Evidence-based treatments for PTSD, new directions, and special challenges

Dissociable contributions of the amygdala and ventral hippocampus to stress-induced changes in defensive behavior

BACKGROUND

Severe stress can produce multiple persistent changes in defensive behavior relevant to psychiatric illness. While much is known about the circuits supporting stress-induced associative fear, how stress-induced circuit plasticity supports non-associative changes in defensive behavior remains unclear.

METHODS

Mice were exposed to an acute severe stressor, and subsequently, both associative and non-associative defensive behavioral responses were assessed. A mixture of local protein synthesis inhibition, pan-neuronal chemogenetic inhibition, and projection-specific chemogenetic inhibition were utilized to isolate the roles of the basolateral amygdala (BLA) and ventral hippocampus (vHC) to the induction and expression of associative and non-associative defensive behavioral changes.

RESULTS

Stress-induced protein synthesis in the BLA was necessary for enhancements in stress sensitivity but not enhancements in anxiety-related behaviors, whereas protein synthesis in the vHC was necessary for enhancements in anxiety-related behavior but not enhancements in stress sensitivity. Like protein synthesis, neuronal activity of the BLA and vHC were found to differentially support the expression of these same defensive behaviors. Additionally, projection-specific inhibition of BLA-vHC connections failed to alter these behaviors, indicating that these defensive behaviors are regulated by distinct BLA and vHC circuits. Lastly, contributions of the BLA and vHC to stress sensitivity and anxiety-related behavior were independent of their contributions to associative fear.

CONCLUSIONS

Stress-induced plasticity in the BLA and vHC were found to support dissociable non-associative behavioral changes, with BLA supporting enhancements in stress sensitivity and vHC supporting increased anxiety-related behavior. These findings demonstrate that independent BLA and vHC circuits are critical for stress-induced defensive behaviors, and that differential targeting of BLA and vHC circuits may be needed in disease treatment.

Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions

Introduction

Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients' experiences of EBPI could help promote safety in PT.

Aim

To systematically review qualitative research on patients' subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them.

Methods

Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified.

Results

40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics.

Conclusion

This study suggests overlap between patients' experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.

An Overview of the Stigmatization of Soldiers in the Context of Mental Health from a Social Work Perspective

Due to its nature, the army is an environment with a high risk of mental illness. Research shows that mental health stigma is a common and serious barrier to early and effective treatment for mental disorders that result from the stress of military operations. Given the need for timely and effective mental health intervention, it is important to understand the barriers to seeking mental health help in a military context. Although there is stigma related to mental health in the studies and compilations carried out in the civil and military context in the national and international literature, there is no literature on mental health stigmatization in the military context, especially in the national literature. This study is a compilation research created by reviewing the national and international literature. In this article, it is aimed to present some innovative social work interventions in order to address the sources of stigma that hinders access to mental health care and the factors that reinforce them, in a military context, to potentially reduce stigma and to maximize the benefit of mental health care.

Treating nightmares in posttraumatic stress disorder with dronabinol: study protocol of a multicenter randomized controlled study (THC PTSD-trial)

BACKGROUND

Distressing nightmares are a core symptom of posttraumatic stress disorder (PTSD) and contribute to psychiatric comorbidity, impaired physical health and decreased social functioning. No specific pharmacological treatment for PTSD-related nightmares is yet approved. Preliminary clinical data indicate that cannabinoid agonists can improve nightmares and overall PTSD symptoms in patients with PTSD. The primary objective of the study is to examine the efficacy of oral dronabinol (BX-1) versus placebo in reducing nightmares in patients with PTSD. The secondary objectives of the study are to examine the efficacy of oral BX-1 in reducing other PTSD symptoms.

METHODS

The study is designed as a multi-centric, double-blind, randomized (1:1), placebo-controlled, parallel group interventional trial. Eligible patients will be randomized to BX-1 or placebo, receiving a once-daily oral dose before bedtime for 10 weeks. Primary efficacy endpoint is the Clinician-Administered PTSD Scale (CAPS-IV) B2 score for the last week, measuring frequency and intensity of nightmares. Secondary efficacy endpoints are other disorder-specific symptoms in patients with PTSD. Further, tolerability and safety of dronabinol will be assessed.

DISCUSSION

This randomized controlled trial will provide evidence whether treating patients with PTSD and nightmares with dronabinol is safe and efficacious.

TRIAL REGISTRATION

NCT04448808, EudraCT 2019-002211-25.

A Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.

The efficacy and acceptability of exposure therapy for the treatment of post-traumatic stress disorder in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) is common among children and adolescents who have experienced traumatic events. Exposure therapy (ET) has been shown to be effective in treating PTSD in adults. However, its efficacy remains uncertain in children and adolescents.

AIMS

To evaluate the efficacy and acceptability of ET in children and adolescents with PTSD.

METHOD

We searched PubMed, EMBASE, Cochrane, Web of Science, PsycINFO, CINAHL, ProQuest, LILACS, and international trial registries for randomized controlled trials (RCTs) assessed ET in children and adolescents (aged ≤18 years) with PTSD up to August 31, 2020. The primary outcomes were efficacy (the endpoint score from PTSD symptom severity rating scales) and acceptability (all-cause discontinuation), secondary outcomes included efficacy at follow-up (score from PTSD scales at the longest point of follow-up), depressive symptoms (end-point score on depressive symptom severity rating scales) and quality of life/social functioning (end-point score on quality of life/social functioning rating scales). This study was registered with PROSPERO (CRD42020150859).

RESULT

A total of 6 RCTs (278 patients) were included. The results showed that ET was statistically more efficacious than control groups (standardized mean differences [SMD]: - 0.47, 95% confidence interval [CI]: - 0.91 to - 0.03). In subgroup analysis, exposure therapy was more efficacious for patients with single type of trauma (SMD: - 1.04, 95%CI: - 1.43 to - 0.65). Patients with an average age of 14 years and older, ET was more effective than the control groups (SMD: - 1.04, 95%CI: - 1.43 to - 0.65), and the intervention using prolonged exposure therapy (PE) (SMD: - 1.04, 95%CI: - 1.43 to - 0.65) was superior than control groups. Results for secondary outcomes of efficacy at follow-up (SMD: - 0.64, 95%CI: - 1.17 to - 0.10) and depressive symptoms (SMD: - 0.58, 95%CI: - 0.93 to - 0.22) were similar to the previous findings for efficacy outcome. No statistically significant effects for acceptability and quality of life/social functioning were found.

CONCLUSION

ET showed superiority in efficacy at post-treatment/follow-up and depressive symptoms improvement in children and adolescents with PTSD. Patients with single type of trauma may benefit more from ET. And ET is more effective in patients 14 years or older. Moreover, PE could be a better choice.

Novel Analysis Identifying Functional Connectivity Patterns Associated with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a prevalent psychiatric disorder that can result from experiencing traumatic events. Accurate diagnosis and optimal treatment strategies can be difficult to achieve, due to the heterogeneous etiology and symptomology of PTSD, and overlap with other psychiatric disorders. Advancing our understanding of PTSD pathophysiology is therefore critical. While functional connectivity alterations have shown promise for elucidating the neurobiological mechanisms of PTSD, previous findings have been inconsistent. Eleven patients with PTSD in our first cohort (PTSD-A) and 11 trauma-exposed controls (TEC) underwent functional magnetic resonance imaging. First, we investigated the intrinsic connectivity within known resting state networks (eg, default mode, salience, and central executive networks) previously implicated in functional abnormalities with PTSD symptoms. Second, the overall topology of network structure was compared between PTSD-A and TEC using graph theory. Finally, we used a novel combination of graph theory analysis and scaled subprofile modeling (SSM) to identify a disease-related, covarying pattern of brain network organization. No significant group differences were found in intrinsic connectivity of known resting state networks and graph theory metrics (clustering coefficients, characteristic path length, smallworldness, global and local efficiencies, and degree centrality). The graph theory/SSM analysis revealed a topographical pattern of altered degree centrality differentiating PTSD-A from TEC. This PTSD-related network pattern expression was additionally investigated in a separate cohort of 33 subjects who were scanned with a different MRI scanner (22 patients with PTSD or PTSD-B, and 11 healthy trauma-naïve controls or TNC). Across all participant groups, pattern expression scores were significantly lower in the TEC group, while PTSD-A, PTSD-B, and TNC subject profiles did not differ from each other. Expression level of the pattern was correlated with symptom severity in the PTSD-B group. This method offers potential in developing objective biomarkers associated with PTSD. Possible interpretations and clinical implications will be discussed.

A thalamo-amygdalar circuit underlying the extinction of remote fear memories

Fear and trauma generate some of the longest-lived memories. Despite the corresponding need to understand how such memories can be attenuated, the underlying brain circuits remain unknown. Here, combining viral tracing, neuronal activity mapping, fiber photometry, chemogenetic and closed-loop optogenetic manipulations in mice, we show that the extinction of remote (30-day-old) fear memories depends on thalamic nucleus reuniens (NRe) inputs to the basolateral amygdala (BLA). We found that remote, but not recent (1-day-old), fear extinction activates NRe-to-BLA inputs, which become potentiated upon fear reduction. Furthermore, both monosynaptic NRe-to-BLA and total NRe activity increase shortly before freezing cessation, suggesting that the NRe registers and transmits safety signals to the BLA. Accordingly, pan-NRe and pathway-specific NRe-to-BLA inhibition impairs, whereas their activation facilitates, remote fear extinction. These findings identify the NRe as a crucial BLA regulator for extinction and provide the first functional description of the circuits underlying the attenuation of consolidated fear memories.

Transcutaneous cervical vagal nerve stimulation reduces sympathetic responses to stress in posttraumatic stress disorder: A double-blind, randomized, sham controlled trial

Objective

Exacerbated autonomic responses to acute stress are prevalent in posttraumatic stress disorder (PTSD). The purpose of this study was to assess the effects of transcutaneous cervical VNS (tcVNS) on autonomic responses to acute stress in patients with PTSD. The authors hypothesized tcVNS would reduce the sympathetic response to stress compared to a sham device.

Methods

Using a randomized double-blind approach, we studied the effects of tcVNS on physiological responses to stress in patients with PTSD (n = 25) using noninvasive sensing modalities. Participants received either sham (n = 12) or active tcVNS (n = 13) after exposure to acute personalized traumatic script stress and mental stress (public speech, mental arithmetic) over a three-day protocol. Physiological parameters related to sympathetic responses to stress were investigated.

Results

Relative to sham, tcVNS paired to traumatic script stress decreased sympathetic function as measured by: decreased heart rate (adjusted β = -5.7%; 95% CI: ±3.6%, effect size d = 0.43, p < 0.01), increased photoplethysmogram amplitude (peripheral vasodilation) (30.8%; ±28%, 0.29, p < 0.05), and increased pulse arrival time (vascular function) (6.3%; ±1.9%, 0.57, p < 0.0001). Similar (p < 0.05) autonomic, cardiovascular, and vascular effects were observed when tcVNS was applied after mental stress or without acute stress.

Conclusion

tcVNS attenuates sympathetic arousal associated with stress related to traumatic memories as well as mental stress in patients with PTSD, with effects persisting throughout multiple traumatic stress and stimulation testing days. These findings show that tcVNS has beneficial effects on the underlying neurophysiology of PTSD. Such autonomic metrics may also be evaluated in daily life settings in tandem with tcVNS therapy to provide closed-loop delivery and measure efficacy.ClinicalTrials.gov Registration # NCT02992899.

The Quality, Readability, Completeness, and Accuracy of PTSD Websites for Firefighters

Firefighters appear at an increased risk for post-traumatic stress disorder (PTSD). Because of PTSD-related stigma, firefighters may search for information online. The current study evaluated the quality, readability, and completeness of PTSD online resources, and to determine how the online treatment recommendations align with current evidence. Google.ca (Canada) searches were performed using four phrases: ‘firefighter PTSD’, ‘firefighter operational stress’, ‘PTSD symptoms’, and ‘PTSD treatment’. The 75 websites identified were assessed using quality criteria for consumer health information (DISCERN), readability and health literacy statistics, content analysis, and a comparison of treatments mentioned to the current best evidence. The average DISCERN score was 43.8 out of 75 (indicating ‘fair’ quality), with 9 ‘poor’ websites (16–30), 31 ‘fair’ websites (31–45), 26 “good” websites (46–60), and nine excellent websites (61–75). The average grade level required to understand the health-related content was 10.6. The most mentioned content was PTSD symptoms (48/75 websites) and PTSD treatments (60/75 websites). The most frequently mentioned treatments were medications (41/75 websites) and cognitive behavioural therapy (40/75 websites). Cognitive behavioural therapy is supported by strong evidence, but evidence for medications appears inconsistent in current systematic reviews. Online PTSD resources exist for firefighters, but the information is challenging to read and lacks evidence-based treatment recommendations.

Differential behavioral, stress, and sleep responses in mice with different delays of fear extinction

STUDY OBJECTIVES

Sleep, in particular rapid eye movement (REM), has been linked to fear learning and extinction; however, their relationship is poorly understood. We determined how different delays of extinction training (ET) impact fear-conditioned behaviors, changes in sleep, and stress responses.

METHODS

EEG activity, movement, and body temperature in mice were monitored via telemetry. Following contextual fear conditioning (shock training [ST]), separate groups of mice were reexposed to the context at 24-hour post-ST (24h ET-1) and at 48-hour post-ST (48h ET-1). Post-ET sleep amount and sleep-associated EEG (delta and theta) activity were compared to baseline and to post-ST sleep. Freezing, locomotion, grooming, and rearing were monitored to determine effects of ET on fear behaviors. Body temperature immediately after ET was monitored to assess stress-induced hyperthermia (SIH).

RESULTS

24h ET-1 and 48h ET-1 produced similar freezing and REM reductions, but dissimilar rearing activity and SIH. 24h ET-1 was followed by periods of suppressed REM-associated theta (REM-θ) activity, immediately after ET and during the subsequent dark period. Suppressed REM-θ was specific to sleep after 24h ET-1, and did not occur after ST, nor after 48h ET-1.

CONCLUSIONS

ET-1 at 24 and 48 hours after ST was associated with similar freezing and REM amounts, but with differences in other overt behaviors, in REM-θ, and in SIH. Freezing was not predictive of changes in other fear-associated responses. This study demonstrated that consideration of time delay from fear acquisition to extinction is important when assessing the relationships between extinction and behavior, sleep, and stress responses.

Cognitive Impairment and Predicting Response to Treatment in an Intensive Clinical Program for Post-9/11 Veterans With Posttraumatic Stress Disorder

OBJECTIVE

This study examined whether objectively measured pretreatment cognitive impairment predicted worse response to treatment for posttraumatic stress disorder. Participants were 113 veterans and active duty service members who participated in a new multidisciplinary 2-week intensive clinical program that included individual trauma-focused cognitive-behavioral therapy, group psychotherapy, psychoeducation, skills-building groups, and complementary and alternative medicine treatments (mean age: 39.7 years [SD=8.5]; 20% women).

METHODS

Prior to treatment, participants completed a brief computerized cognitive battery (CNS Vital Signs) and were operationalized as having cognitive impairment if they scored in the ≤5th percentile on two or more of five core cognitive domains. Participants completed measures of traumatic stress, depression, cognitive self-efficacy, and satisfaction with their ability to participate in social roles before and after treatment.

RESULTS

There were no significant correlations between pretreatment individual cognitive test scores and change in the clinical outcome measures. One-half of the study sample (49.6%) met criteria for cognitive impairment. In a mixed multivariate analysis of variance, the interaction between cognitive impairment and time was not significant (F=0.83, df=4, 108, p=0.51), indicating that the pre- to posttreatment changes in outcome scores were not significantly different for the cognitively impaired group compared with the cognitively intact group. The multivariate main effect for time was significant (F=36.75, df=4, 108, p<0.001). Follow-up univariate tests revealed significant improvement in traumatic stress, depression, cognitive self-efficacy, and satisfaction with social roles after treatment.

CONCLUSIONS

Cognitive impairment was not associated with worse response to treatment in veterans with severe and complex mental health problems. Veterans with and without cognitive impairment reported large improvements in symptoms and functioning after treatment.

White matter integrity differences associated with post-traumatic stress disorder are not normalized by concurrent marijuana use

Marijuana (MJ) use and post-traumatic stress disorder (PTSD) have both been associated with abnormalities in brain white matter tracts, including the cingulum and the anterior thalamic radiations (ATR), which project from subcortical regions to frontal cortex. Studies have not assessed the integrity of these tracts in patients with comorbid PTSD and MJ use. To examine effects of PTSD and MJ use on brain structure, we performed diffusion tensor imaging scans on seventy-two trauma-exposed participants, categorized into four groups: those with PTSD who used MJ at least weekly (PTSD+MJ; n = 20), those with PTSD with no regular MJ use (PTSD; n = 19), trauma-exposed controls without PTSD who used MJ (TEC+MJ; n = 14) and trauma-exposed controls with no PTSD or MJ use (TEC; n = 19). White matter integrity was evaluated by calculating fractional anisotropy (FA). Results showed that while FA values in the right ATR and the cingulum differed across groups, there were no significant interactions between PTSD and MJ in any white matter tracts, indicating that MJ exposure neither normalizes nor worsens white matter abnormalities in those with PTSD. Further study is needed to evaluate the impact of MJ use on other neurobiological markers of PTSD.

The Impact of Psychological Interventions on Posttraumatic Stress Disorder and Pain Symptoms: A Systematic Review and Meta-Analysis

OBJECTIVES

Posttraumatic stress disorder (PTSD) and pain often co-occur, introducing clinical challenges and economic burden. Psychological treatments are considered effective for each condition, yet it is not known which therapies have the potential to concurrently address PTSD and pain-related symptoms.

MATERIALS AND METHODS

To conduct a systematic review and meta-analysis, databases were searched for articles published between January 2007 and December 2017 describing results from clinical trials of interventions addressing PTSD and pain-related symptoms in adults. Two independent reviewers finalized data extraction and risk of bias assessments. A random-effects model was used for meta-analysis and to calculate pooled and subgroup effect sizes (ESs) of psychological-only (single modality) and multimodal interventions.

RESULTS

Eighteen trials (7 uncontrolled, 11 randomized controlled trials, RCTs), totaling 1583 participants, were included in the systematic review. RCT intervention types included exposure-based, cognitive-behavioral, and mindfulness-based therapies. Data from 10 RCTs (N=1, 35) were available for meta-analysis, which demonstrated moderate effect for reduced PTSD severity (ES=-0.55, confidence interval [CI]: -0.83, -0.26) and nonsignificant effect for pain intensity (ES=-0.14, CI: -0.43, 0.15) and pain interference (ES=-0.07, CI: -0.35, 0.20) outcomes. Findings from uncontrolled trials supported meta-analytic results from RCTs. Using GRADE assessment, the quality of evidence was deemed as moderate for RCTs and low for non-RCTs.

DISCUSSION

Findings indicated that the majority of the interventions appeared to have a greater impact on reducing PTSD rather than pain-related symptoms. There remains a need to further develop interventions that consistently impact PTSD and pain-related outcomes when these 2 conditions co-occur.

Remote fear memory is sensitive to reconditioning

Exposure of some individuals to recurring traumatic events from the same perpetrator or situation, such as during child abuse or domestic violence, is quite prevalent. Studies have shown that the number of traumatic events experienced is positively related to the severity of post-traumatic stress disorder and other mental disorders. Using a contextual fear conditioning (Cond1) and reconditioning (Cond2) paradigm, which were separated by either 1 or 35 days, we examined fear responses to immediate extinction and retrieval-extinction procedures after repeated fear conditioning stress. Based on the time interval between Cond1 and Cond2, the animals were divided into recent and remote fear memory groups. We observed that when Cond2 was performed in the original conditioning context in which Cond1 was performed, the reconditioned remote fear memory was resistant to the disruptive effect of immediate extinction and retrieval-extinction paradigms. Furthermore, the resistance to disruptive effects could be induced by very low shock intensities, which cannot even induce any fear response in naive animals. When Cond2 was performed in a novel context, animals with remote fear memory acquired a significantly higher fear response to the novel context. Our findings suggest that remote fear memory may be more sensitive to reconditioning and resistant to post-reconditioning disruption.

ADRB2 gene polymorphism modulates the retention of fear extinction memory

Individual differences in regulation of fear and extinction memory play significant roles in the aetiology development of post-traumatic stress disorder (PTSD). Previous animal based studies showed that the activity of β-adrenergic receptors (β-ARs) are involved in memory modulation. However in humans it is not clear that whether genetic variability in β-ARs contributes to individual differences of fear and extinction memory. In the current study, we investigated the role of a common single-nucleotide polymorphism of β₂-adrenergic receptor (ADRB2) gene in fear memory acquisition, fear memory extinction, extinction recall and fear generalization in human participants. Ninety-one male participants were exposed to a Pavlovian fear conditioning and their fear responses were assessed by the skin conductance response. Participants were genotyped for a polymorphism (rs2400207) located within the promoter region of the human ADRB2. Differences between genotypes were observed in the extinction memory recall test but not in fear acquisition, extinction learning and fear generalization. Particularly, A-allele carriers of rs2400707 displayed successful retention of extinction memory and prevented the return of fear during recall test. The results revealed the involvement of human noradrenergic system in the retention of extinction memory and genetic variability in this system may underlie individual differences in PTSD. Furthermore, rs2400207 polymorphism of ADRB2 gene may play a key role in the treatment efficacy of PTSD and can be a basis for future studies investigating a personalized medicine for fear memory related disorders.

Post-Traumatic Stress Disorder Delineating the Progression and Underlying Mechanisms Following Blast Traumatic Brain Injury

Posttraumatic Stress Disorder (PTSD) is a devastating condition that can develop after blast Traumatic Brain Injury (TBI). Ongoing work has been performed to understand how PTSD develops after injury. In this review, we highlight how PTSD affects individuals, discuss what is known about the physiologic changes to the hypothalamic pituitary axis and neurotransmitter pathways, and present an overview of genetic components that may predispose individuals to developing PTSD. We then provide an overview of current treatment strategies to treat PTSD in veterans and present new strategies that may be useful going forward. The need for further clinical and pre-clinical studies is imperative to improve diagnosis, treatment, and management for patients that develop PTSD following blast TBI.

Prevalence of Posttraumatic Stress Disorder in Patients With Multiple Sclerosis

Chronic and life-threatening illnesses, such as multiple sclerosis (MS), have been identified as significant stressors potentially triggering posttraumatic stress disorder (PTSD). The study aims to investigate the prevalence of PTSD according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) criteria in a large sample of patients with MS. A total of 988 patients with MS were screened with the Impact of Event Scale-Revised, and then assessed with the PTSD module of the Structured Clinical Interview for DSM-IV and with the Clinician-Administered PTSD Scale to confirm PTSD diagnosis. Posttraumatic symptoms were reported by 25.5% of the sample. A confirmed diagnosis of PTSD was found in 5.7% of patients, but prevalence could reach 8.5%, including also dropout patients. Further studies are needed to evaluate if adjustment disorder could better encompass the frequently encountered subthreshold posttraumatic stress symptoms and how clinicians can deal with these symptoms with appropriate interventions.

Impact of Sexual Trauma on HIV Care Engagement: Perspectives of Female Patients with Trauma Histories in Cape Town, South Africa

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no women had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Veterans transitioning from isolation to integration: a look at veteran/service dog partnerships

BACKGROUND

This study explored the dynamics of veteran/service dog partnerships by gathering the perspectives of veterans with a history of post-traumatic stress disorder and/or traumatic brain injury.

METHODS

Exploratory qualitative methods (focus groups and individual interviews) were used to investigate veteran/service dog relationships related to community involvement, family and friend relationships, self-care, work, and leisure. Nine male veterans, Paws, and Stripes program graduates participated. Data were audio recorded and transcribed by two research team members who used qualitative analytic software to manage and code the data. The full research team discussed themes and reached consensus on the themes that emerged from analysis.

RESULTS

Five themes emerged about the perceived benefit of veteran/service dog relationship: Secluded but Seeking Society (moving from isolation to reconnection); Opening Opportunities (navigating daily life); Bridging the Gap (facilitating social opportunities); and Reclaiming Life (transforming sense of worth and purpose). An overarching theme, Calming Catalyst, connected the other four themes.

CONCLUSIONS

Veterans in this study reported that their goal was to reclaim and develop key aspects of their lives and they perceived service dogs as a support in their transition from isolation to reintegration. This study found that service dogs supported the veterans to meet their goal. Implications for rehabilitation There are a significant number of veterans with post-traumatic stress disorder and/or traumatic brain injury who are facing life challenges including self-care, securing work, participating in leisure activities, and integrating into the community. Service dogs are an emerging intervention used to assist veterans with reintegration into civilian life. There is a need for professionals to be aware of potential benefits of service dog/veteran partnerships. Based on our findings, veterans could benefit from being paired with a service dog to facilitate their successful return to community life.

Incentivizing attendance to prolonged exposure for PTSD with opioid use disorder patients: A randomized controlled trial

OBJECTIVE

To determine whether contingent monetary incentives increase opioid use disorder patients' attendance to Prolonged Exposure (PE) therapy and whether attendance is associated with improvement in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) outcomes.

METHOD

Patients (N = 58) with PTSD were offered PE or PE with incentives (PE + I; max $480) to attend PE sessions. Participants were assessed at baseline and weeks 6, 12, and 24 postrandomization.

RESULTS

Participants were mostly women (79%) and Caucasian (71%); mean age 37.43 years (SD = 11.33). PE + I participants attended a median of 9 (of 12) sessions compared to 1 session for PE participants (p < .001), which included more exposure sessions (PE + I mdn = 6; PE mdn = 0; p < .001). A Time × treatment condition interaction indicated that PE + I participants exhibited a greater decrease in PTSD severity over time than PE participants (OR = 3.1; 95% CI = 0.4-5.7; p = .024). PE + I participants remained in substance use treatment longer than PE participants (mdn days = 262 vs. 192; p = .039). There were no group differences in drug use.

CONCLUSIONS

Monetary incentives increased SUD patients' attendance to an otherwise poorly attended treatment for PTSD. Better attendance in the incentivized group was associated with greater PTSD improvement, better SUD treatment retention, and no increased drug use. Incentives are well supported for improving adherence to substance use treatment goals and promising as a means to improve therapy attendance, which may improve the effectiveness of existing psychotherapies in difficult-to-treat populations. (PsycINFO Database Record

Stepwise Psychosocial Palliative Care: A New Approach to the Treatment of Posttraumatic Stress Disorder at the End of Life

Although evidence-based therapies for Posttraumatic Stress Disorder (PTSD) exist for physically healthy populations, these often do not adequately address PTSD in dying patients. Particularly because these interventions require 8-16 weekly sessions, and the median stay in U.S. hospices is 17.5 days (National Hospice and Palliative Care Organization [NHPCO], 2015 ), there is a potentially serious timing mismatch. Moreover, these treatments may temporarily increase trauma symptoms (Nishith, Resick, & Griffin, 2002 ), resulting in some patients dying in greater distress than had they not received care. The Stepwise Psychosocial Palliative Care (SPPC) model presented in this article compensates for these difficulties by embracing a palliative care approach to PTSD. Although it utilizes techniques drawn from existing PTSD interventions, these are re-ordered and utilized in a time-responsive, patient-centered manner that takes into account prognosis, fatigue, and logistical concerns. The SPPC approach is further considered with respect to existing social work palliative care competencies (Gwyther et al., 2005 ) and a case study is used to demonstrate its application.

Psychometric validation of the 16 Item Quick Inventory of Depressive Symptomatology Self-Report Version (QIDS-SR16) in military veterans with PTSD

BACKGROUND

The Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR16) is one example of a screening tool for depression, which has been utilized extensively following validation in a number of clinical populations. Despite the strengths of the QIDS-SR16, it has not been validated in military veterans, a particularly unique population considering their exposure to trauma and high rate of psychiatric comorbidities. The current report describes a psychometric validation of the QIDS-SR16 in a sample of United States military veterans diagnosed with military-related PTSD.

METHODS

Participants (n=240) were administered the QIDS-SR16 and one of two gold-standard semi-structured interviews to establish diagnosis of a current Major Depressive Episode (MDE). The ability to discriminate between individuals with and without a current MDE using the QIDS-SR16 was tested with a stepwise logistic regression. Additionally, an optimal cutoff score for the QIDS-SR16 was established.

RESULTS

The QIDS-SR16 was able to reliabily discriminate between individuals with and without a current MDE. The optimal cutoff score of the QIDS-SR16 for a current MDE was 13, with a sensitivity of 77.55% and specificity of 56.25%.

LIMITATIONS

Limitations of this study included underrepresentation of some racial/ethnic groups, the inability to disentangle the potential influence of trauma type and gender on results, and the use of two diagnostic interviews to diagnose current MDE.

DISCUSSION

The QIDS-SR16 can be effectively utilized in military veterans with comorbid PTSD. However, the calculated cutoff score for this population was higher than the cutoff score for the general population. This could result from the overlap between PTSD and MDE symptoms.

Escitalopram reversed the traumatic stress-induced depressed and anxiety-like symptoms but not the deficits of fear memory

RATIONALE

Posttraumatic stress disorder (PTSD) is a trauma-induced mental disorder characterised by fear extinction dysfunction in which fear circuit monoamines are possibly associated. PTSD often coexists with depressive/anxiety symptoms, and selective serotonin reuptake inhibitors (SSRIs) are recommended to treat PTSD. However, therapeutic mechanisms of SSRIs underlying the PTSD fear symptoms remain unclear.

OBJECTIVES

Using a rodent PTSD model, we examined the effects of early SSRI intervention in mood and fear dysfunctions with associated changes of monoamines within the fear circuit areas.

METHODS

A 14-day escitalopram (ESC) regimen (5 mg/kg/day) was undertaken in two separate experiments in rats which previously received a protocol of single prolonged stress (SPS). In experiment 1, sucrose preference and elevated T-maze were used to index anhedonia depression and avoidance/escape anxiety profiles. In experiment 2, the percentage of freezing time was measured in a 3-day fear conditioning paradigm. At the end of our study, tissue levels of serotonin (5-HT) in the medial prefrontal cortex, amygdala, hippocampus, and striatum were measured in experiment 1, and the efflux levels of infralimbic (IL) monoamines were measured in experiment 2.

RESULTS

In experiment 1, ESC corrected both behavioural (depression/anxiety) and neurochemical (reduced 5-HT tissue levels in amygdala/hippocampus) abnormalities. In experiment 2, ESC was unable to correct the SPS-impaired retrieval of fear extinction. In IL, ESC increased the efflux level of 5-HT but failed to reverse SPS-reduced dopamine (DA) and noradrenaline (NA).

CONCLUSIONS

PTSD-induced mood dysfunction is psychopathologically different from PTSD-induced fear disruption in terms of disequilibrium of monoamines within the fear circuit areas.

Investigation of automatic avoidance in displaced individuals with chronic Posttraumatic Stress Disorder (PTSD)

Avoidance of trauma-related stimuli is a key feature of Posttraumatic Stress Disorder (PTSD). However, avoidance has almost exclusively been investigated with explicit measures targeting more strategic aspects of behavior. The aim of the present study was to examine automatic avoidance in older individuals displaced as children at the end of World War II with (n=22) and without PTSD (n=26) and in non-traumatized control participants (n=23) with an Approach-Avoidance Task (AAT). Participants were instructed to respond to the color (gray, brown) of trauma-related, neutral, and control pictures by pushing or pulling a joystick. Groups did not differ significantly as to their behavioral tendencies towards trauma-related pictures. Thus, there was no evidence for automatic avoidance in individuals with PTSD. However, high vigilance was associated with stronger implicit avoidance towards trauma-related pictures in the PTSD group. Several explanations for the non-significant results as well as implications and limitations of the present findings are discussed.

Nicotine modulation of fear memories and anxiety: Implications for learning and anxiety disorders

Anxiety disorders are a group of crippling mental diseases affecting millions of Americans with a 30% lifetime prevalence and costs associated with healthcare of $42.3 billion. While anxiety disorders show high levels of co-morbidity with smoking (45.3% vs. 22.5% in healthy individuals), they are also more common among the smoking population (22% vs. 11.1% in the non-smoking population). Moreover, there is clear evidence that smoking modulates symptom severity in patients with anxiety disorders. In order to better understand this relationship, several animal paradigms are used to model several key symptoms of anxiety disorders; these include fear conditioning and measures of anxiety. Studies clearly demonstrate that nicotine mediates acquisition and extinction of fear as well as anxiety through the modulation of specific subtypes of nicotinic acetylcholine receptors (nAChRs) in brain regions involved in emotion processing such as the hippocampus. However, the direction of nicotine's effects on these behaviors is determined by several factors that include the length of administration, hippocampus-dependency of the fear learning task, and source of anxiety (novelty-driven vs. social anxiety). Overall, the studies reviewed here suggest that nicotine alters behaviors related to fear and anxiety and that nicotine contributes to the development, maintenance, and reoccurrence of anxiety disorders.

Eye movement desensitization and reprocessing for treating psychological disturbances in Taiwanese adolescents who experienced Typhoon Morakot

In this case-control study, we aimed to assess the intervention effects of four-session eye movement desensitization and reprocessing (EMDR) on reducing the severity of disaster-related anxiety, general anxiety, and depressive symptoms in Taiwanese adolescents who experienced Typhoon Morakot. A total of 83 adolescents with posttraumatic stress disorder related to Typhoon Morakot, major depressive disorder, or current moderate or high suicide risk after experiencing Typhoon Morakot were allocated to a four-session course of EMDR (N = 41) or to treatment as usual (TAU; N = 42). A multivariate analysis of covariance was performed to examine the effects of EMDR in reducing the severity of disaster-related anxiety, general anxiety, and depressive symptoms in adolescents by using preintervention severity values as covariates. The multivariate analysis of covariance results indicated that the EMDR group exhibited significantly lower preintervention severity values of general anxiety and depression than did the TAU group. In addition, the preintervention severity value of disaster-related anxiety in the EMDR group was lower than that in the TAU group (p = 0.05). The results of this study support that EMDR could alleviate general anxiety and depressive symptoms and reduce disaster-related anxiety in adolescents experiencing major traumatic disasters.

Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: a randomized controlled longitudinal study

Given the limited success of conventional treatments for veterans with posttraumatic stress disorder (PTSD), investigations of alternative approaches are warranted. We examined the effects of a breathing-based meditation intervention, Sudarshan Kriya yoga, on PTSD outcome variables in U.S. male veterans of the Iraq or Afghanistan war. We randomly assigned 21 veterans to an active (n = 11) or waitlist control (n = 10) group. Laboratory measures of eye-blink startle and respiration rate were obtained before and after the intervention, as were self-report symptom measures; the latter were also obtained 1 month and 1 year later. The active group showed reductions in PTSD scores, d = 1.16, 95% CI [0.20, 2.04], anxiety symptoms, and respiration rate, but the control group did not. Reductions in startle correlated with reductions in hyperarousal symptoms immediately postintervention (r = .93, p < .001) and at 1-year follow-up (r = .77, p = .025). This longitudinal intervention study suggests there may be clinical utility for Sudarshan Kriya yoga for PTSD.

Design and rationale of a comparative effectiveness trial evaluating transcendental meditation against established therapies for PTSD

BACKGROUND

Although meditation therapies such as the Transcendental Meditation (TM) technique are commonly used to assist with stress and stress-related diseases, there remains a lack of rigorous clinical trial research establishing the relative efficacy of these treatments overall and for populations with psychiatric illness. This study uses a comparative effectiveness design to assess the relative benefits of TM to those obtained from a gold-standard cognitive behavioral therapy for posttraumatic stress disorder (PTSD) in a Veteran population.

METHODS AND DESIGN

This paper describes the rationale and design of an in progress randomized controlled trial comparing TM to an established cognitive behavioral treatment - Prolonged Exposure (PE) - and an active control condition (health education [HE]) for PTSD. This trial will recruit 210 Veterans meeting DSM-IV criteria for PTSD, with testing conducted at 0 and 3 months for PTSD symptoms, depression, mood disturbance, quality of life, behavioral factors, and physiological/biochemical and gene expression mechanisms using validated measures. The study hypothesis is that TM will be noninferior to PE and superior to HE on changes in PTSD symptoms, using the Clinician Administered PTSD Scale (CAPS).

DISCUSSION

The described study represents a methodologically rigorous protocol evaluating the benefits of TM for PTSD. The projected results will help to establish the overall efficacy of TM for PTSD among Veterans, identify bio-behavioral mechanisms through which TM and PE may improve PTSD symptoms, and will permit conclusions regarding the relative value of TM against currently established therapies for PTSD.

Epigenetic priming of memory updating during reconsolidation to attenuate remote fear memories

Traumatic events generate some of the most enduring forms of memories. Despite the elevated lifetime prevalence of anxiety disorders, effective strategies to attenuate long-term traumatic memories are scarce. The most efficacious treatments to diminish recent (i.e., day-old) traumata capitalize on memory updating mechanisms during reconsolidation that are initiated upon memory recall. Here, we show that, in mice, successful reconsolidation-updating paradigms for recent memories fail to attenuate remote (i.e., month-old) ones. We find that, whereas recent memory recall induces a limited period of hippocampal neuroplasticity mediated, in part, by S-nitrosylation of HDAC2 and histone acetylation, such plasticity is absent for remote memories. However, by using an HDAC2-targeting inhibitor (HDACi) during reconsolidation, even remote memories can be persistently attenuated. This intervention epigenetically primes the expression of neuroplasticity-related genes, which is accompanied by higher metabolic, synaptic, and structural plasticity. Thus, applying HDACis during memory reconsolidation might constitute a treatment option for remote traumata.

The Effects of Bilateral Eye Movements on EEG Coherence When Recalling a Pleasant Memory

In an investigation of the interhemispheric coherence (IhC) model for eye movement desensitization and reprocessing (EMDR) bilateral eye movement (BEM) effects, 30 participants were exposed to a stationary dot, a blinking red/green dot, or saccadic BEMs during the contemplation of a positive emotional memory. Electroencephalographies (EEGs) were measured afterward during an eyes-closed processing stage. Analyses revealed no significant IhC enhancement for the BEM condition but significant increases in Delta and Low Beta EEG intrahemispheric BEM coherence in the right and left frontal areas, respectively, and a trend increase in Right Frontal Low Beta BEM coherence. LORETA neuroimaging was employed to visually present significant amplitude changes corresponding to observed coherence effects. The functional significance of these intrahemispheric coherence effects is presented and a cortical coherence extension of the IhC model is suggested.

Translational reciprocity: bridging the gap between preclinical studies and clinical treatment of stress effects on the adolescent brain

The genetic, biological, and environmental backgrounds of an organism fundamentally influence the balance between risk and resilience to stress. Sex, age, and environment transact with responses to trauma in ways that can mitigate or exacerbate the likelihood that post-traumatic stress disorder will develop. Translational approaches to modeling affective disorders in animals will ultimately provide novel treatments and a better understanding of the neurobiological underpinnings behind these debilitating disorders. The extant literature on trauma/stress has focused predominately on limbic and cortical structures that innervate the hypothalamic-pituitary-adrenal axis and influence glucocorticoid-mediated negative feedback. It is through these neuroendocrine pathways that a self-perpetuating fear memory can propagate the long-term effects of early life trauma. Recent work incorporating translational approaches has provided novel pathways that can be influenced by early life stress, such as the glucocorticoid receptor chaperones, including FKBP51. Animal models of stress have differing effects on behavior and endocrine pathways; however, complete models replicating clinical characteristics of risk and resilience have not been rigorously studied. This review discusses a four-factor model that considers the importance of studying both risk and resilience in understanding the developmental response to trauma/stress. Consideration of the multifactorial nature of clinical populations in the design of preclinical models and the application of preclinical findings to clinical treatment approaches comprise the core of translational reciprocity, which is discussed in the context of the four-factor model.

Fear extinction memory consolidation requires potentiation of pontine-wave activity during REM sleep

Sleep plays an important role in memory consolidation within multiple memory systems including contextual fear extinction memory, but little is known about the mechanisms that underlie this process. Here, we show that fear extinction training in rats, which extinguished conditioned fear, increased both slow-wave sleep and rapid-eye movement (REM) sleep. Surprisingly, 24 h later, during memory testing, only 57% of the fear-extinguished animals retained fear extinction memory. We found that these animals exhibited an increase in phasic pontine-wave (P-wave) activity during post-training REM sleep, which was absent in the 43% of animals that failed to retain fear extinction memory. The results of this study provide evidence that brainstem activation, specifically potentiation of phasic P-wave activity, during post-training REM sleep is critical for consolidation of fear extinction memory. The results of this study also suggest that, contrary to the popular hypothesis of sleep and memory, increased sleep after training alone does not guarantee consolidation and/or retention of fear extinction memory. Rather, the potentiation of specific sleep-dependent physiological events may be a more accurate predictor for successful consolidation of fear extinction memory. Identification of this unique mechanism will significantly improve our present understanding of the cellular and molecular mechanisms that underlie the sleep-dependent regulation of emotional memory. Additionally, this discovery may also initiate development of a new, more targeted treatment method for clinical disorders of fear and anxiety in humans that is more efficacious than existing methods such as exposure therapy that incorporate only fear extinction.

Interventions to improve psychological functioning and health outcomes of HIV-infected individuals with a history of trauma or PTSD

The experience of early or later life trauma in HIV-positive adults can have devastating mental and physical health consequences. Women bear the brunt of this double burden. Depression, posttraumatic stress disorder, and alcohol and drug use disorders are among the most common psychiatric disorders documented, both in infected women and men, in high-, middle-, and low-income countries. Traumatized individuals, particularly those with childhood sexual abuse characterized by repeated traumatization, are at high risk of engaging in risky behaviors, including substance abuse and sexual promiscuity. These issues are further compounded by stigma, discrimination, poverty, and low social support. While there is a significant need to pay more attention to psychiatric and psychological outcomes in the context of HIV-trauma and improve screening for traumatic stress in HIV care settings, there are currently few treatment and secondary prevention studies. Group cognitive-behavioral strategies, including prolonged exposure, coping skills training, and stress management have, to date, shown some evidence for efficacy in HIV-positive individuals with childhood trauma and in those with PTSD.

Targeting memory processes with drugs to prevent or cure PTSD

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a chronic debilitating psychiatric disorder resulting from exposure to a severe traumatic stressor and an area of great unmet medical need. Advances in pharmacological treatments beyond the currently approved SSRIs are needed.

AREAS COVERED

Background on PTSD, as well as the neurobiology of stress responding and fear conditioning, is provided. Clinical and preclinical data for investigational agents with diverse pharmacological mechanisms are summarized.

EXPERT OPINION

Advances in the understanding of stress biology and mechanisms of fear conditioning plasticity provide a rationale for treatment approaches that may reduce hyperarousal and dysfunctional aversive memories in PTSD. One challenge is to determine if these components are independent or reflect a common underlying neurobiological alteration. Numerous agents reviewed have potential for reducing PTSD core symptoms or targeted symptoms in chronic PTSD. Promising early data support drug approaches that seek to disrupt dysfunctional aversive memories by interfering with consolidation soon after trauma exposure, or in chronic PTSD, by blocking reconsolidation and/or enhancing extinction. Challenges remain for achieving selectivity when attempting to alter aversive memories. Targeting the underlying traumatic memory with a combination of pharmacological therapies applied with appropriate chronicity, and in combination with psychotherapy, is expected to substantially improve PTSD treatment.

Executive function and PTSD: disengaging from trauma

Neuropsychological approaches represent an important avenue for identifying susceptibility and resiliency factors relating to the development and maintenance of posttraumatic stress disorder (PTSD) symptoms post-trauma. This review will summarize results from prospective longitudinal and retrospective cross-sectional studies investigating executive function associated with PTSD. This research points specifically towards subtle impairments in response inhibition and attention regulation that may predate trauma exposure, serve as risk factors for the development of PTSD, and relate to the severity of symptoms. These impairments may be exacerbated within emotional or trauma-related contexts, and may relate to dysfunction within dorsal prefrontal networks. A model is presented concerning how such impairments may contribute to the clinical profile of PTSD and lead to the use of alternative coping styles such as avoidance. Further neuropsychological research is needed to identify the effects of treatment on cognitive function and to potentially characterize mechanisms of current PTSD treatments. Knowledge gained from cognitive and neuroscientific research may prove valuable for informing the future development of novel, more effective, treatments for PTSD. This article is part of a Special Issue entitled 'Post-Traumatic Stress Disorder'.

Psychogenic nonepileptic seizures: a treatment review. What have we learned since the beginning of the millennium?

Psychogenic nonepileptic seizures (PNES) can significantly affect an individual's quality of life, the health care system, and even society. The first decade of the new millennium has seen renewed interest in this condition, but etiological understanding and evidence-based treatment availability remain limited. After the diagnosis of PNES is established, the first therapeutic step includes a presentation of the diagnosis that facilitates engagement in treatment. The purpose of this review is to present the current evidence of treatments for PNES published since the year 2000 and to discuss further needs for clinical treatment implementation and research. This article reviews clinical trials that have evaluated the efficacy of structured, standardized psychotherapeutic and psychopharmacological interventions. The primary outcome measure in clinical trials for PNES is event frequency, although it is questionable whether this is the most accurate indicator of functional recovery. Cognitive behavioral therapy has evidence of efficacy, including one pilot randomized, controlled trial where cognitive behavioral therapy was compared with standard medical care. The antidepressant sertraline did not show a significant difference in event frequency change when compared to placebo in a pilot randomized, double-blind, controlled trial, but it did show a significant pre- versus posttreatment decrease in the active arm. Other interventions that have shown efficacy in uncontrolled trials include augmented psychodynamic interpersonal psychotherapy, group psychodynamic psychotherapy, group psychoeducation, and the antidepressant venlafaxine. Larger clinical trials of these promising treatments are necessary, while other psychotherapeutic interventions such as hypnotherapy, mindfulness-based therapies, and eye movement desensitization and reprocessing may deserve exploration. Flexible delivery of treatment that considers the heterogeneous backgrounds of patients is emphasized as necessary for successful outcomes in clinical practice.

Inflammation and traumatic stress: the society to cells resiliency model to support integrative interventions

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent psychiatric disorder that develops following a traumatic event and has substantial health implications, including high rates of health morbidity and mortality, as well as significant health-related costs. Medical risks that are associated with PTSD often have an underlying inflammatory pathology, suggesting that inflammation contributes to these health declines.

OBJECTIVES AND DESIGN

In this critical literature review, the authors examine the medical risks associated with PTSD and the inflammatory mechanisms that likely underlie these risks.

RESULTS AND CONCLUSIONS

The authors offer a review of their "Cells to Society Resiliency Model" to motivate the development of integrative interventions that include factors of society, community, family, individual, physiological, and cellular factors to thereby reduce the health risks associated with PTSD.

A chinese herbal formula to improve general psychological status in posttraumatic stress disorder: a randomized placebo-controlled trial on sichuan earthquake survivors

Introduction. Posttraumatic stress disorder (PTSD) is accompanied by poor general psychological status (GPS). In the present study, we investigated the effects of a Chinese herbal formula on GPS in earthquake survivors with PTSD. Methods. A randomized, double-blind, placebo-controlled trial compared a Chinese herbal formula, Xiao-Tan-Jie-Yu-Fang (XTJYF), to placebo in 2008 Sichuan earthquake survivors with PTSD. Patients were randomized into XTJYF (n = 123) and placebo (n = 122) groups. Baseline-to-end-point score changes in the three global indices of the Symptom Checklist-90-Revised (SCL-90-R) and rates of response in the SCL global severity index (GSI) were the primary endpoints. A subanalysis of the nine SCL factors and the sleep quality score were secondary endpoints. Results and Discussion. Compared to placebo, the XTJYF group was significantly improved in all three SCL global indices (P = 0.001~0.028). More patients in the XTJYF group reported “much improved” than the placebo group (P = 0.001). The XTJYF group performed significantly better than control in five out of nine SCL factors (somatization, obsessive-compulsive behavior, depression, anxiety, and hostility (P = 0.001~0.036)), and in sleep quality score (P < 0.001). XTJYF produced no serious adverse events. These findings suggest that XTJYF may be an effective and safe treatment option for improving GPS in patients with PTSD.

Improving the recognition and treatment of cancer-related posttraumatic stress disorder

Life-threatening illness has been identified as a stressor that can precipitate posttraumatic stress disorder (PTSD). Major advances in cancer treatment have led to increased survival periods. At the same time, there is a growing awareness of the psychological impact of cancer diagnosis and treatment on the patient. Cancer survivors report that cancer can elicit symptoms of traumatic stress. When cancer-related PTSD is untreated, medical and psychiatric morbidity increase. Despite the prevalence, impact, and morbidity of cancer-related PTSD, access to mental health care in cancer patients remains limited. It is important to increase mental health providers' awareness of cancer-related PTSD, given rising cancer rates and the potential for enhancing quality of life. This article presents an overview of the recognition, diagnosis, management, and follow-up of cancer-related PTSD for the mental health clinician.

Noradrenergic enhancement of reconsolidation in the amygdala impairs extinction of conditioned fear in rats--a possible mechanism for the persistence of traumatic memories in PTSD

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with enhanced noradrenergic activity. Animal and human studies demonstrate that noradrenergic stimulation augments consolidation of fear learning. Retrieval of well-established memories by presenting a learned fear cue triggers reconsolidation processes during which memories may be updated, weakened, or strengthened. We previously reported that noradrenergic blockade in the rat amygdala impairs reconsolidation of fear memories. Here we investigated the effects of noradrenergic enhancement on reconsolidation of learned fear.

METHODS

Using auditory fear conditioning in rats, we tested the effects of postretrieval intraamygdala infusion of the β-adrenergic receptor agonist isoproterenol or the antagonist propranolol on conditioned fear in the amygdala.

RESULTS

A single intraamygdala infusion of isoproterenol following a retrieval of a well-consolidated memory enhanced fear memory elicited by the learned fear stimulus and impaired extinction of this memory 48 hr later. Intraamygdala infusion of the β-adrenergic receptor antagonist propranolol following a consecutive retrieval trial blocked the enhancing effects of isoproterenol on fear memory.

CONCLUSIONS

Postretrieval β-adrenergic stimulation in the amygdala enhances reconsolidation of fear memories, making them resistant to extinction. Noradrenergic augmentation during retrieval of fear memories may thus contribute to persistence and severity of traumatic memories. Reconsolidation may be a useful tool in understanding the pathology of PTSD and may thus help in developing new and in modifying existing treatments of traumatic memories.

Do Horizontal Saccadic Eye Movements Increase Interhemispheric Coherence? Investigation of a Hypothesized Neural Mechanism Underlying EMDR

Series of horizontal saccadic eye movements (EMs) are known to improve episodic memory retrieval in healthy adults and to facilitate the processing of traumatic memories in eye movement desensitization and reprocessing (EMDR) therapy. Several authors have proposed that EMs achieve these effects by increasing the functional connectivity of the two brain hemispheres, but direct evidence for this proposal is lacking. The aim of this study was to investigate whether memory enhancement following bilateral EMs is associated with increased interhemispheric coherence in the electroencephalogram (EEG). Fourteen healthy young adults were asked to freely recall lists of studied neutral and emotional words after a series of bilateral EMs and a control procedure. Baseline EEG activity was recorded before and after the EM and control procedures. Phase and amplitude coherence between bilaterally homologous brain areas were calculated for six frequency bands and electrode pairs across the entire scalp. Behavioral analyses showed that participants recalled more emotional (but not neutral) words following the EM procedure than following the control procedure. However, the EEG analyses indicated no evidence that the EMs altered participants' interhemispheric coherence or that improvements in recall were correlated with such changes in coherence. These findings cast doubt on the interhemispheric interaction hypothesis, and therefore may have important implications for future research on the neurobiological mechanism underlying EMDR.