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Mallya S, Sutherland J, Pongracic S, Mainland B, Ornstein TJ. The manifestation of anxiety disorders after traumatic brain injury: a review. J Neurotrauma 2015; 32:411-21. [PMID: 25227240 DOI: 10.1089/neu.2014.3504] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The development of anxiety disorders after a traumatic brain injury (TBI) is a strong predictor of social, personal, and work dysfunction; nevertheless, the emergence of anxiety has been largely unexplored and poorly understood in the context of TBI. This article provides an overview of the limited published research to date on anxiety disorders that are known to develop after TBI, including post-traumatic stress disorder, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, specific phobia, and social anxiety disorder. This review also examines diagnostic criteria, the epidemiology of each disorder, and the factors that influence the expression of these conditions, including injury-related and psychosocial variables. Putative neural correlates will be reviewed where known. A discussion of current treatment options and avenues for further research are explored.
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Motzkin JC, Koenigs MR. Post-traumatic stress disorder and traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 128:633-648. [PMID: 25701911 DOI: 10.1016/b978-0-444-63521-1.00039-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Disentangling the effects of "organic" neurologic damage and psychological distress after a traumatic brain injury poses a significant challenge to researchers and clinicians. Establishing a link between traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) has been particularly contentious, reflecting difficulties in establishing a unique diagnosis for conditions with overlapping and sometimes contradictory symptom profiles. However, each disorder is linked to a variety of adverse health outcomes, underscoring the need to better understand how neurologic and psychiatric risk factors interact following trauma. Here, we present data showing that individuals with a TBI are more likely to develop PTSD, and that individuals with PTSD are more likely to develop persistent cognitive sequelae related to TBI. Further, we describe neurobiological models of PTSD, highlighting how patterns of neurologic damage typical in TBI may promote or protect against the development of PTSD in brain-injured populations. These data highlight the unique course of PTSD following a TBI and have important diagnostic, prognostic, and treatment implications for individuals with a dual diagnosis.
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Affiliation(s)
- Julian C Motzkin
- Neuroscience Training Program, University of Wisconsin - Madison, Madison, WI, USA; Medical Scientist Training Program, University of Wisconsin - Madison, Madison, WI, USA
| | - Michael R Koenigs
- Department of Psychiatry, University of Wisconsin - Madison, Madison, WI, USA.
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Bierer LM, Ivanov I, Carpenter DM, Wong EW, Golier JA, Tang CY, Yehuda R. White matter abnormalities in Gulf War veterans with posttraumatic stress disorder: A pilot study. Psychoneuroendocrinology 2015; 51:567-76. [PMID: 25465169 DOI: 10.1016/j.psyneuen.2014.11.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 10/01/2014] [Accepted: 11/10/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Gulf War veterans were exposed to environmental toxins not present in other combat theaters resulting in a unique biological signature that only partially resembles that seen in other combat veterans with PTSD. Thus it is important to determine if brain abnormalities seen in non-Gulf War veterans with PTSD are also present in Gulf War veterans. In this pilot study, diffusion tensor imaging (DTI) tractography was used to assess the ultra-structural integrity of fronto-limbic white matter connections in Gulf War veterans with and without PTSD. The effects of chronic multisymptom illness on DTI measures was also evaluated. METHODS Subjects were 20 previously studied Gulf War veterans on whom MRIs had been obtained. Mean diffusivity (MD) and fractional anisotropy (FA) were determined for left and right cingulum bundle by DTI tractography and compared in separate analyses for 12 veterans with, and 8 without PTSD. The effect of chronic multisymptom illness and it's interaction with PTSD, were similarly investigated using multivariate ACOVA. Partial correlations were used to test the associations of both DTI indices with PTSD severity and plasma cortisol, controlling for whole brain volume. RESULTS Significantly lower MD was demonstrated in the right cingulum bundle among Gulf War veterans with PTSD. There were no significant differences in MD or FA in the left cingulum bundle. The presence of chronic multisymptom illness significantly attenuated the PTSD associated decrement in right cingulum MD. Clinician and self-rated PTSD symptom severity scores were significantly associated with reduced MD and increased FA in the right cingulum. Similar associations were observed for 8am plasma cortisol in a subset of participants. CONCLUSIONS The preliminary findings indicate increased structural integrity - supporting enhanced connectivity - between right amygdala and anterior cingulate cortex in PTSD. This effect was strongest among Gulf War veterans without chronic multisymptom illness. The association of both MD and FA in the right cingulum with PTSD severity, and with heightened glucocorticoid responsivity, suggests that these DTI findings are a reflection of current PTSD illness expression. Although based on a small sample, these microstructural observations are consistent with a functional model suggesting increased amygdala responsivity in association with anterior cingulate modulation in PTSD.
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Affiliation(s)
- Linda M Bierer
- Department of Psychiatry, Traumatic Stress Studies Division, Icahn School of Medicine at Mount Sinai, United States; Traumatic Stress Studies Division, James J. Peters VA Medical Center, United States.
| | - Iliyan Ivanov
- Department of Psychiatry, Traumatic Stress Studies Division, Icahn School of Medicine at Mount Sinai, United States; Traumatic Stress Studies Division, James J. Peters VA Medical Center, United States
| | - David M Carpenter
- Department of Radiology, Icahn School of Medicine at Mount Sinai, United States
| | - Edmund W Wong
- Department of Radiology, Icahn School of Medicine at Mount Sinai, United States
| | - Julia A Golier
- Department of Psychiatry, Traumatic Stress Studies Division, Icahn School of Medicine at Mount Sinai, United States; Traumatic Stress Studies Division, James J. Peters VA Medical Center, United States
| | - Cheuk Y Tang
- Department of Radiology, Icahn School of Medicine at Mount Sinai, United States
| | - Rachel Yehuda
- Department of Psychiatry, Traumatic Stress Studies Division, Icahn School of Medicine at Mount Sinai, United States; Traumatic Stress Studies Division, James J. Peters VA Medical Center, United States
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Irimia A, Van Horn JD. Functional neuroimaging of traumatic brain injury: advances and clinical utility. Neuropsychiatr Dis Treat 2015; 11:2355-65. [PMID: 26396520 PMCID: PMC4576900 DOI: 10.2147/ndt.s79174] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Functional deficits due to traumatic brain injury (TBI) can have significant and enduring consequences upon patients' life quality and expectancy. Although functional neuroimaging is essential for understanding TBI pathophysiology, an insufficient amount of effort has been dedicated to the task of translating functional neuroimaging findings into information with clinical utility. The purpose of this review is to summarize the use of functional neuroimaging techniques - especially functional magnetic resonance imaging, diffusion tensor imaging, positron emission tomography, magnetic resonance spectroscopy, and electroencephalography - for advancing current knowledge of TBI-related brain dysfunction and for improving the rehabilitation of TBI patients. We focus on seven core areas of functional deficits, namely consciousness, motor function, attention, memory, higher cognition, personality, and affect, and, for each of these, we summarize recent findings from neuroimaging studies which have provided substantial insight into brain function changes due to TBI. Recommendations are also provided to aid in setting the direction of future neuroimaging research and for understanding brain function changes after TBI.
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Affiliation(s)
- Andrei Irimia
- USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - John Darrell Van Horn
- USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Davenport ND, Lim KO, Sponheim SR. White matter abnormalities associated with military PTSD in the context of blast TBI. Hum Brain Mapp 2014; 36:1053-64. [PMID: 25387950 DOI: 10.1002/hbm.22685] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 10/07/2014] [Accepted: 10/29/2014] [Indexed: 12/18/2022] Open
Abstract
Mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) are common among recent military veterans and involve substantial symptom overlap, making clinical distinction and effective intervention difficult. Emerging evidence of cerebral white matter abnormalities associated with mTBI may provide a biological measure to inform diagnosis and treatment, but the potentially confounding effects between PTSD and mTBI have largely gone unexamined. We collected diffusion imaging data from 133 recently-deployed American service members who developed PTSD and/or sustained mTBI, or had neither condition. Effects of PTSD and mTBI on traditional tensor-based measures of cerebral white matter integrity (fractional anisotropy [FA] and mean diffusivity [MD]) were compared in anatomical regions of interest and individual voxels throughout the brain. Generalized FA (GFA), which allows for multiple fiber orientations per voxel, was also included to improve sensitivity in white matter areas containing crossing or diverging axon bundles. PTSD was consistently associated with high GFA in select brain regions, greater likelihood of regions and voxels with abnormally low MD, and a greater number of voxels with abnormally high FA, while mTBI was associated with fewer high MD regions. Overall, PTSD was associated with more restricted diffusion (low MD) and greater anisotropy (high GFA) in regions of crossing/diverging fibers poorly characterized by a single tensor (FA), suggesting that interstitial fibers may be involved. Contrary to earlier results in a sample without PTSD, mTBI was not associated with anisotropy abnormalities, perhaps indicating the cooccurrence of PTSD and mTBI requires special consideration with regard to structural brain connectivity.
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Affiliation(s)
- Nicholas D Davenport
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
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Neuroimaging in social anxiety disorder—A meta-analytic review resulting in a new neurofunctional model. Neurosci Biobehav Rev 2014; 47:260-80. [PMID: 25124509 DOI: 10.1016/j.neubiorev.2014.08.003] [Citation(s) in RCA: 237] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 06/26/2014] [Accepted: 08/01/2014] [Indexed: 01/30/2023]
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Shu IW, Onton JA, O'Connell RM, Simmons AN, Matthews SC. Combat veterans with comorbid PTSD and mild TBI exhibit a greater inhibitory processing ERP from the dorsal anterior cingulate cortex. Psychiatry Res 2014; 224:58-66. [PMID: 25150386 DOI: 10.1016/j.pscychresns.2014.07.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 05/10/2014] [Accepted: 07/31/2014] [Indexed: 10/24/2022]
Abstract
Posttraumatic stress disorder (PTSD) is common among combat personnel with mild traumatic brain injury (mTBI). While patients with either PTSD or mTBI share abnormal activation of multiple frontal brain areas, anterior cingulate cortex (ACC) activity during inhibitory processing may be particularly affected by PTSD. To further test this hypothesis, we recorded electroencephalography from 32 combat veterans with mTBI-17 of whom were also comorbid for PTSD (mTBI+PTSD) and 15 without PTSD (mTBI-only). Subjects performed the Stop Task, a validated inhibitory control task requiring inhibition of initiated motor responses. We observed a larger inhibitory processing eventrelated potential (ERP) in veterans with mTBI+PTSD, including greater N200 negativity. Furthermore, greater N200 negativity correlated with greater PTSD severity. This correlation was most dependent on contributions from the dorsal ACC. Support vector machine analysis demonstrated that N200 and P300 amplitudes objectively classified veterans into mTBI-only or mTBI+PTSD groups with 79.4% accuracy. Our results support a model where, in combat veterans with mTBI, larger ERPs from cingulate areas are associated with greater PTSD severity and likely related to difficulty controlling ongoing brain processes, including trauma-related thoughts and feelings.
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Affiliation(s)
- I-Wei Shu
- VISN-22 Mental Illness, Research, Education and Clinical Center, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, United States; Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, United States.
| | - Julie A Onton
- Naval Health Research Center, 140 Sylvester Road, Department162, San Diego, CA 92106, United States; Institute for Neural Computation, University of California San Diego, 9500 Gilman Drive, #0523, La Jolla, CA 92093, United States
| | - Ryan M O'Connell
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, United States; Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, #9116A, La Jolla, CA 92037, United States
| | - Alan N Simmons
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, United States; Veterans Affairs San Diego Healthcare System Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, United States
| | - Scott C Matthews
- VISN-22 Mental Illness, Research, Education and Clinical Center, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, United States; Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, United States; Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, #9116A, La Jolla, CA 92037, United States; Veterans Affairs San Diego Healthcare System Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, United States
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Rabinak CA, MacNamara A, Kennedy AE, Angstadt M, Stein MB, Liberzon I, Phan KL. Focal and aberrant prefrontal engagement during emotion regulation in veterans with posttraumatic stress disorder. Depress Anxiety 2014; 31:851-61. [PMID: 24677490 PMCID: PMC4141895 DOI: 10.1002/da.22243] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/17/2013] [Accepted: 01/03/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Collectively, functional neuroimaging studies implicate frontal-limbic dysfunction in the pathophysiology of posttraumatic stress disorder (PTSD), as reflected by altered amygdala reactivity and deficient prefrontal responses. These neural patterns are often elicited by social signals of threat (fearful/angry faces) and traumatic reminders (combat sounds, script-driven imagery). Although PTSD can be conceptualized as a disorder of emotion dysregulation, few studies to date have directly investigated the neural correlates of volitional attempts at regulating negative affect in PTSD. METHODS Using functional magnetic resonance imaging and a well-validated task involving cognitive regulation of negative affect via reappraisal and known to engage prefrontal cortical regions, the authors compared brain activation in veterans with PTSD (n = 21) and without PTSD (n = 21, combat-exposed controls/CEC), following military combat trauma experience during deployments in Afghanistan or Iraq. The primary outcome measure was brain activation during cognitive reappraisal (i.e., decrease negative affect) as compared to passive viewing (i.e., maintain negative affect) of emotionally evocative content of aversive images RESULTS The subjects in both groups reported similar successful reduction in negative affect following reappraisal. The PTSD group engaged the dorsolateral prefrontal cortex (dlPFC) during cognitive reappraisal, albeit to a lesser extent than the CEC group. Although the amygdala was engaged in both groups during passive viewing of aversive images, neither group exhibited attenuation of amygdala activation during cognitive reappraisal. CONCLUSIONS Veterans with combat-related PTSD showed less recruitment of the dlPFC involved in cognitive reappraisal, suggesting focal and aberrant neural activation during volitional, self-regulation of negative affective states.
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Affiliation(s)
- Christine A. Rabinak
- Mental Health Service, Veteran’s Administration Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Annmarie MacNamara
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL
| | - Amy E. Kennedy
- Mental Health Service, Veteran’s Administration Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL
- Mental Health Service Line, Jesse Brown VA Medical Center, Chicago, IL
| | - Mike Angstadt
- Mental Health Service, Veteran’s Administration Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Murray B. Stein
- Department of Psychiatry, University of California San Diego, San Diego, CA
| | - Israel Liberzon
- Mental Health Service, Veteran’s Administration Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - K. Luan Phan
- Mental Health Service, Veteran’s Administration Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Department of Psychiatry, University of Illinois at Chicago, Chicago, IL
- Mental Health Service Line, Jesse Brown VA Medical Center, Chicago, IL
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Reduction of anterior cingulate in adults with urban violence-related PTSD. J Affect Disord 2014; 168:13-20. [PMID: 25033473 DOI: 10.1016/j.jad.2014.06.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 06/24/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND To evaluate differences in limbic structure volume of subjects exposed to urban violence during adulthood, between those who developed posttraumatic stress disorder (with PTSD) and resilient matched controls (without PTSD). METHODS Limbic volumetric measures of 32 subjects with PTSD and 32 subjects without PTSD who underwent brain MRI were analyzed in an epidemiological study in the city of Sao Paulo. The hippocampus, amygdala, cingulate, and parahipocampal gyri volumes were estimated using FreeSurfer software. We also investigated the association between limbic volumetric measurements, symptom´s severity, and early life stress history (measure by Early Trauma Inventory - ETI). RESULTS Subjects with PTSD presented reduced volume of the right rostral part of the anterior cingulate, compared to subjects without PTSD, after controlling for intracranial volume, ETI, and depressive symptoms. Subjects with PTSD presented larger bilateral hippocampus and right amygdala, but secondary to the higher ETI. In PTSD group there was a positive correlation between ETI with bilateral hippocampus, bilateral amygdala, and left parahippocampus. LIMITATIONS First, the cross-sectional study design precludes causal interpretation of limbic structure reduction in PTSD, consequence of PTSD, or other life events. Finally, since the sample size was not sufficiently large, we could not observe whether or not limbic structure volume could be related to the type of trauma. CONCLUSIONS The present study provides evidence of a reduced anterior cingulate volume in subjects with PTSD than in resilient subjects exposed to urban violence. Enlargement of hippocampus and amygdala volume was observed in subjects with PTSD, however secondary to early trauma experience.
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Taylor CT, Aupperle RL, Flagan T, Simmons AN, Amir N, Stein MB, Paulus MP. Neural correlates of a computerized attention modification program in anxious subjects. Soc Cogn Affect Neurosci 2014; 9:1379-87. [PMID: 23934417 PMCID: PMC4158378 DOI: 10.1093/scan/nst128] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 06/06/2013] [Accepted: 08/06/2013] [Indexed: 12/18/2022] Open
Abstract
Computerized attention modification is a relatively new and empirically validated treatment approach for different types of anxiety disorders. However, its neural basis and processes involved are poorly understood. This study examined the effect of a one-time application of an attention modification program (AMP) on neural substrates underlying emotion processing in individuals with high social anxiety. Fourteen individuals with elevated social anxiety symptoms completed an emotional face processing task during functional magnetic resonance imaging before and after AMP, and were subsequently exposed to a laboratory stressor. Results revealed the following: First, there was attenuated activation from pre- to post-AMP in the bilateral amygdala, bilateral insula and subgenual anterior cingulate cortex. Second, post-AMP, individuals exhibited increased activation in several regions of the prefrontal cortex (PFC). Third, those individuals with greater enhancement of ventromedial PFC activation after AMP showed diminished attentional allocation for threat and attenuated anxiety reactivity to the stressor. We conclude that AMP exerts effects that are similar to those previously reported for standard anxiolytics; however, it also appears to foster deployment of top-down brain processes aimed to regulate anxiety.
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Affiliation(s)
- Charles T Taylor
- San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
| | - Robin L Aupperle
- San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
| | - Taru Flagan
- San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
| | - Alan N Simmons
- San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
| | - Nader Amir
- San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
| | - Murray B Stein
- San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
| | - Martin P Paulus
- San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States San Diego State University, Center for Treating and Understanding Anxiety, Department of Psychology, 6386 Alvarado Court, Suite 301, San Diego, CA 92120, Department of Psychiatry, University of California, San Diego, 8939 Villa La Jolla Drive, Suite 200, San Diego, CA 92037, Department of Psychology, University of Missouri at Kansas City, 64110, Kansas City, Department of Psychology, University of Texas at Austin, 78712, Austin and Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, San Diego, CA 92161, United States
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Reduced amygdala volume is associated with deficits in inhibitory control: a voxel- and surface-based morphometric analysis of comorbid PTSD/mild TBI. BIOMED RESEARCH INTERNATIONAL 2014; 2014:691505. [PMID: 24724093 PMCID: PMC3958771 DOI: 10.1155/2014/691505] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 01/11/2014] [Indexed: 11/17/2022]
Abstract
A significant portion of previously deployed combat Veterans from Operation Enduring Freedom and Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) are affected by comorbid posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). Despite this fact, neuroimaging studies investigating the neural correlates of cognitive dysfunction within this population are almost nonexistent, with the exception of research examining the neural correlates of diagnostic PTSD or TBI. The current study used both voxel-based and surface-based morphometry to determine whether comorbid PTSD/mTBI is characterized by altered brain structure in the same regions as observed in singular diagnostic PTSD or TBI. Furthermore, we assessed whether alterations in brain structures in these regions were associated with behavioral measures related to inhibitory control, as assessed by the Go/No-go task, self-reports of impulsivity, and/or PTSD or mTBI symptoms. Results indicate volumetric reductions in the bilateral anterior amygdala in our comorbid PTSD/mTBI sample as compared to a control sample of OEF/OIF Veterans with no history of mTBI and/or PTSD. Moreover, increased volume reduction in the amygdala predicted poorer inhibitory control as measured by performance on the Go/No-go task, increased self-reported impulsivity, and greater symptoms associated with PTSD. These findings suggest that alterations in brain anatomy in OEF/OIF/OND Veterans with comorbid PTSD/mTBI are associated with both cognitive deficits and trauma symptoms related to PTSD.
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Bahraini NH, Breshears RE, Hernández TD, Schneider AL, Forster JE, Brenner LA. Traumatic brain injury and posttraumatic stress disorder. Psychiatr Clin North Am 2014; 37:55-75. [PMID: 24529423 DOI: 10.1016/j.psc.2013.11.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Given the upsurge of research in posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), much of which has focused on military samples who served in Iraq and Afghanistan, the purpose of this article is to review the literature published after September 11th, 2001 that addresses the epidemiology, pathophysiology, evaluation, and treatment of PTSD in the context of TBI.
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Affiliation(s)
- Nazanin H Bahraini
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA; Department of Psychiatry, School of Medicine, University of Colorado, 13001 East 17th Place, Aurora, CO 80045, USA.
| | - Ryan E Breshears
- Wellstar Health System, Psychological Services, 55 Whitcher Street, Suite 420, Marietta, GA 30060, USA; Department of Counseling and Human Development, University of Georgia, 402 Aderhold Hall, Athens, GA 30602, USA
| | - Theresa D Hernández
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA; Department of Psychology and Neuroscience, University of Colorado, 1905 Colorado Avenue, Boulder, CO 80309, USA
| | - Alexandra L Schneider
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA
| | - Jeri E Forster
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA; Department of Biostatistics & Informatics, Colorado School of Public Health, University of Colorado Denver, 13001 E. 17th Place, Aurora, CO 80045, USA
| | - Lisa A Brenner
- Department of Veterans Affairs, Veteran Integrated Service Network (VISN) 19 Mental Illness Research Education and Clinical Center (MIRECC), 1055 Clermont Street, Denver, CO 80220, USA; Department of Psychiatry, School of Medicine, University of Colorado, 13001 East 17th Place, Aurora, CO 80045, USA; Department of Neurology, School of Medicine, University of Colorado, 13001 E. 17th Place, Aurora, CO 80045, USA; Department of Physical Medicine and Rehabilitation, School of Medicine, University of Colorado, 13001 E. 17th Place, Aurora, CO 80045, USA
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Shu IW, Onton JA, Prabhakar N, O'Connell RM, Simmons AN, Matthews SC. Combat veterans with PTSD after mild TBI exhibit greater ERPs from posterior-medial cortical areas while appraising facial features. J Affect Disord 2014; 155:234-40. [PMID: 24342149 DOI: 10.1016/j.jad.2013.06.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
Abstract
Posttraumatic stress disorder (PTSD) worsens prognosis following mild traumatic brain injury (mTBI). Combat personnel with histories of mTBI exhibit abnormal activation of distributed brain networks-including emotion processing and default mode networks. How developing PTSD further affects these abnormalities has not been directly examined. We recorded electroencephalography in combat veterans with histories of mTBI, but without active PTSD (mTBI only, n=16) and combat veterans who developed PTSD after mTBI (mTBI+PTSD, n=16)-during the Reading the Mind in the Eyes Test (RMET), a validated test of empathy requiring emotional appraisal of facial features. Task-related event related potentials (ERPs) were identified, decomposed using independent component analysis (ICA) and localized anatomically using dipole modeling. We observed larger emotional face processing ERPs in veterans with mTBI+PTSD, including greater N300 negativity. Furthermore, greater N300 negativity correlated with greater PTSD severity, especially avoidance/numbing and hyperarousal symptom clusters. This correlation was dependent on contributions from the precuneus and posterior cingulate cortex (PCC). Our results support a model where, in combat veterans with histories of mTBI, larger ERPs from over-active posterior-medial cortical areas may be specific to PTSD, and is likely related to negative self-referential activity.
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Affiliation(s)
- I-Wei Shu
- VISN-22 Mental Illness, Research, Education and Clinical Center, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, USA; Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, USA.
| | - Julie A Onton
- Naval Health Research Center, 140 Sylvester Rd, Department 162, San Diego, CA 92106, USA
| | - Nitin Prabhakar
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive #9116A, La Jolla, CA 92037, USA
| | - Ryan M O'Connell
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, USA; Department of Psychiatry, University of California San Diego, 9500 Gilman Drive #9116A, La Jolla, CA 92037, USA
| | - Alan N Simmons
- Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, USA; Veterans Affairs San Diego Healthcare System Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, USA
| | - Scott C Matthews
- VISN-22 Mental Illness, Research, Education and Clinical Center, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, USA; Veterans Affairs San Diego Healthcare System Center of Excellence for Stress and Mental Health, 3350 La Jolla Village Drive, #116A, San Diego, CA 92161, USA
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Strigo IA, Spadoni AD, Lohr J, Simmons AN. Too hard to control: compromised pain anticipation and modulation in mild traumatic brain injury. Transl Psychiatry 2014; 4:e340. [PMID: 24399043 PMCID: PMC3905226 DOI: 10.1038/tp.2013.116] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 10/28/2013] [Accepted: 10/29/2013] [Indexed: 11/09/2022] Open
Abstract
Mild traumatic brain injury (MTBI) is a vulnerability factor for the development of pain-related conditions above and beyond those related to comorbid traumatic and emotional symptoms. We acquired functional magnetic resonance imaging (fMRI) on a validated pain anticipation task and tested the hypotheses that individuals with a reported history of MTBI, compared with healthy comparison subjects, would show increased brain response to pain anticipation and ineffective pain modulation after controlling for psychiatric symptoms. Eighteen male subjects with a reported history of blast-related MTBI related to combat, and eighteen healthy male subjects with no reported history of MTBI (healthy controls) underwent fMRI during an event-related experimental pain paradigm with cued high or low intensity painful heat stimuli. No subjects in either group met diagnostic criteria for current mood or anxiety disorder. We found that relative to healthy comparison subjects, after controlling for traumatic and depressive symptoms, participants with a reported history of MTBI showed significantly stronger activations within midbrain periaqueductual grey (PAG), right dorsolateral prefrontal cortex and cuneus during pain anticipation. Furthermore, we found that brain injury was a significant moderator of the relationship between anticipatory PAG activation and reported subjective pain. Our results suggest that a potentially disrupted neurocognitive anticipatory network may result from damage to the endogenous pain modulatory system and underlie difficulties with regulatory pain processing following MTBI. In other words, our findings are consistent with a notion that brain injury makes it more difficult to control acute pain. Understanding these mechanisms of dysfunctional acute pain processing following MTBI may help shed light on the underlying causes of increased vulnerability for the development of pain-related conditions in this population.
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Affiliation(s)
- I A Strigo
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,University of California San Diego, La Jolla, CA, USA,BioCircuits Institute, University of California San Diego, La Jolla, CA, USA,Department of Psychiatry, University of California San Diego, 3350 La Jolla Village Dr, Building 13, MC 9151-B, La Jolla, CA 92161, USA. E-mail:
| | - A D Spadoni
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,University of California San Diego, La Jolla, CA, USA
| | - J Lohr
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,University of California San Diego, La Jolla, CA, USA
| | - A N Simmons
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,University of California San Diego, La Jolla, CA, USA
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Genovese R, Simmons L, Ahlers S, Maudlin-Jeronimo E, Dave J, Boutte A. Effects of mild TBI from repeated blast overpressure on the expression and extinction of conditioned fear in rats. Neuroscience 2013; 254:120-9. [DOI: 10.1016/j.neuroscience.2013.09.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 09/09/2013] [Accepted: 09/10/2013] [Indexed: 10/26/2022]
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Fischer BL, Parsons M, Durgerian S, Reece C, Mourany L, Lowe MJ, Beall EB, Koenig KA, Jones SE, Newsome MR, Scheibel RS, Wilde EA, Troyanskaya M, Merkley TL, Walker M, Levin HS, Rao SM. Neural activation during response inhibition differentiates blast from mechanical causes of mild to moderate traumatic brain injury. J Neurotrauma 2013; 31:169-79. [PMID: 24020449 DOI: 10.1089/neu.2013.2877] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Military personnel involved in Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) commonly experience blast-induced mild to moderate traumatic brain injury (TBI). In this study, we used task-activated functional MRI (fMRI) to determine if blast-related TBI has a differential impact on brain activation in comparison with TBI caused primarily by mechanical forces in civilian settings. Four groups participated: (1) blast-related military TBI (milTBI; n=21); (2) military controls (milCON; n=22); (3) non-blast civilian TBI (civTBI; n=21); and (4) civilian controls (civCON; n=23) with orthopedic injuries. Mild to moderate TBI (MTBI) occurred 1 to 6 years before enrollment. Participants completed the Stop Signal Task (SST), a measure of inhibitory control, while undergoing fMRI. Brain activation was evaluated with 2 (mil, civ)×2 (TBI, CON) analyses of variance, corrected for multiple comparisons. During correct inhibitions, fMRI activation was lower in the TBI than CON subjects in regions commonly associated with inhibitory control and the default mode network. In contrast, inhibitory failures showed significant interaction effects in the bilateral inferior temporal, left superior temporal, caudate, and cerebellar regions. Specifically, the milTBI group demonstrated more activation than the milCON group when failing to inhibit; in contrast, the civTBI group exhibited less activation than the civCON group. Covariance analyses controlling for the effects of education and self-reported psychological symptoms did not alter the brain activation findings. These results indicate that the chronic effects of TBI are associated with abnormal brain activation during successful response inhibition. During failed inhibition, the pattern of activation distinguished military from civilian TBI, suggesting that blast-related TBI has a unique effect on brain function that can be distinguished from TBI resulting from mechanical forces associated with sports or motor vehicle accidents. The implications of these findings for diagnosis and treatment of TBI are discussed.
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Affiliation(s)
- Barbara L Fischer
- 1 Geriatric Research Education and Clinical Center (GRECC), Wm. S. Middleton Memorial Veterans Affairs Hospital , Madison, Wisconsin
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MacNamara A, Post D, Kennedy AE, Rabinak CA, Phan KL. Electrocortical processing of social signals of threat in combat-related post-traumatic stress disorder. Biol Psychol 2013; 94:441-9. [PMID: 24025760 DOI: 10.1016/j.biopsycho.2013.08.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 07/10/2013] [Accepted: 08/30/2013] [Indexed: 10/26/2022]
Abstract
Post-traumatic stress disorder (PTSD) is characterized by avoidance, emotional numbing, increased arousal and hypervigilance for threat following a trauma. Thirty-three veterans (19 with PTSD, 14 without PTSD) who had experienced combat trauma while on deployment in Iraq and/or Afghanistan completed an emotional faces matching task while electroencephalography was recorded. Vertex positive potentials (VPPs) elicited by happy, angry and fearful faces were smaller in veterans with versus without PTSD. In addition, veterans with PTSD exhibited smaller late positive potentials (LPPs) to angry faces and greater intrusive symptoms predicted smaller LPPs to fearful faces in the PTSD group. Veterans with PTSD were also less accurate at identifying angry faces, and accuracy decreased in the PTSD group as hyperarousal symptoms increased. These findings show reduced early processing of emotional faces, irrespective of valence, and blunted prolonged processing of social signals of threat in conjunction with impaired perception for angry faces in PTSD.
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Affiliation(s)
- Annmarie MacNamara
- Department of Psychiatry, University of Illinois at Chicago, United States.
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68
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Simmons AN, Flagan TM, Wittmann M, Strigo IA, Matthews SC, Donovan H, Lohr JB, Paulus MP. The effects of temporal unpredictability in anticipation of negative events in combat veterans with PTSD. J Affect Disord 2013; 146:426-32. [PMID: 22910447 DOI: 10.1016/j.jad.2012.08.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 08/02/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exposure to psychological stress during combat can lead to posttraumatic stress disorder (PTSD). Anticipation of aversive events is often associated with an intense emotional state in individuals with PTSD. Both the valence (i.e., positive or negative) of the anticipated event and the degree of temporal predictability (i.e., one's ability to predict when an event will occur) have profound effects on an individual's emotional experience. This investigation tested the hypothesis that individuals with combat-related PTSD would show increased activation in the insula and related emotion-processing circuitry when anticipating emotionally significant events such as portrayed in combat-related images, and this heighted response within the insula would be particularly enhanced during temporal unpredictability. METHODS About 15 male veterans with PTSD and 15 male veterans with combat-exposure but no current or lifetime history of PTSD (combat exposed controls/CEC) performed a temporal unpredictability anticipation task of unpleasant (combat-related) and pleasant images during fMRI. RESULTS As expected, greater activation in the bilateral anterior insulae was observed in the PTSD versus the CEC subjects during anticipation of combat-related images when the anticipatory period was of uncertain duration (p<0.05). Furthermore, activation in the right anterior insula was related to greater perceived threat in the CEC group (ρ=0.619). LIMITATIONS The current study looks only at combat-related PTSD in a modest preliminary sized sample. CONCLUSIONS These findings suggest that an excessive anticipatory reaction in individuals with PTSD to temporally unpredictable aversive stimulus may relate to greater perceived threat. These findings are concordant with psychological models of PTSD that focus on the association of PTSD with the experience of decreased predictability and control.
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Affiliation(s)
- Alan N Simmons
- Research Service, VA San Diego Healthcare System, San Diego, CA 92130, USA.
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69
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Mendez MF, Owens EM, Jimenez EE, Peppers D, Licht EA. Changes in personality after mild traumatic brain injury from primary blast vs. blunt forces. Brain Inj 2013; 27:10-8. [PMID: 23252434 DOI: 10.3109/02699052.2012.722252] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Injuries from explosive devices can cause blast-force injuries, including mild traumatic brain injury (mTBI). OBJECTIVE This study investigated changes in personality from blast-force mTBI in comparison to blunt-force mTBI. METHODS Clinicians and significant others assessed US veterans who sustained pure blast-force mTBI (n = 12), as compared to those who sustained pure blunt-force mTBI (n = 12). Inclusion criteria included absence of any mixed blast-blunt trauma and absence of post-traumatic stress disorder. Measures included the Interpersonal Measure of Psychopathy (IM-P), the Big Five Inventory (BFI), the Interpersonal Adjectives Scale (IAS) and the Frontal Systems Behaviour Scale (FrSBe). RESULTS There were no group differences on demographic or TBI-related variables. Compared to the Blunt Group, the Blast Group had more psychopathy on the IM-P, with anger, frustration, toughness and boundary violations and tended to more neuroticism on the BFI. When pre-TBI and post-TBI assessments were compared on the IAS and FrSBe, only the patients with blast force mTBI had become more cold-hearted, aloof-introverted and apathetic. CONCLUSION These results suggest that blast forces alone can cause negativistic behavioural changes when evaluated with selected measures of personality. Further research on isolated blast-force mTBI should focus on these personality changes and their relationship to blast over-pressure.
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Affiliation(s)
- Mario F Mendez
- Department of Neurology, David Geffen School of Medicine, University of California at Los Angeles, USA.
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70
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Sartory G, Cwik J, Knuppertz H, Schürholt B, Lebens M, Seitz RJ, Schulze R. In search of the trauma memory: a meta-analysis of functional neuroimaging studies of symptom provocation in posttraumatic stress disorder (PTSD). PLoS One 2013; 8:e58150. [PMID: 23536785 PMCID: PMC3607590 DOI: 10.1371/journal.pone.0058150] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/31/2013] [Indexed: 01/17/2023] Open
Abstract
Notwithstanding some discrepancy between results from neuroimaging studies of symptom provocation in posttraumatic stress disorder (PTSD), there is broad agreement as to the neural circuit underlying this disorder. It is thought to be characterized by an exaggerated amygdalar and decreased medial prefrontal activation to which the elevated anxiety state and concomitant inadequate emotional regulation are attributed. However, the proposed circuit falls short of accounting for the main symptom, unique among anxiety disorders to PTSD, namely, reexperiencing the precipitating event in the form of recurrent, distressing images and recollections. Owing to the technical demands, neuroimaging studies are usually carried out with small sample sizes. A meta-analysis of their findings is more likely to cast light on the involved cortical areas. Coordinate-based meta-analyses employing ES-SDM (Effect Size Signed Differential Mapping) were carried out on 19 studies with 274 PTSD patients. Thirteen of the studies included 145 trauma-exposed control participants. Comparisons between reactions to trauma-related stimuli and a control condition and group comparison of reactions to the trauma-related stimuli were submitted to meta-analysis. Compared to controls and the neutral condition, PTSD patients showed significant activation of the mid-line retrosplenial cortex and precuneus in response to trauma-related stimuli. These midline areas have been implicated in self-referential processing and salient autobiographical memory. PTSD patients also evidenced hyperactivation of the pregenual/anterior cingulate gyrus and bilateral amygdala to trauma-relevant, compared to neutral, stimuli. Patients showed significantly less activation than controls in sensory association areas such as the bilateral temporal gyri and extrastriate area which may indicate that the patients' attention was diverted from the presented stimuli by being focused on the elicited trauma memory. Being involved in associative learning and priming, the retrosplenial cortex may have an important function in relation to trauma memory, in particular, the intrusive reexperiencing of the traumatic event.
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Affiliation(s)
- Gudrun Sartory
- Clinical Psychology Unit, Department of Psychology, University of Wuppertal, Wuppertal, Germany.
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71
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Hayes JP, VanElzakker MB, Shin LM. Emotion and cognition interactions in PTSD: a review of neurocognitive and neuroimaging studies. Front Integr Neurosci 2012; 6:89. [PMID: 23087624 PMCID: PMC3466464 DOI: 10.3389/fnint.2012.00089] [Citation(s) in RCA: 203] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 09/18/2012] [Indexed: 12/14/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is a psychiatric syndrome that develops after exposure to terrifying and life-threatening events including warfare, motor-vehicle accidents, and physical and sexual assault. The emotional experience of psychological trauma can have long-term cognitive effects. The hallmark symptoms of PTSD involve alterations to cognitive processes such as memory, attention, planning, and problem solving, underscoring the detrimental impact that negative emotionality has on cognitive functioning. As such, an important challenge for PTSD researchers and treatment providers is to understand the dynamic interplay between emotion and cognition. Contemporary cognitive models of PTSD theorize that a preponderance of information processing resources are allocated toward threat detection and interpretation of innocuous stimuli as threatening, narrowing one's attentional focus at the expense of other cognitive operations. Decades of research have shown support for these cognitive models of PTSD using a variety of tasks and methodological approaches. The primary goal of this review is to summarize the latest neurocognitive and neuroimaging research of emotion-cognition interactions in PTSD. To directly assess the influence of emotion on cognition and vice versa, the studies reviewed employed challenge tasks that included both cognitive and emotional components. The findings provide evidence for memory and attention deficits in PTSD that are often associated with changes in functional brain activity. The results are reviewed to provide future directions for research that may direct better and more effective treatments for PTSD.
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Affiliation(s)
- Jasmeet P. Hayes
- National Center for PTSD, VA Boston Healthcare SystemBoston, MA, USA
- Department of Psychiatry, Boston University School of MedicineBoston, MA, USA
| | - Michael B. VanElzakker
- Department of Psychology, Tufts UniversityMedford, MA, USA
- Department of Psychiatry, The Massachusetts General HospitalBoston, MA, USA
| | - Lisa M. Shin
- Department of Psychology, Tufts UniversityMedford, MA, USA
- Department of Psychiatry, The Massachusetts General HospitalBoston, MA, USA
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72
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Wall PLH. Posttraumatic stress disorder and traumatic brain injury in current military populations: a critical analysis. J Am Psychiatr Nurses Assoc 2012; 18:278-98. [PMID: 23053745 DOI: 10.1177/1078390312460578] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of unconventional weaponry combined with decreased mortality rates and servicemembers being exposed to intense ground combat during multiple deployments has increased the risk of servicemembers living with the consequences of traumatic brain injuries (TBI) and combat operational stress. OBJECTIVE The purpose of this article is to perform a critical analysis of the literature to identify current rates of comorbid posttraumatic stress disorder (PTSD) and TBI in military and veteran populations who have served in Iraq or Afghanistan and their combined effects on persistent postconcussive symptoms. DESIGN A search of the literature with military and veteran populations published after 2001 in Pubmed, OVID/Medline, Cochran Database, Embase, Scopus, CINAHL, and PsychInfo was conducted using keywords. RESULTS Twenty studies met inclusion criteria. The literature search yielded mixed results for rates of PTSD, TBI, and comorbid conditions. CONCLUSIONS There is some evidence that comorbid PTSD and TBI result in greater reports of postconcussive symptomology than either condition alone. Limitations include lack of consistency of measurements, sampling biases, and lack of experimental design, and these warrant further exploration. Future research is needed to decrease variability in study findings and elucidate relationships between these disorders and their effects on persistent postconcussive symptomology.
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Impaired response inhibition in veterans with post-traumatic stress disorder and mild traumatic brain injury. J Int Neuropsychol Soc 2012; 18:917-26. [PMID: 22595028 DOI: 10.1017/s1355617712000458] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Combat veterans with post-traumatic stress disorder (PTSD) can show impairments in executive control and increases in impulsivity. The current study examined the effects of PTSD on motor response inhibition, a key cognitive control function. A Go/NoGo task was administered to veterans with a diagnosis of PTSD based on semi-structured clinical interview using DSM-IV criteria (n = 40) and age-matched control veterans (n = 33). Participants also completed questionnaires to assess self-reported levels of PTSD and depressive symptoms. Performance measures from the patients (error rates and reaction times) were compared to those from controls. PTSD patients showed a significant deficit in response inhibition, committing more errors on NoGo trials than controls. Higher levels of PTSD and depressive symptoms were associated with higher error rates. Of the three symptom clusters, re-experiencing was the strongest predictor of performance. Because the co-morbidity of mild traumatic brain injury (mTBI) and PTSD was high in this population, secondary analyses compared veterans with PTSD+mTBI (n = 30) to veterans with PTSD only (n = 10). Although preliminary, results indicated the two patient groups did not differ on any measure (p > .88). Since cognitive impairments could hinder the effectiveness of standard PTSD therapies, incorporating treatments that strengthen executive functions might be considered in the future. (JINS, 2012, 18, 1-10).
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Petraglia AL, Maroon JC, Bailes JE. From the Field of Play to the Field of Combat. Neurosurgery 2012; 70:1520-33; discussion 1533. [DOI: 10.1227/neu.0b013e31824cebe8] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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75
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Quantitative meta-analysis of neural activity in posttraumatic stress disorder. BIOLOGY OF MOOD & ANXIETY DISORDERS 2012; 2:9. [PMID: 22738125 PMCID: PMC3430553 DOI: 10.1186/2045-5380-2-9] [Citation(s) in RCA: 324] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 04/26/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND In recent years, neuroimaging techniques such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) have played a significant role in elucidating the neural underpinnings of posttraumatic stress disorder (PTSD). However, a detailed understanding of the neural regions implicated in the disorder remains incomplete because of considerable variability in findings across studies. The aim of this meta-analysis was to identify consistent patterns of neural activity across neuroimaging study designs in PTSD to improve understanding of the neurocircuitry of PTSD. METHODS We conducted a literature search for PET and fMRI studies of PTSD that were published before February 2011. The article search resulted in 79 functional neuroimaging PTSD studies. Data from 26 PTSD peer-reviewed neuroimaging articles reporting results from 342 adult patients and 342 adult controls were included. Peak activation coordinates from selected articles were used to generate activation likelihood estimate maps separately for symptom provocation and cognitive-emotional studies of PTSD. A separate meta-analysis examined the coupling between ventromedial prefrontal cortex and amygdala activity in patients. RESULTS Results demonstrated that the regions most consistently hyperactivated in PTSD patients included mid- and dorsal anterior cingulate cortex, and when ROI studies were included, bilateral amygdala. By contrast, widespread hypoactivity was observed in PTSD including the ventromedial prefrontal cortex and the inferior frontal gyrus. Furthermore, decreased ventromedial prefrontal cortex activity was associated with increased amygdala activity. CONCLUSIONS These results provide evidence for a neurocircuitry model of PTSD that emphasizes alteration in neural networks important for salience detection and emotion regulation.
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Dolan S, Martindale S, Robinson J, Kimbrel NA, Meyer EC, Kruse MI, Morissette SB, Young KA, Gulliver SB. Neuropsychological sequelae of PTSD and TBI following war deployment among OEF/OIF veterans. Neuropsychol Rev 2012; 22:21-34. [PMID: 22350690 PMCID: PMC5032645 DOI: 10.1007/s11065-012-9190-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 01/31/2012] [Indexed: 10/28/2022]
Abstract
Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are highly prevalent among Veterans of the conflicts in Iraq and Afghanistan. These conditions are associated with common and unique neuropsychological and neuroanatomical changes. This review synthesizes neuropsychological and neuroimaging studies for both of these disorders and studies examining their co-occurrence. Recommendations for future research, including use of combined neuropsychological and advanced neuroimaging techniques to study these disorders alone and in concert, are presented. It is clear from the dearth of literature that addiitonal studies are required to examine and understand the impact of specific factors on neurocognitive outcome. Of particular relevance are temporal relationships between PTSD and mTBI, risk and resilience factors associated with both disorders and their co-occurrence, and mTBI-specific factors such as time since injury and severity of injury, utilizing comprehensive, yet targeted cognitive tasks.
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Affiliation(s)
- Sara Dolan
- Department of Psychology and Neuroscience, Baylor University, Waco, TX, USA.
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Hayes JP, Vanelzakker MB, Shin LM. Emotion and cognition interactions in PTSD: a review of neurocognitive and neuroimaging studies. Front Integr Neurosci 2012; 6:89. [PMID: 23087624 DOI: 10.3389/fnint.2012.00089/bibtex] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 09/18/2012] [Indexed: 05/20/2023] Open
Abstract
Posttraumatic stress disorder (PTSD) is a psychiatric syndrome that develops after exposure to terrifying and life-threatening events including warfare, motor-vehicle accidents, and physical and sexual assault. The emotional experience of psychological trauma can have long-term cognitive effects. The hallmark symptoms of PTSD involve alterations to cognitive processes such as memory, attention, planning, and problem solving, underscoring the detrimental impact that negative emotionality has on cognitive functioning. As such, an important challenge for PTSD researchers and treatment providers is to understand the dynamic interplay between emotion and cognition. Contemporary cognitive models of PTSD theorize that a preponderance of information processing resources are allocated toward threat detection and interpretation of innocuous stimuli as threatening, narrowing one's attentional focus at the expense of other cognitive operations. Decades of research have shown support for these cognitive models of PTSD using a variety of tasks and methodological approaches. The primary goal of this review is to summarize the latest neurocognitive and neuroimaging research of emotion-cognition interactions in PTSD. To directly assess the influence of emotion on cognition and vice versa, the studies reviewed employed challenge tasks that included both cognitive and emotional components. The findings provide evidence for memory and attention deficits in PTSD that are often associated with changes in functional brain activity. The results are reviewed to provide future directions for research that may direct better and more effective treatments for PTSD.
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Affiliation(s)
- Jasmeet P Hayes
- National Center for PTSD, VA Boston Healthcare System Boston, MA, USA ; Department of Psychiatry, Boston University School of Medicine Boston, MA, USA
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Altered amygdala activation during face processing in Iraqi and Afghanistani war veterans. BIOLOGY OF MOOD & ANXIETY DISORDERS 2011; 1:6. [PMID: 22738183 PMCID: PMC3384263 DOI: 10.1186/2045-5380-1-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 10/12/2011] [Indexed: 11/17/2022]
Abstract
Background Exposure to combat can have a significant impact across a wide array of domains, and may manifest as post-traumatic stress disorder (PTSD), a debilitating mental illness that is associated with neural and affective sequelae. This study tested the hypothesis that combat-exposed individuals with and without PTSD, relative to healthy control subjects with no history of PTSD or combat exposure, would show amygdala hyperactivity during performance of a well-validated face processing task. We further hypothesized that differences in the prefrontal cortex would best differentiate the combat-exposed groups with and without PTSD. Methods Twelve men with PTSD related to combat in Operations Enduring Freedom and/or Iraqi Freedom, 12 male combat-exposed control patients with a history of Operations Enduring Freedom and/or Iraqi Freedom combat exposure but no history of PTSD, and 12 healthy control male patients with no history of combat exposure or PTSD completed a face-matching task during functional magnetic resonance imaging. Results The PTSD group showed greater amygdala activation to fearful versus happy faces than both the combat-exposed control and healthy control groups. Both the PTSD and the combat-exposed control groups showed greater amygdala activation to all faces versus shapes relative to the healthy control group. However, the combat-exposed control group relative to the PTSD group showed greater prefrontal/parietal connectivity with the amygdala, while the PTSD group showed greater connectivity with the subgenual cingulate. The strength of connectivity in the PTSD group was inversely related to avoidance scores. Conclusions These observations are consistent with the hypothesis that PTSD is associated with a deficiency in top-down modulation of amygdala activation by the prefrontal cortex and shows specific sensitivity to fearful faces.
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