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Schmalbach I, Witthöft M, Strauß B, Joraschky P, Petrowski K. The predictive value of cortisol in psychodynamic psychotherapy for social anxiety disorder: Extended results of the SOPHONET-Study. Transl Psychiatry 2024; 14:188. [PMID: 38605013 PMCID: PMC11009385 DOI: 10.1038/s41398-024-02882-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 03/06/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024] Open
Abstract
Psychotherapy is an effective treatment for anxiety disorders (AD), yet a vast majority of patients do not respond to therapy, necessitating the identification of predictors to enhance outcomes. Several studies have explored the relationship between stress response and treatment outcome, as a potential treatment mechanism. However, the latter remains under-researched in patients with social anxiety disorder (SAD). We studied N = 29 patients undergoing psychodynamic psychotherapy (PDT) within the SOPHONET-Study. Stress reactivity (i.e., area under the curve with respect to the increase; AUCi) was induced by a standardized psychosocial stressor (Trier Social Stress Test; TSST) and assessed by means of adrenocorticotropic hormone (ACTH), blood and salivary cortisol samples before (t1) treatment. Samples of these biomarkers were taken -1 min prior stress exposure and six more blood samples were collected post-TSST ( + 1, + 10, + 20, + 30, + 45, + 60 min.). The participants were diagnosed with SAD based on the Structured Clinical Interview for DSM-IV (SCID) and completed the Liebowitz Social Anxiety Scale as well as the Beck Depression Inventory before (t1) and after psychotherapy (t2). Pre-treatment stress reactivity significantly predicted changes in depression (salivary p < 0.001 and blood cortisol p = 0.001), as well as in avoidance behavior (blood cortisol p = 0.001). None of the biomarkers revealed significant results in fear or in the total LSAS-scores, except for ACTH with a trend finding (p = 0.06). Regarding therapy success, symptoms of social anxiety (p = 0.005) and depression (p < 0.001) were significantly reduced from pre (t1) to post-treatment (t2). Our study showed that stress reactivity pre-treatment may serve as a predictor of psychotherapy outcome. In this regard, alterations in stress response relate to changes in symptoms of social anxiety and depression after PDT. This implies that patients with chronic stress might benefit from a targeted interventions during psychotherapy, especially to manage fear in social contexts.
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Affiliation(s)
- Ileana Schmalbach
- Department of Medical Psychology and Medical Sociology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
| | - Michael Witthöft
- Department of Clinical Psychology, Psychotherapy, and Experimental Psychopathology, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Bernhard Strauß
- Institute for Psychosocial Medicine, Psychotherapy & Psychooncology, University Hospital Jena, Jena, Germany
| | - Peter Joraschky
- University Medical Center Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Katja Petrowski
- Department of Medical Psychology and Medical Sociology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Dresden University of Technology, Carl Gustav Carus Medical Faculty, Department of General Medicine/MK3, Dresden, Germany
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Barnabe A, Gamache K, de Camargo JVP, Allen-Flanagan E, Rioux M, Pruessner J, Leyton M, Nader K. A novel stress-based intervention reduces cigarette use in non-treatment seeking smokers. Neuropsychopharmacology 2023; 48:308-316. [PMID: 36175551 PMCID: PMC9750979 DOI: 10.1038/s41386-022-01455-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 08/25/2022] [Accepted: 09/02/2022] [Indexed: 12/26/2022]
Abstract
Tobacco use is the leading cause of preventable mortality worldwide. Since current smoking cessation aids show only modest efficacy, new interventions are needed. Given the evidence that stress is a potent trigger for smoking, the present randomized clinical trial tested whether stress could augment the effects of a memory updating (retrieval-extinction) intervention. Non-treatment seeking smokers (n = 76) were assigned to one of four conditions composed of either a stressful or non-stressful psychosocial challenge followed by either smoking or neutral cues. Ten minutes after this manipulation, all underwent a 60-minute extinction procedure during which they viewed smoking-related videos and images and manipulated smoking paraphernalia. Compared to participants who were not exposed to the laboratory stressor, the stressor-exposed groups exhibited greater psychophysiological responses during their intervention and greater decreases in cigarette use at two- and six-weeks follow-up independent of smoking cue exposure. Together, these findings suggest that the ability of stress to activate cigarette seeking processes can be exploited to decrease cigarette use. With replication, the stress-based intervention could become a novel strategy for decreasing cigarette use in non-treatment seeking smokers.Clinicaltrials.gov identifier: NCT04843969.
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Affiliation(s)
- Alexandra Barnabe
- grid.14709.3b0000 0004 1936 8649Department of Psychology, McGill University, Montreal, QC Canada
| | - Karine Gamache
- grid.14709.3b0000 0004 1936 8649Department of Psychology, McGill University, Montreal, QC Canada
| | | | - Erin Allen-Flanagan
- grid.14709.3b0000 0004 1936 8649Department of Psychology, McGill University, Montreal, QC Canada
| | - Mathilde Rioux
- grid.14709.3b0000 0004 1936 8649Department of Psychology, McGill University, Montreal, QC Canada
| | - Jens Pruessner
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Baden-Württemberg, Germany ,grid.14709.3b0000 0004 1936 8649Department of Psychiatry, McGill University, Montreal, QC Canada
| | - Marco Leyton
- Department of Psychology, McGill University, Montreal, QC, Canada. .,Department of Psychiatry, McGill University, Montreal, QC, Canada. .,Department of Neurology & Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada. .,Center for Studies in Behavioral Neurobiology, Concordia University, Montreal, QC, Canada.
| | - Karim Nader
- grid.14709.3b0000 0004 1936 8649Department of Psychology, McGill University, Montreal, QC Canada
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4
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Merz CJ, Wolf OT. How stress hormones shape memories of fear and anxiety in humans. Neurosci Biobehav Rev 2022; 142:104901. [DOI: 10.1016/j.neubiorev.2022.104901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/30/2022] [Accepted: 10/01/2022] [Indexed: 11/29/2022]
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Wintermann GB, Noack R, Steudte-Schmiedgen S, Weidner K. Cortisol response under low intensity exercise during cognitive-behavioral therapy is associated with therapeutic outcome in panic disorder–an exploratory study. PLoS One 2022; 17:e0273413. [PMID: 36048809 PMCID: PMC9436097 DOI: 10.1371/journal.pone.0273413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/15/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives
Patients with Panic Disorder (PD) show an abnormal stress-induced functioning of the Hypothalamic-Pituitary-adrenal (HPA)-axis. Different protocols for stress induction are of rather low relevance for the psychotherapeutic treatment. In practice, interoceptive exposure is often realized as Low Intensity Exercise (LIE), as compared to an incremental cycle exercise test to exhaustion. Currently, it is not known, whether LIE displays an effective interoceptive stressor 1.) leading to a significant anxiety induction; 2.) a comparable HPA- and Sympathetic-Adreno-Medullar (SAM)-axis response in both patients and healthy controls; 3.) stress responses under LIE are associated with treatment outcomes.
Patients and methods
N = 20 patients with PD and n = 20 healthy controls were exposed to ten minutes of LIE on an exercise bike. LIE was applied as part of the interoceptive exposure, during an intensive Cognitive-Behavioral Therapy (CBT) in a day clinic. Heart rate was monitored and salivary cortisol samples collected. Before and after the LIE, state anxiety/ arousal were assessed. In order to evaluate psychopathology, the Panic and Agoraphobia Scale, Mobility Inventory, Agoraphobic Cognitions Questionnaire and Body Sensations Questionnaire were applied, before (T1) and after five weeks (T2) of an intensive CBT.
Results
LIE led to a significant and similar heart rate increase in both groups. Cortisol decreased over time in both groups, especially in male patients. A higher psychopathology before, and after CBT, was associated with a significantly lower cortisol response under LIE.
Conclusions
In the present study, LIE led to a divergent stress response: while there was a significant heart rate increase, cortisol decreased over time, particularly in male patients. A lower reactivity of the HPA-axis seems to be associated with a lower treatment outcome, which may affect extinction based learning. The findings suggest, that interoceptive stimuli should be designed carefully in order to be potent stressors.
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Affiliation(s)
- Gloria-Beatrice Wintermann
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Saxony, Germany
- * E-mail:
| | - René Noack
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Saxony, Germany
| | - Susann Steudte-Schmiedgen
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Saxony, Germany
| | - Kerstin Weidner
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Saxony, Germany
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Masdrakis VG, Legaki EM, Papageorgiou C, Markianos M. Stress Hormones as Predictors of Response to Cognitive Behavior Therapy in Panic Disorder. Neuropsychobiology 2022; 80:401-410. [PMID: 33735885 DOI: 10.1159/000514073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/21/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Data regarding the potential association between the outcome of psychotherapy of panic disorder (PD) and biological parameters are few. In 21 (16 females) consecutively referred, medication-free, acutely ill PD outpatients, without comorbidities, except agoraphobia, we systematically explored for potential neuroendocrine and clinical correlates of response to a brief cognitive behavior therapy (CBT). METHODS Cortisol and adrenocorticotropic hormone (ACTH) basal plasma levels were measured. Measures of psychopathology: (a) Symptom Checklist-90-Revised (SCL-90-R), (b) Clinical Global Impressions-Improvement (CGI-I) Scale, (c) Agoraphobic Cognitions Questionnaire (ACQ), and (d) Mobility Inventory (MI)-alone subscale. RESULTS Nonresponders to CBT (CGI-I >2; N = 6) - as compared to the responders (CGI-I ≤2; N = 15) - demonstrated significantly higher cortisol and ACTH basal plasma concentrations. These differences were much stronger when only female patients (nonresponders = 4; responders = 12) were taken into consideration. Regarding psychopathology, nonresponders to CBT suffered from more severe agoraphobia (MI-alone) at baseline. On the contrary, more intense manifestations of anger (SCL-90-R) at baseline were associated with a better treatment outcome. Response to CBT was associated with significant reductions in all SCL-90-R subscales, more pronounced for "phobic anxiety" and "anxiety" subscales. CONCLUSIONS This study suggests that in acutely ill, medication-free PD patients, response to CBT may be associated with certain hormonal and clinical parameters at baseline.
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Affiliation(s)
- Vasilios G Masdrakis
- First Department of Psychiatry, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece,
| | - Emilia-Maria Legaki
- First Department of Psychiatry, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Charalambos Papageorgiou
- First Department of Psychiatry, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Manolis Markianos
- First Department of Psychiatry, School of Medicine, Eginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Steudte-Schmiedgen S, Fay E, Capitao L, Kirschbaum C, Reinecke A. Hydrocortisone as an adjunct to brief cognitive-behavioural therapy for specific fear: Endocrine and cognitive biomarkers as predictors of symptom improvement. J Psychopharmacol 2021; 35:641-651. [PMID: 33908295 PMCID: PMC8278554 DOI: 10.1177/02698811211001087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Glucocorticoid (GC) administration prior to exposure-based cognitive-behavioural therapy (CBT) has emerged as a promising approach to facilitate treatment outcome in anxiety disorders. Further components relevant for improved CBT efficacy include raised endogenous GCs and reductions in information-processing biases to threat. AIMS To investigate hydrocortisone as an adjunct to CBT for spider fear and the modulating role of threat bias change and endogenous short-term and long-term GCs for treatment response. METHODS Spider-fearful individuals were randomized to receiving either 20 mg of hydrocortisone (n = 17) or placebo (n = 16) one hour prior to single-session predominantly computerised exposure-based CBT. Spider fear was assessed using self-report and behavioural approach measures at baseline, 1-day and 1-month follow-up. Threat processing was assessed at baseline and 1-day follow-up. Cortisol and cortisone were analysed from hair and saliva samples at baseline. RESULTS/OUTCOMES Self-report, behavioural and threat processing indices improved following CBT. Hydrocortisone augmentation resulted in greater improvement of self-report spider fear and stronger increase in speed when approaching a spider, but not on threat bias. Neither threat bias nor endogenous GCs predicted symptom change, and no interactive effects with hydrocortisone emerged. Preliminary evidence indicated higher hair cortisone as predictor of a stronger threat bias reduction. CONCLUSIONS/INTERPRETATION Our data extend earlier findings by suggesting that GC administration boosts the success of exposure therapy for specific fear even with a low-level therapist involvement. Future studies corroborating our result of a predictive hair GC relationship with threat bias change in larger clinical samples are needed.
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Affiliation(s)
- Susann Steudte-Schmiedgen
- Department of Psychotherapy and Psychosomatic Medicine, Technische Universität Dresden, Dresden, Germany,Department of Psychiatry, University of Oxford, Oxford, UK,Susann Steudte-Schmiedgen, Department of Psychotherapy and Psychosomatic Medicine, Faculty of Medicine, Technische Universität Dresden, Fetscherstraße 74, Dresden 01062, Germany.
| | - Emily Fay
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Liliana Capitao
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Health NHS Trust, Oxford, UK
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Takaishi M, Asami T, Yoshida H, Nakamura R, Yoshimi A, Hirayasu Y. Smaller volume of right hippocampal CA2/3 in patients with panic disorder. Brain Imaging Behav 2021; 15:320-326. [PMID: 32125615 DOI: 10.1007/s11682-020-00259-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The hippocampus is thought to play an important role in conveying contextual information to the amygdala as the neural basis of panic disorder (PD). Previous studies have revealed functional abnormalities in the hippocampus in patients with PD compared with healthy control subjects (HC), but no study has reported volume abnormalities in the hippocampus or evaluated minute structural changes in the hippocampus in such patients. We thus investigated volume abnormalities in the subfields of the hippocampus to better understand the neurobiological basis of PD. The hippocampus was extracted from structural brain magnetic resonance images obtained from 38 patients with PD and 38 HC and then segmented into six subfields. The relative volume of each subfield was compared between the two groups. The severity of symptoms was assessed using the Panic Disorder Severity Scale (PDSS) and social functioning was assessed using the Global Assessment of Functioning (GAF) scale. Our results revealed that patients with PD had a significantly smaller volume of the right cornu ammonis (CA) 2/3 hippocampal subfield compared with HC. No significant associations were found between the volumes of the right CA 2/3 and the PDSS or GAF scores in correlation analyses. In conclusion, CA2/3 is thought to be related to contextual memory function, and our results suggest that this particular hippocampal subfield plays a role in the development of PD symptoms.
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Affiliation(s)
- Masao Takaishi
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Takeshi Asami
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan.
| | - Haruhisa Yoshida
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Ryota Nakamura
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Asuka Yoshimi
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Yoshio Hirayasu
- Department of Psychiatry, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
- Heian Hospital, Okinawa, Japan
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Abstract
Of all mental disorders, anxiety disorders are currently the strongest contributors to the global burden of disease, with 7.3% of the general population affected worldwide. The hypothalamus is crucial hub of a network of neural structures modulating fear conditioning and extinction and, as such, highly relevant to the pathophysiology of these conditions. Three hypothalamic systems have emerged as particularly relevant in this context. First, the oxytocin system is highly likely to be involved anxiety disorders and in particular in the cognitive and behavioral deficits pertaining to social anxiety disorder. Second, peripheral markers of the hypothalamic-pituitary-adrenal axis appear altered in patients with panic disorder and generalized anxiety disorder, which may denote aberrant functioning of their central corticotropin-releasing hormone system. Furthermore, cortisol seems to augment the effects of exposure therapy in patients with specific phobia. Third, the integrity of the hypothalamic-pituitary-thyroid axis is likely compromised in panic disorder. Further, cross-disciplinary research efforts are required to shed more light on how, exactly, these hypothalamic systems interact with the neural structures involved in fear conditioning and extinction, which should ultimately open up new avenues for the prevention and treatment of anxiety disorders.
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10
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Petrowski K, Schmalbach I, Strunk A, Hoyer J, Kirschbaum C, Joraschky P. Cortisol reactivity in social anxiety disorder: A highly standardized and controlled study. Psychoneuroendocrinology 2021; 123:104913. [PMID: 33160230 DOI: 10.1016/j.psyneuen.2020.104913] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/05/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
In order to understand the psychopathology of the social anxiety disorder (SAD) at the neuroendocrine level, standardized experimental studies on endocrine and physiological markers are necessary, especially since empirical data are still ambiguous. Hence, differences in both, the autonomic nervous system (ANS) and the endocrine stress responses (ACTH, salivary and plasma cortisol) were investigated in a particularly homogenous sample after a standardized stressor (Trier Social Stress Test). The sample consisted of n = 35 patients with SAD, age, and gender matched to n = 35 healthy controls (HC). In terms of the heart rate, the response pattern was comparable in both groups. Concerning ACTH, no significant group differences in the response pattern nor in the total output (AUCG) were exhibited. Significant differences were noticeable only in the plasma cortisol response pattern with less total output (AUCG) in patients suggesting a blunted response. The salivary cortisol response indicated comparable patterns between groups. However, the patients' total output (AUCG) was significantly smaller relative to the controls. In sum, evidence for a hypo-responsiveness of the HPA-axis in SAD by means of blood cortisol was observed, with no differences in ACTH between the two groups. This reduced reactivity of the HPA-axis might be associated with an inability to elicit an adequate hormone release, possibly accompanied by an enhanced perception of the stress stimulus. This might be explained by an adaptation of the adrenocortical system due to prolonged repeated stress exposure such as social evaluation.
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Affiliation(s)
- Katja Petrowski
- Medical Psychology & Medical Sociology, University Medical Center Mainz Johannes Gutenberg University of Mainz, Mainz, Germany; Clinic of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Germany.
| | - Ileana Schmalbach
- Medical Psychology & Medical Sociology, University Medical Center Mainz Johannes Gutenberg University of Mainz, Mainz, Germany; University Hospital Carl Gustav Carus Dresden, Medical Psychology and Medical Sociology, Dresden, Germany
| | - Anne Strunk
- University Hospital, Department of Dermatology, Technical University Dresden, Germany
| | - Jürgen Hoyer
- Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Germany
| | - Clemens Kirschbaum
- Department of Psychology, Institute of Biological Psychology, Technische Universität Dresden, Zellescher Weg 19, 01069 Dresden, Germany
| | - Peter Joraschky
- Clinic of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technical University Dresden, Germany
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van Gelderen MJ, Nijdam MJ, de Vries F, Meijer OC, Vermetten E. Exposure-related cortisol predicts outcome of psychotherapy in veterans with treatment-resistant posttraumatic stress disorder. J Psychiatr Res 2020; 130:387-393. [PMID: 32889356 DOI: 10.1016/j.jpsychires.2020.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/28/2020] [Accepted: 08/12/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hypothalamic-pituitary-adrenal axis functioning has been related to treatment outcome in posttraumatic stress disorder (PTSD). Previous studies have primarily focused on cortisol levels before and after a course of therapy and findings have not been fully consistent. This study investigated session-related cortisol levels in veterans with treatment-resistant PTSD over the course of a novel motion-assisted virtual reality exposure therapy and aimed to determine whether cortisol levels were related to changes in PTSD symptom severity. METHODS Veterans (N = 22) received six exposure sessions during which salivary cortisol samples were collected pre-session, post-session and in the late afternoon following sessions. PTSD symptom severity was assessed by structured clinical interviews at pre- and post-treatment. Average cortisol levels were compared between responders and non-responders. Linear regression analyses were conducted with PTSD symptom change as criterion variable, average cortisol levels as predictor, and timing of sampling and baseline PTSD symptoms as covariates. RESULTS Responders to treatment tended to have higher average cortisol levels at pre-session (p = 0.064) and post-session (p = 0.050) compared to non-responders. Higher average pre-session and post-session cortisol levels predicted greater PTSD symptom improvement (pre: b = -1.83, p = 0.009; post: b = -3.57, p = 0.004). CONCLUSION This study provides preliminary evidence for session-related cortisol as biomarker of response to exposure-based therapies for PTSD. Higher cortisol levels may have facilitated fear extinction and reconsolidation, and may indicate increased physiological stress activation necessary for appropriate treatment engagement. Further work involving comparable methodology is encouraged to establish session-related cortisol as biomarker and to determine the mechanisms through which it interacts with treatment outcome.
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Affiliation(s)
- Marieke J van Gelderen
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Nienoord 5, 1112XE, Diemen, the Netherlands; Department of Psychiatry, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands.
| | - Mirjam J Nijdam
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Nienoord 5, 1112XE, Diemen, the Netherlands; Department of Psychiatry, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Friso de Vries
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Onno C Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Eric Vermetten
- ARQ Centrum'45, ARQ National Psychotrauma Centre, Nienoord 5, 1112XE, Diemen, the Netherlands; Department of Psychiatry, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands; Military Mental Health-Research, Ministry of Defense, Lundlaan 1, 3584 EZ, Utrecht, the Netherlands
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12
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Kellner M, Yassouridis A, Adel F, Muhtz C, Jelinek L, Wiedemann K. Cortisol, DHEA and DHEA-S during exposure therapy in patients with obsessive-compulsive disorder - secretion patterns and prediction of treatment response. Psychiatry Res 2020; 291:113288. [PMID: 32763549 DOI: 10.1016/j.psychres.2020.113288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022]
Abstract
The cortisol response in patients with obsessive-compulsive disorder (OCD) during exposure with response prevention (ERP), a stressful but very effective psychotherapeutic treatment, has shown contradictory findings in three prior studies with low sample sizes. In a larger cohort of 51 patients with OCD we repeatedly measured subjective units of distress (SUD) and the adrenocortical stress hormones cortisol, dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEA-S) in saliva during the very first session of ERP and on the day before. Expectedly, SUD were increased on the ERP day before the session and further rose during ERP, but salivary cortisol and DHEA were statistically indistinguishable from the comparison condition. Interestingly, DHEA-S was significantly elevated throughout the ERP versus the comparison day, but did not further increase in acute response to ERP. According to an explorative analysis in a subsample, hormone levels on the comparison or the ERP day did not predict anti-OCD treatment response one month later. These results corroborate our prior findings of cortisol non-response despite considerable subjective stress in ERP. The role of DHEA-S in anticipatory anxiety and the effects of augmentative cortisol therapy in ERP need further study.
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Affiliation(s)
- Michael Kellner
- University Hospital Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Hamburg, Germany; Herford Hospital, Department of Psychiatry, Psychotherapy & Psychosomatics, Herford, Germany.
| | - Alexander Yassouridis
- Max Planck Institute of Psychiatry, Department of Statistics and Biomathematics, Munich, Germany
| | - Fred Adel
- Herford Hospital, Department of Psychiatry, Psychotherapy & Psychosomatics, Herford, Germany
| | - Christoph Muhtz
- University Hospital Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Hamburg, Germany
| | - Lena Jelinek
- University Hospital Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Hamburg, Germany
| | - Klaus Wiedemann
- University Hospital Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Hamburg, Germany
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Vismara M, Girone N, Cirnigliaro G, Fasciana F, Vanzetto S, Ferrara L, Priori A, D’Addario C, Viganò C, Dell’Osso B. Peripheral Biomarkers in DSM-5 Anxiety Disorders: An Updated Overview. Brain Sci 2020; 10:E564. [PMID: 32824625 PMCID: PMC7464377 DOI: 10.3390/brainsci10080564] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 12/12/2022] Open
Abstract
Anxiety disorders are prevalent and highly disabling mental disorders. In recent years, intensive efforts focused on the search for potential neuroimaging, genetic, and peripheral biomarkers in order to better understand the pathophysiology of these disorders, support their diagnosis, and characterize the treatment response. Of note, peripheral blood biomarkers, as surrogates for the central nervous system, represent a promising instrument to characterize psychiatric disorders, although their role has not been extensively applied to clinical practice. In this report, the state of the art on peripheral biomarkers of DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) Anxiety Disorders is presented, in order to examine their role in the pathogenesis of these conditions and their potential application for diagnosis and treatment. Available data on the cerebrospinal fluid and blood-based biomarkers related to neurotransmitters, neuropeptides, the hypothalamic-pituitary-adrenal axis, neurotrophic factors, and the inflammation and immune system are reviewed. Despite the wide scientific literature and the promising results in the field, only a few of the proposed peripheral biomarkers have been defined as a specific diagnostic instrument or have been identified as a guide in the treatment response to DSM-5 Anxiety Disorders. Therefore, further investigations are needed to provide new biological insights into the pathogenesis of anxiety disorders, to help in their diagnosis, and to tailor a treatment.
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Affiliation(s)
- Matteo Vismara
- Department of Mental Health, Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy; (N.G.); (G.C.); (F.F.); (S.V.); (L.F.); (C.V.); (B.D.)
| | - Nicolaja Girone
- Department of Mental Health, Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy; (N.G.); (G.C.); (F.F.); (S.V.); (L.F.); (C.V.); (B.D.)
| | - Giovanna Cirnigliaro
- Department of Mental Health, Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy; (N.G.); (G.C.); (F.F.); (S.V.); (L.F.); (C.V.); (B.D.)
| | - Federica Fasciana
- Department of Mental Health, Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy; (N.G.); (G.C.); (F.F.); (S.V.); (L.F.); (C.V.); (B.D.)
| | - Simone Vanzetto
- Department of Mental Health, Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy; (N.G.); (G.C.); (F.F.); (S.V.); (L.F.); (C.V.); (B.D.)
| | - Luca Ferrara
- Department of Mental Health, Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy; (N.G.); (G.C.); (F.F.); (S.V.); (L.F.); (C.V.); (B.D.)
| | - Alberto Priori
- Department of Health Sciences, Aldo Ravelli Center for Neurotechnology and Brain Therapeutic, University of Milan, 20142 Milan, Italy;
| | - Claudio D’Addario
- Faculty of Bioscience and Technology for Food, Agriculture and Environment, University of Teramo, 64100 Teramo, Italy;
- Department of Clinical Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Caterina Viganò
- Department of Mental Health, Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy; (N.G.); (G.C.); (F.F.); (S.V.); (L.F.); (C.V.); (B.D.)
| | - Bernardo Dell’Osso
- Department of Mental Health, Department of Biomedical and Clinical Sciences “Luigi Sacco”, University of Milan, 20157 Milan, Italy; (N.G.); (G.C.); (F.F.); (S.V.); (L.F.); (C.V.); (B.D.)
- Department of Health Sciences, Aldo Ravelli Center for Neurotechnology and Brain Therapeutic, University of Milan, 20142 Milan, Italy;
- Department of Psychiatry and Behavioral Sciences, Bipolar Disorders Clinic, Stanford University, Stanford, CA 94305, USA
- “Centro per lo studio dei meccanismi molecolari alla base delle patologie neuro-psico-geriatriche”, University of Milan, 20100 Milan, Italy
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Endogenous in-session cortisol during exposure therapy predicts symptom improvement: Preliminary results from a scopolamine-augmentation trial. Psychoneuroendocrinology 2020; 116:104657. [PMID: 32244170 PMCID: PMC7293922 DOI: 10.1016/j.psyneuen.2020.104657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 01/04/2023]
Abstract
The purpose of this study was to explore whether individual differences in glucocorticoid concentrations were associated with symptom improvement following exposure therapy for patients with social anxiety disorder. To do this, 60 participants with social anxiety disorder completed a randomized-controlled trial of exposure therapy, where participants were randomized to receive scopolamine-augmentation or placebo during their 7 exposure sessions. Scopolamine is an antimuscarinic which blocks the effects of acetylcholine and reduces autonomic arousal. During sessions 1, 4, 7, and during the post-treatment extinction assessment, participants provided up to 16 saliva samples (4 in each session). Pre-treatment, post-treatment, and at 1-month follow-up, participants completed the Liebowitz Social Anxiety Scale to monitor change in fear and avoidance symptoms. Elevated endogenous in-session cortisol during exposure sessions was associated with less symptom improvement from pre- to post-treatment and at 1-month follow-up. The association between elevated endogenous in-session cortisol and attenuated symptom change was not moderated by scopolamine treatment condition. Individuals with social anxiety disorder who have elevated neuroendocrine signaling may under-benefit from exposure therapy. This is the first study, to our knowledge, to examine whether endogenous in-session cortisol concentrations predict symptom changes following exposure therapy for the treatment of social anxiety disorder. More investigation of non-invasive and reliable biological markers that explain variability in responses to effective treatments are needed.
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Roque A, Craske MG, Treanor M, Rosenfield D, Ritz T, Meuret AE. Stress-induced cortisol reactivity as a predictor of success in treatment for affective dimensions. Psychoneuroendocrinology 2020; 116:104646. [PMID: 32200225 PMCID: PMC8978549 DOI: 10.1016/j.psyneuen.2020.104646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/31/2020] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Response rates to first-line treatments for depression and anxiety remain unsatisfactory. Identification of predictors or moderators that can optimize treatment matching is of scientific and clinical interest. This study examined the role of prolonged laboratory-induced stress cortisol reactivity as a predictor of outcome for a treatment of affective dimensions (TAD). Patients received 15-sessions of a treatment targeting reductions in negative affect or increases in positive affect (Craske et al., 2019). A second aim was to examine whether treatment type would moderate the association between cortisol reactivity and treatment outcome. METHODS Thirty-five participants underwent a 36-minute intermittent stress induction task composed of a mental arithmetic task and a fear-potentiated startle task one week before treatment initiation. Cortisol was collected at five-time points with reactivity being quantified as peak during the task minus basal level of cortisol the evening before the assessment. Using multilevel modeling, we examined the associations between cortisol reactivity and slopes of symptom improvement. RESULTS Cortisol reactivity was related to treatment outcome, with average and higher levels of stress-induced cortisol response predicting greater decreases in symptoms throughout treatment and 6-month follow-up. Treatment condition differences (moderation) were not observed in the effect of cortisol reactivity on symptoms. CONCLUSION Our findings demonstrate the impact of greater cortisol stress reactivity on treatment outcome. Future studies should investigate how to enhance this therapeutic benefit through capitalizing on endogenous diurnal fluctuations or exogenous cortisol manipulation.
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Affiliation(s)
- Andres Roque
- Department of Psychology, Southern Methodist University
| | | | - Michael Treanor
- Department of Psychology, University of California Los Angeles
| | | | - Thomas Ritz
- Department of Psychology, Southern Methodist University
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Freire RC, Ferreira-Garcia R, Cabo MC, Martins RM, Nardi AE. Panic attack provocation in panic disorder patients with a computer simulation. J Affect Disord 2020; 264:498-505. [PMID: 31786029 DOI: 10.1016/j.jad.2019.11.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/30/2019] [Accepted: 11/12/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Computer simulations (CS) and virtual reality exposure are promising techniques for research and treatment of panic disorder with agoraphobia (PDA). The objective of this study was to ascertain whether a given CS was a stimulus capable of producing panic attacks (PAs), anxiety and psychophysiological changes in patients with PDA. METHODS Thirty PDA patients and 30 healthy subjects were recruited for this study. Subjects were exposed to a 3-min CS of a situation relevant to agoraphobic patients. Anxiety, panic symptoms, PAs, heart rate, skin conductance and respiration were recorded before, during and after the CS exposure. RESULTS The CS effectively induced anxiety, hyperventilation and electrodermal responses in PDA patients but not in healthy subjects. Forty percent of PDA patients had a PA while none of the control subjects had a PA. A subgroup of patients who were less sensitive to the CS than the other subgroup of PDA patients and did not present full-blown PAs still had more panic symptoms, higher anxiety levels and more respiratory irregularities than the controls. LIMITATIONS Low immersion and low sense of presence, lack of interaction with the environment. CONCLUSIONS Exposure to the CS produced effects similar to in vivo exposure, respiratory and caffeine challenges. Subsequent studies should: make direct comparisons between CS and other challenges for PDA; investigate if CS can be a tool for predicting effects of medication; determine the potential of CS as a desensitization technique for situational PAs.
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Affiliation(s)
- Rafael Christophe Freire
- Department of Psychiatry, Queen's University, Kingston, Canada; Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Rafael Ferreira-Garcia
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mariana Costa Cabo
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Renan Machado Martins
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Antonio Egidio Nardi
- Laboratory of Panic and Respiration, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Rytova V, Ganella DE, Hawkes D, Bathgate RAD, Ma S, Gundlach AL. Chronic activation of the relaxin-3 receptor on GABA neurons in rat ventral hippocampus promotes anxiety and social avoidance. Hippocampus 2019; 29:905-920. [PMID: 30891856 DOI: 10.1002/hipo.23089] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/19/2019] [Accepted: 02/22/2019] [Indexed: 12/24/2022]
Abstract
Anxiety disorders are highly prevalent in modern society and better treatments are required. Key brain areas and signaling systems underlying anxiety include prefrontal cortex, hippocampus, and amygdala, and monoaminergic and peptidergic systems, respectively. Hindbrain GABAergic projection neurons that express the peptide, relaxin-3, broadly innervate the forebrain, particularly the septum and hippocampus, and relaxin-3 acts via a Gi/o -protein-coupled receptor known as the relaxin-family peptide 3 receptor (RXFP3). Thus, relaxin-3/RXFP3 signaling is implicated in modulation of arousal, motivation, mood, memory, and anxiety. Ventral hippocampus (vHip) is central to affective and cognitive processing and displays a high density of relaxin-3-positive nerve fibers and RXFP3 binding sites, but the identity of target neurons and associated effects on behavior are unknown. Therefore, in adult, male rats, we assessed the neurochemical nature of hippocampal RXFP3 mRNA-expressing neurons and anxiety-like and social behavior following chronic RXFP3 activation in vHip by viral vector expression of an RXFP3-selective agonist peptide, R3/I5. RXFP3 mRNA detected by fluorescent in situ hybridization was topographically distributed across the hippocampus in somatostatin- and parvalbumin-mRNA expressing GABA neurons. Chronic RXFP3 activation in vHip increased anxiety-like behavior in the light-dark box and elevated-plus maze, but not the large open-field test, and reduced social interaction with a conspecific stranger. Our data reveal disruptive effects of persistent RXFP3 signaling on hippocampal GABA networks important in anxiety; and identify a potential therapeutic target for anxiety disorders that warrants further investigation in relevant preclinical models.
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Affiliation(s)
- Valeria Rytova
- Discovery Science, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia.,Florey Department of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Despina E Ganella
- Discovery Science, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - David Hawkes
- Discovery Science, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Ross A D Bathgate
- Discovery Science, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia.,Department of Biochemistry and Molecular Biology, The University of Melbourne, Parkville, Victoria, Australia
| | - Sherie Ma
- Discovery Science, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia.,Florey Department of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Andrew L Gundlach
- Discovery Science, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia.,Florey Department of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, Australia.,Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, Victoria, Australia
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Stress hormone response to the DEX-CRH test and its relation to psychotherapy outcome in panic disorder patients with and without agoraphobia. Transl Psychiatry 2018; 8:37. [PMID: 29391399 PMCID: PMC5804025 DOI: 10.1038/s41398-017-0081-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 10/13/2017] [Accepted: 11/13/2017] [Indexed: 11/09/2022] Open
Abstract
This study tested whether the hormonal stress response to the DEX-CRH test may be predictive of the psychotherapy success for panic disorder (PD). Thirty-four patients diagnosed either with agoraphobia with PD or PD without agoraphobia were subjected to cognitive behavioural therapy (CBT). Patients (pre-therapy) and healthy volunteers were exposed to the DEX-CRH test. Blood samples were taken for cortisol and adrenocorticotropic hormone (ACTH) assessment. Established panic-specific questionnaires were handed out for the pre-therapy and post-therapy evaluation of disease severity (with reference to panic beliefs and agoraphobic cognitions, fear of bodily sensations, agoraphobic avoidance behaviour). Repeated measures ANCOVA were conducted for the analysis of the pre-therapy hormonal response, and Pearson's correlation analysis to test for associations with the psychotherapy outcome. Data analyses revealed large effect sizes for CBT in the clinical measures (η2 ≥ 0.321), main effects of time for cortisol and ACTH with no differences between both groups, and significant associations between cortisol release and agoraphobic cognitions for the patients. PD diagnosis had no impact on the hormonal response. However, those patients with higher cortisol release showed less improvement after CBT (significantly for agoraphobic cognitions). Clinical implications of these findings are the prediction of the therapy success from a potential endocrine correlate whose persistency (if assessed repeatedly) during the treatment may predict (non-)response to the current treatment, possibly representing a decision support for a change in treatment to avoid the continuation of an inefficient treatment.
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Mayer SE, Snodgrass M, Liberzon I, Briggs H, Curtis GC, Abelson JL. The psychology of HPA axis activation: Examining subjective emotional distress and control in a phobic fear exposure model. Psychoneuroendocrinology 2017; 82:189-198. [PMID: 28233588 PMCID: PMC5478447 DOI: 10.1016/j.psyneuen.2017.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 02/03/2017] [Accepted: 02/05/2017] [Indexed: 12/11/2022]
Abstract
The HPA axis plays a key role in mediating the effects of "stress" on health, but clarifying mechanisms requires an understanding of psycho-biological linkages. There has long been an implicit assumption that subjective emotional distress (e.g., fear) should activate the HPA axis. Although this assumption was challenged 25 years ago (Curtis, 1976), laboratory studies in humans are limited. In this study we sought to replicate Curtis' findings and extend it by investigating if presence or absence of stressor control shapes HPA axis reactivity in a phobic fear exposure model. We recruited 19-45-year-old specific phobia participants (n=32 spider/snake phobia; n=14 claustrophobia) and gradually exposed them to their feared object or situation while measuring hormonal (ACTH and cortisol) and subjective (emotional distress, perceived control) responses. Utilizing a dyadic yoked design, we compared HPA reactivity when the pace of exposure was controlled by participants to identical exposure given to matched participants in the absence of control. Results showed that phobic fear exposure generated intense emotional distress without a corresponding increase in HPA axis activity. Although our actual manipulation of control failed to impact HPA responses, perceived control during exposure was associated with lower cortisol, an effect that was moderated by actual availability of stressor control. Our findings replicate Curtis' findings and challenge the still common but unsupported assumption that HPA axis activity reflects subjective distress. These results also highlight the importance of both perceived and actual aspects of stressor control in understanding what is truly "stressful" to the HPA axis system.
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Affiliation(s)
- Stefanie E. Mayer
- Department of Psychology, University of Michigan, 530 Church Street, Arbor, MI 48109, USA
| | - Michael Snodgrass
- Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Arbor, MI 48109, USA
| | - Israel Liberzon
- Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Arbor, MI 48109, USA
| | - Hedieh Briggs
- Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Arbor, MI 48109, USA
| | - George C. Curtis
- Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Arbor, MI 48109, USA
| | - James L. Abelson
- Department of Psychiatry, University of Michigan, 4250 Plymouth Rd, Arbor, MI 48109, USA,Corresponding author: James L. Abelson, M.D., Ph.D., 4250 Plymouth Rd (Box 5765, Rm. 2733) Ann Arbor, MI 48109-2700, Phone: 734-764-5348; fax: 734-936-7868,
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Empirically supported psychological treatments and the Research Domain Criteria (RDoC). J Affect Disord 2017; 216:78-88. [PMID: 27836118 DOI: 10.1016/j.jad.2016.10.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 10/11/2016] [Accepted: 10/18/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Research Domain Criteria (RDoC) has been developed as an alternative approach to studying psychiatric disorders. The RDoC constructs and units of analysis, from genes up through paradigms, are intended to describe a hierarchy of priority measurements. Several of these have been investigated in the context of empirically-supported treatments, as either moderators or mediators of outcome. METHOD This review considers the available research on the moderating and mediating role of genes, molecules, circuits and physiology in cognitive-behavior therapy (CBT) outcome studies for negative valence system conditions. FINDINGS Based on the review, research has aspired to identify candidate genes, molecules, circuits and physiological moderators or mediators of treatment, but no definitive tests have been conducted. Instead, several candidate variables have been found that deserve further investigation. LIMITATIONS The available research is based on diagnoses from the DSM, whereas the RDoC initiative endeavors to determine empirically valid taxonomic signs. CONCLUSIONS The results of this review are discussed in the joint context of developments in empirically-supported psychological therapy and the specific aims of the RDoC initiative, and conclude with recommendations for future research.
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Bandelow B, Baldwin D, Abelli M, Bolea-Alamanac B, Bourin M, Chamberlain SR, Cinosi E, Davies S, Domschke K, Fineberg N, Grünblatt E, Jarema M, Kim YK, Maron E, Masdrakis V, Mikova O, Nutt D, Pallanti S, Pini S, Ströhle A, Thibaut F, Vaghix MM, Won E, Wedekind D, Wichniak A, Woolley J, Zwanzger P, Riederer P. Biological markers for anxiety disorders, OCD and PTSD: A consensus statement. Part II: Neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry 2017; 18:162-214. [PMID: 27419272 PMCID: PMC5341771 DOI: 10.1080/15622975.2016.1190867] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Biomarkers are defined as anatomical, biochemical or physiological traits that are specific to certain disorders or syndromes. The objective of this paper is to summarise the current knowledge of biomarkers for anxiety disorders, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD). METHODS Findings in biomarker research were reviewed by a task force of international experts in the field, consisting of members of the World Federation of Societies for Biological Psychiatry Task Force on Biological Markers and of the European College of Neuropsychopharmacology Anxiety Disorders Research Network. RESULTS The present article (Part II) summarises findings on potential biomarkers in neurochemistry (neurotransmitters such as serotonin, norepinephrine, dopamine or GABA, neuropeptides such as cholecystokinin, neurokinins, atrial natriuretic peptide, or oxytocin, the HPA axis, neurotrophic factors such as NGF and BDNF, immunology and CO2 hypersensitivity), neurophysiology (EEG, heart rate variability) and neurocognition. The accompanying paper (Part I) focuses on neuroimaging and genetics. CONCLUSIONS Although at present, none of the putative biomarkers is sufficient and specific as a diagnostic tool, an abundance of high quality research has accumulated that should improve our understanding of the neurobiological causes of anxiety disorders, OCD and PTSD.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University of Göttingen, Germany
| | - David Baldwin
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Marianna Abelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Blanca Bolea-Alamanac
- School of Social and Community Medicine, Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Michel Bourin
- Neurobiology of Anxiety and Mood Disorders, University of Nantes, Nantes, France
| | - Samuel R. Chamberlain
- Hertfordshire Partnership University NHS Foundation Trust and University of Hertfordshire, Parkway, UK
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Eduardo Cinosi
- Department of Neuroscience Imaging and Clinical Sciences, Gabriele D’Annunzio University, Chieti, Italy
| | - Simon Davies
- Centre for Addiction and Mental Health, Geriatric Psychiatry Division, University of Toronto, Toronto, Canada
- School of Social and Community Medicine, Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Katharina Domschke
- Department of Psychiatry Psychosomatics and Psychotherapy, University of Wuerzburg, Wuerzburg, Germany
| | - Naomi Fineberg
- Hertfordshire Partnership University NHS Foundation Trust and University of Hertfordshire, Parkway, UK
| | - Edna Grünblatt
- Department of Psychiatry Psychosomatics and Psychotherapy, University of Wuerzburg, Wuerzburg, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and the ETH Zurich, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Marek Jarema
- Third Department of Psychiatry, Institute of Psychiatry and Neurology, Warszawa, Poland
| | - Yong-Ku Kim
- Department of Psychiatry College of Medicine, Korea University, Seoul, Republic of Korea
| | - Eduard Maron
- Department of Psychiatry, North Estonia Medical Centre, Tallinn, Estonia
- Department of Psychiatry, University of Tartu, Estonia
- Faculty of Medicine Department of Medicine, Centre for Neuropsychopharmacology, Division of Brain Sciences, Imperial College London, UK
| | - Vasileios Masdrakis
- Athens University Medical School, First Department of Psychiatry, Eginition Hospital, Athens, Greece
| | - Olya Mikova
- Foundation Biological Psychiatry, Sofia, Bulgaria
| | - David Nutt
- Faculty of Medicine Department of Medicine, Centre for Neuropsychopharmacology, Division of Brain Sciences, Imperial College London, UK
| | - Stefano Pallanti
- UC Davis Department of Psychiatry and Behavioural Sciences, Sacramento, CA, USA
| | - Stefano Pini
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité – University Medica Center Berlin, Berlin, Germany
| | - Florence Thibaut
- Faculty of Medicine Paris Descartes, University Hospital Cochin, Paris, France
| | - Matilde M. Vaghix
- Department of Psychology and Behavioural and Clinical Neuroscience Institute, University of Cambridge, UK
| | - Eunsoo Won
- Department of Psychiatry College of Medicine, Korea University, Seoul, Republic of Korea
| | - Dirk Wedekind
- Department of Psychiatry and Psychotherapy, University of Göttingen, Germany
| | - Adam Wichniak
- Third Department of Psychiatry, Institute of Psychiatry and Neurology, Warszawa, Poland
| | - Jade Woolley
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Peter Zwanzger
- kbo-Inn-Salzach-Klinikum Wasserburg am Inn, Germany
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Peter Riederer
- Department of Psychiatry Psychosomatics and Psychotherapy, University of Wuerzburg, Wuerzburg, Germany
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Fischer S, Cleare AJ. Cortisol as a predictor of psychological therapy response in anxiety disorders-Systematic review and meta-analysis. J Anxiety Disord 2017; 47:60-68. [PMID: 28273494 DOI: 10.1016/j.janxdis.2017.02.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 01/11/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although psychotherapy generally is effective in anxiety disorders, many patients are treatment-resistant. At the same time, some patients with anxiety disorders show alterations in the hypothalamic-pituitary-adrenal (HPA) axis, one of the major stress-responsive systems. Since raised levels of the end product of the HPA axis, cortisol, adversely affect cognition, we hypothesised that more pronounced alterations in cortisol levels would be associated with a less favourable response to psychotherapy. More specifically, the higher patients' basal levels and the lower their levels during exposure, the less likely we expected them to profit from treatment. METHODS We systematically searched the Cochrane Library, EMBASE, MEDLINE, and PsycINFO to review the literature and perform a meta-analysis on the relationship between pre-treatment cortisol and psychotherapy response. Records were included if they studied patients with any anxiety disorder undergoing psychotherapy, with a pre-treatment cortisol and a post-treatment symptom measure. Correlation coefficients were extracted for meta-analyses. RESULTS We identified six studies (N=274). No relationship between patients' basal cortisol and post-treatment symptoms was found (p=0.981). The systematic review showed higher cortisol during exposure sessions to predict better outcomes. Meta-analysis did not confirm this (p=0.603). CONCLUSIONS Basal cortisol did not seem to predict psychological therapy responses in patients with anxiety disorders. By contrast, the current state of research is equivocal in terms of whether higher cortisol concentrations during exposure sessions are linked with better treatment outcomes, and more research is needed to investigate this.
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Affiliation(s)
- Susanne Fischer
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, Department of Psychological Medicine, Centre for Affective Disorders, London, United Kingdom.
| | - Anthony J Cleare
- King's College London, Institute of Psychiatry, Psychology & Neuroscience, Department of Psychological Medicine, Centre for Affective Disorders, London, United Kingdom
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Wichmann S, Kirschbaum C, Lorenz T, Petrowski K. Effects of the cortisol stress response on the psychotherapy outcome of panic disorder patients. Psychoneuroendocrinology 2017; 77:9-17. [PMID: 27987430 DOI: 10.1016/j.psyneuen.2016.11.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 11/23/2016] [Accepted: 11/23/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND A proportion of patients with panic disorder (PD) fail to show a remission after psychotherapy. Biological correlates of psychotherapy non-response have rarely been described in the literature. The aim of the present study was to research the relationship between the cortisol stress response and the psychotherapy outcome in PD patients. METHODS Twenty-eight PD patients (20 females, mean age±SD: 35.71±13.18) seeking psychological treatment for PD and n=32 age- and sex-matched healthy control participants (21 females, aged 34.66±12.07) participated in this study. The patients underwent five weeks of cognitive behavioural therapy (CBT). Within the first two weeks of the CBT, both study groups were confronted with the Trier Social Stress Test (TSST). Blood sampling for cortisol and adrenocorticotropic hormone (ACTH) evaluation as well as fear-rating (Visual Analogue Scale; Primary Appraisal and Secondary Appraisal Questionnaire, PASA) accompanied the TSST. The global severity of PD (Panic & Agoraphobia Scale; PAS), agoraphobic cognitions (Agoraphobic Cognitions Questionnaire; ACQ), fear of bodily sensations (Bodily Sensations Questionnaire; BSQ), agoraphobic avoidance (Mobility Inventory; MI), and depressiveness (Beck Depression Inventory; BDI) were assessed before and after the CBT (except the BDI). RESULTS The statistical analysis revealed significant main effects of time for cortisol and the ACTH concentration in response to the TSST, independently of the study group. 42.9% of the PD patients and 65.6% of the healthy control participants showed a cortisol stress response to the TSST≥55.2nmol/l (descriptive finding). The data showed a significant inverse association of the TSST cortisol stress response with the MI total score when accompanied. Further, a significant association of the PASA subjective level of fear and the BSQ as well as a trend for an association of the PASA with the ACQ were observed. CONCLUSION Consistent with prior research, we could replicate findings of decreased cortisol concentrations in the PD patients in comparison to the healthy control participants. Furthermore, our findings agree with previous data showing an association of the attenuated cortisol stress response with the psychotherapy non-response. In the present sample, those patients with the lowest cortisol concentrations showed the least improvement in agoraphobic avoidance after psychotherapy. The patients with the highest level of fear showed the most improvement in fear of bodily sensations. Study limitations as well as implications for future studies will be discussed.
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Affiliation(s)
- Susann Wichmann
- Department of Psychology, Institute of Biological Psychology, Technische Universität Dresden, Germany.
| | - Clemens Kirschbaum
- Department of Psychology, Institute of Biological Psychology, Technische Universität Dresden, Germany
| | - Thomas Lorenz
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Germany
| | - Katja Petrowski
- Department of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Germany
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Meuret AE, Rosenfield D, Bhaskara L, Auchus R, Liberzon I, Ritz T, Abelson JL. Timing matters: Endogenous cortisol mediates benefits from early-day psychotherapy. Psychoneuroendocrinology 2016; 74:197-202. [PMID: 27664810 DOI: 10.1016/j.psyneuen.2016.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/09/2016] [Accepted: 09/14/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE No simple way to augment fear extinction has been established. Cortisol has shown to enhance memory extinction and preliminary evidence suggest that extinction learning maybe more successful in the morning when cortisol is high. The aim was to determine whether exposure sessions conducted earlier in the day are associated with superior therapeutic gains in extinction-based psychotherapy. We also examined the role of cortisol levels as a mediator between time of day and therapeutic gains. METHOD Participants were 24 individuals meeting DSM-IV criteria for panic disorder with agoraphobia. Participants received 3 weekly in-vivo exposure sessions, yielding 72 total sessions for analysis of time of day effects. Session start times were evenly distributed across the day. The outcome measures were reductions in panic symptom severity (avoidance behaviors, threat misappraisal, perceived control, and panic disorder symptom severity). RESULTS Sessions starting earlier in the day were associated with superior therapeutic gains by the next therapy session. Earlier sessions were also associated with higher pre-exposure cortisol levels, which in turn were related to greater clinical improvement by the next session. Cortisol thus was found to mediate the effect of time of day on subsequent outcome, providing a link between earlier exposure sessions and greater clinical improvement. CONCLUSION The data suggest that early-day extinction-based therapy sessions yield better outcomes than later-day sessions, partly due to the enhancing effect of higher cortisol levels.
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Affiliation(s)
- Alicia E Meuret
- Southern Methodist University, Department of Psychology, United States.
| | - David Rosenfield
- Southern Methodist University, Department of Psychology, United States
| | - Lavanya Bhaskara
- Southern Methodist University, Department of Psychology, United States
| | - Richard Auchus
- University of Michigan, Department of Psychiatry, United States
| | - Israel Liberzon
- University of Michigan, Department of Psychiatry, United States
| | - Thomas Ritz
- Southern Methodist University, Department of Psychology, United States
| | - James L Abelson
- University of Michigan, Department of Psychiatry, United States
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Predisposition or side effect of the duration: the reactivity of the HPA-axis under psychosocial stress in panic disorder. Int J Psychophysiol 2016; 107:9-15. [DOI: 10.1016/j.ijpsycho.2016.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 05/24/2016] [Accepted: 06/16/2016] [Indexed: 01/13/2023]
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Jakuszkowiak-Wojten K, Landowski J, Wiglusz MS, Cubała WJ. Cortisol awakening response in drug-naïve panic disorder. Neuropsychiatr Dis Treat 2016; 12:1581-5. [PMID: 27390521 PMCID: PMC4930225 DOI: 10.2147/ndt.s107547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
BACKGROUND It is unclear whether hypothalamic-pituitary-adrenal axis is involved in the pathophysiology of panic disorder (PD). The findings remain inconsistent. Cortisol awakening response (CAR) is a noninvasive biomarker of stress system activity. We designed the study to assess CAR in drug-naïve PD patients. MATERIALS AND METHODS We assessed CAR in 14 psychotropic drug-naïve outpatients with PD and 14 healthy controls. The severity of PD was assessed with Panic and Agoraphobia Scale. The severity of anxiety and depression was screened with Hospital Anxiety and Depression Scale. RESULTS No significant difference in CAR between PD patients and control group was found. No correlations were observed between CAR and anxiety severity measures in PD patients and controls. LIMITATIONS The number of participating subjects was relatively small, and the study results apply to nonsuicidal drug-naïve PD patients without agoraphobia and with short-illness duration. There was a lack of control on subjects' compliance with the sampling instructions. CONCLUSION The study provides no support for elevated CAR levels in drug-naïve PD patients without agoraphobia.
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Affiliation(s)
| | - Jerzy Landowski
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
| | - Mariusz S Wiglusz
- Department of Psychiatry, Medical University of Gdańsk, Gdańsk, Poland
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Schumacher S, Miller R, Fehm L, Kirschbaum C, Fydrich T, Ströhle A. Therapists' and patients' stress responses during graduated versus flooding in vivo exposure in the treatment of specific phobia: A preliminary observational study. Psychiatry Res 2015; 230:668-75. [PMID: 26545614 DOI: 10.1016/j.psychres.2015.10.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/12/2015] [Accepted: 10/18/2015] [Indexed: 12/22/2022]
Abstract
Exposure therapy is considered an effective treatment strategy for phobic anxiety, however, it is rarely applied in clinical practice. The under-usage might be due to various factors of which heightened stress levels not only in patients but also in therapists are presumed to be of particular relevance. The present study aimed to investigate whether different forms of exposure might lead to varying physiological and psychological stress responses in therapists and phobic patients. 25 patients with specific phobia underwent individual cognitive behavioural therapy, performed by 25 psychotherapist trainees, applying exposure sessions in graduated form or the flooding technique. Patients and therapists provided subjective evaluations of stress and five saliva samples for analysis of salivary cortisol and alpha-amylase either during two graduated exposure sessions or during one flooding session, while a regular therapy session served as control condition. Therapists displayed heightened salivary alpha-amylase release during exposure of the flooding, but not the graduated, type. Patients showed elevated salivary cortisol during flooding exposure numerically, however, not on a statistically significant level. Therapists reported more pronounced subjective stress during flooding compared to graduated exposure. Elevated stress levels should be addressed in clinical training in order to improve application of exposure in routine practice.
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Affiliation(s)
- Sarah Schumacher
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany; Department of Psychology, Humboldt-University at Berlin, Berlin, Germany.
| | - Robert Miller
- Department of Biopsychology, Technical University Dresden, Dresden, Germany
| | - Lydia Fehm
- Department of Psychology, Humboldt-University at Berlin, Berlin, Germany
| | - Clemens Kirschbaum
- Department of Biopsychology, Technical University Dresden, Dresden, Germany
| | - Thomas Fydrich
- Department of Psychology, Humboldt-University at Berlin, Berlin, Germany
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany
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Abstract
Although exposure-based treatments and anxiolytic medications are more effective than placebo for treating anxiety disorders, there is still considerable room for further improvement. Interestingly, combining these two modalities is usually not more effective than the monotherapies. Recent translational research has identified a number of novel approaches for treating anxiety disorders using agents that serve as neuroenhancers (also known as cognitive enhancers). Several of these agents have been studied to determine their efficacy at improving treatment outcome for patients with anxiety and other psychiatric disorders. In this review, we examine d-cycloserine, yohimbine, cortisol, catecholamines, oxytocin, modafinil, and nutrients such as caffeine and amino fatty acids as potential neuroenhancers. Of these agents, d-cycloserine shows the most promise as an effective neuroenhancer for extinction learning and exposure therapy. Yet, the optimal dosing and dose timing for drug administration remains uncertain. There is partial support for cortisol, catecholamines, yohimbine and oxytocin for improving extinction learning and exposure therapy. There is less evidence to indicate that modafinil and nutrients such as caffeine and amino fatty acids are effective neuroenhancers. More research is needed to determine their long term efficacy and clinical utility of these agents.
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Affiliation(s)
- Stefan G Hofmann
- Psychotherapy and Emotion Research Laboratory, Department of Psychological and Brain Sciences, Boston University, Boston, MA USA
| | - Elizabeth A Mundy
- Psychotherapy and Emotion Research Laboratory, Department of Psychological and Brain Sciences, Boston University, Boston, MA USA
| | - Joshua Curtiss
- Psychotherapy and Emotion Research Laboratory, Department of Psychological and Brain Sciences, Boston University, Boston, MA USA
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Meuret AE, Trueba AF, Abelson JL, Liberzon I, Auchus R, Bhaskara L, Ritz T, Rosenfield D. High cortisol awakening response and cortisol levels moderate exposure-based psychotherapy success. Psychoneuroendocrinology 2015; 51:331-40. [PMID: 25462905 DOI: 10.1016/j.psyneuen.2014.10.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 10/02/2014] [Accepted: 10/08/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Research suggests that elevated stress hormones during exposure can facilitate fear extinction in laboratory settings. However, prospective studies on the clinical benefits of endogenous cortisol on clinical improvements in naturalistic exposures are lacking. METHODS Twenty-six patients with panic disorder and agoraphobia completed three weekly in-vivo exposure sessions and a fourth session 2 months following therapy completion, resulting in a total of 94 in-vivo exposure sessions. Salivary cortisol was collected at multiple times during the first exposure day (cortisol morning response, prior, -during, -after exposure) and at subsequent exposure sessions (prior, -during, -after exposure). Cortisol collection on a non-exposure comparison day followed the same time schedule as session 1. RESULTS Exposure day anxiety and cortisol levels were significantly higher than control day levels. Higher absolute cortisol levels during exposures moderated clinical improvement (avoidance behavior, threat appraisal, perceived control). Therapeutic gains were not just related to exposure day cortisol levels, but were also linked to non-exposure day levels. Greater morning rises in cortisol on exposure day predicted greater treatment gains, but greater rises on the control day were associated with poorer outcomes. CONCLUSIONS The study provides first evidence for a moderating effect of cortisol awakening response and absolute cortisol levels on fear extinction processes during naturalistic, prospective exposure-therapy. Additionally, we replicated and extended prior findings on the therapeutic benefits of high exposure cortisol levels. Together, the findings suggest that cortisol may act as a general moderator of facilitated learning during exposure therapy.
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Affiliation(s)
| | | | | | | | | | | | - Thomas Ritz
- Southern Methodist University, United States
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Jacobson L. Hypothalamic-pituitary-adrenocortical axis: neuropsychiatric aspects. Compr Physiol 2014; 4:715-38. [PMID: 24715565 DOI: 10.1002/cphy.c130036] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Evidence of aberrant hypothalamic-pituitary-adrenocortical (HPA) activity in many psychiatric disorders, although not universal, has sparked long-standing interest in HPA hormones as biomarkers of disease or treatment response. HPA activity may be chronically elevated in melancholic depression, panic disorder, obsessive-compulsive disorder, and schizophrenia. The HPA axis may be more reactive to stress in social anxiety disorder and autism spectrum disorders. In contrast, HPA activity is more likely to be low in PTSD and atypical depression. Antidepressants are widely considered to inhibit HPA activity, although inhibition is not unanimously reported in the literature. There is evidence, also uneven, that the mood stabilizers lithium and carbamazepine have the potential to augment HPA measures, while benzodiazepines, atypical antipsychotics, and to some extent, typical antipsychotics have the potential to inhibit HPA activity. Currently, the most reliable use of HPA measures in most disorders is to predict the likelihood of relapse, although changes in HPA activity have also been proposed to play a role in the clinical benefits of psychiatric treatments. Greater attention to patient heterogeneity and more consistent approaches to assessing treatment effects on HPA function may solidify the value of HPA measures in predicting treatment response or developing novel strategies to manage psychiatric disease.
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Schumacher S, Gaudlitz K, Plag J, Miller R, Kirschbaum C, Fehm L, Fydrich T, Ströhle A. Who is stressed? A pilot study of salivary cortisol and alpha-amylase concentrations in agoraphobic patients and their novice therapists undergoing in vivo exposure. Psychoneuroendocrinology 2014; 49:280-9. [PMID: 25127086 DOI: 10.1016/j.psyneuen.2014.07.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/26/2014] [Accepted: 07/15/2014] [Indexed: 10/25/2022]
Abstract
In cognitive behavioural therapy of phobic anxiety, in vivo exposure is considered as an effective treatment strategy. Apparently, it involves the experience of stress and anxiety in patients. Given the therapist's role during exposure sessions, it is conceivable that the performance is also accompanied with the experience of stress in therapists, especially when unversed in conducting psychotherapy. Studies confirmed that cognitive behavioural therapists tend to avoid therapist-guided in vivo exposure. The objective of this study was the simultaneous investigation of therapist's and patient's stress response during in vivo exposure. Therefore, 23 agoraphobic patients and their 23 treating therapists in training provided five saliva samples during an in vivo exposure and five samples during an ordinary therapy session. Before and during exposure session, subjective evaluations of stress and anxiety were assessed. Results suggested that therapists reported similar levels of perceived stress as patients before exposure. Both groups displayed significantly elevated salivary cortisol (sC) levels during exposure compared to the control session and a trend for alterations in salivary alpha-amylase (sAA) activity was found. Therapists reached peak concentrations of sC before start of the intervention followed by a decline during exposure, while patients displayed peak levels of cortisol secretion after 60 min of exposure. In vivo exposure seems to be a demanding intervention not only for the patient, but also for therapists in training. However, it was also demonstrated that physiological and subjective stress rather decrease during the intervention and that both groups rated exposure to be substantially successful. Based on the presented results, another potential factor contributing to the under-usage of exposure treatment is conceivable and needs to be addressed in future research.
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Affiliation(s)
- Sarah Schumacher
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany; Department of Psychology, Humboldt University of Berlin, Berlin, Germany.
| | - Katharina Gaudlitz
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany
| | - Jens Plag
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany
| | - Robert Miller
- Department of Biopsychology, Technical University Dresden, Dresden, Germany
| | - Clemens Kirschbaum
- Department of Biopsychology, Technical University Dresden, Dresden, Germany
| | - Lydia Fehm
- Department of Psychology, Humboldt University of Berlin, Berlin, Germany
| | - Thomas Fydrich
- Department of Psychology, Humboldt University of Berlin, Berlin, Germany
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, Germany
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Steffen PR, Fidalgo L, Schmuck D, Tsui Y, Brown T. Psychotherapy participants show increased physiological responsiveness to a lab stressor relative to matched controls. Front Psychol 2014; 5:795. [PMID: 25120511 PMCID: PMC4112910 DOI: 10.3389/fpsyg.2014.00795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 07/07/2014] [Indexed: 11/13/2022] Open
Abstract
Accumulating evidence indicates that psychotherapy participants show increased physiological responsiveness to stress. The purpose of the present study was to examine differences between individuals participating in outpatient psychotherapy and matched controls using an experimental design. Forty-two psychotherapy participants and 48 matched controls were assessed on cardiovascular and cortisol functioning at baseline, during the Trier Social Stress Test (TSST), and during a 20-min recovery period. Psychotherapy participants and matched controls did not differ at baseline or during the TSST on the physiological measures but psychotherapy participants had higher cortisol and heart rate (HR) during the recovery period. In regards to reactivity, cortisol increased during the recovery period for the psychotherapy participants but decreased for those in the matched control group. Psychotherapy participants experiencing clinically significant levels of distress displayed elevated systolic and diastolic blood pressure and HR during the TSST when compared to psychotherapy participants not experiencing clinically significant levels of distress. Overall, physiological reactivity to stress appears to be an important issue for those in psychotherapy and directly addressing this issue may help improve psychotherapy outcomes.
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Affiliation(s)
| | - Louise Fidalgo
- Department of Psychology, Brigham Young University Provo, UT, USA
| | - Dominic Schmuck
- Department of Psychology, Brigham Young University Provo, UT, USA
| | - Yoko Tsui
- Department of Psychology, Brigham Young University Provo, UT, USA
| | - Tracy Brown
- Department of Psychology, Brigham Young University Provo, UT, USA
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Lass-Hennemann J, Michael T. Endogenous cortisol levels influence exposure therapy in spider phobia. Behav Res Ther 2014; 60:39-45. [PMID: 25051297 DOI: 10.1016/j.brat.2014.06.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 06/26/2014] [Accepted: 06/30/2014] [Indexed: 10/25/2022]
Abstract
Previous research in patients with phobia showed that the administration of glucocorticoids reduces fear in phobic situations and enhances exposure therapy. Glucocorticoids underlie a daily cycle with a peak in the morning and low levels during the evening and night. The aim of the present study was to investigate whether exposure is more effective when conducted in the morning when endogenous cortisol levels are high. Sixty patients meeting DSM IV criteria for specific phobia (animal type) were randomly assigned to one-session exposure treatment either at 08.00 a.m. (high cortisol group) or at 06.00 p.m. (low cortisol group). Participants returned for a posttreatment assessment one week after therapy and a follow-up assessment three months after therapy. Both groups showed good outcome, but patients treated in the morning exhibited significantly less fear of spiders in the behavioral approach test (BAT) and a trend for lower scores on the Fear of Spiders Questionnaire (FSQ) than patients treated in the evening. This effect was present at posttreatment and follow-up. Our findings indicate that exposure therapy is more effective in the morning than in the evening. We suggest that this may be due to higher endogenous cortisol levels in the morning group that enhance extinction memory.
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Affiliation(s)
| | - Tanja Michael
- Department of Clinical Psychology and Psychotherapy, Saarland University, Germany
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Abstract
A combination of exposure therapy techniques and Acceptance and Commitment Therapy (ACT) strategies were used to treat a 23-year-old pregnant female who was housebound due to symptoms of agoraphobia. The client in this case study had not left her family home in 10 months when she sought treatment for her anxiety. The client was successfully treated over a year, such that she was able to receive prenatal care at an obstetrician’s office and to deliver her infant at a hospital. Neither the client nor her fetus suffered any complications due to treatment. Post-treatment and 1-year follow-up data indicated that the client continued to show significant functional improvements following the birth of her child. Recommendations for integrating ACT strategies into exposure therapy for severe agoraphobia and for anxious pregnant women are provided.
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High-dose corticosterone after fear conditioning selectively suppresses fear renewal by reducing anxiety-like response. Pharmacol Biochem Behav 2014; 124:188-95. [PMID: 24933336 DOI: 10.1016/j.pbb.2014.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 05/22/2014] [Accepted: 06/07/2014] [Indexed: 11/21/2022]
Abstract
Exposure therapy is widely used to treat anxiety disorders, including posttraumatic stress disorder (PTSD). However, preventing the return of fear is still a major challenge after this behavioral treatment. An increasing number of studies suggest that high-dose glucocorticoid treatment immediately after trauma can alleviate the symptoms of PTSD in humans. Unknown is whether high-dose glucocorticoid treatment following fear conditioning suppresses the return of fear. In the present study, a typical fear renewal paradigm (AAB) was used, in which the fear response to an auditory cue can be restored in a novel context (context B) when both training and extinction occur in the same context (context A). We trained rats for auditory fear conditioning and administered corticosterone (CORT; 5 and 25mg/kg, i.p.) or vehicle with different delays (1 and 24h). Forty-eight hours after drug injection, extinction was conducted with no drug in the training context, followed by a test of tone-induced freezing behavior in the same (AAA) or a shifted (AAB) context. Both immediate and delayed administration of high-dose CORT after fear conditioning reduced fear renewal. To examine the anxiolytic effect of CORT, independent rats were trained for cued or contextual fear conditioning, followed by an injection of CORT (5 and 25mg/kg, i.p.) or vehicle at a 1 or 24h delay. One week later, anxiety-like behavior was assessed in the elevated plus maze (EPM) before and after fear expression. We found that high-dose CORT decreased anxiety-like behavior without changing tone- or context-induced freezing. These findings indicate that a single high-dose CORT administration given after fear conditioning may selectively suppress fear renewal by reducing anxiety-like behavior and not by altering the consolidation, retrieval, or extinction of fear memory.
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36
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Elnazer HY, Baldwin DS. Investigation of cortisol levels in patients with anxiety disorders: a structured review. Curr Top Behav Neurosci 2014; 18:191-216. [PMID: 24659553 DOI: 10.1007/7854_2014_299] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Anxiety disorders are common and distressing medical conditions, which typically arise in adolescence or early adult life. They can persist for many years, reducing quality of life, limiting academic and occupational achievement, and being responsible for considerable economic pressures. Although a range of psychological and pharmacological treatments are available, their success is often limited, and many patients remain troubled by significant symptom-related disability for long periods. The detailed pathophysiology of each anxiety disorder is not established, and novel treatments that are based solely on current understanding of conventional neurotransmitter function are unlikely to be substantially more effective or better tolerated than current treatments. Investigations of hypothalamo-pituitary axis function across panic disorder, generalized anxiety disorder, specific phobias and social anxiety disorder have produced intriguing findings but not revealed a consistent pattern of endocrine disturbance, perhaps reflecting differences in methodology and the nature and size of the clinical samples. There is a persistent need for large, prospective studies using standardized methods for investigation and data analysis (164 words).
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Affiliation(s)
- Hesham Yousry Elnazer
- Clinical and Experimental Sciences Academic Unit (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
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Sulkowski ML, Geller DA, Lewin AB, Murphy TK, Mittelman A, Brown A, Storch EA. The Future of D-Cycloserine and Other Cognitive Modifiers in Obsessive-Compulsive and Related Disorders. CURRENT PSYCHIATRY REVIEWS 2014; 10:317-324. [PMID: 25383074 PMCID: PMC4223803 DOI: 10.2174/1573400510666140619224942] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Variants of exposure therapy are effective for treating obsessive-compulsive and related disorders (OCRDs). However, significant numbers of patients do not respond adequately to exposure therapy resulting in continued distress and functional impairment. Therefore, novel approaches to augmenting exposure therapy are needed to adequately treat non- and partial-responders. Emerging research suggests that interventions that augment learning and memory processes associated with exposure therapy (i.e., extinction training) may display promise in enhancing treatment response in OCRDs. As the most studied example, d-cycloserine (DCS) is a relatively safe cognitive enhancer that appears to accelerate treatment gains associated with exposure therapy. This article reviews research on the use of DCS and other putative cognitive modifiers as they relate to the treatment (or prospective treatment) of obsessive-compulsive disorder and other OCRDs.
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Affiliation(s)
- Michael L. Sulkowski
- University of Arizona, Box 210069 Tucson, AZ 85721-0069, Phone: 520-621-7822 Fax: 520-621-3821
| | - Daniel A. Geller
- Massachusetts General Hospital, Department of Psychiatry, 55 Fruit Street, Boston, MA 02114, Phone: (617) 724-5600, Fax: (617) 726-5567
| | - Adam B. Lewin
- University of South Florida, Department of Pediatrics, 880 6th Street South, Suite 460, Box 7523, St. Petersburg, FL 33701, Phone: (727) 767-8230, Fax: (727) 767-7786
| | - Tanya K. Murphy
- University of South Florida, Department of Pediatrics, 880 6th Street South, Suite 460, Box 7523, St. Petersburg, FL 33701, Phone: (727) 767-8230, Fax: (727) 767-7786
- Universitry of South Florida, Department of Psychiatry, 880 6th Street South, Suite 460, Box 7523, St. Petersburg, FL 33701, Phone: (727) 767-8230, Fax: (727) 767-7786
| | - Andrew Mittelman
- Massachusetts General Hospital, Department of Psychiatry, 55 Fruit Street, Boston, MA 02114, Phone: (617) 724-5600, Fax: (617) 726-5567
| | - Ashley Brown
- Massachusetts General Hospital, Department of Psychiatry, 55 Fruit Street, Boston, MA 02114, Phone: (617) 724-5600, Fax: (617) 726-5567
| | - Eric A. Storch
- University of South Florida, Department of Pediatrics, 880 6th Street South, Suite 460, Box 7523, St. Petersburg, FL 33701, Phone: (727) 767-8230, Fax: (727) 767-7786
- Universitry of South Florida, Department of Psychiatry, 880 6th Street South, Suite 460, Box 7523, St. Petersburg, FL 33701, Phone: (727) 767-8230, Fax: (727) 767-7786
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Blunted salivary and plasma cortisol response in patients with panic disorder under psychosocial stress. Int J Psychophysiol 2013; 88:35-9. [DOI: 10.1016/j.ijpsycho.2013.01.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 12/29/2012] [Accepted: 01/02/2013] [Indexed: 01/04/2023]
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Long-lasting increase of corticosterone after fear memory reactivation: anxiolytic effects and network activity modulation in the ventral hippocampus. Neuropsychopharmacology 2013; 38:386-94. [PMID: 22968818 PMCID: PMC3547189 DOI: 10.1038/npp.2012.192] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pathological fear and anxiety can be studied, in rodents, with fear conditioning and exposure to reminder cues. These paradigms are thought to critically involve the ventral hippocampus, which also serves as key site of glucocorticoid action in the brain. Here, we demonstrate a long-lasting reduction of kainate-induced gamma oscillations in slice preparations of the ventral hippocampal area CA3, 30 days after a single fear conditioning training. Reduction of gamma power was sensitive to corticosterone application and associated with a decrease in glucocorticoid and mineralocorticoid receptor mRNA expression across strata of the ventral hippocampal CA3. A fear reactivation session 24 h after the initial conditioning normalized receptor expression levels and attenuated the corticosterone-mediated recovery of gamma oscillations. It moreover increased both baseline and stimulus-induced corticosterone plasma levels and evoked a generalization of fear memory to the background context. Reduced ventral hippocampal gamma oscillation in both fear reactivated and non-reactivated mice were associated with a decrease of anxiety-like behavior in an elevated plus maze. Taking advantage of the circadian fluctuation in corticosterone, we demonstrated the association of high endogenous basal corticosterone plasma concentrations during morning hours with reduced anxiety-like behavior in fear reactivated mice. The anxiolytic effect of the hormone was verified with local applications to the ventral hippocampus. Our data suggest that corticosterone acting on ventral hippocampal network activity has anxiolytic-like effects following fear exposure, highlighting its potential therapeutic value for anxiety disorders.
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Kellner M, Wiedemann K, Yassouridis A, Muhtz C. Non-response of cortisol during stressful exposure therapy in patients with obsessive-compulsive disorder--preliminary results. Psychiatry Res 2012; 199:111-4. [PMID: 22578822 DOI: 10.1016/j.psychres.2012.04.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 04/16/2012] [Accepted: 04/18/2012] [Indexed: 11/30/2022]
Abstract
Exposure with response prevention (ERP) is an established treatment for patients with obsessive-compulsive disorder (OCD) and also an interesting model to characterize neuroendocrine response to psychological stress. However, so far few studies have assessed hypothalamic-pituitary-adrenocortical (HPA) function during ERP and results are inconsistent. In 15 patients with OCD we repeatedly measured salivary cortisol and subjective units of distress (SUD) on two consecutive afternoons. The first day served as a comparison condition; on the second day the very first session of ERP took place. While SUD were significantly increased during ERP versus the comparison day, salivary cortisol was statistically indistinguishable between ERP and comparison conditions before, during and after ERP. Thus, despite considerable psychological stress no increase of cortisol was observed. This response pattern to ERP in OCD patients needs further research.
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Affiliation(s)
- Michael Kellner
- University Hospital Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Hamburg, Germany.
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Petrowski K, Wintermann GB, Kirschbaum C, Bornstein SR. Dissociation between ACTH and cortisol response in DEX-CRH test in patients with panic disorder. Psychoneuroendocrinology 2012; 37:1199-208. [PMID: 22277728 DOI: 10.1016/j.psyneuen.2011.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Panic disorder (PD) has been associated with the altered circadian rhythm of the hypothalamic-pituitary-adrenocortical (HPA) axis. The findings regarding the stress-specific functioning of the HPA-system are inconsistent. It is also unclear whether the HPA-system response after the Corticotropin-Releasing-Hormone (CRH) challenge becomes altered. METHODS For this study, the dexamethasone-corticotropin-releasing-hormone (DEX-CRH) test was implemented to assess the HPA-axis reactivity indicated by the plasma adreno-corticotropin-hormone (ACTH) and the cortisol release. The sample included 32 patients diagnosed with PD in a Structured Clinical Interview (SCID). Fourteen male and eighteen female patients, [mean age = 33.50 years, SD = 12.76] were matched with 32 healthy controls by age and gender. Moreover, a sample of patients with unipolar depression (n = 21, ten females) was examined as a clinical control group. RESULTS In healthy controls as well as in patients with PD and patients with unipolar depression, the ACTH and the cortisol response increased significantly due to the CRH injection after dexamethasone pre-treatment. There were differences between the healthy controls and the patients with PD in the plasma cortisol response pattern, however, not in the ACTH. The patients with PD showed a decreased CRH-induced plasma cortisol response. A median-split gave evidence that patients suffering from PD longer than two years showed a remarkably higher HPA-axis reactivity under CRH-injection than patients suffering from PD two years or less. CONCLUSION These findings provide strong evidence that patients with PD show some dissociation between ACTH and cortisol response under the DEX-CRH test with strong indicators that the length of the duration of the psychopathology is a risk factor for an increased reactivity of the HPA-axis in patients with PD.
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Affiliation(s)
- Katja Petrowski
- Institute of Psychotherapy and Psychosomatic Medicine, University Hospital Carl Gustav Carus Dresden, Technische Universität Dresden, Dresden, Germany.
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Perna G, Daccò S, Menotti R, Caldirola D. Antianxiety medications for the treatment of complex agoraphobia: pharmacological interventions for a behavioral condition. Neuropsychiatr Dis Treat 2011; 7:621-37. [PMID: 22090798 PMCID: PMC3215519 DOI: 10.2147/ndt.s12979] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although there are controversial issues (the "American view" and the "European view") regarding the construct and definition of agoraphobia (AG), this syndrome is well recognized and it is a burden in the lives of millions of people worldwide. To better clarify the role of drug therapy in AG, the authors summarized and discussed recent evidence on pharmacological treatments, based on clinical trials available from 2000, with the aim of highlighting pharmacotherapies that may improve this complex syndrome. METHODS A systematic review of the literature regarding the pharmacological treatment of AG was carried out using MEDLINE, EBSCO, and Cochrane databases, with keywords individuated by MeSH research. Only randomized, placebo-controlled studies or comparative clinical trials were included. RESULTS After selection, 25 studies were included. All the selected studies included patients with AG associated with panic disorder. Effective compounds included selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, selective noradrenergic reuptake inhibitors, and benzodiazepines. Paroxetine, sertraline, citalopram, escitalopram, and clomipramine showed the most consistent results, while fluvoxamine, fluoxetine, and imipramine showed limited efficacy. Preliminary results suggested the potential efficacy of inositol; D-cycloserine showed mixed results for its ability to improve the outcome of exposure-based cognitive behavioral therapy. More studies with the latter compounds are needed before drawing definitive conclusions. CONCLUSION No studies have been specifically oriented toward evaluating the effect of drugs on AG; in the available studies, the improvement of AG might have been the consequence of the reduction of panic attacks. Before developing a "true" psychopharmacology of AG it is crucial to clarify its definition. There may be several potential mechanisms involved, including fear-learning processes, balance system dysfunction, high light sensitivity, and impaired visuospatial abilities, but further studies are warranted.
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Affiliation(s)
- Giampaolo Perna
- Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, University of Maastricht, Maastricht, the Netherlands
- Department of Clinical Neuroscience, San Benedetto Hospital, Hermanas Hospitalarias, Albese con Cassano, Como, Italy
- Department of Psychiatry and Behavioral Sciences, Leonard M Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Silvia Daccò
- Department of Clinical Neuroscience, San Benedetto Hospital, Hermanas Hospitalarias, Albese con Cassano, Como, Italy
| | - Roberta Menotti
- Department of Clinical Neuroscience, San Benedetto Hospital, Hermanas Hospitalarias, Albese con Cassano, Como, Italy
| | - Daniela Caldirola
- Department of Clinical Neuroscience, San Benedetto Hospital, Hermanas Hospitalarias, Albese con Cassano, Como, Italy
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Hofmann SG, Smits JAJ, Asnaani A, Gutner CA, Otto MW. Cognitive enhancers for anxiety disorders. Pharmacol Biochem Behav 2010; 99:275-84. [PMID: 21134394 DOI: 10.1016/j.pbb.2010.11.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 11/17/2010] [Accepted: 11/26/2010] [Indexed: 12/25/2022]
Abstract
Cognitive-behavioral therapy is an effective intervention for anxiety disorders. However, a significant number of people do not respond or only show partial response even after an adequate course of the treatment. Recent research has shown that the efficacy of the intervention can be improved by the use of cognitive enhancers that augment the core learning processes of cognitive-behavior therapy. This manuscript provides a review of the current state of cognitive enhancers for the treatment of anxiety disorders.
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Affiliation(s)
- Stefan G Hofmann
- Department of Psychology, Boston University, 648 Beacon Street, 6th Floor, Boston, MA 02215-2002, USA.
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