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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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Contractor AA, Blumenthal H, Rosenfield D, Shea MT, Taylor DJ, Fentem A, Vingren JL. Study protocol and rationale for a pilot randomized clinical trial comparing processing of positive memories technique with supportive counseling for PTSD. Contemp Clin Trials 2024; 138:107455. [PMID: 38253251 DOI: 10.1016/j.cct.2024.107455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/29/2023] [Accepted: 01/19/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Research indicates that positive memories have a role in posttraumatic stress disorder's (PTSD) symptomatology and treatment. Following treatment development guidelines, a novel PTSD intervention - Processing of Positive Memories Technique (PPMT) - was developed and subsequently examined for its effects and feasibility in pilot studies. Extending this research, the proposed pilot randomized clinical trial with PPMT and Supportive Counseling (SC) arms will examine PPMT's effects on PTSD severity and biomarkers of stress systems' dysregulation (awakening salivary alpha amylase [sAA] and cortisol concentrations); examine mechanistic targets (affect) underlying PPMT's effects; and refine PPMT. We hypothesize that the PPMT arm will report greater decreases in PTSD severity and greater decreases in awakening sAA/cortisol ratio compared to the SC arm; and that improved affect (more positive affect and less negative affect) will mediate associations between intervention arm and changes in PTSD severity. METHODS We will recruit 70 individuals aged 18-65 years with PTSD. They will be randomized to 5 weekly therapy sessions of PPMT or SC, and will be assessed at baseline, weekly during treatment, 1-week post-treatment, and 3-months post-treatment. Primary outcomes are past-week PTSD severity, past-week positive and negative affect levels, and feedback data on PPMT's feasibility, format, and content. The secondary outcome is the awakening sAA/cortisol ratio. Statistical analyses include mixed-effect models and within-subjects cross-lag longitudinal mediation analyses. CONCLUSION Study results will advance knowledge of trauma interventions by examining effects and feasibility of a novel PTSD intervention, and by elucidating potential mechanisms underlying PPMT's effects. Clinical Trials #: NCT05523453.
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Affiliation(s)
- Ateka A Contractor
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America.
| | - Heidemarie Blumenthal
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Expressway Tower, Dallas, TX, 75275, United States of America
| | - M Tracie Shea
- Box G-BH, Brown University, Providence, RI 02912, United States of America
| | - Daniel J Taylor
- Department of Psychology, University of Arizona, 1503 W University Blvd, Tuscon, AZ 85721, United States of America
| | - Andrea Fentem
- Department of Psychology, University of North Texas, Terrill Hall, Denton, TX, 76201, United States of America
| | - Jakob L Vingren
- Department of Kinesiology, Health Promotion and Recreation, University of North Texas, Denton TX 76203, United States of America
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Botschek T, Hußlein V, Peters EMJ, Brosig B. Hair cortisol as outcome parameter for psychological and neuropsychiatric interventions-a literature review. Front Psychiatry 2023; 14:1227153. [PMID: 37881597 PMCID: PMC10595010 DOI: 10.3389/fpsyt.2023.1227153] [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: 05/22/2023] [Accepted: 09/22/2023] [Indexed: 10/27/2023] Open
Abstract
Background Studies measuring hair cortisol concentration (HCC) have been increasingly conducted to document stress-related, endocrine changes aggregated over time. Previous studies have shown that HCC reflects abnormalities in the hypothalamic-pituitary-adrenocortical axis (HPA axis) in the context of somatic diseases, such as Cushing's syndrome. HCC variations also reveal a corresponding alteration in HPA-axis-function in mental disorders, highlighting its potential role as a biomarker for interventions targeting mental health problems. Aims The aim of this study was to investigate the role of HCC in various psychological and neuropsychiatric interventions and to explore the extent to which HCC can serve as a predictive or outcome parameter in such interventions by conducting a PRISMA-compliant review of the literature. Methods From May to July 2022, the databases Web of Science, Google Scholar, PsychINFO, and ResearchGate were systematically searched using different combinations of relevant keywords. Studies of different types that examined HCC in the context of a wide range of psychological and neuropsychiatric interventions were included. Studies in languages other than English or German and animal studies were excluded. The MMAT tool was used, to assesses the Risk of bias. Results The initial search identified 334 studies. After applying the inclusion and exclusion criteria, 14 publications with a total number of 1,916 participants were identified. An association between HCC and PTSD, depressive disorders, and ongoing social and family stress can be documented. The effect of relaxation techniques, mental training, CBT, or PTSD therapy on HCC has been studied with equivocal results. Some studies found decreased HCC after treatment, while others did not show a clear effect. Baseline HCC appears to be of particular importance. In some studies, higher baseline HCC was associated with increased treatment response, providing a predictive value for HCC. Discussion HCC is increasingly being used as a biomarker for the mapping of psychological and neuropsychiatric interventions. However, due to the wide range of study populations and interventions, results are still heterogeneous. Nevertheless, HCC seems to be an encouraging biological parameter to describe the trajectory of different interventions aimed at improving mental health.
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Affiliation(s)
- Tim Botschek
- Family Psychosomatics, Department of Pediatrics and Neonatology, Justus-Liebig University Giessen, Gießen, Germany
| | - Vincent Hußlein
- Family Psychosomatics, Department of Pediatrics and Neonatology, Justus-Liebig University Giessen, Gießen, Germany
| | - Eva M. J. Peters
- Psychoneuroimmunology Laboratory, Department of Psychosomatic Medicine and Psychotherapy, Justus-Liebig University Giessen, Gießen, Germany
- Psychosomatics and Psychotherapy, Charité Center 12 Internal Medicine and Dermatology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Burkhard Brosig
- Family Psychosomatics, Department of Pediatrics and Neonatology, Justus-Liebig University Giessen, Gießen, Germany
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Does panic disorder increase the risk of cardiovascular diseases in diabetics?: A nationwide population-based study. J Affect Disord 2023; 325:604-610. [PMID: 36681301 DOI: 10.1016/j.jad.2023.01.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Several studies have suggested a link between panic disorder (PD) and cardiovascular disease (CVD). However, the extent to which PD confers risk for CVD is still unclear, particularly in diabetics, a group showing high risk for CVD. METHODS A nationwide population-based cohort of 1,624,718 patients with type 2 diabetes were selected from the National Health Screening Program database covering the years 2009 to 2012. The subjects were divided into two groups: those without panic disorder (non-PD group, n = 1,618,263) and those with newly diagnosed PD (PD-group, n = 6455). Follow-up of subjects for up to 10 years was conducted for evaluation of the incidences of myocardial infarction (MI), stroke, and death. RESULTS After adjusting for the baseline covariates and diabetes mellitus (DM)-related variables, no difference in the future risk of MI and stroke was observed between the non-PD group and the PD group. Compared with the non-PD group, the PD group showed an increase in the future risk of death. [adjusted hazard ratio (aHR) = 1.120, 95 % confidence interval (CI): 1.039-1.206]. In contrast to the population aged <40 and > 65 years, in the age group of 40-64 years a significantly higher risk of stroke was observed in the PD group compared with the non-PD group (aHR = 1.352, 95%CI: 1.136-1.610). LIMITATION The diagnoses were based on the diagnostic codes of the claim data. CONCLUSION The current findings suggested that PD might not contribute to the risk of future MI and stroke in diabetics who have already been at risk of various cardiovascular complications.
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Provencher J, Cernik R, Marin MF. Impact of Stress and Exercise on Fear Extinction. Curr Top Behav Neurosci 2023; 64:157-178. [PMID: 37498495 DOI: 10.1007/7854_2023_432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
This chapter reviews the literature on the impact of stress and exercise on fear extinction. Given that key brain regions of the fear circuitry (e.g., hippocampus, amygdala and frontal cortex) can be modulated by stress hormones, it is important to investigate how stress influences this process. Laboratory-based studies performed in healthy adults have yielded mixed results, which are most likely attributable to various methodological factors. Among these factors, inter-individual differences modulating the stress response and timing of stressor administration with respect to the task may contribute to this heterogeneity. Given that fear is a core manifestation of various psychopathologies and that exposure-based therapy relies on fear extinction principles, several studies have attempted to assess the role of stress hormones on exposure-based therapy in patients suffering from post-traumatic stress disorder or anxiety disorders. These studies tend to suggest a beneficial impact of stress hormones (through either natural endogenous variations or synthetic administration) on exposure-based therapy as assessed mostly by subjective fear measures. Similar to stress, exercise can have an impact on many physiological and biological systems in humans. Of note, exercise modulates biomarkers such as brain-derived neurotrophic factor (BDNF) and anandamide (EAE) that act on brain regions implicated in the fear circuitry, supporting the importance of studying the impact of exercise on fear extinction. Overall, the results converge and indicate that fear extinction (tested in the laboratory or via exposure-based therapy in clinical populations) can be enhanced with exercise. Further research is needed to understand the mechanisms by which stress and exercise modulate fear learning and extinction processes, as well as to maximize the applicability to clinical contexts.
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Affiliation(s)
- Jessie Provencher
- Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada
- Research Centre of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
| | - Rebecca Cernik
- Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada
- Research Centre of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada
| | - Marie-France Marin
- Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada.
- Research Centre of the Institut Universitaire en Santé Mentale de Montréal, Montreal, QC, Canada.
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Merz CJ. How Different Factors in Combination Change Fear Extinction Learning: The Case of Sex and Stress Hormones. Curr Top Behav Neurosci 2023; 64:179-191. [PMID: 37455303 DOI: 10.1007/7854_2023_427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Effects of a specific factor on fear extinction or exposure therapy have revealed promising results, for example how sex or stress hormones exert the capability to critically change extinction learning and consolidation processes. However, we must acknowledge that in real life these factors do not operate in isolation, they go hand in hand. In this chapter, the available evidence regarding interactions of sex and stress hormones on extinction processes and exposure therapy will be integrated and discussed. First hints exist that these factors in combination critically target extinction learning and consolidation processes, calling for more detailed research on the exact underlying mechanisms. In addition to experiments with high sample sizes, we must aim for a collaborative effort of laboratories across the whole world to be able to identify critical combinations of factors associated with improved, but also impaired extinction processes and exposure therapy success. We expect that the revelation of further relevant factors will not only be limited to the interplay between sex and stress hormones but will include factors such as sleep and exercise as well. In the long run, uncovering the most important interaction effects will give us critical hints for differential treatment options to be realized in the sense of a personalized medicine approach.
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Affiliation(s)
- Christian J Merz
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, Bochum, 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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Pace-Schott EF, Seo J, Bottary R. The influence of sleep on fear extinction in trauma-related disorders. Neurobiol Stress 2022; 22:100500. [PMID: 36545012 PMCID: PMC9761387 DOI: 10.1016/j.ynstr.2022.100500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/21/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
In Posttraumatic Stress Disorder (PTSD), fear and anxiety become dysregulated following psychologically traumatic events. Regulation of fear and anxiety involves both high-level cognitive processes such as cognitive reattribution and low-level, partially automatic memory processes such as fear extinction, safety learning and habituation. These latter processes are believed to be deficient in PTSD. While insomnia and nightmares are characteristic symptoms of existing PTSD, abundant recent evidence suggests that sleep disruption prior to and acute sleep disturbance following traumatic events both can predispose an individual to develop PTSD. Sleep promotes consolidation in multiple memory systems and is believed to also do so for low-level emotion-regulatory memory processes. Consequently sleep disruption may contribute to the etiology of PTSD by interfering with consolidation in low-level emotion-regulatory memory systems. During the first weeks following a traumatic event, when in the course of everyday life resilient individuals begin to acquire and consolidate these low-level emotion-regulatory memories, those who will develop PTSD symptoms may fail to do so. This deficit may, in part, result from alterations of sleep that interfere with their consolidation, such as REM fragmentation, that have also been found to presage later PTSD symptoms. Here, sleep disruption in PTSD as well as fear extinction, safety learning and habituation and their known alterations in PTSD are first briefly reviewed. Then neural processes that occur during the early post-trauma period that might impede low-level emotion regulatory processes through alterations of sleep quality and physiology will be considered. Lastly, recent neuroimaging evidence from a fear conditioning and extinction paradigm in patient groups and their controls will be considered along with one possible neural process that may contribute to a vulnerability to PTSD following trauma.
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Affiliation(s)
- Edward F. Pace-Schott
- Massachusetts General Hospital, Department of Psychiatry, Charlestown, MA, USA
- Harvard Medical School, Department of Psychiatry, Charlestown, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
- Corresponding author. Harvard Medical School, Massachusetts General Hospital - East, CNY 149 13th Street, Charlestown, MA, 02129, USA.
| | - Jeehye Seo
- Massachusetts General Hospital, Department of Psychiatry, Charlestown, MA, USA
- Harvard Medical School, Department of Psychiatry, Charlestown, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
- Korea University, Department of Brain & Cognitive Engineering, Seongbuk-gu, Seoul, South Korea
| | - Ryan Bottary
- Massachusetts General Hospital, Department of Psychiatry, Charlestown, MA, USA
- Harvard Medical School, Department of Psychiatry, Charlestown, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
- Department of Psychology and Neuroscience, Boston College, Chestnut Hill, MA, USA
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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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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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15
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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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16
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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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17
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Sleep duration and timing in obsessive-compulsive disorder (OCD): evidence for circadian phase delay. Sleep Med 2020; 72:111-117. [PMID: 32575000 DOI: 10.1016/j.sleep.2020.03.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/04/2020] [Accepted: 03/17/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To investigate potential delays in endogenous melatonin in individuals with obsessive-compulsive disorder (OCD). METHODS First, data are presented for 15 individuals with OCD and matched healthy controls. Next, nine additional participants with OCD who did not have matched controls were added, resulting in a sample of 24 individuals with OCD. All participants were assessed for sleep and circadian rhythm disturbance. Dim light melatonin onset (DLMO) was derived from salivary melatonin and was used in conjunction with sleep diaries, interview measures, and questionnaires. A subset of the OCD group (n = 16) also used actigraphy. RESULTS In sum, 42% percent (10/24) of the patients with OCD met the criteria for delayed sleep-wake phase disorder (DSWPD) in comparison to 0% in the control sample. DLMO was significantly later in individuals with OCD compared to controls. DLMO and bedtime were not significantly associated with the severity of obsessive-compulsive symptoms or negative affect. CONCLUSIONS Replication of the findings presented herein, particularly the DLMO results, is warranted. Further, there are now three studies showing that nearly ½ of individuals with OCD meet criteria for a DSWPD. Future studies can explore the mechanisms underlying these connections and the implications of this comorbidity. These findings may increase our understanding of OCD and inform future interventions.
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18
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Personalized prediction of smartphone-based psychotherapeutic micro-intervention success using machine learning. J Affect Disord 2020; 264:430-437. [PMID: 31787419 DOI: 10.1016/j.jad.2019.11.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/18/2019] [Accepted: 11/12/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Tailoring healthcare to patients' individual needs is a central goal of precision medicine. Combining smartphone-based interventions with machine learning approaches may help attaining this goal. The aim of our study was to explore the predictability of the success of smartphone-based psychotherapeutic micro-interventions in eliciting mood changes using machine learning. METHODS Participants conducted daily smartphone-based psychotherapeutic micro-interventions, guided by short video clips, for 13 consecutive days. Participants chose one of four intervention techniques used in psychotherapeutic approaches. Mood changes were assessed using the Multidimensional Mood State Questionnaire. Micro-intervention success was predicted using random forest (RF) tree-based mixed-effects logistic regression models. Data from 27 participants were used, totaling 324 micro-interventions, randomly split 100 times into training and test samples, using within-subject and between-subject sampling. RESULTS Mood improved from pre- to post-intervention in 137 sessions (initial success-rate: 42.3%). The RF approach resulted in predictions of micro-intervention success significantly better than the initial success-rate within and between subjects (positive predictive value: 0.732 (95%-CI: 0.607; 0.820) and 0.698 (95%-CI: 0.564; 0.805), respectively). Prediction quality was highest using the RF approach within subjects (rand accuracy: 0.75 (95%-CI: 0.641; 0.840), Matthew's correlation coefficient: 0.483 (95%-CI: 0.323; 0.723)). LIMITATIONS The RF approach does not allow firm conclusions about the exact contribution of each factor to the algorithm's predictions. We included a limited number of predictors and did not compare whether predictability differed between psychotherapeutic techniques. CONCLUSIONS Our findings may pave the way for translation and encourage scrutinizing personalized prediction in the psychotherapeutic context to improve treatment efficacy.
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19
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Timmers I, Quaedflieg CWEM, Hsu C, Heathcote LC, Rovnaghi CR, Simons LE. The interaction between stress and chronic pain through the lens of threat learning. Neurosci Biobehav Rev 2019; 107:641-655. [PMID: 31622630 DOI: 10.1016/j.neubiorev.2019.10.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 02/06/2023]
Abstract
Stress and pain are interleaved at multiple levels - interacting and influencing each other. Both are modulated by psychosocial factors including fears, beliefs, and goals, and are served by overlapping neural substrates. One major contributing factor in the development and maintenance of chronic pain is threat learning, with pain as an emotionally-salient threat - or stressor. Here, we argue that threat learning is a central mechanism and contributor, mediating the relationship between stress and chronic pain. We review the state of the art on (mal)adaptive learning in chronic pain, and on effects of stress and particularly cortisol on learning. We then provide a theoretical integration of how stress may affect chronic pain through its effect on threat learning. Prolonged stress, as may be experienced by patients with chronic pain, and its resulting changes in key brain networks modulating stress responses and threat learning, may further exacerbate these impairing effects on threat learning. We provide testable hypotheses and suggestions for how this integration may guide future research and clinical approaches in chronic pain.
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Affiliation(s)
- Inge Timmers
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States.
| | - Conny W E M Quaedflieg
- Department of Clinical Psychological Science, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - Connie Hsu
- Feinberg School of Medicine, Northwestern University, 420 E Superior St, Chicago, IL 60611, United States
| | - Lauren C Heathcote
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States
| | - Cynthia R Rovnaghi
- Department of Pediatrics, Stanford University School of Medicine, 770 Welch Road, Suite 435, Stanford, CA 94304, United States
| | - Laura E Simons
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 300, Palo Alto, CA 94304, United States
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20
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Brueckner AH, Lass-Hennemann J, Wilhelm FH, Ferreira de Sá DS, Michael T. Cortisol administration after extinction in a fear-conditioning paradigm with traumatic film clips prevents return of fear. Transl Psychiatry 2019; 9:128. [PMID: 30962423 PMCID: PMC6453889 DOI: 10.1038/s41398-019-0455-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 09/19/2018] [Accepted: 01/11/2019] [Indexed: 12/12/2022] Open
Abstract
Cortisol is a stress hormone and potent modulator of learning and memory processes. If administered after learning, cortisol can enhance memory consolidation. Yet it is unknown whether cortisol administration after fear extinction learning strengthens extinction memory. Extinction is a crucial mechanism underlying psychotherapy of posttraumatic stress disorder (PTSD). The present study examined whether extinction can be enhanced by administering cortisol after extinction training. In a registered, randomized, double-blind and placebo controlled trial, 50 healthy participants were exposed to a differential fear-conditioning paradigm with neutral faces as conditioned stimuli (CS) and traumatic film clips as unconditioned stimuli (US). They received either cortisol (n = 25) or placebo (n = 25) immediately after extinction. The cortisol group showed less fear during a return of fear manipulation (reinstatement) evidenced by attenuated fear potentiated startle responses and US-expectancy ratings than the placebo group. Results indicate that cortisol administration after fear extinction strengthens extinction memory and suggest that it might be advantageous to administer cortisol subsequent to successful exposure treatment sessions.
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Affiliation(s)
- Alexandra H. Brueckner
- 0000 0001 2167 7588grid.11749.3aDivision of Clinical Psychology and Psychotherapy, Department of Psychology, Saarland University, Saarbrücken, Germany
| | - Johanna Lass-Hennemann
- 0000 0001 2167 7588grid.11749.3aDivision of Clinical Psychology and Psychotherapy, Department of Psychology, Saarland University, Saarbrücken, Germany
| | - Frank H. Wilhelm
- 0000000110156330grid.7039.dDivision of Clinical Psychology, Psychotherapy and Health Psychology, Department of Psychology, University of Salzburg, Salzburg, Austria
| | - Diana S. Ferreira de Sá
- 0000 0001 2167 7588grid.11749.3aDivision of Clinical Psychology and Psychotherapy, Department of Psychology, Saarland University, Saarbrücken, Germany
| | - Tanja Michael
- 0000 0001 2167 7588grid.11749.3aDivision of Clinical Psychology and Psychotherapy, Department of Psychology, Saarland University, Saarbrücken, Germany
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21
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Zilcha-Mano S, Roose SP, Brown PJ, Rutherford BR. Not Just Nonspecific Factors: The Roles of Alliance and Expectancy in Treatment, and Their Neurobiological Underpinnings. Front Behav Neurosci 2019; 12:293. [PMID: 30760986 PMCID: PMC6361734 DOI: 10.3389/fnbeh.2018.00293] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 11/13/2018] [Indexed: 12/14/2022] Open
Abstract
Therapeutic factors such as alliance and expectancy have been found to greatly affect treatment outcome in both psychotherapy and psychopharmacotherapy. Often, these factors are referred to as nonspecific because of their common roles across treatment modalities. Here we argue that conceptualizing such factors as nonspecific is not accurate at best, misleading at worst and may undermine treatment outcome across various modalities. We argue that alliance and expectancy contain both a trait-like common factor component and a state-like specific effect, and that it is clinically, conceptually and methodologically critical to disentangle the two. In other words, both alliance and expectancy may also function as active ingredients of treatment, leading to better outcome. We review the literature regarding the neurobiological underpinnings of alliance and of the expectancy effect, and suggest how future studies on the neurobiological basis of these effects can shed further light on the potentially distinct mechanisms of the trait-like and state-like components of each therapeutic factor.
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Affiliation(s)
| | - Steven P Roose
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Patrick J Brown
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Bret R Rutherford
- New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, NY, United States
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22
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Meir Drexler S, Merz CJ, Jentsch VL, Wolf OT. How stress and glucocorticoids timing-dependently affect extinction and relapse. Neurosci Biobehav Rev 2018; 98:145-153. [PMID: 30594494 DOI: 10.1016/j.neubiorev.2018.12.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/15/2018] [Accepted: 12/26/2018] [Indexed: 11/26/2022]
Abstract
In recent years, various research groups aimed to augment extinction learning (the most important underlying mechanism of exposure therapy) using glucocorticoids (GCs), in particular the stress hormone cortisol. In this review, we introduce the STaR (Stress Timing affects Relapse) model, a theoretical model of the timing-dependent effects of stress/GCs treatment on extinction and relapse. In particular, we show that (1) pre-extinction stress/GCs promote memory consolidation in a context-independent manner, making extinction memory more resistant to relapse following context change. (2) Post-extinction stress also enhances extinction consolidation, but in a context-bound manner. These differences may result from the timing-dependent effects of cortisol on emotional memory contextualization. At the neural level, extinction facilitation is reflected in alterations in the amygdala-hippocampal-prefrontal cortex network. (3) Stress/GCs before a retrieval test impair extinction retrieval and promote relapse. This may result from strengthening amygdala signaling or disruption of the inhibitory functioning of the prefrontal cortex. The STaR model can contribute to the understanding and prevention of relapse processes.
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Affiliation(s)
- Shira Meir Drexler
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, 44801 Bochum, Germany
| | - Christian J Merz
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, 44801 Bochum, Germany
| | - Valerie L Jentsch
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, 44801 Bochum, Germany
| | - Oliver T Wolf
- Department of Cognitive Psychology, Institute of Cognitive Neuroscience, Ruhr University Bochum, 44801 Bochum, Germany.
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23
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Bernsdorf M, Schwabe L. Cortisol response to awakening in prepubertal children and adults: Magnitude and variability. Psychophysiology 2018; 55:e13273. [PMID: 30101985 DOI: 10.1111/psyp.13273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/13/2018] [Accepted: 07/04/2018] [Indexed: 12/24/2022]
Abstract
Within the first 30-45 min after awakening, there is a characteristic rise in cortisol that is referred to as cortisol awakening response (CAR). Over the past decades, the CAR has become an important biomarker, mainly because of its reported association with health and disease. Previous research showed that the CAR can already be reliably assessed in infants and children. Yet, earlier findings on the influence of age have been inconsistent, and limited attention has been devoted to prepubertal children. Here, we aimed to contrast the magnitude and stability of the CAR in prepubertal children and adults. To this end, 24 healthy adults between 35 and 50 years of age and 24 healthy children between 6 and 9 years of age collected four salivary cortisol samples within 45 min after awakening on 4 separate days, 2 weekdays, and 2 weekend days. Our results showed that there was a marked CAR on weekdays and weekend days in both adults and children. In children, however, the CAR was overall significantly attenuated relative to adults. Moreover, while the cortisol increases after awakening were, both on weekdays and weekend days, highly correlated in adults, there were no such associations in children. Together, these data suggest that the CAR is less pronounced and less stable in prepubertal children compared to adults. Such age differences need to be taken into account when using the CAR as a biomarker in clinical settings.
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Affiliation(s)
- Manja Bernsdorf
- Department of Cognitive Psychology, Institute of Psychology, University of Hamburg, Hamburg, Germany
| | - Lars Schwabe
- Department of Cognitive Psychology, Institute of Psychology, University of Hamburg, Hamburg, Germany
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24
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de Villiers B, Lionetti F, Pluess M. Vantage sensitivity: a framework for individual differences in response to psychological intervention. Soc Psychiatry Psychiatr Epidemiol 2018; 53:545-554. [PMID: 29302707 PMCID: PMC5959990 DOI: 10.1007/s00127-017-1471-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/11/2017] [Indexed: 11/15/2022]
Abstract
PURPOSE People differ significantly in their response to psychological intervention, with some benefitting more from treatment than others. According to the recently proposed theoretical framework of vantage sensitivity, some of this variability may be due to individual differences in environmental sensitivity, the inherent ability to register, and process external stimuli. In this paper, we apply the vantage sensitivity framework to the field of psychiatry and clinical psychology, proposing that some people are more responsive to the positive effects of psychological intervention due to heightened sensitivity. METHODS After presenting theoretical frameworks related to environmental sensitivity, we review a selection of recent studies reporting individual differences in the positive response to psychological intervention. RESULTS A growing number of studies report that some people benefit more from psychological intervention than others as a function of genetic, physiological, and psychological characteristics. These studies support the vantage sensitivity proposition that treatment response is influenced by factors associated with heightened sensitivity to environmental influences. More recently, studies have also shown that sensitivity can be measured with a short questionnaire which appears to predict the response to psychological intervention. CONCLUSIONS Vantage sensitivity is a framework with significant relevance for our understanding of widely observed heterogeneity in treatment response. It suggests that variability in response to treatment is partly influenced by people's differing capacity for environmental sensitivity, which can be measured with a short questionnaire. Application of the vantage sensitivity framework to psychiatry and clinical psychology may improve our knowledge regarding when, how, and for whom interventions work.
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Affiliation(s)
- Bernadette de Villiers
- Department of Biological and Experimental Psychology, School of Biological and Chemical Sciences, Queen Mary University of London, G.E. Fogg Building, Office 2.01, Mile End Road, London, E1 4NS, UK
| | - Francesca Lionetti
- Department of Biological and Experimental Psychology, School of Biological and Chemical Sciences, Queen Mary University of London, G.E. Fogg Building, Office 2.01, Mile End Road, London, E1 4NS, UK
| | - Michael Pluess
- Department of Biological and Experimental Psychology, School of Biological and Chemical Sciences, Queen Mary University of London, G.E. Fogg Building, Office 2.01, Mile End Road, London, E1 4NS, UK.
- Centre for Economic Performance, London School of Economics, London, UK.
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More than just noise: Inter-individual differences in fear acquisition, extinction and return of fear in humans - Biological, experiential, temperamental factors, and methodological pitfalls. Neurosci Biobehav Rev 2017; 80:703-728. [DOI: 10.1016/j.neubiorev.2017.07.007] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/12/2017] [Accepted: 07/20/2017] [Indexed: 01/07/2023]
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Richter J, Pittig A, Hollandt M, Lueken U. Bridging the Gaps Between Basic Science and Cognitive-Behavioral Treatments for Anxiety Disorders in Routine Care. ZEITSCHRIFT FUR PSYCHOLOGIE-JOURNAL OF PSYCHOLOGY 2017. [DOI: 10.1027/2151-2604/a000309] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. As a core component of cognitive-behavioral therapies (CBT), behavioral exposure is an effective treatment for anxiety disorders. Still, recent treatment studies demonstrate relatively high rates of treatment dropout, nonresponse, and relapse, indicating a substantial need for optimizing and personalizing existing treatment procedures. In the present article, we aim to address current challenges and future demands for translational research in CBT for the anxiety disorders, including (a) a better understanding of those mechanisms conferring behavioral change, (b) identifying important sources of individual variation that may act as moderators of treatment response, and (c) targeting practical barriers for dissemination of exposure therapy to routine care. Based on a recursive process model of psychotherapy research we will describe distinct steps to systematically translate basic and clinical research “from bench to bedside” to routine care, but also vice versa. Some of these aspects may stimulate the future roadmap for evidence-based psychotherapy research in order to better target the treatment of anxiety disorders as one core health challenge of our time.
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Affiliation(s)
- Jan Richter
- Department of Physiological and Clinical Psychology/Psychotherapy, University of Greifswald, Germany
| | - Andre Pittig
- Institute of Clinical Psychology and Psychotherapy, Department of Psychology, Technische Universität Dresden, Germany
| | - Maike Hollandt
- Department of Physiological and Clinical Psychology/Psychotherapy, University of Greifswald, Germany
| | - Ulrike Lueken
- Center of Mental Health, Department of Psychiatry, Psychosomatics, and Psychotherapy, University Hospital of Würzburg, Germany
- Department of Psychology, Humboldt University of Berlin, Germany
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Zuj DV, Palmer MA, Malhi GS, Bryant RA, Felmingham KL. Endogenous cortisol reactivity moderates the relationship between fear inhibition to safety signals and posttraumatic stress disorder symptoms. Psychoneuroendocrinology 2017; 78:14-21. [PMID: 28135580 DOI: 10.1016/j.psyneuen.2017.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/11/2017] [Accepted: 01/11/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Posttraumatic stress symptoms (PTSS) are commonly associated with impairments in extinguishing fear to signals previously associated with danger, and also with inhibiting fear to safety signals. Previous studies indicate that PTSS are associated with low cortisol activity, and cortisol is shown to facilitate fear extinction. Few studies have examined the influence of cortisol reactivity on fear extinction in PTSS. METHOD We used a standardized fear conditioning and extinction paradigm to investigate the relationship between fear extinction and endogenous salivary cortisol activity in participants with high PTSS (n=18), trauma-exposed controls (n=33), and non-trauma-exposed controls (n=27). Skin conductance response (SCR) was used as an index of conditioned responding. Saliva samples were collected at baseline, and 20min post-fear acquisition for basal and reactive cortisol levels, respectively. RESULTS PTSS participants demonstrated a slower rate of extinction learning during the early extinction phase. A moderation analysis revealed that cortisol reactivity was a significant moderator between fear inhibition to the safety signal (CS-) during early extinction and PTSS, but not to the threat signal (CS+). Specifically, this interaction was significant in two ways: (1) participants with elevated cortisol reactivity showed lower PTSS as fear inhibition improved; and (2) participants with low cortisol reactivity showed higher PTSS as fear inhibition improved. CONCLUSION The findings of the present study show that the relationship between fear inhibition and cortisol reactivity is complex, and suggest that cortisol reactivity shapes safety signal learning in PTSS.
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Affiliation(s)
- Daniel V Zuj
- Division of Psychology, School of Medicine, University of Tasmania, Australia.
| | - Matthew A Palmer
- Division of Psychology, School of Medicine, University of Tasmania, Australia
| | - Gin S Malhi
- Royal North Shore Hospital, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
| | | | - Kim L Felmingham
- School of Psychological Sciences, University of Melbourne, Australia
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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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Meuret AE, Kroll J, Ritz T. Panic Disorder Comorbidity with Medical Conditions and Treatment Implications. Annu Rev Clin Psychol 2017; 13:209-240. [PMID: 28375724 DOI: 10.1146/annurev-clinpsy-021815-093044] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Panic disorder (PD) is unique among the anxiety disorders in that panic symptoms are primarily of a physical nature. Consequently, comorbidity with medical illness is significant. This review examines the association between PD and medical illness. We identify shared pathophysiological and psychological correlates and illustrate how physiological activation in panic sufferers underlies their symptom experience in the context of the fight-or-flight response and beyond a situation-specific response pattern. We then review evidence for bodily symptom perception accuracy in PD. Prevalence of comorbidity for PD and medical illness is presented, with a focus on respiratory and cardiovascular illness, irritable bowel syndrome, and diabetes, followed by an outline for potential pathways of a bidirectional association. We conclude by illustrating commonalities in mediating mechanistic pathways and moderating risk factors across medical illnesses, and we discuss implications for diagnosis and treatment of both types of conditions.
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Affiliation(s)
- Alicia E Meuret
- Department of Psychology, Southern Methodist University, Dallas, Texas 75275;
| | - Juliet Kroll
- Department of Psychology, Southern Methodist University, Dallas, Texas 75275;
| | - Thomas Ritz
- Department of Psychology, Southern Methodist University, Dallas, Texas 75275;
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30
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Vlemincx E, Meulders M, Abelson JL. Sigh rate during emotional transitions: More evidence for a sigh of relief. Biol Psychol 2017; 125:163-172. [PMID: 28315375 DOI: 10.1016/j.biopsycho.2017.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/08/2017] [Accepted: 03/09/2017] [Indexed: 11/18/2022]
Abstract
Evidence suggests that sighs regulate stress and emotions, e.g. by facilitating relief. This study aimed to investigate sigh rates during relief. In addition, links between sighs, anxiety sensitivity and HPA-axis activity were explored. Healthy volunteers (N=29) were presented cues predicting the valence of subsequent stimuli. By sequencing cues that predicted pleasant or unpleasant stimuli with or without certainty, transitions to certain pleasantness (relief) or to certain unpleasantness (control) were created and compared to no transitions. Salivary cortisol, anxiety sensitivity and respiration were measured. Sigh frequency was significantly higher during relief than during control transitions and no transition states, and higher during control transitions than during no transition states. Sigh frequency increased with steeper cortisol declines for high anxiety sensitive persons. Results confirm a relationship between sighs and relief. In addition, results suggest that sigh frequency is importantly related to HPA-axis activity, particularly in high anxiety sensitive persons.
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Affiliation(s)
- Elke Vlemincx
- Psychological Sciences Research Institute, Université catholique de Louvain, Louvain-la-Neuve, Belgium; Research Group on Health Psychology, KU Leuven, Leuven, Belgium.
| | - Michel Meulders
- Department of Informatics, Simulation and Modeling, KU Leuven, Leuven, Belgium; Research Group on Quantitative Psychology and Individual Differences, KU Leuven, Leuven, Belgium
| | - James L Abelson
- Trauma, Stress and Anxiety Research Group, University of Michigan, Ann Arbor, MI, United States
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31
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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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32
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Merz CJ, Wolf OT. Sex differences in stress effects on emotional learning. J Neurosci Res 2016; 95:93-105. [DOI: 10.1002/jnr.23811] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/24/2016] [Accepted: 06/10/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Christian J. Merz
- Institute of Cognitive Neuroscience, Department of Cognitive Psychology; Ruhr-University Bochum; Bochum Germany
| | - Oliver T. Wolf
- Institute of Cognitive Neuroscience, Department of Cognitive Psychology; Ruhr-University Bochum; Bochum Germany
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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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Stockhorst U, Antov MI. Modulation of Fear Extinction by Stress, Stress Hormones and Estradiol: A Review. Front Behav Neurosci 2016; 9:359. [PMID: 26858616 PMCID: PMC4726806 DOI: 10.3389/fnbeh.2015.00359] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/14/2015] [Indexed: 12/25/2022] Open
Abstract
Fear acquisition and extinction are valid models for the etiology and treatment of anxiety, trauma- and stressor-related disorders. These disorders are assumed to involve aversive learning under acute and/or chronic stress. Importantly, fear conditioning and stress share common neuronal circuits. The stress response involves multiple changes interacting in a time-dependent manner: (a) the fast first-wave stress response [with central actions of noradrenaline, dopamine, serotonin, corticotropin-releasing hormone (CRH), plus increased sympathetic tone and peripheral catecholamine release] and (b) the second-wave stress response [with peripheral release of glucocorticoids (GCs) after activation of the hypothalamus-pituitary-adrenocortical (HPA) axis]. Control of fear during extinction is also sensitive to these stress-response mediators. In the present review, we will thus examine current animal and human data, addressing the role of stress and single stress-response mediators for successful acquisition, consolidation and recall of fear extinction. We report studies using pharmacological manipulations targeting a number of stress-related neurotransmitters and neuromodulators [monoamines, opioids, endocannabinoids (eCBs), neuropeptide Y, oxytocin, GCs] and behavioral stress induction. As anxiety, trauma- and stressor-related disorders are more common in women, recent research focuses on female sex hormones and identifies a potential role for estradiol in fear extinction. We will thus summarize animal and human data on the role of estradiol and explore possible interactions with stress or stress-response mediators in extinction. This also aims at identifying time-windows of enhanced (or reduced) sensitivity for fear extinction, and thus also for successful exposure therapy.
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Affiliation(s)
- Ursula Stockhorst
- Experimental Psychology II and Biological Psychology, Institute of Psychology, University of OsnabrückOsnabrück, Germany
| | - Martin I. Antov
- Experimental Psychology II and Biological Psychology, Institute of Psychology, University of OsnabrückOsnabrück, Germany
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Khalsa SS, Lapidus RC. Can Interoception Improve the Pragmatic Search for Biomarkers in Psychiatry? Front Psychiatry 2016; 7:121. [PMID: 27504098 PMCID: PMC4958623 DOI: 10.3389/fpsyt.2016.00121] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/21/2016] [Indexed: 01/04/2023] Open
Abstract
Disrupted interoception is a prominent feature of the diagnostic classification of several psychiatric disorders. However, progress in understanding the interoceptive basis of these disorders has been incremental, and the application of interoception in clinical treatment is currently limited to panic disorder. To examine the degree to which the scientific community has recognized interoception as a construct of interest, we identified and individually screened all articles published in the English language on interoception and associated root terms in Pubmed, Psychinfo, and ISI Web of Knowledge. This search revealed that interoception is a multifaceted process that is being increasingly studied within the fields of psychiatry, psychology, neuroscience, and biomedical science. To illustrate the multifaceted nature of interoception, we provide a focused review of one of the most commonly studied interoceptive channels, the cardiovascular system, and give a detailed comparison of the most popular methods used to study cardiac interoception. We subsequently review evidence of interoceptive dysfunction in panic disorder, depression, somatic symptom disorders, anorexia nervosa, and bulimia nervosa. For each disorder, we suggest how interoceptive predictions constructed by the brain may erroneously bias individuals to express key symptoms and behaviors, and outline questions that are suitable for the development of neuroscience-based mental health interventions. We conclude that interoception represents a viable avenue for clinical and translational research in psychiatry, with a well-established conceptual framework, a neural basis, measurable biomarkers, interdisciplinary appeal, and transdiagnostic targets for understanding and improving mental health outcomes.
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Affiliation(s)
- Sahib S Khalsa
- Laureate Institute for Brain Research (LIBR), Tulsa, OK, USA; Oxley College of Health Sciences, University of Tulsa, Tulsa, OK, USA
| | - Rachel C Lapidus
- Laureate Institute for Brain Research (LIBR), Tulsa, OK, USA; Department of Psychology, University of Tulsa, Tulsa, OK, USA
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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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