MRI reveals gross structural abnormalities in PTSD

Posttraumatic Stress Symptoms After Stroke: The Effects of Anatomy and Coping Style

BACKGROUND

Posttraumatic stress disorder (PTSD) can be triggered by life-threatening medical emergencies, such as stroke. Data suggest that up to 25% of stroke survivors will develop PTSD symptomatology, but little is known about predisposing factors. We sought to examine whether neuroimaging measures and coping styles are related to PTSD symptoms after stroke.

METHODS

Participants were survivors of first-ever, mild-moderate ischemic stroke, or transient ischemic attack from the TABASCO study (Tel Aviv Brain Acute Stroke Cohort). All participants underwent a 3T magnetic resonance imaging at baseline and were examined 6, 12, and 24 months thereafter, using neurological, neuropsychological, and functional evaluations. At baseline, coping styles were evaluated by a self-reported questionnaire. PTSD symptoms were assessed using the PTSD checklist. Data were available for 436 patients.

RESULTS

Forty-eight participants (11%) developed probable PTSD (PTSD checklist ≥44) during the first year after the stroke/transient ischemic attack. Stroke was more likely to cause PTSD than transient ischemic attack. Stroke severity, larger white matter lesion volume, and worse hippocampal connectivity were associated with PTSD severity, while infarct volume or location was not. In a multivariate analysis, high-anxious and defensive coping styles were associated with a 6.66-fold higher risk of developing poststroke PTSD ([95% CI, 2.08-21.34]; P<0.01) compared with low-anxious and repressive coping styles, after adjusting for age, education, stroke severity, brain atrophy, and depression.

CONCLUSIONS

In our cohort, PTSD was a common sequela among stroke survivors. We suggest that risk factors for PTSD development include stroke severity, white matter damage, and premorbid coping styles. Early identification of at-risk patients is key to effective treatment.

Pharmacotherapy for post traumatic stress disorder (PTSD)

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment.

OBJECTIVES

To assess the effects of medication for reducing PTSD symptoms in adults with PTSD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Issue 11, November 2020); MEDLINE (1946-), Embase (1974-), PsycINFO (1967-) and PTSDPubs (all available years) either directly or via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR). We also searched international trial registers. The date of the latest search was 13 November 2020.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy for adults with PTSD.

DATA COLLECTION AND ANALYSIS

Three review authors (TW, JI, and NP) independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. We contacted investigators to obtain missing data. We stratified summary statistics by medication class, and by medication agent for all medications. We calculated dichotomous and continuous measures using a random-effects model, and assessed heterogeneity.

MAIN RESULTS

We include 66 RCTs in the review (range: 13 days to 28 weeks; 7442 participants; age range 18 to 85 years) and 54 in the meta-analysis.  For the primary outcome of treatment response, we found evidence of beneficial effect for selective serotonin reuptake inhibitors (SSRIs) compared with placebo (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.59 to 0.74; 8 studies, 1078 participants), which improved PTSD symptoms in 58% of SSRI participants compared with 35% of placebo participants, based on moderate-certainty evidence.  For this outcome we also found evidence of beneficial effect for the noradrenergic and specific serotonergic antidepressant (NaSSA) mirtazapine: (RR 0.45, 95% CI 0.22 to 0.94; 1 study, 26 participants) in 65% of people on mirtazapine compared with 22% of placebo participants, and for the tricyclic antidepressant (TCA) amitriptyline (RR 0.60, 95% CI 0.38 to 0.96; 1 study, 40 participants) in 50% of amitriptyline participants compared with 17% of placebo participants, which improved PTSD symptoms. These outcomes are based on low-certainty evidence. There was however no evidence of beneficial effect for the number of participants who improved with the antipsychotics (RR 0.51, 95% CI 0.16 to 1.67; 2 studies, 43 participants) compared to placebo, based on very low-certainty evidence. For the outcome of treatment withdrawal, we found evidence of a harm for the individual SSRI agents compared with placebo (RR 1.41, 95% CI 1.07 to 1.87; 14 studies, 2399 participants). Withdrawals were also higher for the separate SSRI paroxetine group compared to the placebo group (RR 1.55, 95% CI 1.05 to 2.29; 5 studies, 1101 participants). Nonetheless, the absolute proportion of individuals dropping out from treatment due to adverse events in the SSRI groups was low (9%), based on moderate-certainty evidence. For the rest of the medications compared to placebo, we did not find evidence of harm for individuals dropping out from treatment due to adverse events.

AUTHORS' CONCLUSIONS

The findings of this review support the conclusion that SSRIs improve PTSD symptoms; they are first-line agents for the pharmacotherapy of PTSD, based on moderate-certainty evidence. The NaSSA mirtazapine and the TCA amitriptyline may also improve PTSD symptoms, but this is based on low-certainty evidence. In addition, we found no evidence of benefit for the number of participants who improved following treatment with the antipsychotic group compared to placebo, based on very low-certainty evidence. There remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.

White Matter and Cognitive Changes in Veterans Diagnosed with Alcoholism and PTSD

Alcoholism frequently occurs in returning U.S. Veterans, and is often comorbid with Post Traumatic Stress Disorder (PTSD). The goal of this study was to investigate the relationship between white matter changes and neuropsychological alterations in Operation Enduring Freedom, and/or Operation Iraqi Freedom (OEF/OIF) alcoholic Veterans with two primary aims: (1) to examine the relationship of alcoholism to brain structure and function while controlling for the potential effects of comorbid PTSD, and (2) to examine whether the effects of alcoholism are moderated by the quantity of lifetime alcohol consumption. Our sample consisted of 71 deployed OEF/OIF Veterans stratified into four groups: alcoholics without PTSD, alcoholics with PTSD, participants with PTSD without comorbid alcoholism, and control participants without alcoholism or PTSD. Participants were given an extensive neuropsychological and psychiatric assessment battery, as well as Magnetic Resonance Diffusion Tensor Imaging (DT-MRI) scans. Results showed that disruption of executive functioning, and abnormal fractional anisotropy (FA; a measure of axonal integrity) within the frontal subcortical and dorsolateral frontal-parietal regions, occurred independently of the effects of PTSD. Furthermore, these cognitive and neuronal alterations were unique to the most severe subgroup of alcoholics who consumed the greatest amount of alcohol over the course of their lifetime, as compared to the rest of the sample. Axonal integrity within this subgroup, in regions underlying the frontal subcortical area, was shown to be decreased independently of cognitive changes. Integrity of axons underlying the dorsolateral frontal-parietal region, however, was increased. We hypothesized that this is a compensatory mechanism for executive dysfunction.

Neuro-psychopharmacogenetics and Neurological Antecedents of Posttraumatic Stress Disorder: Unlocking the Mysteries of Resilience and Vulnerability

BACKGROUND AND HYPOTHESIS

Although the biological underpinnings of immediate and protracted trauma-related responses are extremely complex, 40 years of research on humans and other mammals have demonstrated that trauma (particularly trauma early in the life cycle) has long-term effects on neurochemical responses to stressful events. These effects include the magnitude of the catecholamine response and the duration and extent of the cortisol response. In addition, a number of other biological systems are involved, including mesolimbic brain structures and various neurotransmitters. An understanding of the many genetic and environmental interactions contributing to stress-related responses will provide a diagnostic and treatment map, which will illuminate the vulnerability and resilience of individuals to Posttraumatic Stress Disorder (PTSD).

PROPOSAL AND CONCLUSIONS

We propose that successful treatment of PTSD will involve preliminary genetic testing for specific polymorphisms. Early detection is especially important, because early treatment can improve outcome. When genetic testing reveals deficiencies, vulnerable individuals can be recommended for treatment with "body friendly" pharmacologic substances and/or nutrients. Results of our research suggest the following genes should be tested: serotoninergic, dopaminergic (DRD2, DAT, DBH), glucocorticoid, GABAergic (GABRB), apolipoprotein systems (APOE2), brain-derived neurotrophic factor, Monamine B, CNR1, Myo6, CRF-1 and CRF-2 receptors, and neuropeptide Y (NPY). Treatment in part should be developed that would up-regulate the expression of these genes to bring about a feeling of well being as well as a reduction in the frequency and intensity of the symptoms of PTSD.

Severe psychological stress in elderly individuals: a proposed model of neurodegeneration and its implications

During clinical practice, degenerative diseases in some patients appear after exposure to a severe psychological stress. Several studies have suggested that the duration of exposure to corticosteroids or stress, the dose of corticosteroids and the vulnerability of the hippocampus, amygdala and prefrontal cortex areas targeted by elevated stress hormones, mediate the damaging effects of elevated corticosteroids. Although understanding what triggers the transition from adaptive plasticity to the maladaptive effects of stress in the elderly is important, one of the great challenges is to determine individual differences in vulnerability to stress-induced events in both animal and human populations, and to devise strategies that may help protecting the brain from permanent damage. This review provides the basis for creating interventions and educational programs during midlife in order to prevent dementia or other neurodegenerative diseases or to halt the progress of neurodegeneration in the early stages.

Information Processing Bias in Post-traumatic Stress Disorder

This review considers theory and evidence for abnormal information processing in post-traumatic stress disorder (PTSD). Cognitive studies have indicated sensitivity in PTSD for traumatic information, more so than general emotional information. These findings were supported by neuroimaging studies that identify increased brain activity during traumatic cognition, especially in affective networks (including the amygdala, orbitofrontal and anterior cingulate cortex). In theory, it is proposed that traumatic cognition may interfere with neutral cognition and there is evidence of abnormal neutral stimulus processing in PTSD. Firstly, PTSD patients perform poorly on a variety of neuropsychology tasks that involve attention and memory for neutral information. The evidence from event-related potentials and functional neuroimaging also indicates abnormal results in PTSD during neutral stimulus processing. The research evidence generally provides support for theories of trauma sensitivity and abnormal neutral stimulus processing in PTSD. However, there is only tentative evidence that trauma cognition concurrently interferes with neutral cognition. There is even some evidence that traumatic or novelty arousal processes can increase the capacity for attentive processing, thereby enhancing cognition for neutral stimulus information. Research on this topic has not yet fully explored the mechanisms of interaction between traumatic and neutral content in the cognitive dynamics of PTSD.

Neuroimaging endophenotypes: strategies for finding genes influencing brain structure and function

It is vitally important to identify the genetic determinants of complex brain-related disorders such as autism, dementia, mood disorders, and schizophrenia. However, the search for genes predisposing individuals to these illnesses has been hampered by their genetic and phenotypic complexity and by reliance upon phenomenologically based qualitative diagnostic systems. Neuroimaging endophenotypes are quantitative indicators of brain structure or function that index genetic liability for an illness. These indices will significantly improve gene discovery and help us to understand the functional consequences of specific genes at the level of systems neuroscience. Here, we review the feasibility of using neuroanatomic and neuropsychological measures as endophenotypes for brain-related disorders. Specifically, we examine specific indices of brain structure or function that are genetically influenced and associated with neurological and psychiatric illness. In addition, we review genetic approaches that capitalize on the use of quantitative traits, including those derived from brain images.

Intimate partner violence, PTSD, and adverse health outcomes

The high prevalence of adverse health outcomes related to intimate partner violence (IPV) is well documented. Yet we know little about the pathways that lead to adverse health outcomes. Research concerning the psychological, biological, neurological, behavioral, and physiological alterations following exposure to IPV--many of which are associated with posttraumatic stress disorder (PTSD)--represents a promising area of empirical discovery. New technologies and interdisciplinary collaborative efforts are required to integrate diverse methodologies and to apply new findings to improving the health and well being of those affected by IPV. This article focuses on victimization by IPV and addresses the most important research findings in the last 20 years (health and mental health burden of IPV), the most important research issue for the next decade (pathways between IPV and adverse health outcomes), and the most promising methodological innovation for the study of IPV (integrated, interdisciplinary, biobehavioral methodology).

Pharmacotherapy for post traumatic stress disorder (PTSD)

BACKGROUND

Post traumatic stress disorder (PTSD) is a prevalent and disabling disorder. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in the use of medication in its treatment.

OBJECTIVES

To assess the effects of medication for post traumatic stress disorder.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety and Neurosis Group specialised register (CCDANCTR-Studies) on 18 August 2005, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library issue 4, 2004), MEDLINE (January 1966 to December 2004), PsycINFO (1966 to 2004), and the National PTSD Center Pilots database. Reference lists of retrieved articles were searched for additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of pharmacotherapy for PTSD.

DATA COLLECTION AND ANALYSIS

Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin reuptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were undertaken.

MAIN RESULTS

35 short-term (14 weeks or less) RCTs were included in the analysis (4597 participants). Symptom severity for 17 trials was significantly reduced in the medication groups, relative to placebo (weighted mean difference -5.76, 95% confidence intervals (CI) -8.16 to -3.36, number of participants (N) = 2507). Similarly, summary statistics for responder status from 13 trials demonstrated overall superiority of a variety of medication agents to placebo (relative risk 1.49, 95% CI 1.28 to 1.73, number needed to treat = 4.85, 95% CI 3.85 to 6.25, N = 1272). Medication and placebo response occurred in 59.1% (N = 644) and 38.5% (628) of patients, respectively. Of the medication classes, evidence of treatment efficacy was most convincing for the SSRIs. Medication was superior to placebo in reducing the severity of PTSD symptom clusters, comorbid depression and disability. Medication was also less well tolerated than placebo. A narrative review of 3 maintenance trials suggested that long term medication may be required in treating PTSD.

AUTHORS' CONCLUSIONS

Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability. The findings of this review support the status of SSRIs as first line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment. However, there remain important gaps in the evidence base, and a continued need for more effective agents in the management of PTSD.

Alterations in cerebral perfusion in posttraumatic stress disorder patients without re-exposure to accident-related stimuli

Functional neuroimaging studies have shown abnormalities of limbic regions in patients with posttraumatic stress disorder (PTSD) during symptom provocation and cognitive activation.

OBJECTIVE

The aim of this study was to determine whether PTSD patients without re-exposure to accident-related stimuli would exhibit alterations in cerebral perfusion compared with age-matched normal subjects.

METHODS

Brain perfusion SPECT was measured in medication-free 23 PTSD patients and 64 age-matched healthy subjects under resting conditions and analyzed using statistical parametric mapping to compare between the patient and control groups.

RESULTS

We found that PTSD patients exhibited increased cerebral blood perfusion in limbic regions and decreased perfusion in the superior frontal gyrus and parietal and temporal regions in comparison with those of the normal controls.

CONCLUSIONS

This result indicates that PTSD patients have alterations in cerebral perfusion of limbic regions and the frontal and temporal cortex without re-exposure to accident-related stimuli.

SIGNIFICANCE

This finding supports the hypothesis of the involvement of limbic regions, which might be associated with the regulation of emotion and memory, in the pathophysiology of PTSD.

Integrative assessment of brain and cognitive function in post-traumatic stress disorder

The present study combined neuropsychological and electrophysiological measures to obtain a comprehensive profile of the everyday attentional and memory dysfunction reported in PTSD. The event-related potential (ERP) literature has consistently found abnormalities in late components (N2, P3) reflecting working memory (WM) function. However, the neuropsychological profile reported in the literature has considerable variation. The present study examined ERP activity in 33 PTSD participants and matched controls during a standard two-tone auditory oddball task. Neuropsychological assessment was carried out using a task battery assessing a wide range of cognitive functions. Consistent with previous work, the PTSD group showed delayed N2 latency and reduced P3 target amplitude, together with slower and less accurate target detection. Scalp topography provided evidence of widespread abnormality during WM function, but with strongest effects broadly over the left hemisphere. Neuropsychological testing found concomitant difficulties on factorial measures of verbal memory retention/access and sustained attention but enhanced performance on measures of immediate recall. This integrative pattern of effects reflects a specific impairment in the operation of working memory systems that guide ongoing, planned behavior and that facilitate the acquisition and retention of new memories.

Bilateral hippocampal volume reduction in adults with post-traumatic stress disorder: A meta-analysis of structural MRI studies

Over the last decade a significant number of studies have reported smaller hippocampal volume in individuals with symptoms of post-traumatic stress disorder (PTSD) relative to control groups, and in some cases hemispheric asymmetries in this effect have been noted. However these reported asymmetries have not been in a consistent direction, and other well-controlled studies have failed to observe any hippocampal volume difference. This paper reports a systematic review and meta-analysis of studies in which hippocampal volume was estimated from magnetic resonance images in adult patients with PTSD. After applying a variety of selection criteria intended to minimize potential confounds in pooled effect-size estimates, the meta-analysis included 13 studies of adult patients with PTSD that compared the patients to well-matched control groups, for a total of 215 patients and 325 control subjects. The studies varied with respect to participant age, gender distribution, source of trauma, severity of symptoms, duration of disorder, the nature of the control groups, and the methods employed for volumetric quantification. Despite these differences, pooled effect size calculations across the studies indicated significant volume differences in both hemispheres. On average PTSD patients had a 6.9% smaller left hippocampal volume and a 6.6% smaller right hippocampal volume compared with control subjects. These volume differences were smaller when comparing PTSD patients with control subjects exposed to similar levels of trauma, and larger when comparing PTSD patients to control subjects without significant trauma exposure. Such differences are consistent with the notion that exposure to stressful experiences can lead to hippocampal atrophy, although prospective studies would be necessary to unambiguously establish such a relationship.

Clinical perspectives on neurobiological effects of psychological trauma

Physical trauma to the brain has always been known to affect brain functions and subsequent neurobiological development. Research primarily since the early 1990s has shown that psychological trauma can have detrimental effects on brain function that are not only lasting but that may alter patterns of subsequent neurodevelopment, particularly in children although developmental effects may be seen in adults as well. Childhood trauma produces a diverse range of symptoms and defining the brain's response to trauma and the factors that mediate the body's stress response systems is at the forefront of scientific investigation. This paper reviews the current evidence relating psychological trauma to anatomical and functional changes in the brain and discusses the need for accurate diagnosis and treatment to minimize such effects and to recognize their existence in developing treatment programs.

Event-related potentials and EMDR treatment of post-traumatic stress disorder

Ten patients suffering from post-traumatic stress disorder (PTSD) following a severe traumatic event, were assessed with event-related brain potentials (ERPs) in a modified oddball paradigm containing auditory standard, target, and novel tones. ERPs were assessed before and after a treatment session using the eye movement desensitization and reprocessing method. Compared to a control group that underwent sham treatment, ERPs of the patients showed a reduction of the P3a component in the post-treatment recording, suggesting a reduced orienting to novel stimuli and reduced arousal level after the treatment. Moreover, psychometric assessment revealed a marked improvement of the PTSD symptoms after treatment.

Brain-imaging studies of posttraumatic stress disorder

Brain-imaging studies of posttraumatic stress disorder (PTSD) have rapidly increased in recent years. Structural studies have identified potential smaller volumes of the hippocampus of traumatized and/or PTSD subjects. Functional activation studies have implicated hyperactive or altered functioning of brain regions, such as the amygdala and the insula, and a failure to engage emotional regulatory structures, such as the medial prefrontal and anterior cingulate cortex. Recent neurochemical investigations have suggested that neuromodulatory systems (eg, gamma-aminobutyric acid, micro-opioid) may underlie these aberrant brain activation patterns. This article reviews the literature on structural, functional, and neurochemical brain-imaging studies of PTSD.

Reduced hippocampal volume and total white matter volume in posttraumatic stress disorder

BACKGROUND

Reduced hippocampal volumes in posttraumatic stress disorder (PTSD) patients are thought to reflect specific changes of this structure. Previous magnetic resonance imaging (MRI) studies have not consistently examined indices of overall brain atrophy, therefore it cannot be completely ruled out that hippocampal changes are explained by whole-brain atrophy. The purpose of this study was to assess hippocampal and whole-brain volume in civilian PTSD.

METHODS

Twelve subjects with PTSD and 10 control subjects underwent brain MRI. Hippocampal volumes were visually quantified using a computerized volumetric program. Whole-brain volumes were obtained with automated k-means-based segmentation.

RESULTS

No differences were found in intracranial volumes (ICV). Subjects with PTSD had higher cerebrospinal fluid (CSF)/ICV ratios and lower white matter/ICV ratios, consistent with generalized white matter (WM) atrophy. The effect of age on CSF/ICV was more pronounced in the PTSD group. Subjects with PTSD had smaller absolute and normalized bilateral hippocampal volumes. These differences persisted after adjusting for lifetime weeks of alcohol intoxication. Posttraumatic stress disorder and depression scores correlated negatively with left hippocampal volume, but PTSD scores were a better predictor of hippocampal volumes.

CONCLUSIONS

Our results replicate previous findings of reduced hippocampal volume in PTSD but also suggest independent, generalized, white matter atrophy.

Neuroimaging studies in post-traumatic stress disorder

The authors review some of the advances that have been made in understanding the structural, biochemical, and functional neuroanatomy of post-traumatic stress disorder (PTSD). First, the authors review the primary brain regions that had been hypothesized a priori, from the phenomenology and neurobiology of PTSD, to be implicated in the pathophysiology. Next, they review findings from neuroimaging studies of these brain regions in PTSD, and explain the various experimental methods and imaging technologies used in these studies. A broader perspective, including a discussion of additional brain areas that may be involved in PTSD, is synthesized. The authors conclude with a rationale and approach for studies testing sharply defined hypotheses and those using multidisciplinary strategies that integrate neuroimaging data with other cognitive, biologic, and genetic tools to study this complex disorder.

The stress-reaction process and the adaptive modification and reorganization of neuronal networks

On the basis of a comprehensive definition of the stress-reaction process (SRP), the neurobiological and psychological consequences of this process, which are elicited by either controllable or uncontrollable stress, are described. We conclude that controllable stress triggers the stabilization and facilitation of neuronal networks involved in the generation of appropriate patterns of appraisal and coping, whereas uncontrollable stress favors the extinction of inappropriate patterns and the reorganization of neuronal connections underlying certain inappropriate behaviors. Both controllable and uncontrollable stress-reaction processes are therefore inherent challenges to the development and essential prerequisites of the adaptation of an individual's behavior to the demands of the ever-changing external world. The overabundance, as well as the lack, of either kind of SRP may lead to different psychodevelopmental failures and psychiatric disturbances.

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With the increasing application of imaging techniques, characteristic changes in the structure and functional activity of certain neuronal networks and transmitter Systems have been discovered in the brains of patients suffering from various psychiatric disorders. These findings have often been assumed to support biological concepts of the genetic background and causation of these disorders. However, several lines of research are converging to indicate that the initially established genetically programmed neuronal Connectivity is further elaborated, fine tuned and modified by usedependent neuronal and synaptic plasticity. In all socially organized species in general and in human subjects in particular, psychosocial experiences appear to represent the most important trigger of use-dependent adjustments of neuronal Connectivity through the facilitation, modification and reorganization of neuronal networks. In experimental animals, changes in psychosocial rearing conditions were shown to cause profound and persistent changes in the cytoarchitecture, dendritic arborization and synapse formation in individual brain regions as well as in the maturation of monoaminergic afferences. Based on these findings, the mechanisms of the biological affixation of psychosocial experiences are described and the implications of experience dependent neuronal and synaptic plasticity in the prevention and the therapy of mental disorders are outlined.