A beta-adrenergic antagonist reduces traumatic memories and PTSD symptoms in female but not in male patients after cardiac surgery

Do beta-blockers reduce negative intrusive thoughts and anxiety in cancer survivors? - An emulated trial

BACKGROUND

High rates of negative intrusive thoughts have been reported among cancer patients. Prevalent users of beta-blocker therapy have reported lower levels of cancer related intrusive thoughts than non-user. The aim of this study is to investigate if initiation of beta-blocker therapy reduces the prevalence and severity of intrusive thoughts (co-primary endpoints) and the prevalence of anxiety, depressed mood, and low quality of life (secondary endpoints) in cancer survivors.

METHODS

Data on patient-reported outcomes from three cohort studies of Swedish patients diagnosed with colon, prostate or rectal cancer were combined with data on beta-blocker prescriptions retrieved from the Swedish Prescribed Drug Register. Two randomized controlled trials were emulated. Trial 1 had follow-up 1 year after diagnosis, trial 2 had follow-up 2 years after diagnosis, baseline in both trials was 12 months before follow-up. Those who initiated beta-blocker therapy between baseline and follow-up was assigned Active group, those who did not was assigned Control group. All endpoints were analysed using Bayesian ordered logistic regression.

RESULTS

Trial 1 consisted of Active group, n = 59, and Control group, n = 3936. Trial 2 consisted of Active group, n = 87, and Control group, n = 3132. The majority of participants were men, 83% in trial 1 and 94% in trial 2. The prevalence and severity of intrusive thoughts were lower in the Active group in trial 1, but no significant differences between groups were found in either trial. The prevalence of depressed mood, worse quality of life and periods of anxiety were higher in the Active group in both trials with significant differences for quality of life in trial 1 and anxiety in trial 2.

CONCLUSIONS

The emulated trials demonstrated no evidence of a protective effect of beta-blocker therapy against intrusive thoughts. The Active group had reduced quality of life and elevated anxiety compared to the Control group.

TRIAL REGISTRATION

The three cohort studies were registered at isrctn.com/clinicaltrials.gov (ISRCTN06393679, NCT02530593 and NCT01477229).

Effects of neuromodulation on cognitive and emotional responses to psychosocial stressors in healthy humans

Physiological and psychological stressors can exert wide-ranging effects on the human brain and behavior. Research has improved understanding of how the sympatho-adreno-medullary (SAM) and hypothalamic-pituitary-adrenocortical (HPA) axes respond to stressors and the differential responses that occur depending on stressor type. Although the physiological function of SAM and HPA responses is to promote survival and safety, exaggerated psychobiological reactivity can occur in psychiatric disorders. Exaggerated reactivity may occur more for certain types of stressors, specifically, psychosocial stressors. Understanding stressor effects and how the body regulates these responses can provide insight into ways that psychobiological reactivity can be modulated. Non-invasive neuromodulation is one way that responding to stressors may be altered; research into these interventions may provide further insights into the brain circuits that modulate stress reactivity. This review focuses on the effects of acute psychosocial stressors and how neuromodulation might be effective in altering stress reactivity. Although considerable research into stress interventions focuses on treating pathology, it is imperative to first understand these mechanisms in non-clinical populations; therefore, this review will emphasize populations with no known pathology and consider how these results may translate to those with psychiatric pathologies.

Game-matching background music has an add-on effect for reducing emotionality of traumatic memories during reconsolidation intervention

INTRODUCTION

Hospital is a stressful place of employment, and a high proportion of healthcare workers, especially the ICU (Intensive Care Unit) nurses were found to be at risk of PTSD. Previous studies showed that taxing working memory through visuospatial tasks during the reconsolidation process of aversive memories can reduce the number of intrusions afterwards. However, the finds could not be replicated by some researches, indicating there may be some boundary conditions that are subtle and complex.

METHODS

We performed a randomized controlled trial (ChiCTR2200055921; URL: www.chictr.org.cn). In our study, a series of ICU nurses or probationers who performed a cardiopulmonary resuscitation (CPR) were enrolled and instructed to play a visuospatial music tapping game ("Ceaseless Music Note", CMN; Beijing Muyuan Technology Co., Ltd., Beijing, China) at the fourth day after CPR. The numbers of intrusions each day were recorded from the first to the seventh days (24 h×6 day), and the vividness and emotionality of CPR memories were rated at the 4th and 7th days. These parameters were compared between different groups (game with background sound; game with sound off; sound only; none).

RESULTS

The game-matching background music can have an add-on effect for single tapping game with no sound in reducing the emotionality of previous aversive memories.

DISCUSSION

We proposed that flow experience (the subjective experience of effortless attention, reduced self-awareness, and enjoyment, and may be induced by optimal skill-demands compatibility in challenging tasks) as a key boundary condition for successful reconsolidation intervention.

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, identifier: ChiCTR2200055921.

Propranolol versus Other Selected Drugs in the Treatment of Various Types of Anxiety or Stress, with Particular Reference to Stage Fright and Post-Traumatic Stress Disorder

Propranolol, a non-cardioselective β_1,2 blocker, is most commonly recognised for its application in the therapy of various cardiovascular conditions, such as hypertension, coronary artery disease, and tachyarrhythmias. However, due to its ability to cross the blood–brain barrier and affinity towards multiple macromolecules, not only adrenoreceptors, it has also found application in other fields. For example, it is one of the very few medications successfully applied in the treatment of stage fright. This review focuses on the application of propranolol in the treatment of various types of anxiety and stress, with particular reference to stage fright and post-traumatic stress disorder (PTSD). Both mechanisms of action as well as comparison with other therapies are presented. As those indications for propranolol are, in most countries, considered off-label, this review aims to gather information that can be useful while making a decision about the choice of propranolol as a drug in the treatment of those mental conditions.

Prevalence of post-traumatic stress disorder and its predictors following coronary artery bypass graft surgery

BACKGROUND

Cardiac surgery can be traumatic and stressful, and as a result many people experience psychological difficulties following treatment.

AIM

To assess the level of post-traumatic stress disorder (PTSD) 1 month after coronary artery bypass graft (CABG) surgery among Jordanian patients, and to examine the predictors of PTSD after 1 month.

METHOD

A descriptive survey design was used.

FINDINGS

149 patients participated in the study. Their mean age was 59 years (SD=10.2) and most were male (87%) and married (93%). Some 44% of patients had PTSD. Length of stay in hospital (c² (1)=6.598, P<0.05), and age (c² (1)=4.920, P<0.05), predicted the occurrence of PTSD after 1 month.

CONCLUSIONS

Nurses, who are usually in the frontline with patients, should consider using a robust tool and clinical interview to assess and evaluate the presence and the risks of PTSD to promote early detection and optimal management. Follow-up studies after 6 and 12 months would be beneficial.

In it together? The case for endocannabinoid-noradrenergic interactions in fear extinction

Anxiety and trauma-related disorders, such as post-traumatic stress disorder (PTSD), are debilitating mental illnesses with great personal and socioeconomic costs. Examining memory formation and relevant behavioural responding associated with aversive stimuli may improve our understanding of the neurobiology underlying fear memory processing and PTSD treatment. The neurocircuitry underpinning learned fear and its inhibition through extinction is complex, involving synergistic interactions between different neurotransmitter systems in inter-connected brain areas. Endocannabinoid and noradrenergic transmission have both been implicated separately in fear memory processing and PTSD, but potential interactions between these systems in relation to fear extinction have received little attention to date. Their receptors are expressed together in brain areas crucial for fear extinction, which is enhanced by both cannabinoid and noradrenergic receptor activation in these areas. Moreover, cannabinoid signalling modulates the activity of locus coeruleus noradrenaline (NA) neurons and the release of NA in the medial prefrontal cortex, a brain area that is crucial for fear extinction. Interestingly, endocannabinoid-noradrenergic system interactions have been shown to regulate the encoding and retrieval of fear memory. Thus, noradrenergic regulation of fear extinction may also be driven indirectly in part via cannabinoid receptor signalling. In this perspective paper, we collate the available relevant literature and propose a synergistic role for the endocannabinoid and noradrenergic systems in regulating fear extinction, the study of which may further our understanding of the neurobiological substrates of PTSD and its treatment.

Encoding or consolidation? The effects of pre- and post-learning propranolol on the impact of an emotional scene

BACKGROUND AND OBJECTIVES

Researchers have conceived of post-traumatic stress disorder (PTSD) as a disorder of memory, and proposed that blocking the impact of stress-related noradrenaline release in the aftermath of trauma may be a way of preventing the 'over-consolidation' of trauma-related memories. Experimental research in humans has been limited by typically focusing on declarative memory for emotional stories, and has mainly given propranolol before learning. In contrast, the clinical studies that we comprehensively review are hampered by practical challenges, such as reliably administering propranolol in a time window sufficiently close to the traumatic event. In this study, we aimed to assess the impact of both pre- and post-learning propranolol on emotional and declarative memory for an emotional scene, using the 'trauma film paradigm'.

METHODS

To control for drug and timing effects, participants received a pill (40 mg propranolol or placebo) both 60 min before and within 5 min after viewing a 12 min, emotionally arousing trauma film, and were assigned to one of the three conditions: propranolol-placebo (n = 25), placebo-propranolol (n = 25), or placebo-placebo (n = 25). We assessed participants' immediate emotional responses to the scene, as well as delayed impact (intrusions, Impact of Events Scale) and declarative memory.

RESULTS

Using Bayesian informative hypothesis testing, we found that pre-learning propranolol reduced the initial emotional impact of the 'trauma film'. However, we did not find strong evidence for an impact of pre- or post-learning propranolol on later consequences of having watched the emotional film (intrusions, Impact of Events, or tests of declarative memory). Exploratorily restricting analyses to women, we did find evidence suggesting that pre-encoding propranolol could reduce the rate of intrusions and self-reported negative impact of the emotional scene one week later.

LIMITATIONS

Floor effects in the delayed impact of the emotional scene could preclude observing differences as a function of propranolol, and propranolol dosage may need to be increased.

CONCLUSIONS

An impact of propranolol on encoding could raise difficulties in interpretation when only pre-encoding propranolol is used to make inferences about consolidation. We discuss the challenges of elucidating the mechanistic underpinnings of propranolol's reported effects on memory.

Myocardial hypersensitivity to ischemic injury is not reversed by clonidine or propranolol in a predator-based rat model of posttraumatic stress disorder

Individuals with posttraumatic stress disorder (PTSD) are at increased risk for cardiovascular disease. We previously reported that a predator-based model of PTSD increases myocardial sensitivity to ischemic injury. Heightened sympathetic signaling has a well-established role in the formation of anxiety associated with PTSD and may also contribute to worsening of myocardial injury in the ischemic heart. Thus, we examined whether suppression of sympathetic tone protects the ischemic heart in rats subjected to this model of PTSD. Rats were treated with saline or clonidine throughout the 31-day stress paradigm. Behavior on the elevated plus maze (EPM) was assessed on Day 32, and hearts were subjected to an ischemic insult on day 33. Stressed rats exhibited increased anxiety on the EPM and significantly larger myocardial infarcts following ischemia. Clonidine reversed the anxiety-like behavior but had no impact on infarct size. In a subsequent experiment, rats were treated with propranolol in their drinking water throughout the stress paradigm. Propranolol had no effect on either anxiety or myocardial sensitivity to ischemic injury. These findings suggest that the myocardial hypersensitivity to ischemic injury observed in this model is not caused by increased sympathetic tone or chronic β-adrenergic receptor signaling.

Beyond the Intensive Care Unit: Posttraumatic Stress Disorder in Critically Ill Patients

Medical care progress has enabled more patients in the intensive care unit to survive critical illnesses and return to daily living. This shift in survival rates has shed new light on the emotional consequences this experience. For patients surviving an ICU stay, posttraumatic stress disorder has been identified in approximately 9% to 27% compared with 7% of the general US population. Practitioners have an important role to play in early identification of patients experiencing signs and symptoms of this disorder. Timely interventions and treatment may reduce the incidence of physical and psychological comorbid conditions.

GANEing traction: The broad applicability of NE hotspots to diverse cognitive and arousal phenomena

The GANE (glutamate amplifies noradrenergic effects) model proposes that local glutamate-norepinephrine interactions enable "winner-take-more" effects in perception and memory under arousal. A diverse range of commentaries addressed both the nature of this "hotspot" feedback mechanism and its implications in a variety of psychological domains, inspiring exciting avenues for future research.

Beta Blocker Administration During Emergency Department Evaluation for Acute Coronary Syndrome Is Associated With Lower Posttraumatic Stress Symptoms 1-Month Later

We examined whether beta blocker administration in the emergency department (ED) during evaluation for suspected acute coronary syndrome (ACS) was associated with posttraumatic stress disorder (PTSD) symptoms 1-month later. Participants (N = 350) were enrolled in the Reactions to Acute Care and Hospitalization (REACH) study, an ongoing observational cohort study of ED predictors of medical and psychological outcomes after evaluation for suspected ACS. Beta blockade during evaluation in the ED was extracted from medical records, and PTSD symptoms in response to the experience of suspected ACS were assessed 1-month later via telephone. Beta blockade in the ED was associated with lower PTSD symptoms 1-month later, b = -2.80, β = -.09, p = .045, after adjustment for demographics, preexisting psychological and medical covariates, and participants' distress during ED evaluation. Despite small effects, findings suggest that beta blockade during ED evaluation for suspected ACS-a time period relevant to fear consolidation of the memory of this potentially life-threatening event-may have protective effects for later psychological health.

Posttraumatic stress syndrome associated with stays in the intensive care unit: importance of nurses' involvement

More patients in the intensive care unit are surviving their critical illnesses because of advances in medical care. This change in survival has led to an increased awareness of the emotional consequences of being critically ill. Posttraumatic stress disorder has been identified in approximately 9% to 27% of critically ill patients compared with 7% of the general US population. Risk factors such as treatment with mechanical ventilation, sedation, delusional memories, and agitation are associated with development of posttraumatic stress disorder in patients in the intensive care unit. Individuals with posttraumatic stress disorder are more likely to experience negative physical and psychiatric health outcomes and a lower quality of life than are patients without the disorder. Early identification and treatment of patients experiencing these signs and symptoms may reduce these physical and psychological comorbid conditions. Through careful monitoring of medications, early mobilization, sleep promotion, and pain management, nurses may be able to reduce signs and symptoms of posttraumatic stress disorder.

Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers

Outcomes after acute respiratory distress syndrome (ARDS) are similar to those of other survivors of critical illness and largely affect the nerve, muscle, and central nervous system but also include a constellation of varied physical devastations ranging from contractures and frozen joints to tooth loss and cosmesis. Compromised quality of life is related to a spectrum of impairment of physical, social, emotional, and neurocognitive function and to a much lesser extent discrete pulmonary disability. Intensive care unit-acquired weakness (ICUAW) is ubiquitous and includes contributions from both critical illness polyneuropathy and myopathy, and recovery from these lesions may be incomplete at 5 years after ICU discharge. Cognitive impairment in ARDS survivors ranges from 70 to 100 % at hospital discharge, 46 to 80 % at 1 year, and 20 % at 5 years, and mood disorders including depression and post-traumatic stress disorder (PTSD) are also sustained and prevalent. Robust multidisciplinary and longitudinal interventions that improve these outcomes are still uncertain and data in our literature are conflicting. Studies are needed in family members of ARDS survivors to better understand long-term outcomes of the post-ICU family syndrome and to evaluate how it affects patient recovery.

Enhancement of striatum-dependent memory by conditioned fear is mediated by beta-adrenergic receptors in the basolateral amygdala

Emotional arousal can have a profound impact on various learning and memory processes. For example, unconditioned emotional stimuli (e.g., predator odor or anxiogenic drugs) enhance dorsolateral striatum (DLS)-dependent habit memory. These effects critically depend on a modulatory role of the basolateral complex of the amygdala (BLA). Recent work indicates that, like unconditioned emotional stimuli, exposure to an aversive conditioned stimulus (CS) (i.e., a tone previously paired with shock) can also enhance consolidation of DLS-dependent habit memory. The present experiments examined whether noradrenergic activity, particularly within the BLA, is required for a fear CS to enhance habit memory consolidation. First, rats underwent a fear conditioning procedure in which a tone CS was paired with an aversive unconditioned stimulus. Over the course of the next five days, rats received training in a DLS-dependent water plus-maze task, in which rats were reinforced to make a consistent body-turn response to reach a hidden escape platform. Immediately after training on days 1–3, rats received post-training systemic (Experiment 1) or intra-BLA (Experiment 2) administration of the β-adrenoreceptor antagonist, propranolol. Immediately after drug administration, half of the rats were re-exposed to the tone CS in the conditioning context (without shock). Post-training CS exposure enhanced consolidation of habit memory in vehicle-treated rats, and this effect was blocked by peripheral (Experiment 1) or intra-BLA (Experiment 2) propranolol administration. The present findings reveal that noradrenergic activity within the BLA is critical for the enhancement of DLS-dependent habit memory as a result of exposure to conditioned emotional stimuli.

Pharmacological prevention of post-traumatic stress disorder and acute stress disorder: a systematic review and meta-analysis

BACKGROUND

An increasing number of studies have investigated the pharmacological prevention of post-traumatic stress disorder (PTSD) and acute stress disorder (ASD). This is the first systematic review to examine the effects of pharmacotherapies (eg, β blockers, hydrocortisone, and selective serotonin re-uptake inhibitors) given within the first month after a traumatic or aversive event to prevent PTSD or ASD compared with no pharmacotherapy or placebo control.

METHODS

A systematic literature search in PubMed, PsycINFO, Embase, and the Cochrane database of randomised trials was done. Studies included randomised controlled trials, controlled clinical trials, and cohort studies; their overall quality was low to moderate. We computed the pooled incidence risk ratio (IRR): the risk of incidence of PTSD or ASD in the pharmacotherapy groups relative to the incidence of PTSD or ASD in the control groups. Additionally, we computed Hedges'g effect sizes for PTSD or ASD continuous outcomes.

FINDINGS

15 studies met inclusion criteria (1765 individuals). Pharmacotherapy was more effective in preventing PTSD or ASD than placebo or no intervention (14 studies, 1705 individuals, IRR 0·65, 95% CI 0·55-0·78; number needed to treat 11·36), although no effect was found when only randomised controlled trials were included (ten studies, 300 individuals, IRR 0·69, 95% CI 0·40-1·21). Hydrocortisone showed a large effect in reducing the risk of PTSD (five studies, 164 individuals, IRR 0·38, 95% CI 0·16-0·92).

INTERPRETATION

No firm evidence was found for the efficacy of all early pharmacotherapies in the prevention of PTSD or ASD, but hydrocortisone reduced the risk of developing PTSD. The small number of studies and their limited methodological quality cast uncertainty about the effects.

FUNDING

None.

Patient-reported outcomes in post-traumatic stress disorder. Part II: focus on pharmacological treatment

Post-traumatic stress disorder (PTSD) may be associated with long-lasting psychological suffering, distressing psychosocial disability, markedly reduced health-related quality of life, and increased morbidity and mortality in a subgroup of individuals in the aftermath of serious traumatic events. Both etiopathogenesis and treatment modalities of PTSD are best conceptualized within a biopsychosotial model. Pharmacotherapy may lay claim to a major role in the multimodal treatment approaches. Here we outline two different pharmacotherapeutic trends that aim to modify the encoding, consolidation, and rehearsal of traumatic memory in order to reduce the risk of PTSD immediately after trauma exposure on the one hand, and that endeavor to treat the clinical state of PTSD on the other. The theoretical rationales of both pharmacological strategies are the complex neurobiological underpinnings that characterize traumatic memory organization and clinical PTSD. Meanwhile, promising data from randomized controlled trials have been obtained for both approaches. Empirical evidence may inform clinicians in their clinical efforts for this special group of patients. The efficacy of several classes of drugs that have been investigated within a context of research should be evaluated critically and still have to stand the test of effectiveness in daily clinical practice. From a patient perspective, empirical results may serve as a psychoeducative guideline to what pharmacotherapeutic approaches may realistically achieve, what their risks and benefits are, and what their limits are in contributing to reducing the often major chronic suffering caused by serious traumatic events. Ethical issues have to be considered, particularly in the context of pharmacological strategies projected to prevent PTSD in the aftermath of traumatic exposure.

Postoperative pain and subsequent PTSD-related symptoms in patients undergoing lung resection for suspected cancer

BACKGROUND

Because lung cancer resection is at the crossroad between cancer and high-risk surgery, we hypothesized that the patients undergoing lung resection for cancer are exposed to develop a post-traumatic stress disorder (PTSD) syndrome-related symptoms.

METHODS

Forty-seven adult patients were included in the study. Patients were eligible for inclusion if they underwent lung resection for suspected cancer, if they were able to speak and read French, and if they agreed to be reached for a telephone interview. We assessed before, immediately after, and 3 months after surgery the presence of symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) and PTSD-related symptoms (impact of events scale revised [IES-R]). At the 3-month assessment, an IES-R score > 22 was used as criteria for predicting the patients at risk of PTSD-related symptoms.

RESULTS

We identified an IES-R score higher than 22 in 24 participants (51%). Patients with a preoperatory Hospital Anxiety and Depression Scale(anxiety) score more than 7 (T0) and a maximal visual analogic scale score more than 40 during the first 24 hours after surgery were more likely to develop PTSD-related symptoms at 3-months with odd ratios at 4.61 [1.20-17.73] (p = 0.03) and 1.34 [1.05-1.75] (p = 0.02).

CONCLUSION

The prevalence of PTSD-related symptoms after lung cancer resection is high, showing that lung cancer patients undergoing surgical resection are at high risk of postprocedure burden. The presence of preoperative symptoms of anxiety and acute procedural pain during the early postoperative period are strong predictors for developing PTSD-related symptoms after lung cancer surgery.

Interaction of the ADRB2 gene polymorphism with childhood trauma in predicting adult symptoms of posttraumatic stress disorder

IMPORTANCE

Posttraumatic stress disorder (PTSD), while highly prevalent (7.6% over a lifetime), develops only in a subset of trauma-exposed individuals. Genetic risk factors in interaction with trauma exposure have been implicated in PTSD vulnerability.

OBJECTIVE

To examine the association of 3755 candidate gene single-nucleotide polymorphisms with PTSD development in interaction with a history of childhood trauma.

DESIGN, SETTING, AND PARTICIPANTS

Genetic association study in an Ohio National Guard longitudinal cohort (n = 810) of predominantly male soldiers of European ancestry, with replication in an independent Grady Trauma Project (Atlanta, Georgia) cohort (n = 2083) of predominantly female African American civilians.

MAIN OUTCOMES AND MEASURES

Continuous measures of PTSD severity, with a modified (interview) PTSD checklist in the discovery cohort and the PTSD Symptom Scale in the replication cohort.

RESULTS

Controlling for the level of lifetime adult trauma exposure, we identified the novel association of a single-nucleotide polymorphism within the promoter region of the ADRB2 (Online Mendelian Inheritance in Man 109690) gene with PTSD symptoms in interaction with childhood trauma (rs2400707, P = 1.02 × 10-5, significant after correction for multiple comparisons). The rs2400707 A allele was associated with relative resilience to childhood adversity. An rs2400707 × childhood trauma interaction predicting adult PTSD symptoms was replicated in the independent predominantly female African American cohort.

CONCLUSIONS AND RELEVANCE

Altered adrenergic and noradrenergic function has been long believed to have a key etiologic role in PTSD development; however, direct evidence of this link has been missing. The rs2400707 polymorphism has been linked to function of the adrenergic system, but, to our knowledge, this is the first study to date linking the ADRB2 gene to PTSD or any psychiatric disorders. These findings have important implications for PTSD etiology, chronic pain, and stress-related comorbidity, as well as for both primary prevention and treatment strategies.

Prereactivation propranolol fails to reduce skin conductance reactivity to prepared fear-conditioned stimuli

Pharmacologic blockade of memory reconsolidation has been demonstrated in fear-conditioned rodents and humans and may provide a means to reduce fearfulness in anxiety disorders and posttraumatic stress disorder. Studying the efficacy of potential interventions in clinical populations is challenging, creating a need for paradigms within which candidate reconsolidation-blocking interventions can be readily tested. We used videos of biologically prepared conditioned stimuli (tarantulas) to test the efficacy of propranolol in blocking reconsolidation of conditioned fear in healthy young adults. Strong differential conditioning, measured by skin conductance, was observed among a screened subset of participants during acquisition. However, subsequent propranolol failed to reduce reactivity to the reactivated conditioned stimulus. These results are consistent with other recent findings and point to a need for testing other candidate drugs.

The Impact of Stress Hormones on Post-traumatic Stress Disorders Symptoms and Memory in Cardiac Surgery Patients

The relationship and interactions between stress hormones and post-traumatic stress disorder (PTSD) are well established from both animal and human research studies. This interaction is especially important in the post-operative phase of cardiac surgery where the development of PTSD symptoms will result in increased morbidity and mortality and prolong length of stay for critically ill cardiac surgery patients. Cardiopulmonary bypass itself will independently result in massive inflammation response and release of stress hormones in the perioperative period. Glucocorticoid may reduce this response and result in reduction of PTSD symptom clusters and therefore improve health outcome. In this review, we plan to conduct a systemic review and analysis of the literatures on this topic.

Modeling PTSD in the zebrafish: are we there yet?

Post-traumatic stress disorder is an anxiety disorder that can develop following one or more traumatic events that threaten one's safety or make the victim feel helpless. Currently there are an increasing number of cases in the population in part due to the number of soldiers returning from combat. The disorder is characterized by symptoms that include hypervigilance, sleep disturbances, social and cognitive degradation, and memory flashbacks. Most of the research has been centered on the human and rodent as subjects but recently another viable contender has emerged - the zebrafish (Danio rerio). The zebrafish is a strong comparative model with the ability to exhibit a wide variety of behaviors, complex learning, and neurobiological changes that can be extrapolated to the human condition. The zebrafish is an ideal organism to study pharmacological treatments as well as the neurological underpinnings of the disorder. Here we review a sampling of the human and rodent model literature on post-traumatic stress disorder focusing on symptomology, current treatments, and stress paradigms. We also make the argument for the inclusion of the zebrafish model in future studies investigating the causes, symptoms, and treatments of post-traumatic stress disorder.

Pilot study of the effect of lipophilic vs. hydrophilic beta-adrenergic blockers being taken at time of intracardiac defibrillator discharge on subsequent PTSD symptoms

A pathophysiological model of posttraumatic stress disorder (PTSD) posits that an overly strong stress response at the time of the traumatic event leads to overconsolidation of the event's memory in part through a central β-adrenergic mechanism. We hypothesized that the presence of a β-blocker in the patient's brain at the time of the traumatic event would reduce the PTSD outcome by blocking this effect. The unpredictable, uncontrollable discharge of an implantable intracardiac defibrillator (ICD) is experienced by most patients as highly stressful, and it has previously been shown to be capable of causing PTSD symptoms. The present pilot study evaluated a convenience sample of 18 male cardiac patients who had been taking either a lipophilic β-blocker (which penetrates the blood-brain barrier) or a hydrophilic β-blocker (which does not) at the time of a discharge of their ICD. The self- report PTSD Checklist-Specific Version quantified 17 PTSD symptoms pertaining to the ICD discharge during the month preceding the evaluation. There was a statistical trend for patients who had been taking a lipophilic β-blocker at the time of the ICD discharge to have (35%) less severe PTSD symptoms than patients who had been taking a hydrophilic β-blocker (one-tailed p=0.07, g=0.64). Further, prospective, randomized, controlled studies are suggested.

The role of glucocorticoids, catecholamines and endocannabinoids in the development of traumatic memories and posttraumatic stress symptoms in survivors of critical illness

Critically ill patients are at an increased risk for traumatic memories and post-traumatic stress disorder (PTSD). Memories of one or more traumatic events play an important part in the symptom pattern of PTSD. Studies in long-term survivors of intensive care unit (ICU) treatment demonstrated a clear and vivid recall of traumatic experiences and the incidence and intensity of PTSD symptoms increased with the number of traumatic memories present. Preclinical evidence has clearly shown that the consolidation and retrieval of traumatic memories is regulated by an interaction between the noradrenergic, the glucocorticoid and the endocannabinoid system. Critically ill patients in the ICU frequently require treatment with adrenenergic or glucocorticoid drugs and often receive sedative medications; among them propofol is known to influence endocannabinoid signaling. Critical illness could therefore represent a useful model for investigating adrenergic, glucocorticoid as well as endocannabinoid effects on traumatic memory and PTSD development in stressed humans. The endocannabinoid system is an important regulator of HPA-axis activity during stress, an effect which has also been demonstrated in humans. Likewise, a single nucleotide polymorphism (SNP) of the glucocorticoid receptor (GR) gene (the BclI-SNP), which enhances the sensitivity of the glucocorticoid receptors to cortisol and possibly HPA-axis feedback function, was associated with enhanced emotional memory performance in healthy volunteers. The presence of the BclI-SNP increased the risk for traumatic memories and PTSD symptoms in patients after ICU therapy and was linked to lower basal cortisol levels. A number of small studies have demonstrated that the administration of cortisol to critically ill or injured patients results in a significant reduction of PTSD symptoms after recovery without influencing the number of traumatic memories. These glucocorticoid effects can possibly be explained by a cortisol-induced temporary impairment in traumatic memory retrieval which has previously been demonstrated in both rats and humans. The hypothesis that stress doses of glucocorticoids or the pharmacologic manipulation of glucocorticoid-endocannabinoid interaction during traumatic memory consolidation and retrieval could be useful for prophylaxis and treatment of PTSD after critical illness should be tested in larger controlled studies.

Beta-blockers may reduce intrusive thoughts in newly diagnosed cancer patients

OBJECTIVE

A cancer diagnosis provokes significant levels of emotional distress, with intrusive thoughts being the most common manifestation among breast cancer survivors. Cancer-related intrusive thoughts can take the form of emotional memories, flashbacks, nightmares, and intrusive images. Emotional arousal after a severe life stressor prolongs adrenergic activation, which in turn may increase risk for post-traumatic symptomatology. However, antihypertensive beta-blockers block adrenergic activation and are known to reduce traumatic memories and related psychological distress. Thus, the current study examined the association between beta-blocker use and the severity of cancer-related intrusive thoughts and related symptoms following a cancer diagnosis.

METHODS

The 174 breast and 36 female colorectal cancer patients who had recently undergone diagnostic screening or biopsy included 39 beta-blocker users and 171 non-users. Prior to any cancer treatment including surgery, participants completed questionnaires that included the Impact of Events Scale and the Center for Epidemiological Studies Depression Scale. Analyses controlled for age, education, cancer stage, cancer type, days since diagnosis, marital status, depression, and comorbidities.

RESULTS

Although the high rates of cancer-related distress in this sample were similar to those of other studies with recently diagnosed patients, beta-blocker users endorsed 32% fewer cancer-related intrusive thoughts than non-users.

CONCLUSIONS

Recently diagnosed cancer patients using beta-blockers reported less cancer-related psychological distress. These results suggest that beta-blocker use may benefit cancer patients' psychological adjustment following diagnosis, and provide a promising direction for future investigations on the pharmacological benefits of beta-blockers for cancer-related distress.

Memory modulation

Our memories are not all created equally strong: Some experiences are well remembered while others are remembered poorly, if at all. Research on memory modulation investigates the neurobiological processes and systems that contribute to such differences in the strength of our memories. Extensive evidence from both animal and human research indicates that emotionally significant experiences activate hormonal and brain systems that regulate the consolidation of newly acquired memories. These effects are integrated through noradrenergic activation of the basolateral amygdala that regulates memory consolidation via interactions with many other brain regions involved in consolidating memories of recent experiences. Modulatory systems not only influence neurobiological processes underlying the consolidation of new information, but also affect other mnemonic processes, including memory extinction, memory recall, and working memory. In contrast to their enhancing effects on consolidation, adrenal stress hormones impair memory retrieval and working memory. Such effects, as with memory consolidation, require noradrenergic activation of the basolateral amygdala and interactions with other brain regions.

[Targeted prevention of posttraumatic stress disorder]

Posttraumatic stress disorder (PTSD) is a severe, frequently chronic condition with a high rate of co-morbidity with other psychiatric syndromes. In contrast to the majority of psychiatric disorders, the traumatic event in PTSD constitutes a clearly defined etiological factor. A growing understanding of the mechanisms contributing to the development of PTSD has highlighted the possibilities for early preventive psychological and pharmacological treatment during the so-called golden hours after a traumatic experience. Whereas preliminary evidence suggests that a pharmacological recalibration of the HPA system and cognitive behavioral therapy may be helpful, other frequently used strategies, such as psychological debriefing or benzodiazepine treatment, seem to be largely ineffective, possibly even worsening PTSD symptoms.