Racial Discrimination and Resting-State Functional Connectivity of Salience Network Nodes in Trauma-Exposed Black Adults in the United States | Health Disparities | JAMA Network Open | JAMA Network
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Figure 1.  Regions Probed in the Seed-to-Voxel Connectivity Analyses
Regions Probed in the Seed-to-Voxel Connectivity Analyses
Figure 2.  Association of Exposure to Racial Discrimination With Connectivity Between Bilateral Amygdala and Thalamus
Association of Exposure to Racial Discrimination With Connectivity Between Bilateral Amygdala and Thalamus

Each dot represents data from 1 participant, and the blue line is the regression line. PEDQ indicates Perceived Ethnic Discrimination Questionnaire.

Figure 3.  Association of Exposure to Racial Discrimination With Increased Connectivity Between Bilateral Anterior Insula and Precuneus
Association of Exposure to Racial Discrimination With Increased Connectivity Between Bilateral Anterior Insula and Precuneus

Each dot represents data from 1 participant, and the blue line is the regression line. PEDQ indicates Perceived Ethnic Discrimination Questionnaire.

Table 1.  Sample Characteristics and Descriptive Statistics
Sample Characteristics and Descriptive Statistics
Table 2.  Association of Racial Discrimination With Greater Connectivity of Regions Implicated in Emotion Processing
Association of Racial Discrimination With Greater Connectivity of Regions Implicated in Emotion Processing
1.
Devakumar  D, Shannon  G, Bhopal  SS, Abubakar  I.  Racism and discrimination in COVID-19 responses.   Lancet. 2020;395(10231):1194. doi:10.1016/S0140-6736(20)30792-3PubMedGoogle ScholarCrossref
2.
Williams  DR.  Race, socioeconomic status, and health: the added effects of racism and discrimination.   Ann N Y Acad Sci. 1999;896:173-188. doi:10.1111/j.1749-6632.1999.tb08114.xPubMedGoogle ScholarCrossref
3.
Williams  DR, Mohammed  SA, Leavell  J, Collins  C.  Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities.   Ann N Y Acad Sci. 2010;1186:69-101. doi:10.1111/j.1749-6632.2009.05339.xPubMedGoogle ScholarCrossref
4.
Williams  MT, Metzger  IW, Leins  C, DeLapp  C.  Assessing racial trauma within a DSM-5 framework: The UConn Racial/Ethnic Stress & Trauma Survey.   Pract Innov. 2018;3(4):242. doi:10.1037/pri0000076Google ScholarCrossref
5.
Lewis  TT, Van Dyke  ME.  Discrimination and the health of African Americans: the potential importance of intersectionalities.   Curr Dir Psychol Sci. 2018;27(3):176-182. doi:10.1177/0963721418770442PubMedGoogle ScholarCrossref
6.
Bird  CM, Webb  EK, Schramm  AT, Torres  L, Larson  C, deRoon-Cassini  TA.  Racial discrimination is associated with acute posttraumatic stress symptoms and predicts future posttraumatic stress disorder symptom severity in trauma-exposed Black adults in the United States.   J Trauma Stress. 2021;34(5):995-1004. doi:10.1002/jts.22670PubMedGoogle ScholarCrossref
7.
Carter  RT, Lau  MY, Johnson  V, Kirkinis  K.  Racial discrimination and health outcomes among racial/ethnic minorities: a meta-analytic review.   J Multicult Couns Dev. 2017;45(4):232-259. doi:10.1002/jmcd.12076Google ScholarCrossref
8.
Chou  T, Asnaani  A, Hofmann  SG.  Perception of racial discrimination and psychopathology across three U.S. ethnic minority groups.   Cultur Divers Ethnic Minor Psychol. 2012;18(1):74-81. doi:10.1037/a0025432PubMedGoogle ScholarCrossref
9.
Franco  M, Durkee  M, McElroy-Heltzel  S.  Discrimination comes in layers: dimensions of discrimination and mental health for multiracial people.   Cultur Divers Ethnic Minor Psychol. 2021;27(3):343-353. doi:10.1037/cdp0000441PubMedGoogle ScholarCrossref
10.
Hart  AR, Lavner  JA, Carter  SE, Beach  SRH.  Racial discrimination, depressive symptoms, and sleep problems among Blacks in the rural South.   Cultur Divers Ethnic Minor Psychol. 2021;27(1):123-134. doi:10.1037/cdp0000365PubMedGoogle ScholarCrossref
11.
Joseph  NT, Peterson  LM, Gordon  H, Kamarck  TW.  The double burden of racial discrimination in daily-life moments: increases in negative emotions and depletion of psychosocial resources among emerging adult African Americans.   Cultur Divers Ethnic Minor Psychol. 2021;27(2):234-244. doi:10.1037/cdp0000337PubMedGoogle ScholarCrossref
12.
Lavner  JA, Hart  AR, Carter  SE, Beach  SRH.  Longitudinal effects of racial discrimination on depressive symptoms among Black youth: between- and within-person effects.   J Am Acad Child Adolesc Psychiatry. 2021;S0890-8567(21)00309-9. doi:10.1016/j.jaac.2021.04.020PubMedGoogle Scholar
13.
Lei  MK, Lavner  JA, Carter  SE, Hart  AR, Beach  SRH.  Protective parenting behavior buffers the impact of racial discrimination on depression among Black youth.   J Fam Psychol. 2021;35(4):457-467. doi:10.1037/fam0000822PubMedGoogle ScholarCrossref
14.
Mekawi  Y, Carter  S, Brown  B,  et al.  Interpersonal trauma and posttraumatic stress disorder among Black women: does racial discrimination matter?   J Trauma Dissociation. 2021;22(2):154-169. doi:10.1080/15299732.2020.1869098PubMedGoogle ScholarCrossref
15.
Mekawi  Y, Hyatt  CS, Maples-Keller  J, Carter  S, Michopoulos  V, Powers  A.  Racial discrimination predicts mental health outcomes beyond the role of personality traits in a community sample of African Americans.   Clin Psychol Sci. 2021;9(2):183-196. doi:10.1177/2167702620957318Google ScholarCrossref
16.
Paradies  YC. Race, Racism, Stress and Indigenous Health. Dissertation. The University of Melbourne; 2006.
17.
Park  IJK, Du  H, Wang  L, Williams  DR, Alegría  M.  Racial/ethnic discrimination and mental health in Mexican-origin youths and their parents: testing the “linked lives” hypothesis.   J Adolesc Health. 2018;62(4):480-487. doi:10.1016/j.jadohealth.2017.10.010PubMedGoogle ScholarCrossref
18.
Sosoo  EE, Bernard  DL, Neblett  EW  Jr.  The influence of internalized racism on the relationship between discrimination and anxiety.   Cultur Divers Ethnic Minor Psychol. 2020;26(4):570-580. doi:10.1037/cdp0000320PubMedGoogle ScholarCrossref
19.
Allen  AM, Thomas  MD, Michaels  EK,  et al.  Racial discrimination, educational attainment, and biological dysregulation among midlife African American women.   Psychoneuroendocrinology. 2019;99:225-235. doi:10.1016/j.psyneuen.2018.09.001PubMedGoogle ScholarCrossref
20.
Allen  AM, Wang  Y, Chae  DH,  et al.  Racial discrimination, the superwoman schema, and allostatic load: exploring an integrative stress-coping model among African American women.   Ann N Y Acad Sci. 2019;1457(1):104-127. doi:10.1111/nyas.14188PubMedGoogle ScholarCrossref
21.
Cuevas  AG, Ho  T, Rodgers  J,  et al.  Developmental timing of initial racial discrimination exposure is associated with cardiovascular health conditions in adulthood.   Ethn Health. 2021;26(7):949-962. doi:10.1080/13557858.2019.1613517PubMedGoogle ScholarCrossref
22.
Chae  DH, Nuru-Jeter  AM, Adler  NE,  et al.  Discrimination, racial bias, and telomere length in African-American men.   Am J Prev Med. 2014;46(2):103-111. doi:10.1016/j.amepre.2013.10.020PubMedGoogle ScholarCrossref
23.
Chae  DH, Epel  ES, Nuru-Jeter  AM,  et al.  Discrimination, mental health, and leukocyte telomere length among African American men.   Psychoneuroendocrinology. 2016;63:10-16. doi:10.1016/j.psyneuen.2015.09.001PubMedGoogle ScholarCrossref
24.
Lee  DB, Kim  ES, Neblett  EW  Jr.  The link between discrimination and telomere length in African American adults.   Health Psychol. 2017;36(5):458-467. doi:10.1037/hea0000450PubMedGoogle ScholarCrossref
25.
Thomas  MD, Sohail  S, Mendez  RM, Márquez-Magaña  L, Allen  AM.  Racial discrimination and telomere length in midlife African American women: interactions of educational attainment and employment status.   Ann Behav Med. 2021;55(7):601-611. doi:10.1093/abm/kaaa104PubMedGoogle ScholarCrossref
26.
Chambers  BD, Arabia  SE, Arega  HA,  et al.  Exposures to structural racism and racial discrimination among pregnant and early post-partum Black women living in Oakland, California.   Stress Health. 2020;36(2):213-219. doi:10.1002/smi.2922PubMedGoogle ScholarCrossref
27.
Cheeks  BL, Chavous  TM, Sellers  RM.  A daily examination of African American adolescents’ racial discrimination, parental racial socialization, and psychological affect.   Child Dev. 2020;91(6):2123-2140. doi:10.1111/cdev.13416PubMedGoogle ScholarCrossref
28.
Cheng  HL, Mallinckrodt  B.  Racial/ethnic discrimination, posttraumatic stress symptoms, and alcohol problems in a longitudinal study of Hispanic/Latino college students.   J Couns Psychol. 2015;62(1):38-49. doi:10.1037/cou0000052PubMedGoogle ScholarCrossref
29.
Lee  DL, Ahn  S.  Discrimination against Latina/os: a meta-analysis of individual-level resources and outcomes ψ.   Couns Psychol. 2012;40(1):28-65. doi:10.1177/0011000011403326Google ScholarCrossref
30.
Clingerman  EM, Brown  A.  Stress in migrant farmworkers during premigration.   Biol Res Nurs. 2012;14(1):27-37. doi:10.1177/1099800410396703PubMedGoogle ScholarCrossref
31.
Clark  US, Miller  ER, Hegde  RR.  Experiences of discrimination are associated with greater resting amygdala activity and functional connectivity.   Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3(4):367-378. doi:10.1016/j.bpsc.2017.11.011PubMedGoogle Scholar
32.
Fani  N, Carter  SE, Harnett  NG, Ressler  KJ, Bradley  B.  Association of racial discrimination with neural response to threat in Black women in the US exposed to trauma.   JAMA Psychiatry. 2021;78(9):1005-1012. doi:10.1001/jamapsychiatry.2021.1480PubMedGoogle ScholarCrossref
33.
Han  SD, Lamar  M, Fleischman  D,  et al.  Self-reported experiences of discrimination in older Black adults are associated with insula functional connectivity.   Brain Imaging Behav. 2021;15(4):1718-1727. doi:10.1007/s11682-020-00365-9PubMedGoogle ScholarCrossref
34.
Matheson  K, Foster  MD, Bombay  A, McQuaid  RJ, Anisman  H.  Traumatic experiences, perceived discrimination, and psychological distress among members of various socially marginalized groups.   Front Psychol. 2019;10:416. doi:10.3389/fpsyg.2019.00416PubMedGoogle ScholarCrossref
35.
Sawyer  PJ, Major  B, Casad  BJ, Townsend  SSM, Mendes  WB.  Discrimination and the stress response: psychological and physiological consequences of anticipating prejudice in interethnic interactions.   Am J Public Health. 2012;102(5):1020-1026. doi:10.2105/AJPH.2011.300620PubMedGoogle ScholarCrossref
36.
Clark  R, Benkert  RA, Flack  JM.  Large arterial elasticity varies as a function of gender and racism-related vigilance in Black youth.   J Adolesc Health. 2006;39(4):562-569. doi:10.1016/j.jadohealth.2006.02.012PubMedGoogle ScholarCrossref
37.
Hicken  MT, Lee  H, Ailshire  J, Burgard  SA, Williams  DR.  “Every shut eye, ain’t sleep”: the role of racism-related vigilance in racial/ethnic disparities in sleep difficulty.   Race Soc Probl. 2013;5(2):100-112. doi:10.1007/s12552-013-9095-9PubMedGoogle ScholarCrossref
38.
Hicken  MT, Lee  H, Hing  AK.  The weight of racism: vigilance and racial inequalities in weight-related measures.   Soc Sci Med. 2018;199:157-166. doi:10.1016/j.socscimed.2017.03.058PubMedGoogle ScholarCrossref
39.
Forsyth  J, Carter  RT.  The relationship between racial identity status attitudes, racism-related coping, and mental health among Black Americans.   Cultur Divers Ethnic Minor Psychol. 2012;18(2):128-140. doi:10.1037/a0027660PubMedGoogle ScholarCrossref
40.
Masten  CL, Telzer  EH, Eisenberger  NI.  An FMRI investigation of attributing negative social treatment to racial discrimination.   J Cogn Neurosci. 2011;23(5):1042-1051. doi:10.1162/jocn.2010.21520PubMedGoogle ScholarCrossref
41.
Singer  T, Critchley  HD, Preuschoff  K.  A common role of insula in feelings, empathy and uncertainty.   Trends Cogn Sci. 2009;13(8):334-340. doi:10.1016/j.tics.2009.05.001PubMedGoogle ScholarCrossref
42.
Palacios-Barrios  EE, Hanson  JL.  Poverty and self-regulation: connecting psychosocial processes, neurobiology, and the risk for psychopathology.   Compr Psychiatry. 2019;90:52-64. doi:10.1016/j.comppsych.2018.12.012PubMedGoogle ScholarCrossref
43.
Abdallah  CG, Averill  CL, Ramage  AE,  et al.  Salience network disruption in US Army soldiers with posttraumatic stress disorder.   Chronic Stress (Thousand Oaks). 2019;3:2470547019850467. doi:10.1177/2470547019850467Google Scholar
44.
Bryant  RA, Felmingham  KL, Kemp  AH,  et al.  Neural networks of information processing in posttraumatic stress disorder: a functional magnetic resonance imaging study.   Biol Psychiatry. 2005;58(2):111-118. doi:10.1016/j.biopsych.2005.03.021PubMedGoogle ScholarCrossref
45.
Patel  R, Spreng  RN, Shin  LM, Girard  TA.  Neurocircuitry models of posttraumatic stress disorder and beyond: a meta-analysis of functional neuroimaging studies.   Neurosci Biobehav Rev. 2012;36(9):2130-2142. doi:10.1016/j.neubiorev.2012.06.003PubMedGoogle ScholarCrossref
46.
Seeley  WW.  The salience network: a neural system for perceiving and responding to homeostatic demands.   J Neurosci. 2019;39(50):9878-9882. doi:10.1523/JNEUROSCI.1138-17.2019PubMedGoogle ScholarCrossref
47.
Sripada  RK, King  AP, Welsh  RC,  et al.  Neural dysregulation in posttraumatic stress disorder: evidence for disrupted equilibrium between salience and default mode brain networks.   Psychosom Med. 2012;74(9):904-911. doi:10.1097/PSY.0b013e318273bf33PubMedGoogle ScholarCrossref
48.
van Marle  HJF, Hermans  EJ, Qin  S, Fernández  G.  Enhanced resting-state connectivity of amygdala in the immediate aftermath of acute psychological stress.   Neuroimage. 2010;53(1):348-354. doi:10.1016/j.neuroimage.2010.05.070PubMedGoogle ScholarCrossref
49.
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
50.
Brooks Holliday  S, Dubowitz  T, Haas  A, Ghosh-Dastidar  B, DeSantis  A, Troxel  WM.  The association between discrimination and PTSD in African Americans: exploring the role of gender.   Ethn Health. 2020;25(5):717-731. doi:10.1080/13557858.2018.1444150PubMedGoogle ScholarCrossref
51.
Berger  M, Sarnyai  Z.  “More than skin deep”: stress neurobiology and mental health consequences of racial discrimination.   Stress. 2015;18(1):1-10. doi:10.3109/10253890.2014.989204PubMedGoogle ScholarCrossref
52.
Everson-Rose  SA, Lutsey  PL, Roetker  NS,  et al.  Perceived discrimination and incident cardiovascular events: the Multi-Ethnic Study of Atherosclerosis.   Am J Epidemiol. 2015;182(3):225-234. doi:10.1093/aje/kwv035PubMedGoogle ScholarCrossref
53.
Kessler  RC, Mickelson  KD, Williams  DR.  The prevalence, distribution, and mental health correlates of perceived discrimination in the United States.   J Health Soc Behav. 1999;40(3):208-230.PubMedGoogle ScholarCrossref
54.
Lewis  TT, Troxel  WM, Kravitz  HM, Bromberger  JT, Matthews  KA, Hall  MH.  Chronic exposure to everyday discrimination and sleep in a multiethnic sample of middle-aged women.   Health Psychol. 2013;32(7):810-819. doi:10.1037/a0029938PubMedGoogle ScholarCrossref
55.
Brondolo  E, Kelly  KP, Coakley  V,  et al.  The perceived ethnic discrimination questionnaire: development and preliminary validation of a community version.   J Appl Soc Psychol. 2005;35(2):335-365. doi:10.1111/j.1559-1816.2005.tb02124.xGoogle ScholarCrossref
56.
Gray  MJ, Litz  BT, Hsu  JL, Lombardo  TW.  Psychometric properties of the life events checklist.   Assessment. 2004;11(4):330-341. doi:10.1177/1073191104269954PubMedGoogle ScholarCrossref
57.
Weis  CN, Webb  EK, Stevens  SK, Larson  CL, deRoon-Cassini  TA.  Scoring the Life Events Checklist: comparison of three scoring methods.   Psychol Trauma. 2021. doi:10.1037/tra0001049PubMedGoogle Scholar
58.
Blevins  CA, Weathers  FW, Davis  MT, Witte  TK, Domino  JL.  The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation.   J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059PubMedGoogle ScholarCrossref
59.
Whitfield-Gabrieli  S, Nieto-Castanon  A.  CONN: a functional connectivity toolbox for correlated and anticorrelated brain networks.   Brain Connect. 2012;2(3):125-141. doi:10.1089/brain.2012.0073PubMedGoogle ScholarCrossref
60.
Geng  H, Wang  Y, Gu  R,  et al.  Altered brain activation and connectivity during anticipation of uncertain threat in trait anxiety.   Hum Brain Mapp. 2018;39(10):3898-3914. doi:10.1002/hbm.24219PubMedGoogle ScholarCrossref
61.
Jenks  SK, Zhang  S, Li  CR, Hu  S.  Threat bias and resting state functional connectivity of the amygdala and bed nucleus stria terminalis.   J Psychiatr Res. 2020;122:54-63. doi:10.1016/j.jpsychires.2019.12.017PubMedGoogle ScholarCrossref
62.
Carter  RT, Johnson  VE, Roberson  K, Mazzula  SL, Kirkinis  K, Sant-Barket  S.  Race-based traumatic stress, racial identity statuses, and psychological functioning: An exploratory investigation.   Prof Psychol Res Pract. 2017;48(1):30-37. doi:10.1037/pro0000116Google ScholarCrossref
63.
Geng  H, Li  X, Chen  J, Li  X, Gu  R.  Decreased intra- and inter-salience network functional connectivity is related to trait anxiety in adolescents.   Front Behav Neurosci. 2016;9:350. doi:10.3389/fnbeh.2015.00350PubMedGoogle ScholarCrossref
64.
Nicholson  AA, Harricharan  S, Densmore  M,  et al.  Classifying heterogeneous presentations of PTSD via the default mode, central executive, and salience networks with machine learning.   Neuroimage Clin. 2020;27:102262. doi:10.1016/j.nicl.2020.102262PubMedGoogle Scholar
65.
Uddin  LQ.  Salience processing and insular cortical function and dysfunction.   Nat Rev Neurosci. 2015;16(1):55-61. doi:10.1038/nrn3857PubMedGoogle ScholarCrossref
66.
Heitmann  CY, Feldker  K, Neumeister  P,  et al.  Abnormal brain activation and connectivity to standardized disorder-related visual scenes in social anxiety disorder.   Hum Brain Mapp. 2016;37(4):1559-1572. doi:10.1002/hbm.23120PubMedGoogle ScholarCrossref
67.
Cavanna  AE, Trimble  MR.  The precuneus: a review of its functional anatomy and behavioural correlates.   Brain. 2006;129(Pt 3):564-583. doi:10.1093/brain/awl004PubMedGoogle Scholar
68.
Utevsky  AV, Smith  DV, Huettel  SA.  Precuneus is a functional core of the default-mode network.   J Neurosci. 2014;34(3):932-940. doi:10.1523/JNEUROSCI.4227-13.2014PubMedGoogle ScholarCrossref
69.
Hoppe  JM, Holmes  EA, Agren  T.  Exploring the neural basis of fear produced by mental imagery: imaginal exposure in individuals fearful of spiders.   Philos Trans R Soc Lond B Biol Sci. 2021;376(1817):20190690. doi:10.1098/rstb.2019.0690PubMedGoogle Scholar
70.
Cabanis  M, Pyka  M, Mehl  S,  et al.  The precuneus and the insula in self-attributional processes.   Cogn Affect Behav Neurosci. 2013;13(2):330-345. doi:10.3758/s13415-012-0143-5PubMedGoogle ScholarCrossref
71.
Craig  ADB.  How do you feel—now? the anterior insula and human awareness.   Nat Rev Neurosci. 2009;10(1):59-70. doi:10.1038/nrn2555PubMedGoogle ScholarCrossref
72.
Pieterse  AL, Carter  RT.  An exploratory investigation of the relationship between racism, racial identity, perceptions of health, and health locus of control among Black American women.   J Health Care Poor Underserved. 2010;21(1):334-348. doi:10.1353/hpu.0.0244PubMedGoogle ScholarCrossref
73.
Pieterse  AL, Carter  RT.  The role of racial identity in perceived racism and psychological stress among Black American adults: exploring traditional and alternative approaches.   J Appl Soc Psychol. 2010;40(5):1028-1053. doi:10.1111/j.1559-1816.2010.00609.xGoogle ScholarCrossref
74.
Sellers  RM, Shelton  JN.  The role of racial identity in perceived racial discrimination.   J Pers Soc Psychol. 2003;84(5):1079-1092. doi:10.1037/0022-3514.84.5.1079PubMedGoogle ScholarCrossref
75.
Mekawi  Y, Carter  S, Packard  G, Wallace  S, Michopoulos  V, Powers  A.  When (passive) acceptance hurts: race-based coping moderates the association between racial discrimination and mental health outcomes among Black Americans.   Psychol Trauma. Published online July 2021. doi:10.1037/tra0001077Google Scholar
76.
Akiki  TJ, Averill  CL, Abdallah  CG.  A network-based neurobiological model of PTSD: evidence from structural and functional neuroimaging studies.   Curr Psychiatry Rep. 2017;19(11):81. doi:10.1007/s11920-017-0840-4PubMedGoogle ScholarCrossref
77.
Etkin  A, Prater  KE, Hoeft  F, Menon  V, Schatzberg  AF.  Failure of anterior cingulate activation and connectivity with the amygdala during implicit regulation of emotional processing in generalized anxiety disorder.   Am J Psychiatry. 2010;167(5):545-554. doi:10.1176/appi.ajp.2009.09070931PubMedGoogle ScholarCrossref
78.
Feurer  C, Jimmy  J, Chang  F,  et al.  Resting state functional connectivity correlates of rumination and worry in internalizing psychopathologies.   Depress Anxiety. 2021;38(5):488-497. doi:10.1002/da.23142PubMedGoogle ScholarCrossref
79.
Kraynak  TE, Marsland  AL, Wager  TD, Gianaros  PJ.  Functional neuroanatomy of peripheral inflammatory physiology: a meta-analysis of human neuroimaging studies.   Neurosci Biobehav Rev. 2018;94:76-92. doi:10.1016/j.neubiorev.2018.07.013PubMedGoogle ScholarCrossref
80.
Brown  VM, LaBar  KS, Haswell  CC, Gold  AL, McCarthy  G, Morey  RA; Mid-Atlantic MIRECC Workgroup.  Altered resting-state functional connectivity of basolateral and centromedial amygdala complexes in posttraumatic stress disorder.   Neuropsychopharmacology. 2014;39(2):351-359. doi:10.1038/npp.2013.197PubMedGoogle ScholarCrossref
81.
Morey  RA, Dunsmoor  JE, Haswell  CC,  et al; VA Mid-Atlantic MIRECC Workgroup.  Fear learning circuitry is biased toward generalization of fear associations in posttraumatic stress disorder.   Transl Psychiatry. 2015;5(12):e700-e700. doi:10.1038/tp.2015.196PubMedGoogle ScholarCrossref
82.
Bradley  B, DeFife  JA, Guarnaccia  C,  et al.  Emotion dysregulation and negative affect: association with psychiatric symptoms.   J Clin Psychiatry. 2011;72(5):685-691. doi:10.4088/JCP.10m06409bluPubMedGoogle ScholarCrossref
83.
Clark  R, Anderson  NB, Clark  VR, Williams  DR.  Racism as a stressor for African Americans: a biopsychosocial model.   Am Psychol. 1999;54(10):805-816. doi:10.1037/0003-066X.54.10.805PubMedGoogle ScholarCrossref
84.
Carter  RT.  Racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress.   Couns Psychol. 2007;35(1):13-105. doi:10.1177/0011000006292033Google ScholarCrossref
85.
Polanco-Roman  L, Danies  A, Anglin  DM.  Racial discrimination as race-based trauma, coping strategies, and dissociative symptoms among emerging adults.   Psychol Trauma. 2016;8(5):609-617. doi:10.1037/tra0000125PubMedGoogle ScholarCrossref
86.
Harnett  NG, Ressler  KJ.  Structural racism as a proximal cause for race-related differences in psychiatric disorders.   Am J Psychiatry. 2021;178(7):579-581. doi:10.1176/appi.ajp.2021.21050486PubMedGoogle ScholarCrossref
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    Original Investigation
    Psychiatry
    January 24, 2022

    Racial Discrimination and Resting-State Functional Connectivity of Salience Network Nodes in Trauma-Exposed Black Adults in the United States

    Author Affiliations
    • 1Department of Psychology, University of Wisconsin–Milwaukee
    • 2Department of Psychology, Marquette University, Milwaukee, Wisconsin
    • 3Division of Trauma & Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee
    • 4Institute for Health and Equity, Department of Epidemiology, Medical College of Wisconsin, Milwaukee
    • 5Brain Imaging and Analysis Center, Duke University, Durham, North Carolina
    • 6VA Northern California Healthcare System, Martinez
    • 7A Montana Healthcare System, Helena
    JAMA Netw Open. 2022;5(1):e2144759. doi:10.1001/jamanetworkopen.2021.44759
    Key Points

    Question  Are experiences of racial discrimination associated with altered resting-state connectivity patterns of salience network nodes?

    Findings  In this cross-sectional study of 102 Black adults, more experiences of racial discrimination were associated with altered connectivity of the amygdala and anterior insula, even after adjusting for annual household income, lifetime trauma exposure, and current posttraumatic stress disorder symptoms.

    Meaning  These findings suggest that experiencing racial discrimination is associated with modifications to known neural correlates of vigilance, suggesting a viable mechanism by which racism negatively affects mental health.

    Abstract

    Importance  For Black US residents, experiences of racial discrimination are still pervasive and frequent. Recent empirical work has amplified the lived experiences and narratives of Black people and further documented the detrimental effects of racial discrimination on both mental and physical health; however, there is still a need for further research to uncover the mechanisms connecting experiences of racial discrimination with adverse health outcomes.

    Objective  To examine neurobiological mechanisms that may offer novel insight into the association of racial discrimination with adverse health outcomes.

    Design, Setting, and Participants  This cross-sectional study included 102 Black adults who had recently experienced a traumatic injury. In the acute aftermath of the trauma, participants underwent a resting-state functional magnetic resonance imaging scan. Individuals were recruited from the emergency department at a Midwestern level 1 trauma center in the United States between March 2016 and July 2020. Data were analyzed from February to May 2021.

    Exposures  Self-reported lifetime exposure to racial discrimination, lifetime trauma exposure, annual household income, and current posttraumatic stress disorder (PTSD) symptoms were evaluated.

    Main Outcomes and Measures  Seed-to-voxel analyses were conducted to examine the association of racial discrimination with connectivity of salience network nodes (ie, amygdala and anterior insula).

    Results  A total of 102 individuals were included, with a mean (SD) age of 33 (10) years and 58 (57%) women. After adjusting for acute PTSD symptoms, annual household income, and lifetime trauma exposure, greater connectivity between the amygdala and thalamus was associated with greater exposure to discrimination (t(97) = 6.05; false discovery rate (FDR)–corrected P = .03). Similarly, racial discrimination was associated with greater connectivity between the insula and precuneus (t(97) = 4.32; FDR-corrected P = .02).

    Conclusions and Relevance  These results add to the mounting literature that racial discrimination is associated with neural correlates of vigilance and hyperarousal. The study findings extend this theory by showing that this association is apparent even when accounting for socioeconomic position, lifetime trauma, and symptoms of psychological distress related to an acute trauma.

    Introduction

    Racism has been deemed a public health crisis in the United States.1 Racial discrimination, defined as prejudice, unfair treatment, and/or violence against a marginalized racial or ethnic group, is a form of racism that can traverse different contexts. Exposure to discrimination may occur at interpersonal, environmental, and structural levels.2-4 In the United States, Black people report the highest levels of exposure to racial discrimination compared with any other racial or ethnic group.5 The association between racial discrimination and negative health outcomes, such as depression, anxiety, posttraumatic stress disorder (PTSD), hypertension, and heart disease, among others, has been well-established.4,6-18 Experiences of racial discrimination have also been linked to dysfunction of biological stress response systems, including greater allostatic load19-21 and shortened telomere length,22-25 suggesting an association with premature aging and declining health. Evidence of the association between racial discrimination and negative mental health outcomes has mostly relied on demonstrating this connection through self-reported data.6,14,17,26-29 However, the underlying neurobiological consequences of chronic exposure to racial discrimination has been less frequently characterized. The purpose of this study was to examine whether cumulative experiences of racial discrimination—which represent real and frequent threats—are associated with altered functional connectivity of brain regions that monitor and process threatening information.

    Although the neurobiology of threat-related processes has received considerable attention, these scientific advancements (with few exceptions) have largely ignored the stressful experiences specific to racially and ethnically marginalized groups.30-33 There remain many questions regarding the neural consequences of chronic racial discrimination and the biological pathways between these experiences and health outcomes. One plausible pathway is that ongoing exposure to racially charged situations presents imminent social, emotional, and/or physical threats.34,35 The detection, monitoring, and processing of these threats naturally requires vigilance,36-38 and accordingly, threat-related brain regions are reasonably activated during and in ongoing anticipation of experiences of racism-related vigilance.37,39 A number of these threat-related regions are categorized as nodes in the salience network (SN; eg, amygdala and insula), which is recruited during vigilance and heighted arousal; however, the association between the SN and racial discrimination has only recently been considered.

    Two studies31,33 have suggested that altered resting-state connectivity of nodes in the SN, such as the amygdala, insula, and connected sensory-processing regions (eg, thalamus, visual cortex), are associated with racial discrimination. Han and colleagues33 found differential insula connectivity in older Black adults reporting greater racial discrimination. In the context of the SN, the insula is involved in perceptions of self-awareness as well as determining the valence of external stimuli, particularly stimuli tied to social situations.33,40,41 Altered functional connectivity between the insula and regions implicated in vigilance (eg, intracalcarine cortex, supplementary motor area) was associated with a greater number of experiences of racial discrimination, whereas reduced connectivity between the insula and dorsolateral prefrontal cortex was associated with fewer discriminatory experiences.33 These vigilance regions have been implicated in other social constructs frequently associated with the experiences of racial discrimination, including behavioral response-selection to emotional stimuli and mistrust.33 In a racially, ethnically, and sexually diverse sample of adults (10% White, 72% Black, 23% Hispanic, 32% gay or bisexual), greater social discrimination was associated with greater spontaneous resting-state connectivity between the amygdala, another key node of the SN, and various other regions, including the insula.31 Interestingly, Clark and colleagues31 found the most robust association with social discrimination was greater connectivity between the amygdala and thalamus. In this study, and in others on stressful and traumatic experiences, aberrant resting-state functional connectivity between the amygdala and other regions in the SN (eg, anterior insula, medial prefrontal cortex, dorsal anterior cingulate cortex) has been documented.31,42

    The SN, including the amygdala and anterior insula, has also been implicated in the symptoms observed in PTSD symptomology, specifically that of hyperarousal.43-48 Hyperarousal is generally characterized by feelings of persistent alertness and feeling on guard.49 Notably, experiences of racial discrimination are uniquely associated with symptoms of hyperarousal and vigilance,4,37,38 and racial discrimination predicts symptoms of PTSD.6,14,50 The shared experience of hyperarousal and vigilance suggests common activation of the SN31,33,51 and offers theoretical justification that the brain regions affected by traumatic experiences are similarly activated by racism-related vigilance. Indeed, although previous work has found novel associations between resting-state functional connectivity of SN nodes and discrimination, related symptoms, including posttraumatic stress, were not previously considered in the prediction model.31,33

    The current study sought to replicate and advance the existing knowledge on the consequences of racism-related vigilance. Specifically, we examined the association between racial discrimination and connectivity of SN nodes (ie, the amygdala and anterior insula) during resting-state functional magnetic resonance imaging (fMRI), in the acute aftermath of traumatic injury. Given that in multiple studies,52-54 Black US residents reported the highest levels of discrimination and therefore are at high risk of racism-related poor health outcomes, we tested this question in a sample of Black adults. We enrolled Black participants after they experienced an acute traumatic injury, which allowed us to better examine whether SN vigilance systems remain associated with experiencing racial discrimination even after controlling for symptoms resulting from an acute traumatic event.

    Methods
    Participants

    The current cross-sectional study was part of a larger longitudinal project examining acute posttrauma factors associated with PTSD. Individuals were recruited from the emergency department at a Midwestern level 1 trauma center in the United States between March 2016 and July 2020. Overall, 969 injured individuals treated in the emergency department were approached by the study recruitment team. Eligibility criteria were met if the individual spoke English, was aged between 18 and 65 years, could schedule a study visit within 2 weeks of the index trauma, and had experienced a traumatic injury. Participants were considered ineligible if they had a moderate to severe traumatic brain injury, suffered a spinal cord injury, or had a history of psychotic or manic symptoms. Individuals who sustained traumatic injuries resulting from suicide attempts or self-harm were also excluded. Finally, participants were required to be eligible for MRI (eg, could not be pregnant or have ferromagnetic material in the body). The described procedures were approved by the Medical College of Wisconsin institutional review board. Approximately 2 weeks post injury, participants returned for their initial study visit. At this time, individuals provided written informed consent to participate in the study. As part of a larger battery, participants completed various self-report measures and underwent neuroimaging. All individuals were financially compensated for their time. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Of the 215 people who were enrolled in the larger project, 198 completed the resting-state fMRI scan. One hundred and twelve participants self-reported their racial identity as Black and/or African American and had useable resting-state scans. Of those participants, 102 completed the questionnaires on lifetime exposure to racial discrimination, lifetime trauma exposure, and PTSD symptoms (administered during the same study visit). Sample demographic details can be found in Table 1.

    Measures
    Racial Discrimination

    Lifetime exposure to racial discrimination was evaluated using the validated Perceived Ethnic Discrimination Questionnaire (PEDQ).55 This measure consists of 17 items (current sample Cronbach α = 0.93) spanning multiple settings and levels of which racial discrimination can occur. Participants were asked to quantify how frequently each item of discrimination had happened to them. Each exposure type was rated from 1 (never) to 5 (very often) and a total score was created by averaging scores from all items. Previously, greater scores were shown to be associated with baseline PTSD symptoms and predictive of chronic PTSD symptoms in this sample.6

    Life Events Checklist for DSM-5

    Lifetime trauma exposure was evaluated using the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (LEC-5).56 Sixteen different traumatic exposures are evaluated, and participants rate their experience with each event (eg, happened to them, witnessed the event, learned about the event, does not apply). The LEC ranges from 0 to 102, with higher scores indicating more exposure and closer proximity to traumatic events. A newly developed scoring method57 was used in which the total score was weighted according to proximity to the trauma exposure.

    Income

    Annual household income was assessed using a semicontinuous scale. A 1 indicated an annual household income of $0 to $10 000. Each 1-unit increase corresponded with a $10 000 increase in income. An 11 designated that income was greater than $100 000.

    PTSD Checklist for DSM-5

    Acute posttraumatic stress symptoms (ie, current PTSD symptoms related to the index trauma) were measured using the PTSD Checklist for DSM-5 (PCL-5).58 In this validated self-report questionnaire, 20 items (current sample Cronbach α = 0.94) were presented which correspond to the DSM-5 PTSD symptoms.49 Participants rated how much each of the symptoms (ie, items) bothered them on a scale of 1 (not at all) to 5 (extremely) since the time of the injury. A total symptom severity score was created by summing all of the items (sample range 0-73, with higher scores indicating more severe symptoms).

    MRI Data Acquisition

    All neuroimaging was conducted using a Discovery MR750 3.0 Tesla scanner with a 32-channel head-coil (General Electric). High-resolution T1-weighted images were collected for coregistration using the following parameters: field of view (FOV), 240 mm; matrix, 256 × 224; slice thickness, 1 mm; 150 slices; repetition time (TR)/echo time (TE), 8.2/3.2 seconds, flip angle, 12o; voxel size, 1 × 0.938 × 0.938 mm. Participants underwent an 8-minute eyes-open resting-state scan, during which 240 volumes were acquired using the following parameters: FOV, 22.4 mm; matrix, 64 × 64; slice thickness, 3.5 mm; 41 sagittal slices; TR/TE, 2000/25 milliseconds; flip angle, 77°; voxel size, 3.5 × 3.5 × 3.5 mm.

    fMRI Preprocessing

    Structural and resting-state images were preprocessed in the CONN toolbox version 20,59 with SPM version 12 and MatLab version 2019b (Mathworks). The first 3 TRs were discarded, and then images were motion-corrected using a 6-parameter linear transformation, normalized to Montreal Neurological Institute template (MNI 152) and then spatially smoothed using a 4-mm full-width-at-half-maximum kernel. During the first-level analyses, head motion parameters (and their first-order derivates) as well as white matter signal and cerebrospinal fluid signal were regressed out. If more than 20% of the resting-state volumes were scrubbed or the scan quality was deemed poor after visual inspection, the participant was removed from analyses (n = 4).

    Statistical Analysis

    Bilateral seed regions of interests were defined using atlases in the CONN toolbox.59 In the toolbox, the anterior insula was functionally defined, whereas the amygdala seed was anatomically defined.59 We conducted 2 separate seed-to-voxel analyses (performed in CONN) in which the mean blood oxygenation level dependent signals from the bilateral amygdala (Figure 1A and B) and anterior insula (Figure 1C and D) were separately correlated with all other voxels in the brain. In group-level regression analyses, PCL-5 scores, annual household income, and lifetime trauma exposure were included as covariates. The main association of interest was that of the PEDQ mean item score on connectivity patterns.

    Connectivity statistics were considered significant at a 2-tailed P < .05, with a height threshold of P < .001 uncorrected and a cluster-size threshold of an adjusted P < .05 false discovery rate (FDR)-corrected. The CONN toolbox was used for these analyses. Data were analyzed from February to May 2021.

    Results

    Of the 102 participants (mean [SD] age, 33 [10] years; 58 [57%] women), 71 (70%) experienced a motor vehicle crash (Table 1). Pearson correlations between study measures revealed higher PCL-5 scores were significantly associated with greater exposure to racial discrimination (r(100) = 0.49; P < .001) and lifetime trauma (r(100) = 0.48; P < .001). PTSD symptoms were not associated with age (r(100) = −0.06; P = .53) or income (r(100) = 0.01; P = .90). Higher LEC-5 weighted total scores were correlated with more experiences of racial discrimination (r(100) = 0.40; P < .001) but not age (r(100) < −0.01; P= .97) or income (r(100) = 0.09; P= .38).

    Associations of Racial Discrimination With Resting-State Connectivity Patterns

    Greater exposure to racial discrimination was significantly associated with increased bilateral amygdala connectivity with the thalamus, even after adjusting for PTSD symptoms, lifetime trauma, and income (MNI coordinates x = −6; y = −26; z = 16; cluster size: k = 80; t(97) = 6.05; FDR-corrected P = .03; Cohen d= 0.61) (Figure 2). After controlling for PCL-5 scores, income, and LEC-5 scores, greater connectivity between bilateral anterior insula and precuneus was associated with more exposure to racial discrimination (MNI coordinates: x = −6; y = −74; z= 26; cluster size: k = 99; t(97) = 4.32; FDR-corrected P = .02; Cohen d= 0.44) (Figure 3 and Table 2).

    Discussion

    We evaluated the association between experiences of racial discrimination and resting-state functional connectivity of the SN (ie, amygdala and anterior insula) in Black US residents recently exposed to a trauma. By analyzing this association in a sample of individuals who recently experienced a traumatic injury, we attempted to evaluate the neural consequences of experiencing discrimination while adjusting for the contributions related to an acute trauma. These findings replicated recent work, demonstrating experiences of discrimination are associated with increased connectivity between threat-activated brain regions, particularly those responsible for initial processing of salient stimuli.31-33

    Greater amygdala connectivity with the thalamus, a crucial intermediary between sensory systems and affective/cognitive regions, has been previously correlated with more exposure to social discrimination.31 Similar patterns of connectivity are demonstrated during anticipation of uncertain threats,60 a category which discriminatory experiences may frequently fall in. We position the current findings within studies on threat appraisal, such as that by Jenks et al,61 which suggest greater amygdala and thalamus connectivity reflects a greater sensitivity to threatening situations. Importantly, increased amygdala-thalamus connectivity at rest may be reflective of an adaptative coping strategy to mentally prepare for threats associated with racial discrimination, which are horrifically persistent for Black US residents living in a White-centric society.62 Attempting to use and maintain coping strategies to combat racism may be associated with increased demands on psychosocial resources (ie, cognitive and affective processes11), thereby leading to neural vulnerabilities or an increased biological sensitivity exploited by acute trauma.39 Supporting this theory are findings from Fani et al32: in Black women with trauma exposure, more experiences of racial discrimination were significantly associated with greater activation of visual regions and the ventromedial prefrontal cortex (a node in the SN) during trauma-relevant images compared with neutral images.

    Increased SN connections with sensory regions is also frequently characterized as evidence for vigilance, integration of external information, and internal arousal.43,46,63-65 Given the precuneus’s role in mental imagery, greater insula-precuneus connectivity at rest aligns with the theory that discrimination is associated with increased preparedness for biologically relevant information and general arousal.66 The precuneus, a node of the default mode network, is also involved in self-elicited recollection of past experiences.67,68 In fact, mental imagery of negative or fear stimuli elicits activation of both the insula and precuneus.69 The anterior insula and precuneus also underly aspects of self-awareness,40,70,71 which could relate to the heighted awareness a Black person may feel when navigating through the White-centric United States. A strong sense of self, belonging, and commitment to a racial or ethnic community seems to have a protective function against the psychological consequences of discrimination.62,72-74 In addition, Mekawi and colleagues75 found that more active race-based coping strategies (eg, talking about experiences of racism and doing something to address it) rather than more passive (eg, accept the experience and do not talk about it) also helped to buffer the association between discrimination and mental health outcomes.

    Alterations to SN nodes have been associated health outcomes, including symptoms of PTSD,43,64,76 general anxiety disorder,63,77,78 and even peripheral inflammation.79 Although we did not directly examine the association between discrimination and future health outcomes, within the context of this broader literature, the current work supports a discrimination-perpetual vigilance-altered SN–health outcome pathway. Indeed, in the literature on PTSD, aberrations in amygdala-thalamus activation and connectivity are broadly thought to correlate with emotion dysregulation.80,81 Difficulty regulating emotions or using adaptive coping strategies may stem from challenges in appropriately identifying and early processing of emotionally relevant stimuli.82 Perhaps this is one mechanism by which racism instigates symptoms of anxiety and depression, although more work is needed in this area.

    These findings are situated in and constrained by the complexities of racial discrimination, trauma exposure, and PTSD symptoms. Greater previous exposure to traumatic and stressful experiences increases the risk of PTSD development after an acute trauma.57 In tandem, racial discrimination increases risk of PTSD.15,83,84 Previously, in this sample, we found that racial discrimination was associated with baseline posttraumatic stress symptoms and nonremitting (6 months post injury) PTSD symptoms.6 Thus, acute trauma exposure and racial discrimination together present a compounded risk factor that may affect neural connectivity and lead to subsequent PTSD.84 In fact, racial discrimination in the absence of an acute trauma is associated with PTSD symptoms.85 Although we included PTSD symptom severity scores as a covariate in the models, adjusting for these scores alone may not fully capture the neural consequences of experiencing a traumatic injury. Acute posttraumatic stress symptoms are also correlated with racial discrimination,6,14 which presents the possibility that the PTSD symptoms assessed, although the measures explicitly queried the index trauma, may also capture experiences of discrimination. We did not specifically probe racism-related vigilance or hyperarousal; future directions include administering surveys specifically designed to measure the construct,37 rather than relying on surveys developed for PTSD assessment.

    In the current study, we evaluated racial discrimination in the absence of any protective factors that may buffer the harmful consequences of racism. Unfortunately, we did not capture any racism-related coping strategies39 that may help prevent negative mental health symptoms from developing. This is certainly a limitation; identifying resilience factors is critical because they represent ideal targets that therapeutic interventions can help bolster. For example, Forsyth and Carter39 chronicled how different racial identity attitudes and racism-related coping strategies were associated with varying degrees of psychological symptoms. In the ongoing discussion and future work on racism and mental health outcomes, it is imperative we move forward by evaluating protective factors which may mitigate the neural consequences of racism.

    Conceptualizing experiences of racial discrimination as a both a form of psychological trauma and as a shared risk factor for psychopathology represents an important shift in the White-centric understanding of the consequences of racism.84 The threat associated with racial discrimination increases racism-related vigilance.37,38 In this study, we observed an association between racial discrimination and the amygdala and anterior insula, 2 SN regions underlying threat-related vigilance. This is a viable mechanism by which these experiences can contribute to PTSD and also possibly alter neural functioning even independent of an acute trauma (as shown in other studies31-33). Moreover, racism-related vigilance may confound work on vigilance tied to an acute trauma, therefore, we (and other researchers14,86) recommend assessing racial discrimination in studies on trauma and stress.

    Limitations

    This study has additional limitations that temper its generalizability. It used a homogeneous sample, such that majority of the participants experienced a motor vehicle crash. This may result in a unique profile of posttrauma symptomatology and/or brain connectivity. However, given that traumatically injured, Black US residents are generally understudied, the findings from the current study remain particularly valuable and informative. Previous work in the same sample6 demonstrated that discrimination was associated with acute posttraumatic stress and predictive of future PTSD. This further supports theories characterizing racial discrimination as a form of racial trauma.4,5,7,84 Based on this conceptualization, it is challenging to fully disentangle the neural impact of past racial trauma, current PTSD symptoms, and lifetime nonracialized trauma. Nevertheless, we attempted to statistically control for these associations by including LEC and PCL-5 scores in our models. Notably, we conducted cross-sectional analyses and therefore cannot draw conclusions about causal relationships. Future work should explore these relationships longitudinally and test whether altered SN connectivity mediates the association between racial discrimination and nonremitting PTSD. Examining the association of racial discrimination, in the context of trauma, with both brain function and structure is necessary to elucidate how discrimination affects the neurobiological underpinnings of PTSD and drives posttrauma health disparities.

    Conclusions

    Consistent with the limited existing work31-33 on the associations between racial discrimination and the brain, in this study we found these experiences were associated with alterations in functional connectivity in individuals exposed to trauma. Taken together, this accumulating evidence emphasizes the gravity of racism as a public health crisis. While neuroscience research can be used to underscore the biological consequences of racism and help test factors that may buffer against these effects, the overarching goals should be to provide culturally informed treatment to Black Americans with PTSD symptoms and combat racism—interpersonal and structural—in US society.

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    Article Information

    Accepted for Publication: November 29, 2021.

    Published: January 24, 2022. doi:10.1001/jamanetworkopen.2021.44759

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Webb EK et al. JAMA Network Open.

    Corresponding Author: E. Kate Webb, PhD, Department of Psychology, University of Wisconsin–Milwaukee, 2441 E Hartford Ave, Garland Hall 334, Milwaukee, WI 53211 (ekwebb@uwm.edu).

    Author Contributions: Drs Webb and Larson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Webb and Mx Bird share first authorship. Drs Torres and Larson share senior authorship.

    Concept and design: Webb, Bird, deRoon-Cassini, Weis, Huggins, Miskovich, Bennett, Larson.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Webb, Bird, Weis, Torres, Larson.

    Critical revision of the manuscript for important intellectual content: Webb, Bird, deRoon-Cassini, Weis, Huggins, Fitzgerald, Miskovich, Bennett, Krukowski, Torres, Larson.

    Statistical analysis: Webb, Weis.

    Obtained funding: Webb, deRoon-Cassini, Larson.

    Administrative, technical, or material support: Webb, Weis, Huggins, Miskovich, Krukowski.

    Supervision: Torres, Larson.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This work was supported by grant R01MH106574 from the National Institutes of Mental Health. The project described was supported by grants 2UL1TR001436 and 2TL1TR001437 from the National Center for Advancing Translational Sciences to Mx Bird and Dr Webb.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The content is solely the responsibility of the author(s) and does not necessarily represent the official views of the National Institutes of Health.

    References
    1.
    Devakumar  D, Shannon  G, Bhopal  SS, Abubakar  I.  Racism and discrimination in COVID-19 responses.   Lancet. 2020;395(10231):1194. doi:10.1016/S0140-6736(20)30792-3PubMedGoogle ScholarCrossref
    2.
    Williams  DR.  Race, socioeconomic status, and health: the added effects of racism and discrimination.   Ann N Y Acad Sci. 1999;896:173-188. doi:10.1111/j.1749-6632.1999.tb08114.xPubMedGoogle ScholarCrossref
    3.
    Williams  DR, Mohammed  SA, Leavell  J, Collins  C.  Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities.   Ann N Y Acad Sci. 2010;1186:69-101. doi:10.1111/j.1749-6632.2009.05339.xPubMedGoogle ScholarCrossref
    4.
    Williams  MT, Metzger  IW, Leins  C, DeLapp  C.  Assessing racial trauma within a DSM-5 framework: The UConn Racial/Ethnic Stress & Trauma Survey.   Pract Innov. 2018;3(4):242. doi:10.1037/pri0000076Google ScholarCrossref
    5.
    Lewis  TT, Van Dyke  ME.  Discrimination and the health of African Americans: the potential importance of intersectionalities.   Curr Dir Psychol Sci. 2018;27(3):176-182. doi:10.1177/0963721418770442PubMedGoogle ScholarCrossref
    6.
    Bird  CM, Webb  EK, Schramm  AT, Torres  L, Larson  C, deRoon-Cassini  TA.  Racial discrimination is associated with acute posttraumatic stress symptoms and predicts future posttraumatic stress disorder symptom severity in trauma-exposed Black adults in the United States.   J Trauma Stress. 2021;34(5):995-1004. doi:10.1002/jts.22670PubMedGoogle ScholarCrossref
    7.
    Carter  RT, Lau  MY, Johnson  V, Kirkinis  K.  Racial discrimination and health outcomes among racial/ethnic minorities: a meta-analytic review.   J Multicult Couns Dev. 2017;45(4):232-259. doi:10.1002/jmcd.12076Google ScholarCrossref
    8.
    Chou  T, Asnaani  A, Hofmann  SG.  Perception of racial discrimination and psychopathology across three U.S. ethnic minority groups.   Cultur Divers Ethnic Minor Psychol. 2012;18(1):74-81. doi:10.1037/a0025432PubMedGoogle ScholarCrossref
    9.
    Franco  M, Durkee  M, McElroy-Heltzel  S.  Discrimination comes in layers: dimensions of discrimination and mental health for multiracial people.   Cultur Divers Ethnic Minor Psychol. 2021;27(3):343-353. doi:10.1037/cdp0000441PubMedGoogle ScholarCrossref
    10.
    Hart  AR, Lavner  JA, Carter  SE, Beach  SRH.  Racial discrimination, depressive symptoms, and sleep problems among Blacks in the rural South.   Cultur Divers Ethnic Minor Psychol. 2021;27(1):123-134. doi:10.1037/cdp0000365PubMedGoogle ScholarCrossref
    11.
    Joseph  NT, Peterson  LM, Gordon  H, Kamarck  TW.  The double burden of racial discrimination in daily-life moments: increases in negative emotions and depletion of psychosocial resources among emerging adult African Americans.   Cultur Divers Ethnic Minor Psychol. 2021;27(2):234-244. doi:10.1037/cdp0000337PubMedGoogle ScholarCrossref
    12.
    Lavner  JA, Hart  AR, Carter  SE, Beach  SRH.  Longitudinal effects of racial discrimination on depressive symptoms among Black youth: between- and within-person effects.   J Am Acad Child Adolesc Psychiatry. 2021;S0890-8567(21)00309-9. doi:10.1016/j.jaac.2021.04.020PubMedGoogle Scholar
    13.
    Lei  MK, Lavner  JA, Carter  SE, Hart  AR, Beach  SRH.  Protective parenting behavior buffers the impact of racial discrimination on depression among Black youth.   J Fam Psychol. 2021;35(4):457-467. doi:10.1037/fam0000822PubMedGoogle ScholarCrossref
    14.
    Mekawi  Y, Carter  S, Brown  B,  et al.  Interpersonal trauma and posttraumatic stress disorder among Black women: does racial discrimination matter?   J Trauma Dissociation. 2021;22(2):154-169. doi:10.1080/15299732.2020.1869098PubMedGoogle ScholarCrossref
    15.
    Mekawi  Y, Hyatt  CS, Maples-Keller  J, Carter  S, Michopoulos  V, Powers  A.  Racial discrimination predicts mental health outcomes beyond the role of personality traits in a community sample of African Americans.   Clin Psychol Sci. 2021;9(2):183-196. doi:10.1177/2167702620957318Google ScholarCrossref
    16.
    Paradies  YC. Race, Racism, Stress and Indigenous Health. Dissertation. The University of Melbourne; 2006.
    17.
    Park  IJK, Du  H, Wang  L, Williams  DR, Alegría  M.  Racial/ethnic discrimination and mental health in Mexican-origin youths and their parents: testing the “linked lives” hypothesis.   J Adolesc Health. 2018;62(4):480-487. doi:10.1016/j.jadohealth.2017.10.010PubMedGoogle ScholarCrossref
    18.
    Sosoo  EE, Bernard  DL, Neblett  EW  Jr.  The influence of internalized racism on the relationship between discrimination and anxiety.   Cultur Divers Ethnic Minor Psychol. 2020;26(4):570-580. doi:10.1037/cdp0000320PubMedGoogle ScholarCrossref
    19.
    Allen  AM, Thomas  MD, Michaels  EK,  et al.  Racial discrimination, educational attainment, and biological dysregulation among midlife African American women.   Psychoneuroendocrinology. 2019;99:225-235. doi:10.1016/j.psyneuen.2018.09.001PubMedGoogle ScholarCrossref
    20.
    Allen  AM, Wang  Y, Chae  DH,  et al.  Racial discrimination, the superwoman schema, and allostatic load: exploring an integrative stress-coping model among African American women.   Ann N Y Acad Sci. 2019;1457(1):104-127. doi:10.1111/nyas.14188PubMedGoogle ScholarCrossref
    21.
    Cuevas  AG, Ho  T, Rodgers  J,  et al.  Developmental timing of initial racial discrimination exposure is associated with cardiovascular health conditions in adulthood.   Ethn Health. 2021;26(7):949-962. doi:10.1080/13557858.2019.1613517PubMedGoogle ScholarCrossref
    22.
    Chae  DH, Nuru-Jeter  AM, Adler  NE,  et al.  Discrimination, racial bias, and telomere length in African-American men.   Am J Prev Med. 2014;46(2):103-111. doi:10.1016/j.amepre.2013.10.020PubMedGoogle ScholarCrossref
    23.
    Chae  DH, Epel  ES, Nuru-Jeter  AM,  et al.  Discrimination, mental health, and leukocyte telomere length among African American men.   Psychoneuroendocrinology. 2016;63:10-16. doi:10.1016/j.psyneuen.2015.09.001PubMedGoogle ScholarCrossref
    24.
    Lee  DB, Kim  ES, Neblett  EW  Jr.  The link between discrimination and telomere length in African American adults.   Health Psychol. 2017;36(5):458-467. doi:10.1037/hea0000450PubMedGoogle ScholarCrossref
    25.
    Thomas  MD, Sohail  S, Mendez  RM, Márquez-Magaña  L, Allen  AM.  Racial discrimination and telomere length in midlife African American women: interactions of educational attainment and employment status.   Ann Behav Med. 2021;55(7):601-611. doi:10.1093/abm/kaaa104PubMedGoogle ScholarCrossref
    26.
    Chambers  BD, Arabia  SE, Arega  HA,  et al.  Exposures to structural racism and racial discrimination among pregnant and early post-partum Black women living in Oakland, California.   Stress Health. 2020;36(2):213-219. doi:10.1002/smi.2922PubMedGoogle ScholarCrossref
    27.
    Cheeks  BL, Chavous  TM, Sellers  RM.  A daily examination of African American adolescents’ racial discrimination, parental racial socialization, and psychological affect.   Child Dev. 2020;91(6):2123-2140. doi:10.1111/cdev.13416PubMedGoogle ScholarCrossref
    28.
    Cheng  HL, Mallinckrodt  B.  Racial/ethnic discrimination, posttraumatic stress symptoms, and alcohol problems in a longitudinal study of Hispanic/Latino college students.   J Couns Psychol. 2015;62(1):38-49. doi:10.1037/cou0000052PubMedGoogle ScholarCrossref
    29.
    Lee  DL, Ahn  S.  Discrimination against Latina/os: a meta-analysis of individual-level resources and outcomes ψ.   Couns Psychol. 2012;40(1):28-65. doi:10.1177/0011000011403326Google ScholarCrossref
    30.
    Clingerman  EM, Brown  A.  Stress in migrant farmworkers during premigration.   Biol Res Nurs. 2012;14(1):27-37. doi:10.1177/1099800410396703PubMedGoogle ScholarCrossref
    31.
    Clark  US, Miller  ER, Hegde  RR.  Experiences of discrimination are associated with greater resting amygdala activity and functional connectivity.   Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3(4):367-378. doi:10.1016/j.bpsc.2017.11.011PubMedGoogle Scholar
    32.
    Fani  N, Carter  SE, Harnett  NG, Ressler  KJ, Bradley  B.  Association of racial discrimination with neural response to threat in Black women in the US exposed to trauma.   JAMA Psychiatry. 2021;78(9):1005-1012. doi:10.1001/jamapsychiatry.2021.1480PubMedGoogle ScholarCrossref
    33.
    Han  SD, Lamar  M, Fleischman  D,  et al.  Self-reported experiences of discrimination in older Black adults are associated with insula functional connectivity.   Brain Imaging Behav. 2021;15(4):1718-1727. doi:10.1007/s11682-020-00365-9PubMedGoogle ScholarCrossref
    34.
    Matheson  K, Foster  MD, Bombay  A, McQuaid  RJ, Anisman  H.  Traumatic experiences, perceived discrimination, and psychological distress among members of various socially marginalized groups.   Front Psychol. 2019;10:416. doi:10.3389/fpsyg.2019.00416PubMedGoogle ScholarCrossref
    35.
    Sawyer  PJ, Major  B, Casad  BJ, Townsend  SSM, Mendes  WB.  Discrimination and the stress response: psychological and physiological consequences of anticipating prejudice in interethnic interactions.   Am J Public Health. 2012;102(5):1020-1026. doi:10.2105/AJPH.2011.300620PubMedGoogle ScholarCrossref
    36.
    Clark  R, Benkert  RA, Flack  JM.  Large arterial elasticity varies as a function of gender and racism-related vigilance in Black youth.   J Adolesc Health. 2006;39(4):562-569. doi:10.1016/j.jadohealth.2006.02.012PubMedGoogle ScholarCrossref
    37.
    Hicken  MT, Lee  H, Ailshire  J, Burgard  SA, Williams  DR.  “Every shut eye, ain’t sleep”: the role of racism-related vigilance in racial/ethnic disparities in sleep difficulty.   Race Soc Probl. 2013;5(2):100-112. doi:10.1007/s12552-013-9095-9PubMedGoogle ScholarCrossref
    38.
    Hicken  MT, Lee  H, Hing  AK.  The weight of racism: vigilance and racial inequalities in weight-related measures.   Soc Sci Med. 2018;199:157-166. doi:10.1016/j.socscimed.2017.03.058PubMedGoogle ScholarCrossref
    39.
    Forsyth  J, Carter  RT.  The relationship between racial identity status attitudes, racism-related coping, and mental health among Black Americans.   Cultur Divers Ethnic Minor Psychol. 2012;18(2):128-140. doi:10.1037/a0027660PubMedGoogle ScholarCrossref
    40.
    Masten  CL, Telzer  EH, Eisenberger  NI.  An FMRI investigation of attributing negative social treatment to racial discrimination.   J Cogn Neurosci. 2011;23(5):1042-1051. doi:10.1162/jocn.2010.21520PubMedGoogle ScholarCrossref
    41.
    Singer  T, Critchley  HD, Preuschoff  K.  A common role of insula in feelings, empathy and uncertainty.   Trends Cogn Sci. 2009;13(8):334-340. doi:10.1016/j.tics.2009.05.001PubMedGoogle ScholarCrossref
    42.
    Palacios-Barrios  EE, Hanson  JL.  Poverty and self-regulation: connecting psychosocial processes, neurobiology, and the risk for psychopathology.   Compr Psychiatry. 2019;90:52-64. doi:10.1016/j.comppsych.2018.12.012PubMedGoogle ScholarCrossref
    43.
    Abdallah  CG, Averill  CL, Ramage  AE,  et al.  Salience network disruption in US Army soldiers with posttraumatic stress disorder.   Chronic Stress (Thousand Oaks). 2019;3:2470547019850467. doi:10.1177/2470547019850467Google Scholar
    44.
    Bryant  RA, Felmingham  KL, Kemp  AH,  et al.  Neural networks of information processing in posttraumatic stress disorder: a functional magnetic resonance imaging study.   Biol Psychiatry. 2005;58(2):111-118. doi:10.1016/j.biopsych.2005.03.021PubMedGoogle ScholarCrossref
    45.
    Patel  R, Spreng  RN, Shin  LM, Girard  TA.  Neurocircuitry models of posttraumatic stress disorder and beyond: a meta-analysis of functional neuroimaging studies.   Neurosci Biobehav Rev. 2012;36(9):2130-2142. doi:10.1016/j.neubiorev.2012.06.003PubMedGoogle ScholarCrossref
    46.
    Seeley  WW.  The salience network: a neural system for perceiving and responding to homeostatic demands.   J Neurosci. 2019;39(50):9878-9882. doi:10.1523/JNEUROSCI.1138-17.2019PubMedGoogle ScholarCrossref
    47.
    Sripada  RK, King  AP, Welsh  RC,  et al.  Neural dysregulation in posttraumatic stress disorder: evidence for disrupted equilibrium between salience and default mode brain networks.   Psychosom Med. 2012;74(9):904-911. doi:10.1097/PSY.0b013e318273bf33PubMedGoogle ScholarCrossref
    48.
    van Marle  HJF, Hermans  EJ, Qin  S, Fernández  G.  Enhanced resting-state connectivity of amygdala in the immediate aftermath of acute psychological stress.   Neuroimage. 2010;53(1):348-354. doi:10.1016/j.neuroimage.2010.05.070PubMedGoogle ScholarCrossref
    49.
    American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
    50.
    Brooks Holliday  S, Dubowitz  T, Haas  A, Ghosh-Dastidar  B, DeSantis  A, Troxel  WM.  The association between discrimination and PTSD in African Americans: exploring the role of gender.   Ethn Health. 2020;25(5):717-731. doi:10.1080/13557858.2018.1444150PubMedGoogle ScholarCrossref
    51.
    Berger  M, Sarnyai  Z.  “More than skin deep”: stress neurobiology and mental health consequences of racial discrimination.   Stress. 2015;18(1):1-10. doi:10.3109/10253890.2014.989204PubMedGoogle ScholarCrossref
    52.
    Everson-Rose  SA, Lutsey  PL, Roetker  NS,  et al.  Perceived discrimination and incident cardiovascular events: the Multi-Ethnic Study of Atherosclerosis.   Am J Epidemiol. 2015;182(3):225-234. doi:10.1093/aje/kwv035PubMedGoogle ScholarCrossref
    53.
    Kessler  RC, Mickelson  KD, Williams  DR.  The prevalence, distribution, and mental health correlates of perceived discrimination in the United States.   J Health Soc Behav. 1999;40(3):208-230.PubMedGoogle ScholarCrossref
    54.
    Lewis  TT, Troxel  WM, Kravitz  HM, Bromberger  JT, Matthews  KA, Hall  MH.  Chronic exposure to everyday discrimination and sleep in a multiethnic sample of middle-aged women.   Health Psychol. 2013;32(7):810-819. doi:10.1037/a0029938PubMedGoogle ScholarCrossref
    55.
    Brondolo  E, Kelly  KP, Coakley  V,  et al.  The perceived ethnic discrimination questionnaire: development and preliminary validation of a community version.   J Appl Soc Psychol. 2005;35(2):335-365. doi:10.1111/j.1559-1816.2005.tb02124.xGoogle ScholarCrossref
    56.
    Gray  MJ, Litz  BT, Hsu  JL, Lombardo  TW.  Psychometric properties of the life events checklist.   Assessment. 2004;11(4):330-341. doi:10.1177/1073191104269954PubMedGoogle ScholarCrossref
    57.
    Weis  CN, Webb  EK, Stevens  SK, Larson  CL, deRoon-Cassini  TA.  Scoring the Life Events Checklist: comparison of three scoring methods.   Psychol Trauma. 2021. doi:10.1037/tra0001049PubMedGoogle Scholar
    58.
    Blevins  CA, Weathers  FW, Davis  MT, Witte  TK, Domino  JL.  The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation.   J Trauma Stress. 2015;28(6):489-498. doi:10.1002/jts.22059PubMedGoogle ScholarCrossref
    59.
    Whitfield-Gabrieli  S, Nieto-Castanon  A.  CONN: a functional connectivity toolbox for correlated and anticorrelated brain networks.   Brain Connect. 2012;2(3):125-141. doi:10.1089/brain.2012.0073PubMedGoogle ScholarCrossref
    60.
    Geng  H, Wang  Y, Gu  R,  et al.  Altered brain activation and connectivity during anticipation of uncertain threat in trait anxiety.   Hum Brain Mapp. 2018;39(10):3898-3914. doi:10.1002/hbm.24219PubMedGoogle ScholarCrossref
    61.
    Jenks  SK, Zhang  S, Li  CR, Hu  S.  Threat bias and resting state functional connectivity of the amygdala and bed nucleus stria terminalis.   J Psychiatr Res. 2020;122:54-63. doi:10.1016/j.jpsychires.2019.12.017PubMedGoogle ScholarCrossref
    62.
    Carter  RT, Johnson  VE, Roberson  K, Mazzula  SL, Kirkinis  K, Sant-Barket  S.  Race-based traumatic stress, racial identity statuses, and psychological functioning: An exploratory investigation.   Prof Psychol Res Pract. 2017;48(1):30-37. doi:10.1037/pro0000116Google ScholarCrossref
    63.
    Geng  H, Li  X, Chen  J, Li  X, Gu  R.  Decreased intra- and inter-salience network functional connectivity is related to trait anxiety in adolescents.   Front Behav Neurosci. 2016;9:350. doi:10.3389/fnbeh.2015.00350PubMedGoogle ScholarCrossref
    64.
    Nicholson  AA, Harricharan  S, Densmore  M,  et al.  Classifying heterogeneous presentations of PTSD via the default mode, central executive, and salience networks with machine learning.   Neuroimage Clin. 2020;27:102262. doi:10.1016/j.nicl.2020.102262PubMedGoogle Scholar
    65.
    Uddin  LQ.  Salience processing and insular cortical function and dysfunction.   Nat Rev Neurosci. 2015;16(1):55-61. doi:10.1038/nrn3857PubMedGoogle ScholarCrossref
    66.
    Heitmann  CY, Feldker  K, Neumeister  P,  et al.  Abnormal brain activation and connectivity to standardized disorder-related visual scenes in social anxiety disorder.   Hum Brain Mapp. 2016;37(4):1559-1572. doi:10.1002/hbm.23120PubMedGoogle ScholarCrossref
    67.
    Cavanna  AE, Trimble  MR.  The precuneus: a review of its functional anatomy and behavioural correlates.   Brain. 2006;129(Pt 3):564-583. doi:10.1093/brain/awl004PubMedGoogle Scholar
    68.
    Utevsky  AV, Smith  DV, Huettel  SA.  Precuneus is a functional core of the default-mode network.   J Neurosci. 2014;34(3):932-940. doi:10.1523/JNEUROSCI.4227-13.2014PubMedGoogle ScholarCrossref
    69.
    Hoppe  JM, Holmes  EA, Agren  T.  Exploring the neural basis of fear produced by mental imagery: imaginal exposure in individuals fearful of spiders.   Philos Trans R Soc Lond B Biol Sci. 2021;376(1817):20190690. doi:10.1098/rstb.2019.0690PubMedGoogle Scholar
    70.
    Cabanis  M, Pyka  M, Mehl  S,  et al.  The precuneus and the insula in self-attributional processes.   Cogn Affect Behav Neurosci. 2013;13(2):330-345. doi:10.3758/s13415-012-0143-5PubMedGoogle ScholarCrossref
    71.
    Craig  ADB.  How do you feel—now? the anterior insula and human awareness.   Nat Rev Neurosci. 2009;10(1):59-70. doi:10.1038/nrn2555PubMedGoogle ScholarCrossref
    72.
    Pieterse  AL, Carter  RT.  An exploratory investigation of the relationship between racism, racial identity, perceptions of health, and health locus of control among Black American women.   J Health Care Poor Underserved. 2010;21(1):334-348. doi:10.1353/hpu.0.0244PubMedGoogle ScholarCrossref
    73.
    Pieterse  AL, Carter  RT.  The role of racial identity in perceived racism and psychological stress among Black American adults: exploring traditional and alternative approaches.   J Appl Soc Psychol. 2010;40(5):1028-1053. doi:10.1111/j.1559-1816.2010.00609.xGoogle ScholarCrossref
    74.
    Sellers  RM, Shelton  JN.  The role of racial identity in perceived racial discrimination.   J Pers Soc Psychol. 2003;84(5):1079-1092. doi:10.1037/0022-3514.84.5.1079PubMedGoogle ScholarCrossref
    75.
    Mekawi  Y, Carter  S, Packard  G, Wallace  S, Michopoulos  V, Powers  A.  When (passive) acceptance hurts: race-based coping moderates the association between racial discrimination and mental health outcomes among Black Americans.   Psychol Trauma. Published online July 2021. doi:10.1037/tra0001077Google Scholar
    76.
    Akiki  TJ, Averill  CL, Abdallah  CG.  A network-based neurobiological model of PTSD: evidence from structural and functional neuroimaging studies.   Curr Psychiatry Rep. 2017;19(11):81. doi:10.1007/s11920-017-0840-4PubMedGoogle ScholarCrossref
    77.
    Etkin  A, Prater  KE, Hoeft  F, Menon  V, Schatzberg  AF.  Failure of anterior cingulate activation and connectivity with the amygdala during implicit regulation of emotional processing in generalized anxiety disorder.   Am J Psychiatry. 2010;167(5):545-554. doi:10.1176/appi.ajp.2009.09070931PubMedGoogle ScholarCrossref
    78.
    Feurer  C, Jimmy  J, Chang  F,  et al.  Resting state functional connectivity correlates of rumination and worry in internalizing psychopathologies.   Depress Anxiety. 2021;38(5):488-497. doi:10.1002/da.23142PubMedGoogle ScholarCrossref
    79.
    Kraynak  TE, Marsland  AL, Wager  TD, Gianaros  PJ.  Functional neuroanatomy of peripheral inflammatory physiology: a meta-analysis of human neuroimaging studies.   Neurosci Biobehav Rev. 2018;94:76-92. doi:10.1016/j.neubiorev.2018.07.013PubMedGoogle ScholarCrossref
    80.
    Brown  VM, LaBar  KS, Haswell  CC, Gold  AL, McCarthy  G, Morey  RA; Mid-Atlantic MIRECC Workgroup.  Altered resting-state functional connectivity of basolateral and centromedial amygdala complexes in posttraumatic stress disorder.   Neuropsychopharmacology. 2014;39(2):351-359. doi:10.1038/npp.2013.197PubMedGoogle ScholarCrossref
    81.
    Morey  RA, Dunsmoor  JE, Haswell  CC,  et al; VA Mid-Atlantic MIRECC Workgroup.  Fear learning circuitry is biased toward generalization of fear associations in posttraumatic stress disorder.   Transl Psychiatry. 2015;5(12):e700-e700. doi:10.1038/tp.2015.196PubMedGoogle ScholarCrossref
    82.
    Bradley  B, DeFife  JA, Guarnaccia  C,  et al.  Emotion dysregulation and negative affect: association with psychiatric symptoms.   J Clin Psychiatry. 2011;72(5):685-691. doi:10.4088/JCP.10m06409bluPubMedGoogle ScholarCrossref
    83.
    Clark  R, Anderson  NB, Clark  VR, Williams  DR.  Racism as a stressor for African Americans: a biopsychosocial model.   Am Psychol. 1999;54(10):805-816. doi:10.1037/0003-066X.54.10.805PubMedGoogle ScholarCrossref
    84.
    Carter  RT.  Racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress.   Couns Psychol. 2007;35(1):13-105. doi:10.1177/0011000006292033Google ScholarCrossref
    85.
    Polanco-Roman  L, Danies  A, Anglin  DM.  Racial discrimination as race-based trauma, coping strategies, and dissociative symptoms among emerging adults.   Psychol Trauma. 2016;8(5):609-617. doi:10.1037/tra0000125PubMedGoogle ScholarCrossref
    86.
    Harnett  NG, Ressler  KJ.  Structural racism as a proximal cause for race-related differences in psychiatric disorders.   Am J Psychiatry. 2021;178(7):579-581. doi:10.1176/appi.ajp.2021.21050486PubMedGoogle ScholarCrossref
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