Using neurobiological measures to predict and assess treatment outcome of psychotherapy in posttraumatic stress disorder: systematic review

Distinct saliva DNA methylation profiles in relation to treatment outcome in youth with posttraumatic stress disorder

In youth with posttraumatic stress disorder (PTSD) non-response rates after treatment are often high. Epigenetic mechanisms such as DNA methylation (DNAm) have previously been linked to PTSD pathogenesis, additionally DNAm may affect response to (psychological) therapies. Besides investigating the direct link between DNAm and treatment response, it might be helpful to investigate the link between DNAm and previously associated biological mechanisms with treatment outcome. Thereby gaining a deeper molecular understanding of how psychotherapy (reflecting a change in the environment) relates to epigenetic changes and the adaptability of individuals. To date, limited research is done in clinical samples and no studies have been conducted in youth. Therefore we conducted a study in a Dutch cohort of youth with and without PTSD (n = 87, age 8-18 years). We examined the cross-sectional and longitudinal changes of saliva-based genome-wide DNA methylation (DNAm) levels, and salivary cortisol secretion. The last might reflect possible abbreviations on the hypothalamic-pituitary- adrenal (HPA) axis. The HPA-axis is previously linked to DNAm and the development and recovery of PTSD. Youth were treated with 8 sessions of either Eye Movement Reprocessing Therapy (EMDR) or Trauma Focused Cognitive behavioral Therapy (TF-CBT). Our epigenome wide approach showed distinct methylation between treatment responders and non-responders on C18orf63 gene post-treatment. This genomic region is related to the PAX5 gene, involved in neurodevelopment and inflammation response. Additionally, our targeted approach indicated that there were longitudinal DNAm changes in successfully treated youth at the CRHR2 gene. Methylation at this gene was further correlated with cortisol secretion pre- and post-treatment. Awaiting replication, findings of this first study in youth point to molecular pathways involved in stress response and neuroplasticity to be associated with treatment response.

Autonomic nervous system function before and after trauma-focused psychotherapy in youth with (partial) posttraumatic stress disorder

While trauma-focused psychotherapies have been shown effective in youth with PTSD, the relationship between treatment response and alterations in the autonomic nervous system (ANS) associated with PTSD, remains incompletely understood. During neutral and personalized trauma script imagery heart rate (HR), pre-ejection period (PEP) and respiratory sinus arrhythmia (RSA) were recorded in youth aged 8-18 with PTSD or partial PTSD (n = 76) and trauma-exposed controls (TEC) (n = 27) to determine ANS activity and stress reactivity. Within the patient group, 77.6% met the full DSM-IV diagnostic criteria for PTSD, the remaining 22.4% met the criteria for partial PTSD. Youth with (partial) PTSD were subsequently treated with eight sessions of either trauma-focused cognitive behavioral therapy or eye movement desensitization and reprocessing. PTSD severity was assessed using the Clinician-Administered PTSD scale for Children and Adolescents to divide patients into responders and non-responders. Youth with (partial) PTSD relative to TEC had higher overall HR during both neutral and trauma imagery (p = .05). Youth with (partial) PTSD showed RSA decrease during trauma imagery relative to neutral imagery, the reverse of TEC (p = .01). Relative to non-responders, responders demonstrated a significant baseline to posttreatment increase of RSA response to stress only when employing a ≥ 50% response criterion (p = .05) and not with the primary ≥ 30% criterion (p = .12). Our results suggest overall higher HR and sympathetic nervous system activity as well as vagal withdrawal in response to stress in youth with (partial) PTSD and only provide partial support for normalization of the latter with successful trauma-focused psychotherapy.

Brain structural change associated with Cognitive Behavioral Therapy in maltreated children

BACKGROUND

Severely maltreatment child is a harmful social factor that can disrupt normal neurodevelopment. Two commonly reported effects of maltreatment are post-traumatic stress disorder (PTSD) symptoms and brain structural and functional alteration. While Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is effectively used to reduce PTSD symptoms in maltreated children, yet, its impact on brain structural alterations has not been fully explored. This study investigated whether TF-CBT can attenuate alterations in brain structures associated with PTSD in middle childhood.

METHODS

The study evaluated the longitudinal effects of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) on post-traumatic stress disorder (PTSD) symptoms and gray matter volume (GMV) in two groups of children under 12 years old: maltreated children (MC) and healthy non- maltreatmentd children (HC). Structural magnetic resonance images T1 were obtained before and after TF-CBT in the MC group, while the HC group was scanned twice within the same time interval. Voxel-based morphometry (VBM) was used to analyze GMV changes over time.

RESULTS

After TF-CBT, maltreated children showed significantly reduced PTSD symptoms. Furthermore, a significant group-by-time interaction effect was observed in certain areas of the Left Temporal, Left Occipital, and bilateral Frontal Cortex, the Basal Ganglia and Cerebellum. These interaction effects were driven by a GMV decrease in the MC group compared to the HC group. GMV changes can be predicted with clinical improvement in the left Middle Temporal gyrus, left Precuneus, and Cerebellum.

CONCLUSIONS

Our results suggest that TF-CBT intervention in very young maltreated children may have an effect on gray matter. This evidence demonstrates the importance of timely intervention when neuroplasticity mechanisms may be activated.

Biological Psychiatry in Displaced Populations: What We Know, and What We Need to Begin to Learn

Conflict and climate change continue to displace millions of people, who experience unique trauma and stressors as they resettle in host countries. Both children and adults who are forcibly displaced, or choose to migrate, experience posttraumatic stress disorder, anxiety, depression, and other mental health conditions at higher rates than the general population. This may be attributed to severe, cumulative stress and trauma (largely interpersonal traumas); discrimination and harassment in host countries; and structural barriers to accessing and addressing mental health concerns, including clinician availability, language barriers, cultural differences, geographic accessibility, health care access, and stigma. Despite high exposure to and clinical impact of such experiences, and despite representing 1% of the world population, forcibly displaced people are underrepresented in neuroscientific research. The availability of such literature and research findings is significant in understanding the unique genetic and cultural aspects of trauma- and stress-related mental health, advocacy, reducing stigma, informing prevention, and treatment. The present work aimed to explore how the field of neuroscience can address mental health equity for individuals who have been uprooted in relation to land, with a focus on refugee populations. We offer practical suggestions on how to improve research in this area and narrow the gap in knowledge.

Mechanisms by which adverse childhood experiences, other traumas and PTSD influence the health and well-being of individuals with eating disorders throughout the life span

BACKGROUND

Multiple published sources from around the world have confirmed an association between an array of adverse childhood experiences (ACEs) and other traumatic events with eating disorders (EDs) and related adverse outcomes, including higher morbidity and mortality.

METHODS

In keeping with this Special Issue's goals, this narrative review focuses on the ACEs pyramid and its purported mechanisms through which child maltreatment and other forms of violence toward human beings influence the health and well-being of individuals who develop EDs throughout the life span. Relevant literature on posttraumatic stress disorder (PTSD) is highlighted when applicable.

RESULTS

At every level of the pyramid, it is shown that EDs interact with each of these proclaimed escalating mechanisms in a bidirectional manner that contributes to the predisposition, precipitation and perpetuation of EDs and related medical and psychiatric comorbidities, which then predispose to early death. The levels and their interactions that are discussed include the contribution of generational embodiment (genetics) and historical trauma (epigenetics), social conditions and local context, the ACEs and other traumas themselves, the resultant disrupted neurodevelopment, subsequent social, emotional and cognitive impairment, the adoption of health risk behaviors, and the development of disease, disability and social problems, all resulting in premature mortality by means of fatal complications and/or suicide.

CONCLUSIONS

The implications of these cascading, evolving, and intertwined perspectives have important implications for the assessment and treatment of EDs using trauma-informed care and trauma-focused integrated treatment approaches. This overview offers multiple opportunities at every level for the palliation and prevention of EDs and other associated trauma-related conditions, including PTSD.

Morning light treatment for traumatic stress: The role of amygdala reactivity study protocol

Background

Exposure to trauma can result in various mental health disorders including anxiety, depression, and posttraumatic stress disorder (PTSD). Although psychotherapies and pharmacotherapies exist for the treatment of these disorders, many individuals fail to receive treatment and among those who do, many remain symptomatic. Therefore, it is critical to continue developing new interventions for traumatic stress that target underlying mechanisms of pathology and offer a safe and acceptable alternative to current treatments. Morning light treatment has good potential as a novel non-invasive, low risk treatment for traumatic stress. Evidence suggests that morning light may improve traumatic stress by reducing reactivity in the amygdala, a brain region implicated in the pathophysiology of PTSD and anatomically linked to circadian photoreceptors in the eye.

Methods

In this study, we aim to establish a significant dose-response relationship between duration of morning light treatment and reduction in amygdala reactivity among individuals with traumatic stress symptoms (NCT# 04117347). Using a transdiagnostic approach, sixty-six individuals with a history of a DSM-5 criterion A trauma and traumatic stress symptoms will be recruited to participate in a 5-week study. Participants will be randomized across three treatment arms based on morning light treatment duration: 15-minutes, 30-minutes, or 60-minutes of light treatment per day for four weeks. To evaluate amygdala activity, participants will undergo fMRI at pre-treatment, mid-treatment, and post-treatment. Participants will also complete clinical assessments and self-report measures of PTSD, depression, and anxiety at pre-treatment, mid-treatment, and post-treatment.

Discussion

Morning light therapy may be an acceptable, feasible, and effective treatment for individuals suffering from traumatic stress. Identifying mechanistically relevant targets, and the doses needed to impact them, are critical steps in developing this new treatment approach for the sequelae of traumatic stress.

How a transdiagnostic approach can improve the treatment of emotional disorders: Insights from clinical psychology and neuroimaging

Multiple psychological treatments for emotional disorders have been developed and implemented, improving the quality of life of individuals. Nevertheless, relapse and poor response to psychotherapy are common. This article argues that a greater understanding of both the psychological and neurobiological mechanisms of change in psychotherapy is essential to improve treatment for emotional disorders. It aims to demonstrate how an understanding of these mechanisms provides a basis for (i) reconceptualizing some mental disorders, (ii) refining and establishing the evidence for existing therapeutic techniques and (iii) designing new techniques that precisely target the processes that maintain these disorders. Possible future directions for researchers and practitioners working at the intersection of neuropsychology and clinical psychology are discussed.

Autonomic nervous system correlates of posttraumatic stress symptoms in youth: Meta-analysis and qualitative review

Physiological dysregulation is a key diagnostic criterion for posttraumatic stress disorder (PTSD). While PTSD is defined by trauma exposure, symptom presentations are varied. Similarly, findings of autonomic nervous system (ANS), including parasympathetic (PNS) and sympathetic nervous system (SNS), function in youth exposed to trauma are mixed (e.g., hyporeactivity and hyperreactivity). The present meta-analysis quantitatively assesses the relation between ANS measures broadly, and PNS- and SNS-specific measures, and posttraumatic stress symptoms (PTSS) in youth (ages 4.98 to 19.55 years) across 38 cross-sectional and longitudinal studies (N = 3488). Findings demonstrate that heightened ANS activity is related to increased PTSS during stress tasks (r = 0.07), while decreased SNS activity at rest corresponded to increased PTSS (r = -0.09). The correlation between PNS measures and PTSS was non-significant. The moderation effect of age on the relation between PNS activity measured during stress tasks and PTSS approached significance, such that younger children showed a stronger negative relation between symptoms and PNS activity compared to older youth. Qualitative review of included studies revealed significant variability across sample and stressor characteristics and study methodology. Findings indicate the importance of autonomic dysregulation in youth with PTSS. Additional considerations for future research are discussed.

Individual prediction of trauma-focused psychotherapy response in youth with posttraumatic stress disorder using resting-state functional connectivity

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ML and rs-fMRI have shown promise in predicting treatment-response in adults with PTSD.

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Currently, no biomarkers for treatment-response are available in youth with PTSD.

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FC between the FPN and SMN was stronger in treatment non-responders on the group-level.

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A network within the bilateral STG predicted response for individual youth with 76% accuracy.

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Future studies should test generalizability of these findings and test if larger cohorts increase accuracy.

Randomized controlled trials have shown efficacy of trauma-focused psychotherapies in youth with posttraumatic stress disorder (PTSD). However, response varies considerably among individuals. Currently, no biomarkers are available to assist clinicians in identifying youth who are most likely to benefit from treatment. In this study, we investigated whether resting-state functional magnetic resonance imaging (rs-fMRI) could distinguish between responders and non-responders on the group- and individual patient level. Pre-treatment rs-fMRI was recorded in 40 youth (ages 8–17 years) with (partial) PTSD before trauma-focused psychotherapy. Change in symptom severity from pre- to post-treatment was assessed using the Clinician-Administered PTSD scale for Children and Adolescents to divide participants into responders (≥30% symptom reduction) and non-responders. Functional networks were identified using meta-independent component analysis. Group-differences within- and between-network connectivity between responders and non-responders were tested using permutation testing. Individual predictions were made using multivariate, cross-validated support vector machine classification. A network centered on the bilateral superior temporal gyrus predicted treatment response for individual patients with 76% accuracy (p_FWE = 0.02, 87% sensitivity, 65% specificity, area-under-receiver-operator-curve of 0.82). Functional connectivity between the frontoparietal and sensorimotor network was significantly stronger in non-responders (t = 5.35, p_FWE = 0.01) on the group-level. Within-network connectivity was not significantly different between groups. This study provides proof-of-concept evidence for the feasibility to predict trauma-focused psychotherapy response in youth with PTSD at an individual-level. Future studies are required to test if larger cohorts could increase accuracy and to test further generalizability of the prediction models.

The psychophysiological response during post-traumatic stress disorder treatment with modular motion-assisted memory desensitisation and reconsolidation (3MDR)

Background: Psychophysiological changes are part of post-traumatic stress disorder (PTSD) symptomatology and can signal emotional engagement during psychological treatment. Objectives: The aim of this study was to explore psychophysiological responses during multi-modular motion-assisted memory desensitization and reconsolidation (3MDR) therapy. Increased self-reported distress, substantially increased heart rate (HR) and breathing rate (BR) were expected at the start of therapy and predicted to improve over time. Since physical exercise demands during therapy were low, any large HR or BR responses were considered part of the psychophysiological response. Methods: This study used pooled data collected during a randomized controlled trial of 3MDR, which demonstrated significant improvement as measured by the Clinician Administered PTSD Scale. Whilst attending therapy, HR and BR data, subjective units of distress (SUD) score and phrases to describe feelings whilst exposed to trauma-related images were collected continuously from 37 UK male military veterans with PTSD. Results: HR and BR were significantly increased throughout all sessions (p < .01 for both). Whilst HR was raised slightly remaining on average below 100 beats/minute, BR was increased substantially with average values between 40 and 50 breaths/minute. SUD scores were very high during therapy which concurred with the many negative feelings experienced during therapy sessions. Across the course of the treatment, SUD scores (p < .01) and negative feelings were reduced (p < .001), and positive feelings have increased (p < .01) significantly, reflecting improvements in clinicians assessed PTSD symptoms. Across therapy sessions, HR (p = .888) and BR (p = .466) responses did not change. Conclusions: The strong psychophysiological response alongside high levels of self-reported distress and negative feelings is interpreted as high emotional engagement during therapy. A novel finding was the very significant BR increase throughout recorded sessions. Future PTSD research should include BR response to therapy and explore breathing control as a treatment target.

Trauma-focused psychotherapy response in youth with posttraumatic stress disorder is associated with changes in insula volume

Randomized controlled trials have shown efficacy of trauma-focused psychotherapies in youth with posttraumatic stress disorder (PTSD), but little is known about the relationship between treatment response and alternations in brain structures associated with PTSD. In this study, we longitudinally examined the association between treatment response and pre-to posttreatment changes in structural magnetic resonance imaging (MRI) scans using a voxel-based morphometry approach. We analyzed MRI scans of 35 patients (ages 8-18 years, 21 female) with PTSD (80%) or partial PTSD (20%) before and after eight weekly sessions of trauma-focused psychotherapy. PTSD severity was assessed longitudinally using the Clinician-Administered PTSD scale for Children and Adolescents to divide participants into responders and non-responders. Group by time interaction analysis showed significant differences in grey-matter volume in the bilateral insula due to volume reductions over time in non-responders compared to responders. Despite the significant group by time interaction, there were no significant group differences at baseline or follow-up. As typical development is associated with insula volume increase, these longitudinal MRI findings suggest that treatment non-response is associated with atypical neurodevelopment of the insula, which may underlie persistence of PTSD in youth. The absence of structural MRI changes in treatment responders, while in need of replication, suggest that successful trauma-focused psychotherapy may not directly normalize brain abnormalities associated with PTSD.

Neural function during emotion processing and modulation associated with treatment response in a randomized clinical trial for posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with exaggerated threat processing and deficits in emotion modulation circuitry. It remains unknown how neural circuits are associated with response to evidence-based treatments for PTSD.

METHOD

We examined associations between PTSD symptoms and indicators of neural response in key emotion processing and modulation regions. Fifty-six military Veterans with PTSD were randomly assigned to one of three evidence-based treatments (prolonged exposure, sertraline, and PE plus sertraline) in a randomized clinical trial ("PROGrESS"; 2018, Contemp Clin Trials, 64, 128-138). Twenty-seven combat-exposed controls (CCs) served as a comparison group at pretreatment. Before and after PTSD treatment, functional magnetic resonance imaging was used to assess brain activation and connectivity during the validated Shifted Attention Emotion Appraisal Task (2003, J Neurosci, 23, 5627-5633; 2013, Biol Psychiatry, 73, 1045-1053).

RESULTS

Greater activation in emotion processing (anterior insula) and modulation (prefrontal cortex) regions and increased connectivity between attentional control (dorsolateral prefrontal cortex and superior parietal cortex) and emotion processing (amygdala) regions, at pretreatment, were associated with subsequent PTSD symptom improvement.

CONCLUSIONS

This study is one of the first to examine task-based activation and functional connectivity in a PTSD treatment trial, and provides evidence to suggest that activation in and connectivity between emotion processing and modulation regions are important predictors of treatment response.

Pretreatment cortisol predicts trauma-focused psychotherapy response in youth with (partial) posttraumatic stress disorder

BACKGROUND

Despite availability of effective trauma-focused psychotherapies, treatment non-response in youth with (partial) posttraumatic stress disorder remains substantial. Studies in adult PTSD have suggested that cortisol is associated with treatment outcome. Furthermore, cortisol prior to treatment could be used to predict treatment success. However, there is a lack of comparable studies in youth with (partial) PTSD. The objective of the current study was therefore to test whether cortisol prior to treatment would differ between treatment responders and non-responders and would positively predict the extent of clinical improvement in youth with (partial) PTSD.

METHODS

Youth aged 8-18 with PTSD (79.2%) or partial PTSD (20.8%) were treated with 8 sessions of either trauma-focused cognitive behavioral therapy (TF-CBT) or eye movement desensitization and reprocessing (EMDR). Prior to treatment initiation, salivary cortisol was measured in treatment responders (n = 23) and treatment non-responders (n = 30) at 10 and 1 min before and 10, 20 and 30 min after personalized trauma script driven imagery (SDI). The cortisol stress response (>1.5 nmol/L increase from baseline) and basal cortisol secretion was assessed during the SDI procedure. We hypothesized that treatment responders would display higher cortisol levels caused by increased cortisol reactivity prior to trauma-focused psychotherapy relative to psychotherapy non-responders and higher cortisol levels would positively predict the extent of clinical improvement.

RESULTS

Script driven imagery did not induce a cortisol stress response in all but two participants. Prior to treatment responders showed significantly higher basal cortisol secretion during SDI compared to treatment non-responders. This effect remained significant after controlling for gender. Higher pre-treatment basal cortisol secretion further positively predicted the extent of clinical improvement during trauma-focused psychotherapy.

CONCLUSION

Because SDI failed to provoke a cortisol stress response in our sample, the question if cortisol reactivity differs between treatment responders and non-responders remains inconclusive. However, our results do suggest that higher pretreatment basal cortisol secretion forms a potential indicator of prospective trauma-focused psychotherapy response in youth with (partial) PTSD. Although, the amount of uniquely explained variance in clinical improvement by pre-treatment cortisol secretion is limited and still renders insufficient basis for clinical applicability, these findings do suggest directions for future studies to delineate the mechanisms of treatment success in youth with (partial) PTSD.

Poor Quality in Systematic Reviews on PTSD and EMDR - An Examination of Search Methodology and Reporting

Background: Different user groups regard systematic reviews as reliable and valuable sources for answering research questions. For systematic reviews to fulfill their purpose, methodological quality in all stages are of importance. The studies identified in a systematic search form the basis of the review, thus the search process methodology is important for both performing and reporting the search. The purpose of the present study was to evaluate the quality of non-Cochrane systematic reviews by analyzing how they perform and report the search. This is exemplified by systematic reviews on eye movement desensitization and reprocessing (EMDR), a trauma-focused therapy commonly used for post-traumatic stress disorder (PTSD).

Methods and Results: We examined the method chapters of 20 systematic reviews on the subject, and rated their searches and reporting using relevant elements from the Cochrane Handbook and PRISMA. We found inadequacies in the methods employed for searching and reporting the search strategy, which could have been avoided by greater adherence to guiding documents for performing systematic reviews.

Conclusion: Our findings raise important questions for future debate on the risk of omitting studies, thus impairing the conclusions in a systematic review. For clinical purposes, researchers should investigate if, and how, the search strategy in a systematic review affects the body of knowledge and the results.

Neurocognition in PTSD: Treatment Insights and Implications

Post-traumatic stress disorder (PTSD) is classified as a traumatic stress-related condition and is most often discussed in terms of emotional dysfunction. However, given that cognitive and emotional processes are intricately intertwined, implemented by overlapping brain networks, and effectively integrated in at least some of the same regions (e.g., prefrontal cortex, for a review, see Crocker et al. 2013), an abundance of literature now highlights the key role that cognitive functioning plays in both the development and maintenance (or exacerbation) of PTSD symptoms (Aupperle et al. 2012a; Verfaellie et al. 2012). Findings from this body of work detail objective impairment in neuropsychological function in those with PTSD (Brandes et al. 2002; Hayes et al. 2012a; Koenen et al. 2001). Yet despite the impact of neurocognition on PTSD treatment engagement and success (e.g., Haaland et al. 2016; Nijdam et al. 2015) and conversely, the role of PTSD treatment in normalizing cognitive dysfunction, a much smaller literature exists on neurocognitive changes following treatment for PTSD. Even aside from its role in treatment, cognitive functioning in PTSD has significant implications for daily functioning for individuals with this disorder, as cognition is predictive of school achievement, obtaining and maintaining employment, job advancement, maintaining relationships, greater wealth, and better health and quality of life (e.g., Diamond and Ling 2016).

Respiratory Sinus Arrhythmia in Cognitive Behavioral Therapy for Posttraumatic Stress Symptoms in Children: Preliminary Treatment and Gender Effects

Cognitive behavioral therapy (CBT) is an efficacious treatment for posttraumatic stress disorder (PTSD) symptoms, but the effect of CBT on physiological indicators is largely unknown. Respiratory sinus arrhythmia (RSA) is an established parasympathetic marker of self-regulatory capacity and stress responsivity. The present study tested if and how resting RSA and RSA reactivity changed following treatment among a sample of children (n = 48) who experienced at least one traumatic event and presented with PTSD symptoms. RSA reactivity was measured in response to personalized trauma-related scripts. Results indicated that changes in RSA after treatment were dependent on pretreatment resting levels of RSA, with individuals with high and low pretreatment resting RSA levels appearing to converge over time in both resting RSA and RSA reactivity by the 3-month follow up. Specific to RSA reactivity, a sex difference was evident, as following treatment, females showed less RSA withdrawal whereas males showed more RSA withdrawal. PTSD symptoms were significantly reduced after CBT but symptom change was not associated with pretreatment resting RSA levels. Overall, these results suggest that there may be multiple physiological patterns within children with PTSD and the direction of the physiological changes after CBT may depend on initial differences in resting RSA levels.

Fear extinction and memory reconsolidation as critical components in behavioral treatment for posttraumatic stress disorder and potential augmentation of these processes

Posttraumatic stress disorder (PTSD) is associated with alterations in critical brain regions such as the amygdala, hippocampus, and prefrontal cortex. This brief review has two objectives: (1) to discuss research examining extinction and reconsolidation processes as mechanisms in PTSD psychotherapy, and (2) present possibilities for augmenting extinction and reconsolidation within treatment through alterations to therapeutic interventions and novel approaches. A key component of many effective PTSD therapies is exposure, which involves intentional confrontation and processing of the traumatic memory. Our review suggests that extinction and reconsolidation processes underlie effective exposure-based treatment, but the neurobiological mechanisms of these processes in behavioral treatments for PTSD remains unclear. We argue that enhancing extinction and/or disrupting reconsolidation of a feared memory may improve the efficacy of existing treatments (e.g., increased change for limited/non-responders, faster/greater changes for responders), which can be done through multiple channels. Potential avenues for augmentation of the processes of extinction and reconsolidation in PTSD psychotherapies are reviewed, including behavioral modifications, pharmacotherapy agents, and the use of devices during therapy. We further suggest that investigations towards understanding the extent to which extinction and reconsolidation processes are necessary in effective PTSD psychotherapy is an important future direction for enhancing clinical care among PTSD populations.

Effects of psychotherapy on DNA strand break accumulation originating from traumatic stress

BACKGROUND

Previous research reveals an association between traumatic stress and an increased risk for numerous diseases, including cancer. At the molecular level, stress may increase carcinogenesis via increased DNA damage and impaired DNA repair mechanisms. We assessed DNA breakage in peripheral blood mononuclear cells from individuals with post-traumatic stress disorder (PTSD) and measured the cellular capacity to repair single-strand breaks after exposure to ionizing X-radiation. We also investigated the effect of psychotherapy on both DNA breakage and DNA repair.

METHODS

In a first study we investigated DNA breakage and repair in 34 individuals with PTSD and 31 controls. Controls were subdivided into 11 trauma-exposed subjects and 20 individuals without trauma exposure. In a second study, we analysed the effect of psychotherapy (Narrative Exposure Therapy) on DNA breakage and repair. Thirty-eight individuals with PTSD were randomly assigned to either a treatment or a waitlist control condition. Follow-up was performed 4 months and 1 year after therapy.

RESULTS

In study 1 we found higher levels of basal DNA breakage in individuals with PTSD and trauma-exposed subjects than in controls, indicating that traumatic stress is associated with DNA breakage. However, single-strand break repair was unimpaired in individuals with PTSD. In study 2, we found that psychotherapy reversed not only PTSD symptoms, but also DNA strand break accumulation.

CONCLUSION

Our results show - for the first time in vivo - an association between traumatic stress and DNA breakage; they also demonstrate changes at the molecular level, i.e., the integrity of DNA, after psychotherapeutic interventions.

Listening to the heart: A meta-analysis of cognitive behavior therapy impact on the heart rate of patients with anxiety disorders

INTRODUCTION

The future of psychotherapy relies on the dialog with the basic science, being the identification of psychotherapeutifc biomarkers of efficacy a core necessity. Heart rate (HR) is one of the most studied psychophysiological parameters in anxiety disorders.

METHODS

To investigate the impact of cognitive behavior therapy (CBT) on the HR of patients with anxiety disorders, we conducted a meta-analysis and systematic review. Electronic searches were conducted in the ISI/Web of Knowledge, PsychINFO and PubMed/MEDLINE for studies which evaluated HR at least once before and after CBT. Keywords related to anxiety disorders, HR and CBT were used in the search.

RESULTS

474 studies, of which 47 were selected for the systematic review and 8 for the meta-analysis, were identified. The results provide evidence that CBT significantly decreases the HR of posttraumatic stress disorder patients. In social phobia, obsessive-compulsive disorder and acute stress disorder, the results point in the same direction, although it is still early to attribute the decrease in HR to CBT. In specific phobias, traditional exposure therapy showed greater effect size than exposure with distractors or without psycho-education.

LIMITATIONS

Most of the randomized trials have not been conducted in accordance with rigorous methodological quality criteria.

CONCLUSIONS

Standardization in the methods used and in treatment protocols, as well as investigations in groups of patients with low physiological reactivity, are necessary in order to reach better conclusions. Notwithstanding these limitations, HR is beginning to emerge as a potential biomarker of efficacy in anxiety disorders.

Neural circuits in anxiety and stress disorders: a focused review

Anxiety and stress disorders are among the most prevalent neuropsychiatric disorders. In recent years, multiple studies have examined brain regions and networks involved in anxiety symptomatology in an effort to better understand the mechanisms involved and to develop more effective treatments. However, much remains unknown regarding the specific abnormalities and interactions between networks of regions underlying anxiety disorder presentations. We examined recent neuroimaging literature that aims to identify neural mechanisms underlying anxiety, searching for patterns of neural dysfunction that might be specific to different anxiety disorder categories. Across different anxiety and stress disorders, patterns of hyperactivation in emotion-generating regions and hypoactivation in prefrontal/regulatory regions are common in the literature. Interestingly, evidence of differential patterns is also emerging, such that within a spectrum of disorders ranging from more fear-based to more anxiety-based, greater involvement of emotion-generating regions is reported in panic disorder and specific phobia, and greater involvement of prefrontal regions is reported in generalized anxiety disorder and posttraumatic stress disorder. We summarize the pertinent literature and suggest areas for continued investigation.

Reducing Delusional Conviction through a Cognitive-Based Group Training Game: A Multicentre Randomized Controlled Trial

OBJECTIVE

"Michael's game" (MG) is a card game targeting the ability to generate alternative hypotheses to explain a given experience. The main objective was to evaluate the effect of MG on delusional conviction as measured by the primary study outcome: the change in scores on the conviction subscale of the Peters delusions inventory (PDI-21). Other variables of interest were the change in scores on the distress and preoccupation subscales of the PDI-21, the brief psychiatric rating scale, the Beck cognitive insight scale, and belief flexibility assessed with the Maudsley assessment of delusions schedule (MADS).

METHODS

We performed a parallel, assessor-blinded, randomized controlled superiority trial comparing treatment as usual plus participation in MG with treatment as usual plus being on a waiting list (TAU) in a sample of adult outpatients with psychotic disorders and persistent positive psychotic symptoms at inclusion.

RESULTS

The 172 participants were randomized, with 86 included in each study arm. Assessments were performed at inclusion (T1: baseline), at 3 months (T2: post-treatment), and at 6 months after the second assessment (T3: follow-up). At T2, a positive treatment effect was observed on the primary outcome, the PDI-21 conviction subscale (p = 0.005). At T3, a sustained effect was observed for the conviction subscale (p = 0.002). Further effects were also observed at T3 on the PDI-21 distress (p = 0.002) and preoccupation subscales (p = 0.001), as well as on one of the MADS measures of belief flexibility ("anything against the belief") (p = 0.001).

CONCLUSION

The study demonstrated some significant beneficial effect of MG.

Post-Traumatic Stress Disorder among Cardiac Patients: Prevalence, Risk Factors, and Considerations for Assessment and Treatment

There is increasing awareness of the impact of post-traumatic stress disorder (PTSD) on physical health, particularly cardiovascular disease. We review the literature on the role of trauma in the development of cardiovascular risk factors and disease, aftermath of a cardiac event, and risk for recurrence in cardiac patients. We explore possible mechanisms to explain these relationships, as well as appropriate assessment and treatment strategies for this population. Our main conclusion is that screening and referral for appropriate treatments are important given the high prevalence rates of PTSD in cardiac populations and the associated impact on morbidity and mortality.

Review of psychodynamic psychotherapy neuroimaging studies

The clinical efficacy of psychodynamic psychotherapy (PDT) has undergone extensive study and review. Recently, researchers have studied the effects of this treatment on brain metabolic or synaptic activity, but the collective findings have never been reviewed. The objective of this review was to describe the findings of all neuroimaging studies of any form of PDT treatment. An extensive literature search through databases along with surveying of research groups were undertaken to acquire all available published studies. Eleven series were included in the final sample, consisting of 2 randomized controlled trials, 5 controlled trials and 4 case series, altogether involving 210 people: 94 healthy controls and 116 people with mood disorders, panic disorder, somatoform disorders and borderline personality disorder. A variety of neuroimaging techniques were used to examine regional metabolic activity and synaptic neurotransmission before and after treatment. The common finding was normalization of synaptic or metabolic activity in limbic, midbrain and prefrontal regions, occurring in association with improved clinical outcomes. PDT has demonstrable effects on brain function in diverse clinical populations as evidenced by a modest group of mixed neuroimaging studies.

The role of stress and fear in the development of mental disorders

The most common pathologic manifestation of fear is posttraumatic stress disorder (PTSD). Developing PTSD is closely related with predisposing factors such as genes and early traumatic experiences. In PTSD, enhanced fear learning and poor extinction are common. Fear is manifested through autonomic responses and persistent memories of the traumatic event. These manifestations are related to stress responses modulated by the hypothalamic-pituitary-adrenal axis. This article evaluates the role of fear and stress in the course of PTSD. Findings on fear learning and extinction are presented in order to guide future treatments of patients with PTSD.

Fear but not fright: re-evaluating traumatic experience attenuates anxiety-like behaviors after fear conditioning

Fear allows organisms to cope with dangerous situations and remembering these situations has an adaptive role preserving individuals from injury and death. However, recalling traumatic memories can induce re-experiencing the trauma, thus resulting in a maladaptive fear. A failure to properly regulate fear responses has been associated with anxiety disorders, like Posttraumatic Stress Disorder (PTSD). Thus, re-establishing the capability to regulate fear has an important role for its adaptive and clinical relevance. Strategies aimed at erasing fear memories have been proposed, although there are limits about their efficiency in treating anxiety disorders. To re-establish fear regulation, here we propose a new approach, based on the re-evaluation of the aversive value of traumatic experience. Mice were submitted to a contextual-fear-conditioning paradigm in which a neutral context was paired with an intense electric footshock. Three weeks after acquisition, conditioned mice were treated with a less intense footshock (pain threshold). The effectiveness of this procedure in reducing fear expression was assessed in terms of behavioral outcomes related to PTSD (e.g., hyper-reactivity to a neutral tone, anxiety levels in a plus maze task, social avoidance, and learning deficits in a spatial water maze) and of amygdala activity by evaluating c-fos expression. Furthermore, a possible role of lateral orbitofrontal cortex (lOFC) in mediating the behavioral effects induced by the re-evaluation procedure was investigated. We observed that this treatment: (i) significantly mitigates the abnormal behavioral outcomes induced by trauma; (ii) persistently attenuates fear expression without erasing contextual memory; (iii) prevents fear reinstatement; (iv) reduces amygdala activity; and (v) requires an intact lOFC to be effective. These results suggest that an effective strategy to treat pathological anxiety should address cognitive re-evaluation of the traumatic experience mediated by lOFC.

Decreased occipital cortical glutamate levels in response to successful cognitive-behavioral therapy and pharmacotherapy for major depressive disorder

BACKGROUND

Previous studies have demonstrated that antidepressant medication and electroconvulsive therapy increase occipital cortical γ-aminobutyric acid (GABA) in major depressive disorder (MDD), but a small pilot study failed to show a similar effect of cognitive-behavioral therapy (CBT) on occipital GABA. In light of these findings we sought to determine if baseline GABA levels predict treatment response and to broaden the analysis to other metabolites and neurotransmitters in this larger study.

METHODS

A total of 40 MDD outpatients received baseline proton magnetic resonance spectroscopy (1H-MRS), and 30 subjects completed both pre- and post-CBT 1H-MRS; 9 CBT nonresponders completed an open-label medication phase followed by an additional/3rd 1H-MRS. The magnitude of treatment response was correlated with occipital amino acid neurotransmitter levels.

RESULTS

Baseline GABA did not predict treatment outcome. Furthermore, there was no significant effect of CBT on GABA levels. However, we found a significant group × time interaction (F1, 28 = 6.30, p = 0.02), demonstrating reduced glutamate in CBT responders, with no significant glutamate change in CBT nonresponders.

CONCLUSIONS

These findings corroborate the lack of effect of successful CBT on occipital cortical GABA levels in a larger sample. A reduction in glutamate levels following treatment, on the other hand, correlated with successful CBT and antidepressant medication response. Based on this finding and other reports, decreased occipital glutamate may be an antidepressant response biomarker. Healthy control comparator and nonintervention groups may shed light on the sensitivity and specificity of these results.

Characterization of post-traumatic stress disorder using resting-state fMRI with a multi-level parametric classification approach

Functional neuroimaging studies have found intra-regional activity and inter-regional connectivity alterations in patients with post-traumatic stress disorder (PTSD). However, the results of these studies are based on group-level statistics and therefore it is unclear whether PTSD can be discriminated at single-subject level, for instance using the machine learning approach. Here, we proposed a novel framework to identify PTSD using multi-level measures derived from resting-state functional MRI (fMRI). Specifically, three levels of measures were extracted as classification features: (1) regional amplitude of low-frequency fluctuations (univariate feature), which represents local spontaneous synchronous neural activity; (2) temporal functional connectivity (bivariate feature), which represents the extent of similarity of local activity between two regions, and (3) spatial functional connectivity (multivariate feature), which represents the extent of similarity of temporal correlation maps between two regions. Our method was evaluated on 20 PTSD patients and 20 demographically matched healthy controls. The experimental results showed that the features of each level could successfully discriminate PTSD patients from healthy controls. Furthermore, the combination of multi-level features using multi-kernel learning can further improve the classification performance. Specifically, the classification accuracy obtained by the proposed framework was 92.5 %, which was an increase of at least 5 and 17.5 % from the two-level and single-level feature based methods, respectively. Particularly, the limbic structure and prefrontal cortex provided the most discriminant features for classification, consistent with results reported in previous studies. Together, this study demonstrated for the first time that patients with PTSD can be identified at the individual level using resting-state fMRI data. The promising classification results indicated that this method may provide a complementary approach for improving the clinical diagnosis of PTSD.

Animal models of fear relapse

Whereas fear memories are rapidly acquired and enduring over time, extinction memories are slow to form and are susceptible to disruption. Consequently, behavioral therapies that involve extinction learning (e.g., exposure therapy) often produce only temporary suppression of fear and anxiety. This review focuses on the factors that are known to influence the relapse of extinguished fear. Several phenomena associated with the return of fear after extinction are discussed, including renewal, spontaneous recovery, reacquisition, and reinstatement. Additionally, this review describes recent work, which has focused on the role of psychological stress in the relapse of extinguished fear. Recent developments in behavioral and pharmacological research are examined in light of treatment of pathological fear in humans.