Service (NHS), particularly following the COVID-19 pandemic. In 2015, a total of 48 technologies were reportedly used in NHS services in England, but over the past decade, substantial changes to regulatory requirements, evidence standards, and procurement processes have reshaped the digital mental health landscape. There is limited clarity regarding which DMHIs are currently being formally procured and funded by NHS mental health services across the United Kingdom. <strong>Objective:</strong> This study aimed to identify and describe the DMHIs currently procured, contracted, or paid for by NHS mental health service providers in England, Scotland, and Wales for adult common mental health problems and to compare current procurement practices with findings reported in 2015. <strong>Methods:</strong> Freedom of Information requests were submitted to all NHS mental health trusts in England and all health boards in Scotland and Wales. Responses were collated and screened to provide an updated and extended record of which technologies are reportedly procured or paid for by services. <strong>Results:</strong> In total, 19 different DMHIs were identified as being procured across mental health service providers for adult common mental health problems at the time of data collection. This demonstrates a substantial reduction in the number of technologies being adopted into practice compared to the 48 reported in England in 2015. The findings reveal several key insights, including that only 2 technologies have remained in use for a decade, and they shed light on the types of technologies being selected and the variations in procurement practices among the 3 national health services. <strong>Conclusions:</strong> Despite the expansion of the digital mental health marketplace, the number of DMHIs formally procured by NHS mental health services has markedly decreased over the past decade. This consolidation may reflect increased selectivity and the adoption of higher-quality products, driven by strengthened regulatory oversight, evidence standards, and national guidance. Although these developments may enhance safety and quality assurance, they also raise important questions about innovation, market sustainability, and equitable access to digital mental health care. Ongoing monitoring of procurement practices is needed to inform policy, service design, and the future development of DMHIs.
Large-scale meta- and cross-trait analyses uncover shared genetic risk factors for IBS and psychiatric disorders
IntroductionIrritable bowel syndrome (IBS) is a common gut-brain axis disorder characterized by abdominal pain and altered bowel habits, and it shows high comorbidity with psychiatric disorders. However, the shared genetic mechanisms underlying these associations remain incompletely understood.MethodsWe performed a large-scale meta-analysis of IBS in individuals of European ancestry by integrating genome-wide association study (GWAS) summary statistics from the UK Biobank, Bellygenes, and the Million Veteran Program (MVP), thereby increasing statistical power to detect novel IBS loci. We further conducted global genetic correlation analyses with psychiatric traits, followed by multi-trait analysis of GWAS (MTAG) and conditional false discovery rate (condFDR) analyses to identify pleiotropic loci. Transcriptomic, methylomic, and expression quantitative trait locus (eQTL) data were integrated to explore potential regulatory mechanisms.ResultsThe meta-analysis identified up to ten previously unreported IBS loci, several of which were supported by colonic and brain eQTL effects. Global genetic correlation analyses confirmed substantial genetic overlap between IBS and psychiatric traits, particularly major depressive disorder and neuroticism. MTAG and condFDR analyses uncovered more than 100 pleiotropic loci, including signals at SORCS1, SLC35D1, COA1, and TLE1. Integrative analyses of transcriptome- and methylome-wide data highlighted regulatory mechanisms spanning colonic, immune, and neuronal tissues, supporting neuro-immune crosstalk and mitochondrial involvement.DiscussionOur findings provide a comprehensive genetic characterization of IBS, refine its heritable basis, reveal pleiotropic links with psychiatric disorders, and implicate molecular pathways across the gut-brain axis. These results advance mechanistic understanding of IBS and may inform future therapeutic development for IBS and its psychiatric comorbidities.
Brain Histamine Map Links Genetic Factors to Mental Health and Psychiatric Disorders
A study headed by researchers at King’s College London and the University of Porto has mapped the histamine system in the brain. Histamine, a molecule more commonly associated with allergies, plays a separate but poorly understood role in brain function. The new study addresses this gap, building the first multiscale map of the histamine system which spans from genetics to behavior and related mental health conditions.
The findings provide a new framework for understanding how this often-overlooked chemical system contributes to brain function and could point towards new treatment strategies for histamine-related conditions such as depression, ADHD, and schizophrenia. The study was funded by the National institute for Health and Care Research (NIHR) Maudsley Biomedical Research Centre.
Daniel Martins, MD, PhD, visiting senior research fellow at the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) King’s College London, said, “This work provides a crucial foundation for future research. By integrating molecular biology, brain imaging, and computational analysis, it offers a new perspective on how neurotransmitter systems are organized across the human brain. As neuroscience moves toward more integrated and personalized models of mental health, understanding systems like histamine may prove essential for unlocking new approaches to diagnosis and treatment.”
Martins is first and corresponding author of the team’s published paper in Nature Mental Health, which is titled “Mapping histamine pathway networks in the human brain across cognition and psychiatric disorders.” In their paper the team concluded, “This study provides an integrated characterization of the histaminergic system in the human brain, leveraging transcriptomic, neuroimaging, and functional datasets to delineate its molecular organization and relevance to brain function underlying cognition and psychiatric disorders.”
Histamine is a neurotransmitter, a molecule crucial for neurons to communicate with one another, the authors explained. “Neuronal histamine plays a crucial role in the regulation of brain function, serving as a neuromodulator with widespread influence across multiple neurotransmitter systems.” However, neuroscience research has classically focused on understanding other neurotransmitter systems such as dopamine and serotonin.
As the investigators noted, the organization of histamine in the human brain remains incompletely characterized. However, they explained, dysregulation of the histaminergic system has been implicated in a number of neuropsychiatric conditions, including anxiety, depression, schizophrenia, and autism spectrum disorder (ASD), as well as neurodegenerative diseases including Alzheimer’s, Parkinson’s, and Huntington’s diseases. “Therefore, targeting the brain histamine system has garnered significant attention as a potential new therapeutic strategy for treating these disorders, with pharmacological interventions aimed at modulating histamine receptor activity showing promise in preclinical models.”
Histamine acts through four known histamine receptors, which are responsible for how the signal will influence receiver neurons. Each of these histamine receptors, (histamine receptor H1 (encoded by HRH1), H2 (HRH2), H3 (HRH3) and H4 (HRH4)), mediates distinct functions. For their newly reported study, Martins and colleagues carried out what they described as multimodal analysis, integrating transcriptomic, neuroimaging, developmental and functional datasets to map the architecture of the histaminergic system.
To build a comprehensive map of how histamine acts in the brain, researchers first combined genetic and molecular data with physical maps of the brain.
This revealed which brain regions receive more input from the brain’s histamine system, and which parts show greater capacity to respond to histamine. These molecular data were then linked with positron emission tomography imaging of histamine receptors in living individuals, as well as functional neuroimaging databases that map brain regions to specific cognitive processes and mental health conditions. This type of scan shows how different parts of the brain are working by tracking a tiny amount of radioactive tracer in real time.
Their results found that different histamine receptors were found on brain cells that either turn activity up (excitation) or turn it down (inhibition). “The findings reveal that histaminergic genes exhibit distinct cellular and regional expression profiles, closely aligning with known histaminergic neuroanatomy and function,” they wrote. “At the single-cell level, histamine receptor H1 and histamine receptor H2 were enriched in excitatory neurons, whereas histamine receptor H3 showed preferential expression in inhibitory populations.” This suggests histamine may be important in maintaining the balance between excitation and inhibition, a fundamental property of healthy brain function.
Brain regions with higher histamine-related gene expression were consistently associated with processes such as emotional regulation, stress and fear responses, decision-making, impulsivity, reward, sleep, and memory.
The parts of the brain where histamine-related genes were most active also overlapped significantly with brain regions known to be affected in several psychiatric conditions, including attention-deficit/hyperactivity disorder, major depressive disorder, schizophrenia, and anorexia nervosa. This is in keeping with previous hypotheses linking histamine to these disorders. “By linking histaminergic gene expression to brain-cell types, neurotransmitter systems, cognitive domains and psychiatric disorders, these correlational findings generate several hypotheses concerning histamine’s critical role in brain organization, neurodevelopment and mental health, which further experimental mechanistic work should prioritize and build onto investigate causal relationships,” the investigators concluded.
Martins said, “Current psychiatric treatments largely target neurotransmitters such as serotonin and dopamine, yet histamine interacts closely with these systems and influences their activity. By providing a detailed map of histamine-related pathways, this work suggests new opportunities for developing treatments that target this system more directly, particularly for symptoms such as cognitive dysfunction, fatigue, and impaired motivation.
While these findings do not establish a direct causal role, they suggest that histamine signalling may contribute to regional vulnerability in these disorders. This aligns with a growing view in psychiatry that mental health conditions arise from disruptions across interacting brain systems rather than a single chemical imbalance.”
This new map paints a neural picture of a previously lesser-studied molecule. It opens up future avenues of research into exactly what histamine is doing in various cell types and parts of the brain.
“We want to emphasise that these findings are hypothesis-generating and based on large-scale datasets that capture patterns rather than direct mechanisms,” commented senior author Steve Williams, PhD, professor of neuroimaging at IoPPN King’s College London. Future studies will focus on testing how histamine signaling changes in living individuals, for example through pharmacological interventions or longitudinal imaging approaches.
Co-author Daniel Van Wamelen, PhD, clinical senior lecturer in neuroscience at IoPPN, King’s College London and one of the authors on the paper said: “This kind of work is already taking place at King’s College London, for example in the iMarkHD project. In this project we use Positron Emission Tomography scans to study a specific histamine receptor (called H3) in people with Huntington’s disease, an inherited condition that affects the brain. The goal is to see how histamine activity changes in different parts of the brain over time, and how these changes relate to symptoms such as apathy, depression, and anxiety.”
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Surf Therapy: A Powerful Low-Intensity Approach in Global Youth Mental Health Care
By Mai El Shoush, Partnerships Campaign Manager, Stavros Niarchos Foundation (SNF) Global Center for Child and Adolescent Mental Health at the Child Mind Institute
In Conversation with Waves for Change
The world’s oceans have long been profound forces that shape coastlines, cultures, and scientific discovery. And today, through targeted programs, they also serve as therapeutic environments transforming youth mental health worldwide.
As global health systems continue to explore solutions that minimize resource constraints while addressing child and adolescent mental health demands, innovative approaches like surf therapy are demonstrating remarkable effectiveness as low-intensity initiatives. From the beaches of California to the coastal communities of South Africa, Australia, Hawai’i, the United Kingdom, and Senegal, these programs are creating accessible entry points for young people.
Wave for Change (W4C) — a South Africa-based organization and valued implementation partner of the Stavros Niarchos Foundation (SNF) Global Center at the Child Mind Institute — has developed an evidence-based Surf Therapy program for youth in underserved communities. We spoke with their chief development officer Paula Yarrow and senior grant manager Jill Sloan about the award-winning program. As a highly regarded Cape Town‑based NGO that uses surfing as a therapeutic tool to support youth mental health, W4C offers safe spaces, evidence‑based emotional regulation tools, community mentorship, and a pathway to resilience for young people growing up in challenging environments.
The partnership includes the identification of workforce gaps and training needs for frontline workers such as NGOs, to further expand evidence-based support and brief interventions through culturally appropriate, low-intensity psychological therapy approaches. The context-specific training materials are expected to be piloted later in the year in South Africa and are intended to improve access to quality mental health care for young people.
W4C launched Surf Therapy in 2009, which has since helped more than 10,000 adolescents experiencing high-stress environments gain valuable coping skills across its hubs in the Western and Eastern Cape as well as Cape Town. Participants learn how to build positive social networks and develop self-regulation skills to support healthy emotional and behavioral responses to stress, with coaches themselves aged between 18-25. The program creates a fun, culturally relevant environment through the Take 5 model — a framework W4C has designed to be adapted for a range of sports, arts, and cultural initiatives. The model has been utilized by several leading global organizations, including UNICEF.
Waves for Change also played a key role in the founding of the International Surf Therapy Organization (ISTO), connecting practitioners, clinicians, and researchers to advance science research, raise awareness, and support surf therapy.
How does Waves for Change use evidence-based Surf Therapy and capacity building as a solution to fill the gap in youth mental health care?
Approximately 90 percent of the world’s adolescents live in low- and middle-income countries (LMICs). In the most underserved communities, adolescents may experience repeated exposure to violence, unmet basic needs, and limited access to safe spaces or trusted caregivers. Typically, there are very few mental health services that are accessible to such youth.
The more Adverse Childhood Experiences (ACEs) a child or adolescent has whilst growing up, the more likely they are to develop toxic stress — an ongoing stress state without respite. This can often lead to mental health conditions such as anxiety, depression, substance misuse, and cognitive impairment. This can also result in the development of physical health conditions such as heart disease as they grow into adulthood.
The main problem we’ve identified is that there aren’t enough trained workforces (e.g., sports coaches, youth facilitators) that are able to deliver simple, fun, structured play-based sessions with consistency at scale. Our work provides a response to this issue within the adolescent mental health promotion and illness prevention arena. Additionally, our initiatives significantly increase the number of individuals — coaches, teachers, mentors or others — who are already in contact with young adolescents and can provide them with mental health support to foster their immediate and longer-term mental health.
How has Waves for Change adapted the organization’s Surf Therapy program to develop the Take 5 model?
Waves for Change’s Take 5 training model has been incubated, tested, and rigorously evaluated within W4C’s award-winning Surf Therapy program. Take 5 distils the key components of our Surf Therapy program, providing coaches with the essential skills they need to build and sustain caring relationships with children. And it uses a simple teaching routine that creates consistently engaging, fun, structured programs for children and adolescents that suit their language, culture, and context.
Take 5 is low intensity and cost-effective — tailored for high-stress environments and the unique mental wellness needs of adolescents living in multidimensional poverty, conflict, or crisis.
How has partnering with young people to research and co-develop programs made the work more impactful?
In research studies we’ve conducted, adolescent participants (ages 10-16) reported experiencing between 6-8 adverse events every year, including violence and abuse. When asked what sorts of spaces they wanted to see at Waves for Change, the adolescents identified core components such as access to a safe space where they could have fun, be heard, and learn skills to cope. These components now form the bedrock of our Surf Therapy program. We initially worked with 9-12-year-olds and have since developed the follow-on programme for adolescents up to age 16 who have graduated the Surf Therapy programme. This is called Surf Club and is available to all Surf Therapy graduates.
Waves for Change also conducts pre- and post-intervention surveys with participants to monitor the impact of our work. Our coaches (ages 18-25) are at the frontline of delivering our services. A key role they play is to listen with care and respect to the adolescents’ concerns, and to share them with our Child Protection team for review and follow-up when needed.
What makes your partnership with the SNF Global Center at the Child Mind Institute unique?
Working with the Child Mind Institute allows Waves for Change to collaborate with and learn from colleagues doing similar work in the adolescent mental health space across South Africa, the United Kingdom, and Brazil. The partnership offers an opportunity to learn about approaches that have been successful in other health systems. It has also allowed Waves for Change to share detailed information about the training and supervision protocol used to develop key competencies in the coach workforce that leads Surf Therapy in South Africa. This has helped the Child Mind Institute to develop a comprehensive guide for other similar workforces.
Can you expand on the importance of partnerships in strengthening youth mental health care and community empowerment?
Partnerships allow for the consolidation of skills and resources so that a greater impact can be achieved. For example, at Waves for Change, we work with over 70 referral partners every year to identify young adolescents who can benefit from our Surf Therapy program. We are also partnering with the Department of Cultural Affairs and Sport to use our Take 5 model to train MOD and YearBeyond coaches and mentors, who are already reaching large numbers of children and young adolescents through their work. And we’re contributing to building the broader ecosystem of mental health support for adolescents and children by training large national NGOs, government agencies, and humanitarian organizations with our Take 5 model.
How can non-profits further help foster strong peer networks and inclusive safe spaces?
Some of the key lessons we have learnt are the following:
- In the field of youth mental health, make youth the leaders on program implementation
- Provide youth with skills, opportunities, supervision, and support so that they can grow and develop further
- Maintain a strong culture of protection, respect, and communication so that all participants feel safe, welcome, accepted, and heard
Read more about W4C’s Surf Therapy from Youth Liaison Officer, Azola Sibanda and Training Manager Jamie-Lee Davids
The post Surf Therapy: A Powerful Low-Intensity Approach in Global Youth Mental Health Care appeared first on Child Mind Institute.
What Is Traumatic Separation?
You may have a memory of being separated from a parent when you were a child, even just for a few minutes. Maybe you lost them in a crowd or wandered a little too far at the store and felt panicked and afraid.
A moment like this might be among your earliest memories because the feeling was so intense, says Caitlyn Downie, LCSW, the Director of Trauma and Resilience at the Child Mind Institute. That offers some insight into the fear of a child of any age who is separated from a parent or caregiver in a more serious way. The effects of this stress are so powerful they can actually change the way a child develops.
A toddler whose mother goes to prison. A kindergartener whose father is detained and deported. A teen who is placed in foster care. These are a few examples of what experts call traumatic separation, a clinical concept based on the importance of the parent-child bond and the profound effects that can result from breaking it.
What is traumatic separation?
Traumatic separation isn’t a clinical diagnosis, but research shows that it can be profoundly harmful to kids. What makes it traumatic (as opposed to routine partings, like when an adult regularly leaves their child to go to work) is the character of the separation: ones that are sudden, unexpected, or confusing, or those that come about through larger distressing events, like a natural disaster or war. It’s not defined by the time spent apart — both short and long-term separations can be harmful.
Some common examples of separation that can become traumatic include:
- Parental deportation
- Immigration (e.g., forced separation at the border)
- Parental military deployment
- Parental incarceration
- Termination of parental rights
Separating from a parent or primary caregiver can be distressing to a child even when it’s deemed necessary for their safety, as in cases where the parent they have been separated from has abused them, says Kimberly Alexander, PsyD, a psychologist at the Child Mind Institute. “There’s still a natural attachment that occurs. And the separation disrupts that relationship, even if it’s for the support and care of the child.”
Why is traumatic separation harmful?
More than eight decades of research has shown the profound developmental importance of the parent-child bond. This is the guiding principle of attachment theory, which was pioneered by a British psychologist who studied children who were evacuated during the Blitz, the aerial bombardment of London in World War II.
Here’s what the research tells us about the harms of traumatic separation:
It can disrupt secure attachment
Think of secure attachment as a “fundamental sense of security and safety” that a child feels with a parent or caregiver, says Dylan Gee, PhD, a psychologist at Yale University who studies how early-life stress affects children’s development.
“Attachment is the lens through which children come to know what they can expect from the world around them,” she explains. “Is this going to be a safe place or a dangerous place? This is foundational to a child’s sense of their ability to navigate the world. Traumatic separation can shatter that sense of safety.”
It can affect neurobiological development
Children’s brains are especially plastic, says Dr. Gee, constantly learning to understand their environment and how to deal with stress. “Trauma that occurs in childhood can be even more consequential than trauma that occurs later in life,” she says, and experiencing these disruptions in childhood can affect the way your brain and body are primed to react to stress later on.
But heightened plasticity is a paradox, she adds. “It confers more vulnerability, but it also confers more potential for resilience — children have heightened potential for supportive intervention and for healing and recovery.”
What do the effects of traumatic separation look like?
There are acute and short-term effects that are common across kids of all ages:
Sleep problems: “It’s often one of the first things that we see: nightmares, trouble falling asleep, or a lot of crying as kids are trying to fall asleep,” Dr. Gee says.
Separation anxiety: This might look like distraction, withdrawal, or clinginess because of fear of being separated from their new caregivers, Dr. Alexander says.
But signs may take weeks or months to show up. Dr. Alexander advises caregivers to consider the child’s baseline — their typical patterns of eating, sleeping, or engaging with others. “If they’re having more trouble with sleep, they’re eating more, eating less, they’re withdrawing or expressing a lot of worried thoughts three or four months later — that’s something worth getting looked at by a clinician,” she says.
Signs of traumatic separation at different ages
“Sometimes people ask, ‘Well, when is separation the most harmful?’ It can be extremely harmful at any age,” Dr. Gee emphasizes. But there are specific signs at different developmental stages:
Infants
Babies may not be as consciously aware of being separated from a parent as older children, “but they’re fundamentally aware that their primary source of regulation and safety is missing,” Dr. Gee says. Because infants are so reliant on caregivers for nurturing and sustenance, the separation “can be experienced as a threat to their survival.” That might look like “crying a lot or becoming withdrawn,” she says. “And at any age we can see intense fear.”
Toddlers and young children (3–6)
Toddlers and young children might become extra clingy with new caregivers or show regressive behaviors like bedwetting or baby talk. Regressive behaviors happen when kids are overwhelmed by stress and can’t express themselves another way, Downie says. “It’s like your nervous system goes kind of haywire,” she explains, “so it uses the body to signal that something is wrong.”
Similarly, kids at this age might act out more, throwing more tantrums, or withdraw. They might develop selective mutism, a condition where kids are too anxious or distressed to speak, even when they want to, in certain situations or with certain people.
School-age children
School-age children might act out or experience separation anxiety. They may also struggle to understand the meaning of the separation, why it happened, or who is at fault for it. Thus, kids at this age are more prone to magical or distorted thinking and feelings of guilt, thinking or saying things like, “I’m the one that caused this” or “This is my fault.”
The weight of these distorted thoughts or other worries, Dr. Alexander says, might make it appear as though a child is struggling to concentrate or that they’re disengaged or distracted. They might withdraw in a group or be averse to stepping outside of their comfort zone.
Children who are school age or older can also experience emotional desensitization — a kind of emptiness of feeling — Downie says, which can look like spikes in irritability, a lack of empathy, not smiling or expressing positive emotions, or an inability to relate to others.
Preteens and teenagers
“I’ve seen teenagers have a lot of mistrust with systems and be very oppositional,” says Downie. “Like, ‘I don’t trust you. I don’t trust my teacher. I don’t trust this child services worker.’” It might make sense that, say, a teen in foster care would be wary of the foster care system. But Downie says it’s often a larger instinct for anger and mistrust, one that extends beyond any specific entity or person.
The teenage years are also when kids are forming their identity, and traumatic separation can fundamentally alter that process. For example, a teen with younger siblings may step into a parent role, taking on new worries and responsibilities. Conversely, teens may become more reckless in a caregiver’s absence, putting them at risk for substance abuse or incarceration.
How to help kids separated from a parent
Adults caring for a child who has been separated from a parent — family members, foster parents, teachers — “can play a profound role in supporting their mental health and resilience,” says Dr. Gee.
Validate feelings
One of the most important things caregivers can do is be present as a child reacts to their experiences, especially if and when scary feelings come up. But be careful not to lead kids or assume they feel a certain way. “You don’t want to make something more distressing to a child if it’s not presenting itself,” says Downie.
If a child expresses guilt, or says something like, “This is my fault,” there are still ways to validate the feeling without endorsing the statement, says Dr. Alexander. You might say something like: “I can understand why that thought comes to mind and how difficult it is to feel that way. When you’re ready, let’s think about other possibilities to this situation.”
Create consistency and stability
One of the hardest things about traumatic separation is the uncertainty — Where did they go? When will they come back? What is happening? Giving kids some sense of consistency and stability can help them feel safe despite the unknowns. So as much as possible, help them stick to any routines: going to school, seeing friends, doing activities they enjoy.
Dr. Alexander advises focusing on things you can control — for example, shielding kids from potentially worrying discussions in a family where a parent has been deported.
“There would likely be a lot of conversations in the home about the situation, maybe a lot of watching the news, maybe making a lot of phone calls to attorneys,” she explains. “So where are you having those conversations, and can you have them in an area or at a time of day where your kid isn’t overhearing the discussions out of context?”
For young kids, it might be as simple as asking them to play in their room. For teens, it might be better to have certain conversations when they are out of the house and invite them to participate directly in others.
Be honest but reassuring
Caregivers might not have all the answers — like knowing when a child’s parent is coming back — but they can create a sense of consistency and stability in how they respond to kids’ questions, too.
Avoid undue reassurance (“Everything is going to be fine”) or over-promising (“They’ll be back in two weeks”) by focusing on what kids can expect, says Dr. Gee. For example: “What I can tell you is that I’m here for you, and I’m going to be with you until he’s back,” or “You’re safe with me, and I’m going to stay with you through this really hard time.”
Model handling stress
Children are sensitive to tone, Dr. Alexander says. “So, if you’re having really big emotions that are out of context for a child, the child is looking at these emotions and trying to understand what’s happening. ‘Am I in danger in this specific moment?’”
She says it helps to have conversations about these moments, especially with younger kids. “Like, ‘I know you noticed mommy crying. We’re feeling really big feelings, and this is how we’re going to deal with those big feelings. I’m going to take a break. I’m going to get a sip of water. Whenever you’re having big feelings, I want you to let me know so that I can help you try doing the same things,’” Dr. Alexander says, explaining the importance of naming the emotion and then teaching kids that there are ways of dealing with it.
Long-term risks of traumatic separation
The effects of traumatic separation can persist even after a child and their caregiver are reunited. Traumatic separation, like other adverse childhood experiences, puts kids at risk for a host of long-term medical and mental health conditions, including depression, anxiety, attention issues, and post-traumatic stress disorder (PTSD).
But Downie notes that not everyone who experiences traumatic separation develops PTSD. “Just because someone’s experiencing trauma now doesn’t mean that it’s going to become a PTSD diagnosis,” she says. “A lot of the behaviors that we’re talking about are normal and expected. There’s an adjustment period when a separation happens.” But if symptoms persist or escalate over several months, a child may need more serious support.
Treatment for a trauma diagnosis
While not every child who experiences a separation may receive a trauma diagnosis or require treatment, cognitive behavioral therapy (CBT) — and the more specific trauma-focused cognitive behavioral therapy (TF-CBT) — is the “gold standard,” says Downie. TF-CBT is specifically for children experiencing trauma-related symptoms. An important component of TF-CBT is creating a trauma narrative, where kids create a story about what happened to help them process it. “But if you have a child who is not ready to process and integrate that trauma, you can’t force the pacing of the treatment,” she says.
In short, a good clinician will follow a child’s lead — even if that means just sitting in the same room with them to build trust. “People really need to feel like they’re being heard and that they can trust someone,” Downie says. Which is why a supportive caregiver or trusted adult can make a big difference.
“If people can take anything away from this, it’s that you want to make kids understand that that they’re not responsible for what’s happened and that people do care about them,” Downie says. “Kids are really resilient, and they can adapt in a good-enough environment. They don’t have to have everything to be successful.”
The post What Is Traumatic Separation? appeared first on Child Mind Institute.
Barriers and Facilitators in the Implementation of the Systematic Medical Appraisal, Referral, and Treatment (SMART) Mental Health Digital Intervention in Rural India: Mixed Methods Process Evaluation Study
<strong>Background:</strong> An estimated 150 million people have mental health care needs in India, but only 15% are able to access care. Depression and anxiety contribute to a large proportion of mental morbidity. The Systematic Medical Appraisal, Referral, and Treatment (SMART) Mental Health trial used a mobile-based clinical decision support system for primary care doctors and community health workers (CHWs) to identify and treat people at risk of depression, anxiety disorders, and self-harm. A community-based antistigma campaign was also delivered. The intervention led to improved remission rates for depression and anxiety and lower stigma scores. <strong>Objective:</strong> A process evaluation assessed (1) implementation fidelity, barriers, and facilitators; (2) perceptions of doctors and CHWs on the use of SMART Mental Health; and (3) the causal pathways that led to trial outcomes. <strong>Methods:</strong> A mixed methods evaluation combining backend program data and qualitative data was conducted. A total of 38 focus group discussions and 37 key informant interviews were conducted with primary doctors, CHWs, government officials, local community leaders, and research project staff. The data were coded and analyzed using a framework analysis approach based on the UK Medical Research Council guidance on process evaluations and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. <strong>Results:</strong> The intervention had high implementation fidelity. Across clusters, the median proportion of participants with at least 1 CHW follow-up was 98% (IQR 96.6%-100%). The referral rate for a psychiatrist was low (224/1697, 13.2%), and only 23.6% (53/224) of those referred visited the psychiatrist. The median exposure to antistigma audiovisual content was 84% (IQR 65.7%-95.9%). At the community level, key implementation barriers included cultural inhibitions in seeking mental health care and the unavailability of patients due to competing demands. Proximity and tight social connections between CHWs and their communities were important facilitators in seeking medical help. Doctor and CHW training, mentoring, and feedback provided by program staff were important facilitators to support the use of the digital health components by the health workforce. <strong>Conclusions:</strong> A complex intervention that included both community-based antistigma and clinical digital health interventions achieved high implementation fidelity. Key areas to consider for maintenance of such interventions include (1) the need for sustained community-based strategies to address stigma and other cultural barriers; (2) health workforce strengthening policies, including supportive supervision for CHWs and doctors to increase capability in the use of mental health digital health tools; and (3) strategies to improve access to specialist care for those with more complex care needs. <strong>Trial Registration:</strong> Clinical Trial Registry India CTRI/2018/08/015355; https://tinyurl.com/5r63suxp
