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Titone MK, Hunt C, Bismark A, Nokes B, Lee E, Ramanathan D, Park J, Colvonen P. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med 2023; 19:2043-2051. [PMID: 37539643 PMCID: PMC10692930 DOI: 10.5664/jcsm.10746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
STUDY OBJECTIVES Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression. METHODS Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories. RESULTS We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis. CONCLUSIONS Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD. CITATION Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.
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Affiliation(s)
- Madison K. Titone
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | | | | | - Brandon Nokes
- VA San Diego Healthcare System, San Diego, California
| | - Ellen Lee
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Dhakshin Ramanathan
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Jane Park
- VA San Diego Healthcare System, San Diego, California
| | - Peter Colvonen
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
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Zoladz PR, Cordes CN, Weiser JN, Reneau KE, Boaz KM, Helwig SJ, Virden EM, Thebeault CK, Pfister CL, Getnet BA, Niese TD, Parker SL, Stanek ML, Long KE, Norrholm SD, Rorabaugh BR. Pre-Learning Stress That Is Temporally Removed from Acquisition Impairs Fear Learning. BIOLOGY 2023; 12:775. [PMID: 37372060 DOI: 10.3390/biology12060775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Few studies have examined the time-dependent effects of stress on fear learning. Previously, we found that stress immediately before fear conditioning enhanced fear learning. Here, we aimed to extend these findings by assessing the effects of stress 30 min prior to fear conditioning on fear learning and fear generalization. Two hundred and twenty-one healthy adults underwent stress (socially evaluated cold pressor test) or a control manipulation 30 min before completing differential fear conditioning in a fear-potentiated startle paradigm. One visual stimulus (CS+), but not another (CS-), was associated with an aversive airblast to the throat (US) during acquisition. The next day, participants were tested for their fear responses to the CS+, CS-, and several generalization stimuli. Stress impaired the acquisition of fear on Day 1 but had no significant impact on fear generalization. The stress-induced impairment of fear learning was particularly evident in participants who exhibited a robust cortisol response to the stressor. These findings are consistent with the notion that stress administered 30 min before learning impairs memory formation via corticosteroid-related mechanisms and may help us understand how fear memories are altered in stress-related psychological disorders.
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Affiliation(s)
- Phillip R Zoladz
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Chloe N Cordes
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Jordan N Weiser
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Kassidy E Reneau
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Kayla M Boaz
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Sara J Helwig
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Emma M Virden
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Caitlin K Thebeault
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Cassidy L Pfister
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Bruktawit A Getnet
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Taylor D Niese
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Sydney L Parker
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Mercedes L Stanek
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Kristen E Long
- Psychology Program, The School of Health and Behavioral Sciences, Ohio Northern University, Ada, OH 45810, USA
| | - Seth D Norrholm
- Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI 48202, USA
| | - Boyd R Rorabaugh
- Department of Pharmaceutical Sciences, School of Pharmacy, Marshall University, Huntington, WV 25755, USA
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Woodford J, Riser M, Norrholm SD. Understanding Human Fear Extinction: Insights from Psychophysiology. Curr Top Behav Neurosci 2023; 64:59-77. [PMID: 37528308 DOI: 10.1007/7854_2023_435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
The study of fear extinction has been driven largely by Pavlovian fear conditioning methods across the translational spectrum. The primary methods used to study these processes in humans have been recordings of skin conductance (historically termed galvanic skin response) and fear-potentiation of the acoustic startle reflex. As outlined in the following chapter, the combined corpus of this work has demonstrated the value of psychophysiology in better understanding the underlying neurobiology of extinction learning in healthy humans as well as those with psychopathologies. In addition, psychophysiological approaches, which allow for the preservation of methods between species, have shown their applicability to the assessment of wide-ranging treatment effects. The chapter concludes with potential trajectories for future study in this area.
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Affiliation(s)
- Jessica Woodford
- Department of Psychiatry and Behavioral Neurosciences, Neuroscience Center for Anxiety, Stress, and Trauma, Wayne State University School of Medicine, Detroit, MI, USA
| | - Manessa Riser
- Department of Psychiatry and Behavioral Neurosciences, Neuroscience Center for Anxiety, Stress, and Trauma, Wayne State University School of Medicine, Detroit, MI, USA
| | - Seth Davin Norrholm
- Department of Psychiatry and Behavioral Neurosciences, Neuroscience Center for Anxiety, Stress, and Trauma, Wayne State University School of Medicine, Detroit, MI, USA.
- Department of Behavioral Sciences and Leadership, United States Air Force Academy, Colorado Springs, CO, USA.
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Vanuk JR, Pace-Schott EF, Bullock A, Esbit S, Dailey NS, Killgore WDS. Morning blue light treatment improves sleep complaints, symptom severity, and retention of fear extinction memory in post-traumatic stress disorder. Front Behav Neurosci 2022; 16:886816. [PMID: 36172467 PMCID: PMC9510714 DOI: 10.3389/fnbeh.2022.886816] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
Disrupted sleep is a major feature in numerous clinical disorders and is related to decrements in affective memory processing. The prevalence of sleep disruption in post-traumatic stress disorder (PTSD) is suggested to be a key feature that exacerbates the impaired ability to recall extinction memories during experimental fear conditioning. We hypothesized that an intervention employing blue-wavelength light therapy (BLT) to regulate sleep and stabilize circadian rhythms in patients with PTSD (i.e., via regulated morning exposure) would be associated with PTSD symptom improvement, decreased sleep-related complaints, as well as improved consolidation and retention of extinction memories relative to a fear conditioning/extinction paradigm. Eighty-two individuals with PTSD underwent a well-validated fear conditioning/extinction protocol with subsequent assignment to receive morning BLUE (BLT) or placebo AMBER (ALT) light therapy daily for 30-min over 6-weeks. Participants returned after the intervention for post-treatment extinction recall, comprised of exposure to the previously conditioned stimuli, with the difference in skin conductance response between the "extinguished" and the "never-extinguished" stimuli at follow-up. Participants also viewed previously conditioned stimuli in a novel context during a functional magnetic resonance imaging (fMRI) scan. BLUE light therapy was associated with improvements relative to correlated decreases between PTSD symptoms and sleep-related complaints. Participants receiving BLT also sustained retention of the extinction memory, while those in the placebo amber light treatment group showed impairment, characterized by the restoration of the extinguished fear response after 6-weeks. Participants in the ALT also demonstrated greater reactivity in the left insula when viewing the previously extinguished fear-conditioned stimuli in a novel context. Daily BLUE-wavelength morning light exposure was associated with greater retention of extinction learning in patients with PTSD when compared to ALT, as supported by both autonomic and neurobiological reactivity. We speculate that improved sleep facilitated by a stabilized circadian rhythm, after fear-learning, led to greater consolidation of the fear extinction memory, decreased PTSD symptom presentation, and associated decreases in sleep-related complaints. Prominent exposure treatments for PTSD incorporate principles of fear extinction, and our findings suggest that blue light treatment may facilitate treatment gains by promoting the consolidation of extinction memories via improved sleep.
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Affiliation(s)
- John R. Vanuk
- Department of Psychiatry, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Edward F. Pace-Schott
- Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, United States
| | - Ayla Bullock
- Department of Psychiatry, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Simon Esbit
- Department of Psychiatry, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Natalie S. Dailey
- Department of Psychiatry, College of Medicine, University of Arizona, Tucson, AZ, United States
| | - William D. S. Killgore
- Department of Psychiatry, College of Medicine, University of Arizona, Tucson, AZ, United States
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Maples-Keller J, Watkins LE, Nylocks KM, Yasinski C, Coghlan C, Black K, Jovanovic T, Rauch SA, Rothbaum BO, Norrholm SD. Acquisition, extinction, and return of fear in veterans in intensive outpatient prolonged exposure therapy: A fear-potentiated startle study. Behav Res Ther 2022; 154:104124. [PMID: 35642990 DOI: 10.1016/j.brat.2022.104124] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 04/27/2022] [Accepted: 05/13/2022] [Indexed: 11/02/2022]
Abstract
Prolonged exposure (PE) therapy is a first-line treatment for posttraumatic stress disorder (PTSD) and involves repeated presentation of trauma-related cues without aversive outcomes. A primary learning mechanism of PE is fear extinction (new learning that a dangerous cue is now safe) and its retention (maintaining this new learning over time). Extant research suggests extinction is impaired in PTSD patients. In this study, we employed an established fear-potentiated startle-based paradigm to examine fear acquisition, extinction learning and retention before and after completion of intensive outpatient treatment. First, PTSD patients undergoing PE (n = 55) were compared to trauma-exposed patients without PTSD (n = 57). We identified excessive fear in PTSD patients during acquisition and extinction before treatment compared to non-PTSD patients. At post-treatment, we examined the return of fear after extinction in PTSD patients showing high or low treatment response to PE (≥50% change in PTSD symptom severity vs. < 50%). High PE responders maintained fear extinction learning whereas low PE responders showed significant return of fear at post-treatment. These results replicate and extend previous findings of impaired extinction in PTSD and provide support for the proposed theoretical link between fear extinction and PE response.
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A Narrative Review of the Association between Post-Traumatic Stress Disorder and Obstructive Sleep Apnea. J Clin Med 2022; 11:jcm11020415. [PMID: 35054110 PMCID: PMC8780754 DOI: 10.3390/jcm11020415] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 12/10/2022] Open
Abstract
Obstructive sleep apnea (OSA) and post-traumatic stress disorder (PTSD) are often co-morbid with implications for disease severity and treatment outcomes. OSA prevalence is higher in PTSD sufferers than in the general population, with a likely bidirectional effect of the two illnesses. There is substantial evidence to support the role that disturbed sleep may play in the pathophysiology of PTSD. Sleep disturbance associated with OSA may interfere with normal rapid eye movement (REM) functioning and thus worsen nightmares and sleep-related movements. Conversely, hyperarousal and hypervigilance symptoms of PTSD may lower the arousal threshold and thus increase the frequency of sleep fragmentation related to obstructive events. Treating OSA not only improves OSA symptoms, but also nightmares and daytime symptoms of PTSD. Evidence suggests that positive airway pressure (PAP) therapy reduces PTSD symptoms in a dose-dependent fashion, but also presents challenges to tolerance in the PTSD population. Alternative OSA treatments may be better tolerated and effective for improving both OSA and PTSD. Further research avenues will be introduced as we seek a better understanding of this complex relationship.
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Fendt M, Kreutzmann JC, Jovanovic T. Learning safety to reduce fear: Recent insights and potential implications. Behav Brain Res 2021; 411:113402. [PMID: 34089756 DOI: 10.1016/j.bbr.2021.113402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Markus Fendt
- Otto-von-Guericke University Magdeburg, Institute for Pharmacology and Toxicology, Leipziger Str. 44, D-39120, Magdeburg, Germany.
| | - Judith C Kreutzmann
- Otto-von-Guericke University Magdeburg, Institute for Pharmacology and Toxicology, Leipziger Str. 44, D-39120, Magdeburg, Germany.
| | - Tanja Jovanovic
- Wayne State University, School of Medicine, Psychiatry and Behavioral Neuroscience, 245 Tolan Park Medical Building, 3901 Chrysler Service Drive, Detroit, MI, 48201, USA
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