# A neurocognitive account of complex PTSD: self-modelling, affective dysregulation, and implications for MDMA-assisted and targeted psychotherapies

## TL;DR

This paper proposes a new neurocognitive model for complex PTSD, focusing on how the brain processes emotions and self-identity, and suggests that MDMA-assisted therapy could help treat it.

## Contribution

The paper introduces a novel neurocognitive framework for C-PTSD based on predictive processing and insula function, and explores how MDMA-assisted therapy may recalibrate self-referential and emotional processes.

## Key findings

- The insula is central to emotional awareness and self-referential processing in C-PTSD.
- MDMA-assisted therapy may transiently modulate affective salience and self-referential cognition.
- Disturbances in self-organization in C-PTSD arise from maladaptive predictive regulation.

## Abstract

Background: Complex post-traumatic stress disorder (C-PTSD) is a trauma-related condition characterized by pervasive disturbances in affect regulation, self-concept, and interpersonal functioning that extend beyond the symptom profile of post-traumatic stress disorder (PTSD). While neurobiological studies have implicated limbic, salience, and prefrontal systems in C-PTSD, mechanistic accounts linking these findings to disturbances in self-organization and treatment-relevant processes remain underdeveloped.

Objective: This narrative review develops a hypothesis-generating neurocognitive account of C-PTSD grounded in predictive processing and self-modelling frameworks, with particular emphasis on affective dysregulation and disturbances in self-organization.

Method: We synthesize clinical, neurobiological, and theoretical evidence to conceptualize PTSD and C-PTSD along a continuum of regulatory stability, and to advance a conceptual model highlighting the role of insula-mediated self-modelling processes. Within this framework, we examine 3,4-methylenedioxymethamphetamine (MDMA)-assisted psychotherapy, as one illustrative intervention that may transiently modulate affective salience, interpersonal trust, and self-referential cognition.

Results: The proposed model integrates converging evidence linking insular function to interoception, affective experience, salience processing, and self-referential cognition, and situates disturbances in self-organization as emerging from maladaptive predictive regulation under conditions of prolonged interpersonal adversity. This framework helps reconcile overlapping neurobiological findings across PTSD and C-PTSD while accounting for differences in symptom generalization, relational threat processing, and affective stability.

Conclusions: This review delineates a set of testable, mechanistically grounded hypotheses concerning the role of self-modelling processes in C-PTSD. These hypotheses generate specific predictions for future empirical work and inform the design and evaluation of pharmacological and psychotherapeutic interventions that aim to recalibrate affective regulation and self-referential processing in complex trauma presentations.

Complex post-traumatic stress disorder (C-PTSD) arises from prolonged and/or severe trauma and is marked by difficulties with self-identity, emotional regulation, and interpersonal relationships.Our proposed model is based in active inference and highlights the insula, a key brain region for emotional awareness, as central to understanding how C-PTSD disrupts the sense of self.We propose that MDMA-assisted therapy may help rebuild a stable sense of self and improve emotional regulation, offering new hope where traditional treatments fall short.

Complex post-traumatic stress disorder (C-PTSD) arises from prolonged and/or severe trauma and is marked by difficulties with self-identity, emotional regulation, and interpersonal relationships.

Our proposed model is based in active inference and highlights the insula, a key brain region for emotional awareness, as central to understanding how C-PTSD disrupts the sense of self.

We propose that MDMA-assisted therapy may help rebuild a stable sense of self and improve emotional regulation, offering new hope where traditional treatments fall short.