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Titone MK, Hunt C, Bismark A, Nokes B, Lee E, Ramanathan D, Park J, Colvonen P. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med 2023; 19:2043-2051. [PMID: 37539643 PMCID: PMC10692930 DOI: 10.5664/jcsm.10746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
STUDY OBJECTIVES Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression. METHODS Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories. RESULTS We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis. CONCLUSIONS Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD. CITATION Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.
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Affiliation(s)
- Madison K. Titone
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | | | | | - Brandon Nokes
- VA San Diego Healthcare System, San Diego, California
| | - Ellen Lee
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Dhakshin Ramanathan
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Jane Park
- VA San Diego Healthcare System, San Diego, California
| | - Peter Colvonen
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
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Lee J, Shin J, Chae S, Chun J, Choi JW, Lee JY, Park TW, Kim KM, Kim K, Kim JW. The Factors Affecting Longitudinal Course of Posttraumatic Stress Disorder Symptoms in Sexual Assault Victims. Psychiatry Investig 2023; 20:1061-1068. [PMID: 37997334 PMCID: PMC10678143 DOI: 10.30773/pi.2023.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/05/2023] [Accepted: 08/22/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVE This study aimed to identify the factors affecting posttraumatic stress disorder (PTSD) symptom remission prospectively through a 1-year follow-up of sexual assault (SA) victims. METHODS A total 65 female SA victims who visited the crisis intervention center were included. Self-administered questionnaires regarding PTSD symptoms and PTSD related prognostic factors were conducted at both recruitment (T1) and 1 year after recruitment (T2). The multivariate analyses were used to determine the significant predictors of PTSD remission/non-remission state 1 year after SA. RESULTS In logistic regression analysis, both anxiety and secondary victimization were identified as significant factors explaining the results on PTSD remission/non-remission state at T2 (Beck's Anxiety Inventory [BAI], p=0.003; Secondary Victimization Questionnaire, p=0.024). In a linear mixed analysis, both depression and anxiety were found to be significant variables leading to changes in Posttraumatic Diagnostic Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition from T1 to T2 (BAI, p<0.001; Center for Epidemiological Studies Depression Scale, p<0.001). CONCLUSION Depression, anxiety symptoms, and secondary victimization after SA were associated with PTSD symptom non-remission 1 year after SA.
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Affiliation(s)
- Jaewon Lee
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jiyoon Shin
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Child and Adolescent Psychiatry, Department of Psychiatry & Behavioral Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Soohyun Chae
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Child and Adolescent Psychiatry, Department of Psychiatry & Behavioral Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeeyoung Chun
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Child and Adolescent Psychiatry, Department of Psychiatry & Behavioral Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae-Won Choi
- Department of Psychiatry, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Ju-Yeon Lee
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Tae-Won Park
- Department of Psychiatry, Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Kyoung Min Kim
- Department of Psychiatry, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Kihyun Kim
- Department of Social Welfare, College of Social Sciences, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jae-Won Kim
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Child and Adolescent Psychiatry, Department of Psychiatry & Behavioral Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
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Nieto-Quero A, Infantes-López MI, Zambrana-Infantes E, Chaves-Peña P, Gavito AL, Munoz-Martin J, Tabbai S, Márquez J, Rodríguez de Fonseca F, García-Fernández MI, Santín LJ, Pedraza C, Pérez-Martín M. Unveiling the Secrets of the Stressed Hippocampus: Exploring Proteomic Changes and Neurobiology of Posttraumatic Stress Disorder. Cells 2023; 12:2290. [PMID: 37759512 PMCID: PMC10527244 DOI: 10.3390/cells12182290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/28/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Intense stress, especially traumatic stress, can trigger disabling responses and in some cases even lead to the development of posttraumatic stress disorder (PTSD). PTSD is heterogeneous, accompanied by a range of distress symptoms and treatment-resistant disorders that may be associated with a number of other psychopathologies. PTSD is a very heterogeneous disorder with different subtypes that depend on, among other factors, the type of stressor that provokes it. However, the neurobiological mechanisms are poorly understood. The study of early stress responses may hint at the way PTSD develops and improve the understanding of the neurobiological mechanisms involved in its onset, opening the opportunity for possible preventive treatments. Proteomics is a promising strategy for characterizing these early mechanisms underlying the development of PTSD. The aim of the work was to understand how exposure to acute and intense stress using water immersion restraint stress (WIRS), which could be reminiscent of natural disaster, may induce several PTSD-associated symptoms and changes in the hippocampal proteomic profile. The results showed that exposure to WIRS induced behavioural symptoms and corticosterone levels reminiscent of PTSD. Moreover, the expression profiles of hippocampal proteins at 1 h and 24 h after stress were deregulated in favour of increased inflammation and reduced neuroplasticity, which was validated by histological studies and cytokine determination. Taken together, these results suggest that neuroplastic and inflammatory dysregulation may be a therapeutic target for the treatment of post-traumatic stress disorders.
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Affiliation(s)
- Andrea Nieto-Quero
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - María Inmaculada Infantes-López
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain; (P.C.-P.); (J.M.-M.)
| | - Emma Zambrana-Infantes
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Patricia Chaves-Peña
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain; (P.C.-P.); (J.M.-M.)
| | - Ana L. Gavito
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Jose Munoz-Martin
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain; (P.C.-P.); (J.M.-M.)
| | - Sara Tabbai
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Javier Márquez
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
- Departamento de Biología Molecular y Bioquímica, Canceromics Lab, Universidad de Málaga, 29010 Malaga, Spain
| | - Fernando Rodríguez de Fonseca
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - María Inmaculada García-Fernández
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
- Departamento de Fisiología Humana, Histología Humana, Anatomía Patológica y Educación Física y Deportiva, Universidad de Málaga, 29010 Malaga, Spain
| | - Luis J. Santín
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Carmen Pedraza
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Margarita Pérez-Martín
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain; (P.C.-P.); (J.M.-M.)
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Nijdam MJ, Vermetten E, McFarlane AC. Toward staging differentiation for posttraumatic stress disorder treatment. Acta Psychiatr Scand 2023; 147:65-80. [PMID: 36367112 PMCID: PMC10100486 DOI: 10.1111/acps.13520] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Several medical and psychiatric disorders have stage-based treatment decision-making methods. However, international treatment guidelines for posttraumatic stress disorder (PTSD) fail to give specific treatment recommendations based on chronicity or stage of the disorder. There is convincing evidence of a finite range of PTSD symptom trajectories, implying that different phenotypes of the disorder can be distinguished, which are highly relevant for a staging typology of PTSD. METHODS State-of-the-art review building on prior work on staging models in other disorders as a mapping tool to identify and synthesize toward PTSD. RESULTS We propose a four-stage model of PTSD ranging from stage 0: trauma-exposed asymptomatic but at risk to stage 4: severe unremitting illness of increasing chronicity. We favor a symptom description in various chronological characteristics based on neurobiological markers, information processing systems, stress reactivity, and consciousness dimensions. We also advocate for a separate phenomenology of treatment resistance since this can yield treatment recommendations. CONCLUSION A staging perspective in the field of PTSD is highly needed. This can facilitate the selection of interventions that are proportionate to patients' current needs and risk of illness progression and can also contribute to an efficient framework to organize biomarker data and guide service delivery. Therefore, we propose that a neurobiologically driven trajectory-based typology of PTSD can help deduct several treatment recommendations leading to a more personalized and refined grid to strategize, plan and evaluate treatment interventions.
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Affiliation(s)
- Mirjam J Nijdam
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,ARQ National Psychotrauma Center, Diemen, The Netherlands
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexander C McFarlane
- Discipline of Psychiatry, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
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5
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Thierrée S, Raulin-Briot M, Legrand M, Le Gouge A, Vancappel A, Tudorache AC, Brizard B, Clarys D, Caille A, El-Hage W. Combining Trauma Script Exposure With rTMS to Reduce Symptoms of Post-Traumatic Stress Disorder: Randomized Controlled Trial. Neuromodulation 2022; 25:549-557. [PMID: 35667770 DOI: 10.1111/ner.13505] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 06/20/2021] [Accepted: 06/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Innovative therapeutic interventions for post-traumatic stress disorder (PTSD) are required. We opted to facilitate fear extinction by combining trauma script exposure with repetitive transcranial magnetic stimulation (rTMS) to reduce symptoms of PTSD. OBJECTIVE The efficacy and safety of 10 Hz rTMS of the right dorsolateral prefrontal cortex simultaneously with exposure to personal traumatic narrative were studied in patients with PTSD. MATERIALS AND METHODS This trial was a single-center randomized controlled trial (NCT02584894). Patients were randomly assigned 1:1 to receive eight daily sessions of 110% of motor threshold high frequency (HF) 10 Hz rTMS (110% HF rTMS) or 70% low frequency (LF) 1 Hz rTMS (70% LF rTMS) with trauma script exposure in both groups. Severity of PTSD, depression, and anxiety were assessed before and after study treatment (one month, three months) by an assessor masked to the trial group assignment. The primary outcome was the severity of PTSD assessed by the Clinician Administered PTSD Scale (CAPS). We used mixed linear regression models for statistical comparisons. RESULTS Thirty-eight patients (65.8% females) were randomly assigned to 110% HF rTMS (n = 18, 31.3 ± 10.0 years, 13 females) or 70% LF rTMS (n = 20, 33.5 ± 11.1 years, 12 females). From baseline to three months, mean CAPS scores decreased by 51% in the 110% HF rTMS group (from 83.7 ± 14.4 to 41.8 ± 31.9) and by 36.9% in the 70% LF rTMS group (from 81.8 ± 15.6 to 51.6 ± 23.7), but with no significant difference in improvement (time by treatment interaction -3.61 [95% confidence interval (CI), -9.70 to 2.47]; p = 0.24; effect size 0.53). One serious adverse event occurred during the study (psychogenic nonepileptic seizure). CONCLUSION We found no evidence of difference in clinical improvement or remission rates between the 110% HF and 70% LF stimulation. These findings may reflect the importance of exposure procedure and that larger number of participants is needed.
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Affiliation(s)
- Sarah Thierrée
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
| | | | - Marc Legrand
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
| | | | - Alexis Vancappel
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France; Clinique Psychiatrique Universitaire, CHRU de Tours, Tours, France
| | - Andrei-Cristian Tudorache
- UMR CNRS 7295, Centre de Recherches sur la Cognition et l'Apprentissage, Université de Poitiers, Poitiers, France
| | - Bruno Brizard
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France
| | - David Clarys
- UMR CNRS 7295, Centre de Recherches sur la Cognition et l'Apprentissage, Université de Poitiers, Poitiers, France
| | - Agnès Caille
- CIC 1415, CHRU Tours, Inserm, Tours, France; SPHERE, UMR 1246, Université de Tours, Université de Nantes, Inserm, Tours, France
| | - Wissam El-Hage
- UMR 1253, iBrain, Université de Tours, Inserm, Tours, France; Clinique Psychiatrique Universitaire, CHRU de Tours, Tours, France; CIC 1415, CHRU Tours, Inserm, Tours, France; CHRU de Tours, CIC 1415, Inserm, Tours, France.
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Miller DB, Rassaby MM, Collins KA, Milad MR. Behavioral and neural mechanisms of latent inhibition. Learn Mem 2022; 29:38-47. [PMID: 35042827 PMCID: PMC8774194 DOI: 10.1101/lm.053439.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Abstract
Fear is an adaptive emotion that serves to protect an organism against potential dangers. It is often studied using classical conditioning paradigms where a conditioned stimulus is paired with an aversive unconditioned stimulus to induce a threat response. Less commonly studied is a phenomenon that is related to this form of conditioning, known as latent inhibition. Latent inhibition (LI) is a paradigm in which a neutral cue is repeatedly presented in the absence of any aversive associations. Subsequent pairing of this pre-exposed cue with an aversive stimulus typically leads to reduced expression of a conditioned fear/threat response. In this article, we review some of the theoretical basis for LI and its behavioral and neural mechanisms. We compare and contrast LI and fear/threat extinction-a process in which a previously conditioned cue is repeatedly presented in the absence of aversive outcomes. We end with highlighting the potential clinical utility of LI. Particularly, we focus on how LI application could be useful for enhancing resilience, especially for individuals who are more prone to continuous exposure to trauma and stressful environments, such as healthcare workers and first responders. The knowledge to be gained from advancing our understanding of neural mechanisms in latent inhibition could be applicable across psychiatric disorders characterized by exaggerated fear responses and impaired emotion regulation.
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Affiliation(s)
- Dylan B Miller
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York 10016, USA
| | - Madeleine M Rassaby
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York 10016, USA
| | - Katherine A Collins
- Nathan Kline Institute for Psychiatric Research, Orangeburg, New York 10962, USA
| | - Mohammad R Milad
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York 10016, USA
- Nathan Kline Institute for Psychiatric Research, Orangeburg, New York 10962, USA
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Hinton M, O'Donnell M, Cowlishaw S, Kartal D, Metcalf O, Varker T, McFarlane AC, Hopwood M, Bryant RA, Forbes D, Howard A, Lau W, Cooper J, Phelps AJ. Defining post-traumatic stress disorder recovery in veterans: Benchmarking symptom change against functioning indicators. Stress Health 2021; 37:547-556. [PMID: 33336551 DOI: 10.1002/smi.3019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/07/2020] [Accepted: 12/11/2020] [Indexed: 11/08/2022]
Abstract
Improved metrics of Post-traumatic stress disorder (PTSD) treatment response that extend beyond a focus on symptom reduction to incorporate meaningful, patient-centred indicators of functioning are needed in veteran populations. The aim of this study was to extend previous research by investigating whether indicators of functioning can successfully distinguish against symptom response categories derived from the Post-Traumatic Stress Disorder Checklist (PCL-5) pre- and post- PTSD treatment. Participants were 472 veterans receiving hospital-based treatment for PTSD. In addition to the PCL-5, measures included quality of life, social relationships, physical health and psychological distress. Four mutually exclusive, progressive response categories were used to define treatment response including: No Response, Response, Response and Below Threshold, and Remission. PTSD symptom reductions were associated with corresponding improvements in broader indicators of functioning. However, it was only when the magnitude of symptom reduction placed the individual in the 'Response and Below Threshold' category that improvement on functioning measures achieved levels indicative of a good end state. Traditional metrics of treatment 'response' in PTSD treatment do not necessarily indicate recovery on important functioning indicators. Only when an individual both responds to treatment and drops below threshold for probable disorder are they likely to report having meaningful levels of functioning.
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Affiliation(s)
- Mark Hinton
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - Meaghan O'Donnell
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - Sean Cowlishaw
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia.,Bristol Medical School, University of Bristol, Bristol, UK
| | - Dzenana Kartal
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - Olivia Metcalf
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - Tracey Varker
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - Alexander C McFarlane
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Kensington, Australia
| | - David Forbes
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - Alexandra Howard
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - Winnie Lau
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - John Cooper
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
| | - Andrea J Phelps
- Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia
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8
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Sogo K, Sogo M, Okawa Y. Centrally acting anticholinergic drug trihexyphenidyl is highly effective in reducing nightmares associated with post-traumatic stress disorder. Brain Behav 2021; 11:e02147. [PMID: 33991066 PMCID: PMC8213645 DOI: 10.1002/brb3.2147] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/11/2021] [Accepted: 03/27/2021] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Following a case study on scopolamine butyl bromide, an anticholinergic drug, we studied the effect of a central anticholinergic drug on post-traumatic stress disorder (PTSD)-related flashbacks and nightmares. METHODS We administered trihexyphenidyl (TP) to 34 patients with refractory PTSD-related nightmares and flashbacks (open-label trial [n = 22]; single-blind trial [n = 12]), who had previously received psychiatric treatment for approximately 2-15 years, without therapeutic benefits. The effect of TP was determined using the Clinician-Administered PTSD Scale (CAPS) and the Impact of Event Scale-Revised (IES-R). RESULTS Overall, most patients reported an improvement to none or mild on the CAPS for nightmares (88%) and flashbacks (79%). CONCLUSION This study is the first to demonstrate the potential efficacy of TP in the treatment of refractory PTSD-related nightmares and flashbacks. Further double-blind, randomized control trials are needed to explore the potential clinical benefits of TP in PTSD.
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Affiliation(s)
- Katsumasa Sogo
- Sogo PTSD InstituteMedical Corporation SogokaiHiroshima‐cityJapan
| | - Masanobu Sogo
- Sogo PTSD InstituteMedical Corporation SogokaiHiroshima‐cityJapan
| | - Yoshie Okawa
- Sogo PTSD InstituteMedical Corporation SogokaiHiroshima‐cityJapan
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9
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van Gelderen MJ, Nijdam MJ, Haagen JFG, Vermetten E. Interactive Motion-Assisted Exposure Therapy for Veterans with Treatment-Resistant Posttraumatic Stress Disorder: A Randomized Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 89:215-227. [PMID: 32203971 DOI: 10.1159/000505977] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 01/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Veterans with posttraumatic stress disorder (PTSD) tend to benefit less from evidence-based treatments than other PTSD populations. A novel virtual reality and motion-assisted exposure therapy, called 3MDR, provides treatment in an immersive, personalized and activating context. OBJECTIVE To study the efficacy of 3MDR for veterans with treatment-resistant PTSD. METHOD In a randomized controlled trial (n = 43) 3MDR was compared to a non-specific treatment component control group. Primary outcome was clinician-rated PTSD symptoms at baseline, after 3MDR, and at the 12-week and 16-week follow-up (primary end point). Intention-to-treat analyses of covariance and mixed models were applied to study differences between groups at the end point and over the course of intervention, controlling for baseline scores. RESULTS The decrease in PTSD symptom severity from baseline to end point was significantly greater for 3MDR as compared to the control group, with a large effect size (F[1, 37] = 6.43, p = 0.016, d = 0.83). No significant between-group difference was detected in the course of PTSD symptoms during treatment when including all time points. The dropout rate was low (7%), and 45% of the patients in the 3MDR group improved clinically. The number needed to treat was 2.86. CONCLUSIONS In this trial, 3MDR significantly decreased PTSD symptoms in veterans with, on average, a history of 4 unsuccessful treatments. The low dropout rate may be indicative of high engagement. However, a lack of significant differences on secondary outcomes limits conclusions that can be drawn on its efficacy and underlines the need for larger phase III trials. These data show emerging evidence for 3MDR and its potential to progress PTSD treatment for veterans (Dutch Trial Register Identifier: NL5126).
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Affiliation(s)
- Marieke J van Gelderen
- ARQ Centrum'45, Diemen, The Netherlands, .,Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands,
| | - Mirjam J Nijdam
- ARQ Centrum'45, Diemen, The Netherlands.,Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.,ARQ National Psychotrauma Centre, Diemen, The Netherlands.,Military Mental Health Research, Ministry of Defense, Utrecht, The Netherlands
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Ney LJ, Akhurst J, Bruno R, Laing PAF, Matthews A, Felmingham KL. Dopamine, endocannabinoids and their interaction in fear extinction and negative affect in PTSD. Prog Neuropsychopharmacol Biol Psychiatry 2021; 105:110118. [PMID: 32991952 DOI: 10.1016/j.pnpbp.2020.110118] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/03/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022]
Abstract
There currently exist few frameworks for common neurobiology between reexperiencing and negative cognitions and mood symptoms of PTSD. Adopting a dopaminergic framework for PTSD unites many aspects of unique symptom clusters, and this approach also links PTSD symptomology to common comorbidities with a common neurobiological deficiency. Here we review the dopamine literature and incorporate it with a growing field of research that describes both the contribution of endocannabinoids to fear extinction and PTSD, as well as the interactions between dopaminergic and endocannabinoid systems underlying this disorder. Based on current evidence, we outline an early, preliminary model that links re-experiencing and negative cognitions and mood in PTSD by invoking the interaction between endocannabinoid and dopaminergic signalling in the brain. These interactions between PTSD, dopamine and endocannabinoids may have implications for future therapies for treatment-resistant and comorbid PTSD patients.
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Affiliation(s)
- Luke J Ney
- School of Psychology, University of Tasmania, Australia.
| | - Jane Akhurst
- School of Psychology, University of Tasmania, Australia
| | | | - Patrick A F Laing
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, University of Melbourne & Melbourne Health, Australia
| | | | - Kim L Felmingham
- School of Psychological Sciences, University of Melbourne, Australia
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Efficacy of Vortioxetine Monotherapy for Posttraumatic Stress Disorder: A Randomized, Placebo-Controlled Trial. J Clin Psychopharmacol 2021; 41:172-179. [PMID: 33587394 DOI: 10.1097/jcp.0000000000001363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE/BACKGROUND There are few efficacious pharmacological treatments for posttraumatic stress disorder (PTSD) and many patients fail to benefit from existing treatments. Vortioxetine, a recently developed antidepressant, acts as a serotonin modulator through inhibition of the serotonin transporter and actions at multiple types of serotonin receptors. Its unique pharmacodynamic profile suggests it may have efficacy for the treatment of PTSD. METHODS/PROCEDURES We conducted a 12-week placebo-controlled, randomized clinical trial of vortioxetine (flexibly dosed from 10 to 20 mg/d) versus placebo in adults with PTSD. The primary outcome was change from baseline in the past-month version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), analyzed using a mixed-model repeated-measures analysis of variance. FINDINGS/RESULTS Forty-one patients were randomized, and 32 (78%) completed the 12 weeks of treatment. The mean reduction in CAPS-5 scores at week 12 did not significantly differ between the 2 arms; the effect size for the difference in changes between vortioxetine and placebo on CAPS-5 total scores at week 12 was Cohen d = 0.29. However, at week 8, the drug-placebo difference was d = 0.78, which met the multivariate criteria for statistical significance, P = 0.014. IMPLICATIONS/CONCLUSIONS In this study of 41 patients, vortioxetine did not demonstrate superiority over placebo for adults with PTSD. Future PTSD trials may benefit from stratifying the randomization based on number of years since the index traumatic event and a history of failure to respond to treatment.
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12
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Lang AJ, Malaktaris A, Maluf KS, Kangas J, Sindel S, Herbert M, Bomyea J, Simmons AN, Weaver J, Velez D, Liu L. A randomized controlled trial of yoga vs nonaerobic exercise for veterans with PTSD: Understanding efficacy, mechanisms of change, and mode of delivery. Contemp Clin Trials Commun 2021; 21:100719. [PMID: 33604485 PMCID: PMC7875811 DOI: 10.1016/j.conctc.2021.100719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/07/2020] [Accepted: 01/15/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Posttraumatic stress disorder (PTSD) is a chronic, disabling, and prevalent mental health disorder among Veterans. Despite the availability of empirically supported psychotherapies, many Veterans remain symptomatic after treatment and/or prefer to seek complementary and integrative health approaches, including yoga, to manage PTSD. The randomized controlled trial (RCT) described herein will evaluate the efficacy of a manualized yoga program as compared to nonaerobic exercise in reducing PTSD severity among Veterans. A secondary aim of this study is to better understand the mechanisms of change. METHODS Veterans (N = 192) with PTSD will be randomized to hatha yoga or nonaerobic physical activity control; both groups consist of 12 weekly, 60-min group or online training sessions with 15-20 min of daily at-home practice. Outcome measures will be administered at baseline, mid-treatment, posttreatment, and 12-week follow-up. PROJECTED OUTCOMES This study will evaluate changes in PTSD severity (primary outcome) as well as depression, anxiety, anger, sleep problems, and psychosocial disability (secondary outcomes). We will also use multiple mediation to examine two potential models of the mechanisms of clinical effect: the Attention Model (i.e., yoga increases attentional control, which reduces PTSD symptoms), the Coping Model (i.e., yoga increases distress tolerance, which improves coping, which reduces PTSD symptoms), and the combination of these models. This aspect of the study is innovative and important given the absence of an existing, comprehensive model for understanding yoga's impact on PTSD. Ultimately, we hope to develop guidelines for application of yoga to PTSD recovery.
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Affiliation(s)
- Ariel J. Lang
- VA San Diego Center of Excellence for Stress and Mental Health, UCSD Departments of Psychiatry and Family Medicine and Public Health, 3350 La Jolla Village Dr. (MC 111N1), San Diego, CA, 92161, USA
| | - Anne Malaktaris
- VA San Diego Healthcare System/Center of Excellence for Stress and Mental Health, UCSD Department of Psychiatry, 3350 La Jolla Village Dr., San Diego, CA, 92161, USA
| | - Katrina S. Maluf
- San Diego State University, School of Exercise and Nutritional Sciences, Doctor of Physical Therapy Program, 5500 Campanile Dr., San Diego, CA, 92182, USA
| | - Julie Kangas
- VA San Diego Healthcare System, UCSD Department of Psychiatry, 8810 Rio San Diego Dr., San Diego, CA, 92108, USA
| | - Selin Sindel
- University of California San Diego, Department of Cognitive Science, 9500 Gilman Dr, La Jolla, CA, 92093, USA
| | - Matthew Herbert
- VA San Diego Center of Excellence for Stress and Mental Health, UCSD Department of Psychiatry, 9500 Gilman Dr. MC 0855, La Jolla, CA, 92037, USA
| | - Jessica Bomyea
- VA San Diego Center of Excellence for Stress and Mental Health, UCSD Department of Psychiatry, 9500 Gilman Dr. MC 0855, La Jolla, CA, 92037, USA
| | - Alan N. Simmons
- VA San Diego Center of Excellence for Stress and Mental Health, UCSD Department of Psychiatry, 9500 Gilman Dr. MC 0855, La Jolla, CA, 92037, USA
| | - Judy Weaver
- Connected Warriors, 4950 Communication Ave, Ste 115, Boca Raton, FL, 33431, USA
| | - Deborah Velez
- Veteran's Medical Research Foundation, 3350 La Jolla Village Dr, San Diego, CA, 92037, USA
| | - Lin Liu
- VA San Diego Healthcare System, UCSD Department of Preventive Medicine and Public Health, 9500 Gilman Dr., MC0725, La Jolla, CA, 92093-0725, USA
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Herzog P, Voderholzer U, Gärtner T, Osen B, Svitak M, Doerr R, Rolvering-Dijkstra M, Feldmann M, Rief W, Brakemeier EL. Predictors of outcome during inpatient psychotherapy for posttraumatic stress disorder: a single-treatment, multi-site, practice-based study. Psychother Res 2020; 31:468-482. [PMID: 32762508 DOI: 10.1080/10503307.2020.1802081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Objective: The aims of this study were to determine the effectiveness of a routine clinical care treatment and to identify predictors of treatment outcome in PTSD inpatients. Methods: A routinely collected data set of 612 PTSD inpatients (M = 42.3 years [SD = 11.6], 75.7% female) having received trauma-focused psychotherapy was analyzed. Primary outcome was the clinical symptom severity change score, secondary outcomes were assessed using functional, anxiety, and depression change scores. Hedges g-corrected pre-post effect sizes (ES) were computed for all outcomes. Elastic net regulation as a data-driven, stability-based machine-learning approach was used to build stable clinical prediction models. Results: Hedges g ES indicated medium to large effects on all outcomes. The results of the predictor analyses suggested that a combined predictor model with sociodemographic, clinical, and psychometric variables contribute to predicting different treatment outcomes. Across the clinical and functional outcome, psychoticism, total number of diagnoses, and bronchial asthma consistently showed a stable negative predictive relationship to treatment outcome. Conclusion: Trauma-focused psychotherapy could effectively be implemented in a routine inpatient setting. Some important prognostic variables could be identified. If the proposed models of predictors are replicated, they may help personalize treatment for patients receiving routine clinical care.
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Affiliation(s)
- Philipp Herzog
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Marburg, Germany
| | | | - Thomas Gärtner
- Schön-Klinik Bad Arolsen, Psychosomatic Clinic, Bad Arolsen, Germany
| | - Bernhard Osen
- Schön-Klinik Bad Bramstedt, Psychosomatic Clinic, Bad Bramstedt, Germany
| | - Michael Svitak
- Schön-Klinik Bad Staffelstein, Psychsomatic Clinic, Bad Staffelstein, Germany
| | - Robert Doerr
- Schön-Klinik Berchtesgadener Land, Psychosomatic Clinic, Schönau am Königssee, Germany
| | | | - Matthias Feldmann
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Marburg, Germany
| | - Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Marburg, Germany
| | - Eva-Lotta Brakemeier
- Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Marburg, Germany
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Song K, Xiong F, Ding N, Huang A, Zhang H. Complementary and alternative therapies for post-traumatic stress disorder: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2020; 99:e21142. [PMID: 32664144 PMCID: PMC7360199 DOI: 10.1097/md.0000000000021142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a psychiatric disorder. While bringing psychologic pain to patients, it also damages their social function, which is a great threat to people's life and health. Complementary and alternative medicine (CAM) therapies have been used clinically to treat PTSD; however, the selection strategies of different CAM interventions in clinical practice is still uncertain, and the purpose of this study is to evaluate the efficacy and acceptability of different CAM therapies using systematic review and network meta-analysis. METHODS According to the strategy, the authors will retrieve a total of 7 electronic databases by June 2020. After a series of screening, the 2 researchers will use Aggregate Data Drug Information System and Stata software to analyze the data extracted from randomized controlled trials of CAM therapies for the PTSD. Finally, the evidence grade of the results will be evaluated. RESULTS This study will provide a reliable evidence for the selection of CAM therapies for PTSD. CONCLUSION The results of this study will provide references for evaluating the influence of different CAM therapies for PTSD, and provide decision-making references for clinical research.
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Affiliation(s)
- Kai Song
- College of Acupuncture and Tuina
| | | | - Ning Ding
- College of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
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15
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Brunault P, Lebigre K, Idbrik F, Maugé D, Adam P, Barrault S, Baudin G, Courtois R, El Ayoubi H, Grall-Bronnec M, Hingray C, Ballon N, El-Hage W. Childhood Trauma Predicts Less Remission from PTSD among Patients with Co-Occurring Alcohol Use Disorder and PTSD. J Clin Med 2020; 9:jcm9072054. [PMID: 32629872 PMCID: PMC7408730 DOI: 10.3390/jcm9072054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/16/2020] [Accepted: 06/27/2020] [Indexed: 01/17/2023] Open
Abstract
Post-traumatic stress disorder (PTSD) is highly prevalent among patients hospitalized for an alcohol use disorder (AUD). Hospitalization can improve PTSD and AUD outcomes in some but not all patients, but we lack data on the baseline predictors of PTSD non-remission. This study aimed to determine the baseline risk factors for non-remitted PTSD in patients hospitalized for an AUD. Of 298 AUD inpatients recruited in a rehabilitation center (Le Courbat, France), we included 91 AUD inpatients with a co-occurring PTSD and a longitudinal assessment at baseline (T1) and before discharge (T2: 8 weeks later). Patients were assessed for PTSD diagnosis/severity (PCL-5=PTSD Checklist for DSM-5), different types of trauma including childhood trauma (LEC-5=Life Events Checklist for DSM-5/CTQ-SF=Childhood Trauma Questionnaire, Short-Form), and AUD diagnosis/severity (clinical interview/AUDIT=Alcohol Use Disorders Identification Test). Rate of PTSD remission between T1 and T2 was 74.1%. Non-remitted PTSD at T2 was associated with a history of childhood trauma (physical, emotional or sexual abuse, physical negligence), but not with other types of trauma experienced, nor baseline PTSD or AUD severity. Among patients hospitalized for an AUD with co-occurring PTSD, PTSD remission was more strongly related to the existence of childhood trauma than to AUD or PTSD severity at admission. These patients should be systematically screened for childhood trauma in order to tailor evidence-based interventions.
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Affiliation(s)
- Paul Brunault
- CHRU de Tours, Service d’Addictologie Universitaire, Équipe de Liaison et de Soins en Addictologie, 37044 Tours, France; (K.L.); (D.M.); (H.E.A.); (N.B.)
- CHRU de Tours, Clinique Psychiatrique Universitaire, 37044 Tours, France; (R.C.); (W.E.-H.)
- UMR 1253, iBrain, Université de Tours, Inserm, 37020 Tours, France
- Qualipsy EE 1901, Université de Tours, 37020 Tours, France; (S.B.); (G.B.)
- Correspondence: ; Tel.: +33-218-370-581
| | - Kevin Lebigre
- CHRU de Tours, Service d’Addictologie Universitaire, Équipe de Liaison et de Soins en Addictologie, 37044 Tours, France; (K.L.); (D.M.); (H.E.A.); (N.B.)
- CHRU de Tours, Clinique Psychiatrique Universitaire, 37044 Tours, France; (R.C.); (W.E.-H.)
| | - Fatima Idbrik
- Soins de Suite et de Réadaptation en Addictologie “Le Courbat”, 37460 Le Liège, France; (F.I.); (P.A.)
| | - Damien Maugé
- CHRU de Tours, Service d’Addictologie Universitaire, Équipe de Liaison et de Soins en Addictologie, 37044 Tours, France; (K.L.); (D.M.); (H.E.A.); (N.B.)
- CHRU de Tours, Centre de Soins d’Accompagnement et de Prévention en Addictologie CSAPA-37, 37044 Tours, France
| | - Philippe Adam
- Soins de Suite et de Réadaptation en Addictologie “Le Courbat”, 37460 Le Liège, France; (F.I.); (P.A.)
| | - Servane Barrault
- Qualipsy EE 1901, Université de Tours, 37020 Tours, France; (S.B.); (G.B.)
- CHRU de Tours, Centre de Soins d’Accompagnement et de Prévention en Addictologie CSAPA-37, 37044 Tours, France
| | - Grégoire Baudin
- Qualipsy EE 1901, Université de Tours, 37020 Tours, France; (S.B.); (G.B.)
- Laboratory of Psychopathology and Health Processes EA 4057, University Paris Descartes, Sorbonne Paris Cité, 92100 Boulogne-Billancourt, France
| | - Robert Courtois
- CHRU de Tours, Clinique Psychiatrique Universitaire, 37044 Tours, France; (R.C.); (W.E.-H.)
- Qualipsy EE 1901, Université de Tours, 37020 Tours, France; (S.B.); (G.B.)
| | - Hussein El Ayoubi
- CHRU de Tours, Service d’Addictologie Universitaire, Équipe de Liaison et de Soins en Addictologie, 37044 Tours, France; (K.L.); (D.M.); (H.E.A.); (N.B.)
- CHRU de Tours, Centre de Soins d’Accompagnement et de Prévention en Addictologie CSAPA-37, 37044 Tours, France
| | - Marie Grall-Bronnec
- Addictology and Psychiatry Department, Hôpital Saint Jacques, University Hospital of Nantes, 85 rue Saint Jacques, Cedex 1, 44093 Nantes, France;
- Inserm, SPHERE U1246 methodS in Patients-Centered Outcomes and HEalth ResEarch, Université de Nantes, Université de Tours, 22 boulevard Benoni Goullin, 44200 Nantes, France
| | - Coraline Hingray
- Pôle Universitaire du Grand Nancy, Centre Psychothérapique de Nancy, 54520 Laxou, France;
| | - Nicolas Ballon
- CHRU de Tours, Service d’Addictologie Universitaire, Équipe de Liaison et de Soins en Addictologie, 37044 Tours, France; (K.L.); (D.M.); (H.E.A.); (N.B.)
- CHRU de Tours, Clinique Psychiatrique Universitaire, 37044 Tours, France; (R.C.); (W.E.-H.)
- UMR 1253, iBrain, Université de Tours, Inserm, 37020 Tours, France
| | - Wissam El-Hage
- CHRU de Tours, Clinique Psychiatrique Universitaire, 37044 Tours, France; (R.C.); (W.E.-H.)
- UMR 1253, iBrain, Université de Tours, Inserm, 37020 Tours, France
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Fonzo GA, Federchenco V, Lara A. Predicting and Managing Treatment Non-Response in Posttraumatic Stress Disorder. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2020; 7:70-87. [PMID: 33344106 PMCID: PMC7748158 DOI: 10.1007/s40501-020-00203-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review aims to synthesize existing research regarding the definition of treatment resistance in posttraumatic stress disorder (PTSD), predictors of treatment non-response to first-line interventions, and emerging second-line PTSD treatment options into an accessible resource for the practicing clinician. RECENT FINDINGS The concept of treatment resistance in PTSD is currently poorly defined and operationalized. There are no well-established predictors of treatment non-response utilized in routine clinical care, but existing research identifies several potential candidate markers, including male gender, low social support, chronic and early life trauma exposure, comorbid psychiatric disorders, severe PTSD symptoms, and poor physical health. The most promising available treatment options for PTSD patients non-responsive to first-line psychotherapies and antidepressants include transcranial magnetic stimulation and ketamine infusion. Methylenedioxymethamphetamine-assisted psychotherapy also appears promising but is only available in a research context. These options require careful consideration of risks and benefits for a particular patient. SUMMARY More research is required to develop a robust, clinically-useful definition of treatment resistance in PTSD; identify reliable, readily assessable, and generalizable predictors of PTSD treatment non-response; and implement measurement and prediction in clinical settings to identify individuals unlikely to respond to first-line treatments and direct them to appropriate second-line treatments.
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Affiliation(s)
- Gregory A. Fonzo
- Department of Psychiatry, Dell Medical School, The University of Texas at Austin
| | - Vecheslav Federchenco
- General Psychiatry Residency, Dell Medical School, The University of Texas at Austin
- Equal contributions to authorship
| | - Alba Lara
- General Psychiatry Residency, Dell Medical School, The University of Texas at Austin
- Equal contributions to authorship
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O'Connor M. Adjunctive therapy with brexpiprazole improves treatment resistant complex post traumatic stress disorder in domestic family violence victims. Australas Psychiatry 2020; 28:264-266. [PMID: 31896271 DOI: 10.1177/1039856219889303] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Domestic family violence (FV) is a serious problem with serious impacts on mental health of victims. One such impact is post-traumatic stress disorder (PTSD), and it can be resistant to treatment (treatment-resistant or TR). This article offers novel treatment. METHODS Two treatment resistant case studies are described where adjunctive treatment with brexpiprazole was commenced. Possible theoretical considerations are presented to explain improvement. RESULTS Adjunctive treatment with brexpiprazole was associated with significant improvement in FV subjective and objective measures, with enhanced response to trauma therapy. CONCLUSION Brexpiprazole improved complex post traumatic stress disorder in FV victims and needs further evaluation.
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Affiliation(s)
- Manjula O'Connor
- Department of Psychiatry, The University of Melbourne, Australia
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18
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Abstract
Despite strong evidence to support trauma-focused treatment as the gold standard in treating PTSD, many studies report elevated drop-out rates. The study by Holmes et al. (2019) examines temporal patterns of treatment non-completion and reported individuals who improved at a greater rate attended all sessions. This commentary discusses some of the factors that contribute to premature termination, including treatment modality (e.g., exposure-based), barriers to care, treatment format, motivation, treatment resistance, and lack of multimodal assessments. Future investigations comparing individual differences in response to treatment would allow for the examination of characteristics that facilitate or impede treatment response.
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Affiliation(s)
- Barbara O Rothbaum
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.
| | - Lauren B McSweeney
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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Feng B, Zhang Y, Luo LY, Wu JY, Yang SJ, Zhang N, Tan QR, Wang HN, Ge N, Ning F, Zheng ZL, Zhu RM, Qian MC, Chen ZY, Zhang ZJ. Transcutaneous electrical acupoint stimulation for post-traumatic stress disorder: Assessor-blinded, randomized controlled study. Psychiatry Clin Neurosci 2019; 73:179-186. [PMID: 30565342 DOI: 10.1111/pcn.12810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/19/2018] [Accepted: 12/15/2018] [Indexed: 12/28/2022]
Abstract
AIM Transcutaneous electrical acupoint stimulation (TEAS) has the potential to alleviate post-traumatic stress disorder (PTSD). The purpose of this study was to determine whether adding TEAS to sertraline or cognitive behavioral therapy (CBT) could improve the anti-PTSD efficacy. METHODS In this randomized controlled trial, 240 PTSD patients (60 in each group) were assigned to receive simulated TEAS combined with sertraline (group A) or with CBT (group B), active TEAS combined with CBT (group C), or active TEAS combined with CBT plus sertraline (group D) for 12 weeks. The outcomes were measured using the Clinician-Administered PTSD Scale, PTSD Check List-Civilian Version, and 17-item Hamilton Rating Scale for Depression. RESULTS While PTSD symptoms reduced over time in all patients, groups C and D had markedly greater improvement in both PTSD and depressive measures than groups A and B in all post-baseline measurement points, with moderate to very large effect sizes of 0.484-2.244. Groups C and D also had a significantly higher rate than groups A and B on clinical response (85.0% and 95.0% vs 63.3% and 60.0%, P < 0.001) and on remission (15.0% and 25.0% vs 3.3% and 1.7%, P < 0.001). The incidence of adverse events was similar between groups A and D and between groups B and C. CONCLUSIONS Additional TEAS augments the anti-PTSD and antidepressant efficacy of antidepressants or CBT, without increasing the incidence of adverse effects. TEAS could serve as an effective intervention for PTSD and comorbid depression. This trial was registered with www.chictr.org (no.: ChiCTR1800017255).
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Affiliation(s)
- Bin Feng
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Ying Zhang
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Li-Yuan Luo
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Jian-Yong Wu
- Department of Psychiatry, Yiwu Central Hospital, Yiwu, China
| | - Sen-Jun Yang
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Ning Zhang
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Qing-Rong Tan
- Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Hua-Ning Wang
- Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Nan Ge
- Department of Psychiatry, The Second Clinical Medical College, Zhejiang University of Traditional Chinese Medicine, Hangzhou, China
| | - Fang Ning
- Department of Psychiatry, The Second Clinical Medical College, Zhejiang University of Traditional Chinese Medicine, Hangzhou, China
| | - Zi-Li Zheng
- Department of Psychiatry, The Second Clinical Medical College, Zhejiang University of Traditional Chinese Medicine, Hangzhou, China
| | - Rui-Ming Zhu
- Department of Psychiatry, Yiwu Hospital of Chinese Medicine, Yiwu, China
| | - Min-Cai Qian
- Department of Psychiatry, Third People's Hospital of Huzhou City, Huzhou, China
| | - Zhi-Yu Chen
- Department of Psychiatry, Seventh People's Hospital of Hangzhou City, Hangzhou, China
| | - Zhang-Jin Zhang
- School of Chinese Medicine, LKS Faculty of Medicine, University of Hong Kong, Pokfulam, Hong Kong
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Lang AJ, Malaktaris AL, Casmar P, Baca SA, Golshan S, Harrison T, Negi L. Compassion Meditation for Posttraumatic Stress Disorder in Veterans: A Randomized Proof of Concept Study. J Trauma Stress 2019; 32:299-309. [PMID: 30929283 DOI: 10.1002/jts.22397] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 12/04/2018] [Accepted: 12/21/2018] [Indexed: 01/07/2023]
Abstract
There is considerable interest in developing complementary and integrative approaches for ameliorating posttraumatic stress disorder (PTSD). Compassion meditation (CM) and loving-kindness meditation appear to offer benefits to individuals with PTSD, including symptom reduction. The present study was a pilot randomized controlled trial of CM for PTSD in veterans. The CM condition, an adaptation of Cognitively-Based Compassion Training (CBCT®), consists of exercises to stabilize attention, develop present-moment awareness, and foster compassion. We compared CM to Veteran.calm (VC), which consists of psychoeducation about PTSD, rationale for relaxation, relaxation training, and sleep hygiene. Both conditions consist of 10 weekly 90-min group sessions with between-session practice assignments. A total of 28 veterans attended at least one session of the group intervention and completed pre- and posttreatment measures of PTSD severity and secondary outcomes as well as weekly measures of PTSD, depressive symptoms, and positive and negative emotions. Measures of treatment credibility, attendance, practice compliance, and satisfaction were administered to assess feasibility. A repeated measures analysis of variance revealed a more substantive reduction in PTSD symptoms in the CM condition than in the VC condition, between-group d = -0.85. Credibility, attendance, and satisfaction were similar across CM and VC conditions thus demonstrating the feasibility of CM and the appropriateness of VC as a comparison condition. The findings of this initial randomized pilot study provide rationale for future studies examining the efficacy and effectiveness of CM for veterans with PTSD.
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Affiliation(s)
- Ariel J Lang
- VA San Diego Center of Excellence for Stress and Mental Health, San Diego, California, USA.,Department of Psychiatry, University of California San Diego, La Jolla, California, USA.,Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
| | - Anne L Malaktaris
- VA San Diego Center of Excellence for Stress and Mental Health, San Diego, California, USA.,Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Pollyanna Casmar
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA.,VA San Diego Healthcare System, San Diego, California, USA
| | - Selena A Baca
- Veterans Medical Research Foundation, San Diego, California, USA
| | - Shahrokh Golshan
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA.,VA San Diego Healthcare System, San Diego, California, USA
| | | | - Lobsang Negi
- Department of Religion, Emory University, Atlanta, Georgia, USA
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21
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Ahmadizadeh MJ, Ebadi A, Sirati Nir M, Tavallaii A, Sharif Nia H, Lotfi MS. Development and psychometric evaluation of the Treatment Adherence Questionnaire for Patients with Combat Post-traumatic Stress Disorder. Patient Prefer Adherence 2019; 13:419-430. [PMID: 30962678 PMCID: PMC6434911 DOI: 10.2147/ppa.s175353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Treatment adherence is one of the major strategies in treating post-traumatic stress disorder (PTSD) in combat veterans. This study developed and psychometrically assessed the Treatment Adherence Questionnaire for Patients with Combat Post-Traumatic Stress Disorder. PARTICIPANTS AND METHODS This methodological study was conducted in Tehran, Iran, during 2016-2017 in two phases. First, the concept of treatment adherence in combatants with PTSD was analyzed using a hybrid model. This model consisted of three phases: literature review phase, fieldwork phase, and final analysis phase. The consequences and attributes of the concept of treatment adherence in combatants with PTSD were identified, and based on the findings, the Treatment Adherence Questionnaire for PTSD veterans was developed. In the second stage, the face and content validities of the questionnaire were investigated both quantitatively and qualitatively. Exploratory factor analysis and confirmatory factor analysis were used to determine the questionnaire's validity. Internal consistency correlation coefficient of the questionnaire was estimated with Cronbach's alpha coefficient, while the reliability of the questionnaire was established using intra-class test-retest correlation coefficient. Study participants were selected from inpatients and outpatients referred to a hospital, clinic, and health center in Tehran and Kashan, Iran. All patients were diagnosed with combat PTSD by a psychiatrist, based on psychiatric interview and other clinical findings. RESULTS The Persian version of the Treatment Adherence Questionnaire for Patients with Combat Post-Traumatic Stress Disorder included 17 items. Exploratory factor analysis identified three factors which accounted for a total of 87.57% of the total variance of treatment adherence score. The identified factors were labeled as "maintenance of treatment", "follow-up and treatment contribution", and "purposefulness and responsibility". The Cronbach's alpha correlation coefficient was 0.92 and the intra-class correlation coefficient of the questionnaire's reliability was estimated at 0.92 (P<0.001). CONCLUSION The data obtained confirmed the hypothesis of the factor structure model with a latent second-order variable. The final version of the Treatment Adherence Questionnaire for Iranian combatants with PTSD can be applied as a valid and reliable questionnaire for measuring treatment adherence in these patients.
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Affiliation(s)
- Mohammad Javad Ahmadizadeh
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Janbazan Medical and Engineering Research Center (JMERC), Tehran, Iran
| | - Masoud Sirati Nir
- Behavioral Sciences Research Center, Life Style Institute, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Tavallaii
- Medicine, Quran and Hadith Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Hamid Sharif Nia
- School of Nursing and Midwifery Amol, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mohammad-Sajjad Lotfi
- Iranian Research Center on Ageing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran,
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22
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Abstract
A vast number of veterans with posttraumatic stress disorder (PTSD) have chronic somatic comorbidities. However, their relationship with quality of life (QoL) has received little attention. We aimed to compare QoL of veterans with similar intensity of PTSD but different number of chronic somatic disorders. Of 129 veterans, 78% had at least one somatic disorder, and they reported lower QoL across all domains than veterans without somatic comorbidities. The greatest effect size was observed on social relationship (d = 0.65), it was notable on environment (d = 0.4) and psychological health (d = 0.38), and it was not relevant on physical health (d = 0.05). There was a negative correlation between the number of somatic disorders and scores on psychological health (rs = -0.217, p = 0.014), social relationships (rs = -0.248, p = 0.005), and environment (rs = -0.279, p = 0.001). The QoL of war veterans decreases significantly with the number of comorbid somatic conditions, particularly on the nonphysical domains of QoL.
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23
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Schubert CF, Schreckenbach M, Kirmeier T, Gall-Kleebach DJ, Wollweber B, Buell DR, Uhr M, Rosner R, Schmidt U. PTSD psychotherapy improves blood pressure but leaves HPA axis feedback sensitivity stable and unaffected: First evidence from a pre-post treatment study. Psychoneuroendocrinology 2019; 100:254-263. [PMID: 30391833 DOI: 10.1016/j.psyneuen.2018.10.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 01/05/2023]
Abstract
Although key to development of tailored drugs for augmentation treatment of psychotherapy for posttraumatic stress disorder (PTSD), the biological correlates of PTSD remission are still unknown, probably because pre-post treatment studies searching for them are rare. Not even the feedback sensitivity of the otherwise well-studied hypothalamic-pituitary-adrenal (HPA) axis nor arterial blood pressure (BP), which was previously reported to be elevated in PTSD patients, have so far been analyzed during PTSD treatment. To narrow this knowledge gap, we first performed an overnight dexamethasone suppression test (DST) in a mixed-sex cohort of 25 patients with severe PTSD vs. 20 non-traumatized healthy controls (nt-HC). In addition to hormones, BP and heart rate (HR) were measured at each of the four assessment points (APs). Second, the same parameters were assessed again in 16 of these patients after 12 sessions of integrative trauma-focused cognitive behavioral therapy (iTF-CBT). In relation to nt-HC, PTSD patients showed a significant elevation in HR and diastolic BP while their systolic BP, DST outcomes and basal serum cortisol levels (BSCL) were not significantly altered. In response to iTF-CBT, PTSD symptoms and dysfunctional stress coping strategies improved significantly in PTSD patients. Most important, also their systolic and diastolic BP levels ameliorated at distinct APs while their DST outcomes and BSCL remained unchanged. To our knowledge, this is the first pre-post treatment study assessing the stability of the DST outcome and BP levels during PTSD treatment. Our results provide first evidence for a non-involvement of HPA axis feedback sensitivity in PTSD symptom improvement and, furthermore, suggest a possible role for BP-regulating pathways such as the sympathetic nervous system in PTSD remission. Limitations arise from the small sample size, the lack of an untreated patient group and drug treatment of patients.
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Affiliation(s)
- Christine F Schubert
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany; Catholic University of Eichstätt-Ingolstadt, Ostenstraße 25, 85072 Eichstätt, Germany; Ludwig Maximilians University, Department of Psychology, Leopoldstraße 44, 80802 Munich, Germany
| | - Monika Schreckenbach
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany
| | | | - Dominique J Gall-Kleebach
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany; Verein für Klinische Verhaltenstherapie (VFKV) - Ausbildungsinstitut München gGmbH, Lindwurmstr. 117, 80337 München, Germany
| | - Bastian Wollweber
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany
| | - Dominik R Buell
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany
| | - Manfred Uhr
- Max Planck Institute of Psychiatry, Clinical Department, Kraepelinstrasse 10, 80804 Munich, Germany
| | - Rita Rosner
- Catholic University of Eichstätt-Ingolstadt, Ostenstraße 25, 85072 Eichstätt, Germany
| | - Ulrike Schmidt
- Max Planck Institute of Psychiatry, Department of Translational Psychiatry, RG Molecular Psychotraumatology, Kraepelinstrasse 10, 80804 Munich, Germany; University Medical Center Göttingen (UMG), Department of Psychiatry and Psychotherapy, Psychotrauma Treatment Unit & RG Stress Modulation of Neurodegeneration, Göttingen, Germany; Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands.
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24
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Criswell SR, Sherman R, Krippner S. Cognitive Behavioral Therapy with Heart Rate Variability Biofeedback for Adults with Persistent Noncombat-Related Posttraumatic Stress Disorder. Perm J 2019; 22:17-207. [PMID: 30285917 DOI: 10.7812/tpp/17-207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test the effectiveness of a mental health therapy designed to reduce noncombat-related persistent posttraumatic stress disorder (PTSD) symptoms in 30 adult outpatients with a diagnosis of PTSD. The individual treatment offered modules to address PTSD nightmare distress, dissociation, general core skills, alterations in arousal and reactivity, avoidance, intrusion, and negative alternations in cognitions and mood. The therapeutic approach centered on cognitive behavioral therapy and heart rate variability biofeedback. METHODS The study had 2 components: The quality improvement project that performed the treatment within a standard care environment, and a retrospective medical chart review process that analyzed the results. The Clinician-Administered PTSD Scale for the Diagnostic and Statistical Manual, Fifth Edition, was used to confirm the initial PTSD diagnosis and was the primary measure used to monitor change in the diagnosis following treatment. RESULTS None of the patients who completed the PTSD treatment met criteria for a PTSD diagnosis in the posttreatment assessment. A 1-sample test of proportions, with a 95% confidence interval and a significance level of p < 0.05, showed p = 0.0008, and that the proportion of patients who would not have PTSD if the study was repeated would be 86.77% to 100.00%. The treatment dropout rate was 13% (4 patients). CONCLUSION The study findings suggest that this intervention is an effective treatment for helping adult patients, including those with a history of childhood abuse, remit their PTSD diagnosis.
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Affiliation(s)
- Shawn R Criswell
- Mental Health Therapist with the Department of Mental Health at Kaiser Permanente Northwest in Portland, OR
| | - Richard Sherman
- Chair of the Department of Psychophysiology at Saybrook University in Oakland, CA, and the Director of the Behavioral Medicine Research and Training Foundation in Port Angeles, WA
| | - Stanley Krippner
- Instructor of Psychology in the College of Social Sciences with the Department of Humanistic and Clinical Psychology at Saybrook University in Oakland, CA
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25
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Abstract
Posttraumatic stress disorder (PTSD) differs from other anxiety disorders in that experience of a traumatic event is necessary for the onset of the disorder. The condition runs a longitudinal course, involving a series of transitional states, with progressive modification occurring with time. Notably, only a small percentage of people that experience trauma will develop PTSD. Risk factors, such as prior trauma, prior psychiatric history, family psychiatric history, peritraumatic dissociation, acute stress symptoms, the nature of the biological response, and autonomic hyperarousal, need to be considered when setting up models to predict the course of the condition. These risk factors influence vulnerability to the onset of PTSD and its spontaneous remission. In the majority of cases, PTSD is accompanied by another condition, such as major depression, an anxiety disorder, or substance abuse. This comorbidity can also complicate the course of the disorder and raises questions about the role of PTSD in other psychiatric conditions. This article reviews what is known about the emergence of PTSD following exposure to a traumatic event using data from clinical studies.
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Affiliation(s)
- A C McFarlane
- Department of Psychiatry, University of Adelaide, Queen Elizabeth Hospital, Woodville, South Australia, Australia.
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26
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Church D, Stapleton P, Mollon P, Feinstein D, Boath E, Mackay D, Sims R. Guidelines for the Treatment of PTSD Using Clinical EFT (Emotional Freedom Techniques). Healthcare (Basel) 2018; 6:E146. [PMID: 30545069 PMCID: PMC6316206 DOI: 10.3390/healthcare6040146] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/07/2018] [Accepted: 12/07/2018] [Indexed: 11/16/2022] Open
Abstract
Clinical EFT (Emotional Freedom Techniques) is an evidence-based method that combines acupressure with elements drawn from cognitive and exposure therapies. The approach has been validated in more than 100 clinical trials. Its efficacy for post-traumatic stress disorder (PTSD) has been investigated in a variety of demographic groups including war veterans, victims of sexual violence, the spouses of PTSD sufferers, motor accident survivors, prisoners, hospital patients, adolescents, and survivors of natural and human-caused disasters. Meta-analyses of EFT for anxiety, depression, and PTSD indicate treatment effects that exceed those of both psychopharmacology and conventional psychotherapy. Studies of EFT in the treatment of PTSD show that (a) time frames for successful treatment generally range from four to 10 sessions; (b) group therapy sessions are effective; (c) comorbid conditions such as anxiety and depression improve simultaneously; (d) the risk of adverse events is low; (e) treatment produces physiological as well as psychological improvements; (f) patient gains persist over time; (g) the approach is cost-effective; (h) biomarkers such as stress hormones and genes are regulated; and (i) the method can be adapted to online and telemedicine applications. This paper recommends guidelines for the use of EFT in treating PTSD derived from the literature and a detailed practitioner survey. It has been reviewed by the major institutions providing training or supporting research in the method. The guidelines recommend a stepped-care model, with five treatment sessions for subclinical PTSD, 10 sessions for PTSD, and escalation to intensive psychotherapy or psychopharmacology or both for nonresponsive patients and those with developmental trauma. Group therapy, social support, apps, and online and telemedicine methods also contribute to a successful treatment plan.
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Affiliation(s)
- Dawson Church
- National Institute for Integrative Healthcare, Fulton, CA 20759, USA.
| | - Peta Stapleton
- School of Psychology, Faculty of Society and Design, Bond University, Robina, Gold Coast, QLD 4229, Australia.
| | - Phil Mollon
- Institute of Psychoanalysis, London W9 2BT, UK.
| | | | - Elizabeth Boath
- Department of Social Work and Social Welfare, School of Health and Social Care, Staffordshire University, Staffordshire ST42DE, UK.
| | - David Mackay
- Asociacion Hispana de EFT, Mexico City 72150, Mexico.
| | - Rebecca Sims
- School of Psychology, Faculty of Society and Design, Bond University, Robina, Gold Coast, QLD 4229, Australia.
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27
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Sippel LM, Holtzheimer PE, Friedman MJ, Schnurr PP. Defining Treatment-Resistant Posttraumatic Stress Disorder: A Framework for Future Research. Biol Psychiatry 2018; 84:e37-e41. [PMID: 29752073 DOI: 10.1016/j.biopsych.2018.03.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 03/28/2018] [Accepted: 03/31/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Lauren M Sippel
- National Center for Posttraumatic Stress Disorder Executive Division, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
| | - Paul E Holtzheimer
- National Center for Posttraumatic Stress Disorder Executive Division, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Matthew J Friedman
- National Center for Posttraumatic Stress Disorder Executive Division, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Paula P Schnurr
- National Center for Posttraumatic Stress Disorder Executive Division, White River Junction, Vermont; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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28
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Hendriks L, de Kleine RA, Broekman TG, Hendriks GJ, van Minnen A. Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attempts. Eur J Psychotraumatol 2018; 9:1425574. [PMID: 29410776 PMCID: PMC5795659 DOI: 10.1080/20008198.2018.1425574] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/23/2017] [Indexed: 11/15/2022] Open
Abstract
Background: Suboptimal response and high dropout rates leave room for improvement of trauma-focused treatment (TFT) effectiveness in ameliorating posttraumatic stress disorder (PTSD) symptoms. Objective: To explore the effectiveness and safety of intensive prolonged exposure (iPE) targeting chronic PTSD patients with a likely diagnosis of ICD-11 Complex PTSD following multiple interpersonal trauma and a history of multiple treatment attempts. Method: Participants (N = 73) received iPE in 12 × 90-minute sessions over four days (intensive phase) followed by four weekly 90-minute booster prolonged exposure (PE) sessions (booster phase). The primary outcomes, clinician-rated severity of PTSD symptoms, and diagnostic status (Clinician-Administered PTSD Scale; CAPS-IV) were assessed at baseline, post-treatment, and at three and six months. Treatment response trajectories were identified and predictors of these trajectories explored. Results: Mixed model repeated measures analysis of CAPS-IV scores showed a baseline-to-posttreatment decrease in PTSD symptom severity (p < .001) that persisted during the three- and six-month follow-ups with large effect sizes (Cohen's d > 1.2); 71% of the participants responded. None of the participants dropped out during the intensive phase and only 5% during the booster phase. Adverse events were extremely low and only a minority showed symptom exacerbation. Cluster analysis demonstrated four treatment response trajectories: Fast responders (13%), Slow responders (26%), Partial responders (32%), and Non-responders (29%). Living condition and between-session fear habituation were found to predict outcome. Participants living alone were more likely to belong to the Partial responders than to the Non-responders cluster, and participants showing more between-session fear habituation were more likely to belong to the Fast responders than to the Non-responders cluster. Conclusions: The results of this open study suggest that iPE can be effective in PTSD patients with multiple interpersonal trauma and after multiple previous treatment attempts. In addition, in this chronic PTSD population iPE was safe.
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Affiliation(s)
- Lotte Hendriks
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands
| | - Rianne A de Kleine
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands., Institute of Psychology, Leiden University, Leiden, The Netherlands
| | | | - Gert-Jan Hendriks
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands.,Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Agnes van Minnen
- Overwaal Centre of Expertise for Anxiety Disorders, OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands.,Behavioural Science Institute, NijCare, Radboud University, Nijmegen, The Netherlands.,Psychotrauma Expertise Centre (PSYTREC), Bilthoven, The Netherlands
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29
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Starke JA, Stein DJ. Management of Treatment-Resistant Posttraumatic Stress Disorder. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s40501-017-0130-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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30
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Reist C, Gory A, Hollifield M. Sleep-Disordered Breathing Impact on Efficacy of Prolonged Exposure Therapy for Posttraumatic Stress Disorder. J Trauma Stress 2017; 30:186-189. [PMID: 28273371 DOI: 10.1002/jts.22168] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 11/27/2016] [Accepted: 12/01/2016] [Indexed: 11/11/2022]
Abstract
There is growing evidence that sleep disturbances may impede the utility of existing therapeutic interventions for people with posttraumatic stress disorder (PTSD). This retrospective medical record review examined the hypothesis that sleep disturbance affects the outcome of prolonged exposure (PE) therapy for PTSD. We identified 18 combat veterans with PTSD who had completed PE therapy. There were 6 subjects who had sleep-disordered breathing, 5 of whom were documented by sleep polysomnography. All subjects in the sleep-disordered group took part in a minimum of 10 sessions; the mean number of sessions was comparable between the sleep-disordered group and the group without a sleep disorder. Posttreatment PTSD Checklist scores were significantly reduced in those without a sleep disorder (-28.25; 58.0% reduction, F(1, 11) = 59.04, p < .001), but were not reduced in those with sleep-disordered breathing (-7.17; 13.5% reduction, dIGPP = 2.25 [independent groups pretest-posttest design]). These observations supported the hypothesis that the efficacy of PE therapy is affected by sleep quality. If these findings are replicated, treatment algorithms may need to incorporate the presence or absence of sleep disorders as a factor in treatment choice.
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Affiliation(s)
- Christopher Reist
- Mental Health Healthcare Group, Long Beach VA Healthcare System, Long Beach, California, USA.,Department of Psychiatry and Human Behavior, University of California, Irvine, California, USA
| | - Andrea Gory
- Mental Health Healthcare Group, Long Beach VA Healthcare System, Long Beach, California, USA
| | - Michael Hollifield
- Mental Health Healthcare Group, Long Beach VA Healthcare System, Long Beach, California, USA.,Department of Psychiatry and Human Behavior, University of California, Irvine, California, USA
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31
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Treatment-refractory posttraumatic stress disorder (TRPTSD): a review and framework for the future. Prog Neuropsychopharmacol Biol Psychiatry 2016; 70:170-218. [PMID: 26854815 DOI: 10.1016/j.pnpbp.2016.01.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 01/04/2023]
Abstract
Post-traumatic stress disorder (PTSD) is a serious psychiatric consequence of trauma that occurs in a proportion of individuals exposed to life-threatening events. Trauma-focused psychotherapy is often recommended as first choice for those who do not recover spontaneously. But many individuals require medications. In the US, only paroxetine (PRX) and sertraline (SRT) are FDA approved for PTSD. But response and remission rates with these medications are low, so numerous other pharmacologic interventions have been tried. To date, there has not been a systematic review of the data on what are the best next-step pharmacologic strategies for individuals who fail standard treatments. To that end, we review 168 published trials of medications other than PRX or SRT and provide a detailed analysis of the 88/168 studies that describe alternative pharmacologic interventions in patients refractory to other treatment. We also review clinical factors relevant to treatment-refractory PTSD; the neurobiology of extinction, as well as evidence-based psychotherapy and neuromodulation strategies for this condition.
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32
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Wells SY, Lang AJ, Schmalzl L, Groessl EJ, Strauss JL. Yoga as an Intervention for PTSD: a Theoretical Rationale and Review of the Literature. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s40501-016-0068-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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33
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Schmidt U. A plea for symptom-based research in psychiatry. Eur J Psychotraumatol 2015; 6:27660. [PMID: 25994024 PMCID: PMC4439426 DOI: 10.3402/ejpt.v6.27660] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/09/2015] [Accepted: 04/11/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The significant proportion of patients suffering from subthreshold diagnoses such as partial posttraumatic stress disorder (PTSD) shows that today's diagnostic entities do not fully meet the reality and needs of clinical practice. Moreover, as stated also in the recently announced concept of research domain criteria (RDoC), the use of today's traditional diagnostic systems in psychiatric research does not sufficiently promote an integrative understanding of mental disorders across multiple units of analysis from behavior to neurobiology. Besides RDoC, core symptom-based research concepts have been proposed to bridge the translational gap in psychiatry, but, unfortunately, have not yet become the rule. OBJECTIVE/METHOD First, this article briefly reviews literature on subthreshold PTSD (as an example for subthreshold diagnoses) and, second, pleas for and proposes a modified symptom-based research concept in psychiatry. RESULTS Subthreshold PTSD has, like other subthreshold psychiatric diagnoses, not yet been clearly defined. Diagnostic entities such as subthreshold PTSD are subject to a certain arbitrariness as they are mainly the result of empiricism. This fact stresses the urgent need for neurobiologically-informed psychiatric diagnoses and motivated the here-presented proposal of a symptom-based research concept. As proposed here, and before by other researchers, symptom-based research in psychiatry should refrain from studying patient cohorts compiled according to diagnoses but, instead, should focus on assessing cohorts grouped according to chief complaints or predominant psychopathological symptoms. CONCLUSIONS The linkage of the RDoC concept and symptom-based psychiatric research might probably speed up the definition of biologically or symptom-based psychiatric diagnoses, which might replace the auxiliary constructs of "traditional" diagnoses such as full and subthreshold PTSD, and promote the development of novel psychological and pharmacological treatments.
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Affiliation(s)
- Ulrike Schmidt
- RG Molecular Psychotraumatology, Clinical Department, Max Planck Institute of Psychiatry, Munich, Germany;
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