Glucocorticoid augmentation of prolonged exposure therapy: rationale and case report

Exogenous glucocorticoids to improve extinction learning for post-traumatic stress disorder patients with hypothalamic-pituitary-adrenal-axis dysregulation: a study protocol description

Background: Trauma-focused treatments for post-traumatic stress disorder (PTSD) are effective for many patients. However, relapse may occur when acquired extinction memories fail to generalize beyond treatment contexts. A subgroup of PTSD patients - potentially with substantial exposure to early-life adversity (ELA) - show dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which results in lower cortisol levels. Glucocorticoids, including cortisol, appear to facilitate strength and generalization of emotional memories.Objective: We describe the protocol of an integrated PTSD study. We investigate (A) associations between HPA-axis dysregulation, ELA, epigenetic markers, and PTSD treatment outcome (observational study); and (B) effects of exogenous glucocorticoids on strength and generalization of extinction memories and associated neural mechanisms [pharmacological intervention study with functional magnetic resonance imaging (fMRI)]. The objective is to provide proof of concept that PTSD patients with HPA-axis dysregulation often experienced ELA and may show improved strength and generalization of extinction learning after glucocorticoid administration.Method: The observational study (n = 160 PTSD group, n = 30 control group) assesses ELA, follow-up PTSD symptoms, epigenetic markers, and HPA-axis characteristics (salivary cortisol levels during low-dose dexamethasone suppression test and socially evaluated cold-pressor test). The pharmacological intervention study (n = 80 PTSD group, with and without HPA-axis dysregulation) is a placebo-controlled fMRI study with a crossover design. To investigate strength and generalization of extinction memories, we use a differential fear acquisition, extinction, and extinction recall task with spatial contexts within a virtual environment. Prior to extinction learning, 20 mg hydrocortisone or placebo is administered. During next-day recall, strength of the extinction memory is determined by recovery of skin conductance and pupil dilation differential responding, whereas generalization is assessed by comparing responses between different spatial contexts.Conclusion: The integrated study described in the current protocol paper could inform a personalized treatment approach in which these PTSD patients may receive glucocorticoids as a treatment enhancer in trauma-focused therapies.Trial registration: The research project is registered in the European Union Drug Regulating Authorities Clinical Trials (EudraCT) database, https://eudract.ema.europa.eu/, EudraCT number 2020-000712-30.

Impact of Stress and Exercise on Fear Extinction

This chapter reviews the literature on the impact of stress and exercise on fear extinction. Given that key brain regions of the fear circuitry (e.g., hippocampus, amygdala and frontal cortex) can be modulated by stress hormones, it is important to investigate how stress influences this process. Laboratory-based studies performed in healthy adults have yielded mixed results, which are most likely attributable to various methodological factors. Among these factors, inter-individual differences modulating the stress response and timing of stressor administration with respect to the task may contribute to this heterogeneity. Given that fear is a core manifestation of various psychopathologies and that exposure-based therapy relies on fear extinction principles, several studies have attempted to assess the role of stress hormones on exposure-based therapy in patients suffering from post-traumatic stress disorder or anxiety disorders. These studies tend to suggest a beneficial impact of stress hormones (through either natural endogenous variations or synthetic administration) on exposure-based therapy as assessed mostly by subjective fear measures. Similar to stress, exercise can have an impact on many physiological and biological systems in humans. Of note, exercise modulates biomarkers such as brain-derived neurotrophic factor (BDNF) and anandamide (EAE) that act on brain regions implicated in the fear circuitry, supporting the importance of studying the impact of exercise on fear extinction. Overall, the results converge and indicate that fear extinction (tested in the laboratory or via exposure-based therapy in clinical populations) can be enhanced with exercise. Further research is needed to understand the mechanisms by which stress and exercise modulate fear learning and extinction processes, as well as to maximize the applicability to clinical contexts.

Exposure-related cortisol predicts outcome of psychotherapy in veterans with treatment-resistant posttraumatic stress disorder

BACKGROUND

Hypothalamic-pituitary-adrenal axis functioning has been related to treatment outcome in posttraumatic stress disorder (PTSD). Previous studies have primarily focused on cortisol levels before and after a course of therapy and findings have not been fully consistent. This study investigated session-related cortisol levels in veterans with treatment-resistant PTSD over the course of a novel motion-assisted virtual reality exposure therapy and aimed to determine whether cortisol levels were related to changes in PTSD symptom severity.

METHODS

Veterans (N = 22) received six exposure sessions during which salivary cortisol samples were collected pre-session, post-session and in the late afternoon following sessions. PTSD symptom severity was assessed by structured clinical interviews at pre- and post-treatment. Average cortisol levels were compared between responders and non-responders. Linear regression analyses were conducted with PTSD symptom change as criterion variable, average cortisol levels as predictor, and timing of sampling and baseline PTSD symptoms as covariates.

RESULTS

Responders to treatment tended to have higher average cortisol levels at pre-session (p = 0.064) and post-session (p = 0.050) compared to non-responders. Higher average pre-session and post-session cortisol levels predicted greater PTSD symptom improvement (pre: b = -1.83, p = 0.009; post: b = -3.57, p = 0.004).

CONCLUSION

This study provides preliminary evidence for session-related cortisol as biomarker of response to exposure-based therapies for PTSD. Higher cortisol levels may have facilitated fear extinction and reconsolidation, and may indicate increased physiological stress activation necessary for appropriate treatment engagement. Further work involving comparable methodology is encouraged to establish session-related cortisol as biomarker and to determine the mechanisms through which it interacts with treatment outcome.

Traumatic imagery following glucocorticoid administration in earthquake-related post-traumatic stress disorder: A preliminary functional magnetic resonance imaging study

OBJECTIVE

Post-traumatic stress disorder involves excessive retrieval of traumatic memories. Glucocorticoids impair declarative memory retrieval. This preliminary study examined the effect of acute hydrocortisone administration on brain activation in individuals with earthquake-related post-traumatic stress disorder compared with earthquake-exposed healthy individuals, during retrieval of traumatic memories.

METHOD

Participants exposed to earthquakes with (n = 11) and without post-traumatic stress disorder (n = 11) underwent two functional magnetic resonance imaging scans, 1-week apart, in a double-blind, placebo-controlled, counter-balanced design. On one occasion, they received oral hydrocortisone (20 mg), and on the other, placebo, 1 hour before scanning. Symptom provocation involved script-driven imagery (traumatic and neutral scripts) and measures of self-reported anxiety.

RESULTS

Arterial spin labelling showed that both post-traumatic stress disorder and trauma-exposed controls had significantly reduced cerebral blood flow in response to retrieval of traumatic versus neutral memories in the right hippocampus, parahippocampal gyrus, calcarine sulcus, middle and superior temporal gyrus, posterior cingulate, Heschl's gyrus, inferior parietal lobule, angular gyrus, middle occipital gyrus, supramarginal gyrus, lingual gyrus and cuneus, and the left prefrontal cortex. Hydrocortisone resulted in non-significant trends of increasing subjective distress and reduced regional cerebral blood flow in the left inferior frontal gyrus, left anterior cingulate gyrus, middle temporal gyrus, cerebellum, postcentral gyrus and right frontal pole, during the trauma script.

CONCLUSION

Findings do not fit with some aspects of the accepted neurocircuitry model of post-traumatic stress disorder, i.e., failure of the medial prefrontal cortex to quieten hyperresponsive amygdala activity, and the potential therapeutic benefits of hydrocortisone. They do, however, provide further evidence that exposure to earthquake trauma, regardless of whether post-traumatic stress disorder eventuates, impacts brain activity and highlights the importance of inclusion of trauma-exposed comparisons in studies of post-traumatic stress disorder.

A decennial review of psychotraumatology: what did we learn and where are we going?

On 6 December 2019 we start the 10th year of the European Journal of Psychotraumatogy (EJPT), a full Open Access journal on psychotrauma. This editorial is part of a special issue/collection celebrating the 10 years anniversary of the journal where we will acknowledge some of our most impactful articles of the past decade (also discussed below and marked with * in the reference list). In this editorial the editors present a decennial review of the field addressing a range of topics that are core to both the journal and to psychotraumatology as a discipline. These include neurobiological developments (genomics, neuroimaging and neuroendocrine research), forms of trauma exposure and impact across the lifespan, mass trauma and early interventions, work-related trauma, trauma in refugee populations, and the potential consequences of trauma such as PTSD or Complex PTSD, but also resilience. We address innovations in psychological, medication (enhanced) and technology-assisted treatments, mediators and moderators like social support and finally how new research methods help us to gain insights in symptom structures or to better predict symptom development or treatment success. We aimed to answer three questions 1. Where did we stand in 2010? 2. What did we learn in the past 10 years? 3. What are our knowledge gaps? We conclude with a number of recommendations concerning top priorities for the future direction of the field of psychotraumatology and correspondingly the journal.

Translating Molecular and Neuroendocrine Findings in Posttraumatic Stress Disorder and Resilience to Novel Therapies

Many biological systems are altered in association with posttraumatic stress disorder (PTSD) and resilience. However, there are only few approved pharmacological treatments for PTSD, and no approved medications to enhance resilience. This article provides a critical review of select neurobiological findings in PTSD and resilience, and also of pharmacologic approaches that have emerged from this work. The medications summarized involve engagement with targets in the adrenergic, hypothalamic-pituitary-adrenal axis, and neuropeptide Y systems. Other highlighted approaches involve the use of ketamine and 3,4-methylenedioxymethamphetamine-assisted psychotherapy, which recently surfaced as promising strategies for PTSD, though the neurobiological mechanisms underlying their actions, including for promoting resilience, are not yet fully understood. The former approaches fall within the broad concept of "rational pharmacotherapy," in that they attempt to directly target dysregulated systems known to be associated with posttraumatic symptoms. To the extent that use of ketamine and 3,4-methylenedioxymethamphetamine promotes symptom improvement and resilience in PTSD, this provides an opportunity for reverse translation and identification of relevant targets and mechanisms of action through careful study of biological changes resulting from these interventions. Promoting resilience in trauma-exposed individuals may involve more than pharmacologically manipulating dysregulated molecules and pathways associated with developing and sustaining PTSD symptom severity, but also producing a substantial change in mental state that increases the ability to engage with traumatic material in psychotherapy. Neurobiological examination in the context of treatment studies may yield novel targets and promote a greater understanding of mechanisms of recovery from trauma.

Glucocorticoid-induced enhancement of extinction-from animal models to clinical trials

Extensive evidence from both animal model and human research indicates that glucocorticoid hormones are crucially involved in modulating memory performance. Glucocorticoids, which are released during stressful or emotionally arousing experiences, enhance the consolidation of new memories, including extinction memory, but reduce the retrieval of previously stored memories. These memory-modulating properties of glucocorticoids have recently received considerable interest for translational purposes because strong aversive memories lie at the core of several fear-related disorders, including post-traumatic stress disorder and phobias. Moreover, exposure-based psychological treatment of these disorders relies on successful fear extinction. In this review, we argue that glucocorticoid-based interventions facilitate fear extinction by reducing the retrieval of aversive memories and enhancing the consolidation of extinction memories. Several clinical trials have already indicated that glucocorticoids might be indeed helpful in the treatment of fear-related disorders.

Preextinction Stress Prevents Context-Related Renewal of Fear

Extinction learning, which creates new safety associations, is thought to be the mechanism underlying exposure therapy, commonly used for the treatment of anxiety disorders and posttraumatic stress disorder. The relative strength and availability for retrieval of both the fear and safety memories determine the response in a given situation. While the fear memory is often context-independent and may easily generalize, extinction memory is highly context-specific. "Renewal" of the extinguished fear memory might thus occur following a shift in context. The aim of the current work was to create an enhanced and generalized extinction memory to a discrete stimulus using stress exposure before extinction learning, thereby preventing renewal. In our contextual fear conditioning paradigm, 40 healthy men acquired (Day 1), retrieved and extinguished (Day 2) the fear memories, with no differences between the stress and the control group. A significant difference between the groups emerged in the renewal test (Day 3). A renewal effect was seen in the control group (N = 20), confirming the context-dependency of the extinction memory. In contrast, the stress group (N = 20) showed no renewal effect. Fear reduction was generalized to the acquisition context as well, suggesting that stress rendered the extinction memory more context-independent. These results are in line with previous studies that showed contextualization disruption as a result of pre-learning stress, mediated by the rapid effects of glucocorticoids on the hippocampus. Our findings support research investigating the use of glucocorticoids or stress induction in exposure therapy and suggest the right timing of administration in order to optimize their effects.

Neuroendocrine and neuroimmune markers in PTSD: pre-, peri- and post-trauma glucocorticoid and inflammatory dysregulation

We review current knowledge on how posttraumatic stress disorder (PTSD) is associated with dysregulation of the most commonly studied markers of the endocrine and immune systems pre-, peri- and post-trauma. Lower basal cortisol output, enhanced glucocorticoid receptor function, and a proinflammatory state have been most consistently found in PTSD, with considerable variability among studies and participants. Longitudinal research is scarce, but there is converging evidence that biological dysregulation is present before PTSD onset. Biological dysregulation may become more apparent with increasing time since trauma, and may be reversible with and predict effective treatment. However, considering the variability of findings and the complex interplay of these systems with other factors, the current clinical application of these findings remains limited.

Facilitating Fear-Based Memory Extinction With Dexamethasone: A Randomized Controlled Trial in Male Veterans With Combat-Related PTSD

OBJECTIVE

Animal and preliminary human studies have demonstrated that glucocorticoids enhance the extinction of fear memories. Impaired extinction of fear memories is a critical component in the development and maintenance of posttraumatic stress disorder (PTSD). The purpose of this translational study was to determine the effectiveness of pairing a glucocorticoid with trauma memory reactivation as a novel intervention to treat PTSD and to measure the duration of the effect.

METHOD

A total of 54 male veterans with combat-related PTSD in this double-blind, randomized, placebo-controlled trial received either four weekly glucocorticoid (dexamethasone [DEX]) or placebo administrations paired with a 45-second trauma memory reactivation task. PTSD and depressive symptom severity were assessed at baseline and at one three, and six months.

RESULTS

Trauma memory activation paired with DEX versus trauma memory activation paired with placebo demonstrated a significantly greater reduction of PTSD symptoms for DEX at the one-month (p = .037) and three-month (p = .036) posttreatment assessments, but the difference was no longer evident at six months. DEX showed a nonsignificantly greater reduction of PTSD symptoms than placebo over the course of the study (p = .067). Significantly more veterans in the DEX group lost their diagnosis of PTSD at one month posttreatment compared to the placebo group, but the difference was not maintained at three or six months. DEX had no effect on depression symptoms.

CONCLUSIONS

Despite insufficient power to test differences in PTSD symptom reduction, findings suggest that this novel intervention may have potential for treatment of combat-related PTSD.

Stress, glucocorticoids and memory: implications for treating fear-related disorders

Glucocorticoid stress hormones are crucially involved in modulating mnemonic processing of emotionally arousing experiences. They enhance the consolidation of new memories, including those that extinguish older memories, but impair the retrieval of information stored in long-term memory. As strong aversive memories lie at the core of several fear-related disorders, including post-traumatic stress disorder and phobias, the memory-modulating properties of glucocorticoids have recently become of considerable translational interest. Clinical trials have provided the first evidence that glucocorticoid-based pharmacotherapies aimed at attenuating aversive memories might be helpful in the treatment of fear-related disorders. Here, we review important advances in the understanding of how glucocorticoids mediate stress effects on memory processes, and discuss the translational potential of these new conceptual insights.

Stress and Fear Extinction

Stress has a critical role in the development and expression of many psychiatric disorders, and is a defining feature of posttraumatic stress disorder (PTSD). Stress also limits the efficacy of behavioral therapies aimed at limiting pathological fear, such as exposure therapy. Here we examine emerging evidence that stress impairs recovery from trauma by impairing fear extinction, a form of learning thought to underlie the suppression of trauma-related fear memories. We describe the major structural and functional abnormalities in brain regions that are particularly vulnerable to stress, including the amygdala, prefrontal cortex, and hippocampus, which may underlie stress-induced impairments in extinction. We also discuss some of the stress-induced neurochemical and molecular alterations in these brain regions that are associated with extinction deficits, and the potential for targeting these changes to prevent or reverse impaired extinction. A better understanding of the neurobiological basis of stress effects on extinction promises to yield novel approaches to improving therapeutic outcomes for PTSD and other anxiety and trauma-related disorders.

Dexamethasone-suppressed cortisol awakening response predicts treatment outcome in posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with several alterations in the neuroendocrine system, including enhanced cortisol suppression in response to the dexamethasone suppression test. The aim of this study was to examine whether specific biomarkers of PTSD predict treatment success in trauma-focused psychotherapy.

METHODS

Data were collected in the context of a randomized controlled trial comparing two forms of trauma-focused psychotherapy. Basal cortisol and dehydroepiandrosterone sulfate levels, and the response to the dexamethasone suppression test were assessed pre-treatment in 24 PTSD patients. Treatment success was measured by pre- to post-treatment decrease in self-reported PTSD severity.

RESULTS

A more suppressed cortisol curve after dexamethasone significantly predicted greater PTSD symptom decrease in trauma-focused psychotherapy, independent of the effects of gender, pre-treatment PTSD symptom severity, and trauma history. Basal early morning cortisol and dehydroepiandrosterone sulfate did not predict treatment response.

LIMITATIONS

The number of participants who completed the neuroendocrine measurements was small and a significant number of participants fulfilled criteria of co-morbid major depressive disorder.

CONCLUSIONS

This study suggests the use of the dexamethasone-suppression test for the cortisol awakening response as a biomarker for treatment response to trauma-focused psychotherapy. Measures of HPA-axis sensitivity appear to be an important predictor of positive clinical response in PTSD patients, and may lead to biomarker-based treatment matching in the future.

Cortisol augmentation of a psychological treatment for warfighters with posttraumatic stress disorder: Randomized trial showing improved treatment retention and outcome

BACKGROUND

Prolonged exposure (PE) therapy for post-traumatic stress disorder (PTSD) in military veterans has established efficacy, but is ineffective for a substantial number of patients. PE is also associated with high dropout rates. We hypothesized that hydrocortisone augmentation would enhance symptom improvement and reduce drop-out rates by diminishing the distressing effects of traumatic memories retrieved during imaginal exposure. We also hypothesized that in responders, hydrocortisone augmentation would be more effective in reversing glucocorticoid indices associated with PTSD than placebo augmentation.

METHOD

Twenty-four veterans were randomized to receive either 30 mg oral hydrocortisone or placebo prior to PE sessions 3-10 in a double-blind protocol. Glucocorticoid receptor sensitivity was assessed in cultured peripheral blood mononuclear cells (PBMC) using the in vitro lysozyme inhibition test and was determined before and after treatment. Intent-to-treat analysis was performed using latent growth curve modeling of treatment effects on change in PTSD severity over time. Veterans who no longer met diagnostic criteria for PTSD at post-treatment were designated as responders.

RESULTS

Veterans randomized to hydrocortisone or placebo augmentation did not differ significantly in clinical severity or glucocorticoid sensitivity at pre-treatment. Hydrocortisone augmentation was associated with greater reduction in total PTSD symptoms compared to placebo, a finding that was explained by significantly greater patient retention in the hydrocortisone augmentation condition. A significant treatment condition by responder status interaction for glucocorticoid sensitivity indicated that responders to hydrocortisone augmentation had the highest pre-treatment glucocorticoid sensitivity (lowest lysozyme IC50-DEX) that diminished over the course of treatment. There was a significant association between decline in glucocorticoid responsiveness and improvement in PTSD symptoms among hydrocortisone recipients.

CONCLUSIONS

The results of this pilot study suggest that hydrocortisone augmentation of PE may result in greater retention in treatment and thereby promote PTSD symptom improvement. Further, the results suggest that particularly elevated glucocorticoid responsiveness at pre-treatment may identify veterans likely to respond to PE combined with an intervention that targets glucocorticoid sensitivity. Confirmation of these findings will suggest that pharmacologic interventions that target PTSD-associated glucocorticoid dysregulation may be particularly helpful in promoting a positive clinical response to PTSD psychotherapy.

Pharmacology of cognitive enhancers for exposure-based therapy of fear, anxiety and trauma-related disorders

Pathological fear and anxiety are highly debilitating and, despite considerable advances in psychotherapy and pharmacotherapy they remain insufficiently treated in many patients with PTSD, phobias, panic and other anxiety disorders. Increasing preclinical and clinical evidence indicates that pharmacological treatments including cognitive enhancers, when given as adjuncts to psychotherapeutic approaches [cognitive behavioral therapy including extinction-based exposure therapy] enhance treatment efficacy, while using anxiolytics such as benzodiazepines as adjuncts can undermine long-term treatment success. The purpose of this review is to outline the literature showing how pharmacological interventions targeting neurotransmitter systems including serotonin, dopamine, noradrenaline, histamine, glutamate, GABA, cannabinoids, neuropeptides (oxytocin, neuropeptides Y and S, opioids) and other targets (neurotrophins BDNF and FGF2, glucocorticoids, L-type-calcium channels, epigenetic modifications) as well as their downstream signaling pathways, can augment fear extinction and strengthen extinction memory persistently in preclinical models. Particularly promising approaches are discussed in regard to their effects on specific aspects of fear extinction namely, acquisition, consolidation and retrieval, including long-term protection from return of fear (relapse) phenomena like spontaneous recovery, reinstatement and renewal of fear. We also highlight the promising translational value of the preclinial research and the clinical potential of targeting certain neurochemical systems with, for example d-cycloserine, yohimbine, cortisol, and L-DOPA. The current body of research reveals important new insights into the neurobiology and neurochemistry of fear extinction and holds significant promise for pharmacologically-augmented psychotherapy as an improved approach to treat trauma and anxiety-related disorders in a more efficient and persistent way promoting enhanced symptom remission and recovery.

The role of acute cortisol and DHEAS in predicting acute and chronic PTSD symptoms

BACKGROUND

Decreased activation of the hypothalamus-pituitary-adrenal (HPA) axis in response to stress is suspected to be a vulnerability factor for posttraumatic stress disorder (PTSD). Previous studies showed inconsistent findings regarding the role of cortisol in predicting PTSD. In addition, no prospective studies have examined the role of dehydroepiandrosterone (DHEA), or its sulfate form DHEAS, and the cortisol-to-DHEA(S) ratio in predicting PTSD. In this study, we tested whether acute plasma cortisol, DHEAS and the cortisol-to-DHEAS ratio predicted PTSD symptoms at 6 weeks and 6 months post-trauma.

METHODS

Blood samples of 397 adult level-1 trauma center patients, taken at the trauma resuscitation room within hours after the injury, were analyzed for cortisol and DHEAS levels. PTSD symptoms were assessed at 6 weeks and 6 months post-trauma with the Clinician Administered PTSD Scale.

RESULTS

Multivariate linear regression analyses showed that lower cortisol predicted PTSD symptoms at both 6 weeks and 6 months, controlling for age, gender, time of blood sampling, injury, trauma history, and admission to intensive care. Higher DHEAS and a smaller cortisol-to-DHEAS ratio predicted PTSD symptoms at 6 weeks, but not after controlling for the same variables, and not at 6 months.

CONCLUSIONS

Our study provides important new evidence on the crucial role of the HPA-axis in response to trauma by showing that acute cortisol and DHEAS levels predict PTSD symptoms in survivors of recent trauma.

Exposure to stress attenuates fear retrieval in healthy men

The stress hormone cortisol reduces retrieval of emotional memories, which has been suggested to support the treatment of psychiatric disorders characterized by exaggerated fear-related memories. Indeed, studies in patients with anxiety disorders have indicated that the success of exposure therapy can be enhanced with accompanying cortisol administration. Fear renewal refers to the clinically relevant phenomenon that successfully extinguished fear can return after a context change. It remains to be investigated whether the effects of stress hormones on fear retrieval also generalize across different contexts. Healthy men were exposed to a fear renewal design with fear acquisition in context A and extinction in context B. Pictures of rooms served as contexts, coloured lights were introduced as conditioned stimuli (CS), and an electrical stimulation served as the unconditioned stimulus (UCS). On the next day, participants were randomly assigned to a stress (Socially Evaluated Cold Pressor Test) or a control condition (n=20 each). We tested for fear retrieval in contexts A and B during peak cortisol concentrations after stress induction. Overall, a context×stress interaction occurred, revealing that stress attenuated skin conductance responses in the extinction context B. Stress also reduced UCS expectancy in context B. Additionally, stress abolished the renewal effect (differentiation between CS in context A) at the electrodermal level. These results demonstrate a decreased return of fear after acute exposure to stress. Stress interferes with the retrieval of the original fear memory which in turn affects extinction responding. Thus, acute stress reduces rather than promotes the return of fear.

Pharmacological enhancement of exposure-based treatment in PTSD: a qualitative review

There is a good amount of evidence that exposure therapy is an effective treatment for posttraumatic stress disorder (PTSD). Notwithstanding its efficacy, there is room for improvement, since a large proportion of patients does not benefit from treatment. Recently, an interesting new direction in the improvement of exposure therapy efficacy for PTSD emerged. Basic research found evidence of the pharmacological enhancement of the underlying learning and memory processes of exposure therapy. The current review aims to give an overview of clinical studies on pharmacological enhancement of exposure-based treatment for PTSD. The working mechanisms, efficacy studies in PTSD patients, and clinical utility of four different pharmacological enhancers will be discussed: d-cycloserine, MDMA, hydrocortisone, and propranolol.

Stress enhances the consolidation of extinction memory in a predictive learning task

Extinction is not always permanent, as indicated by several types of recovery effects, such as the renewal effect, which may occur after a context change and points towards the importance of contextual cues. Strengthening the retrieval of extinction memory is a crucial aim of extinction-based psychotherapeutic treatments of anxiety disorders to prevent relapse. Stress is known to modulate learning and memory, with mostly enhancing effects on memory consolidation. However, whether such a consolidation-enhancing effect of acute stress can also be found for extinction memory has not yet been examined in humans. In this study, we investigated the effect of stress after extinction learning on the retrieval of extinction memory in a predictive learning renewal paradigm. Participants took the part of being the doctor of a fictitious patient and learned to predict whether certain food stimuli were associated with "stomach trouble" in two different restaurants (contexts). On the first day, critical stimuli were associated with stomach trouble in context A (acquisition phase). On the second day, these associations were extinguished in context B. Directly after extinction, participants were either exposed to a stressor (socially evaluated cold pressor test; n = 22) or a control condition (n = 24). On the third day, we tested retrieval of critical associations in contexts A and B. Participants exposed to stress after extinction exhibited a reduced recovery of responding at test in context B, suggesting that stress may context-dependently enhance the consolidation of extinction memory. Furthermore, the increase in cortisol in response to the stressor was negatively correlated with the recovery of responding in context A. Our findings suggest that in parallel to the known effects of stress on the consolidation of episodic memory, stress also enhances the consolidation of extinction memory, which might be relevant for potential applications in extinction-based psychotherapy.

Stress impairs retrieval of extinguished and unextinguished associations in a predictive learning task

Recovery effects which can frequently be observed after a seemingly successful extinction procedure indicate that extinction does not lead to an erasure of the memory trace. Investigating factors which modulate the retrieval of extinction memory is highly relevant for basic science and clinical applications alike. This study investigated the effect of stress on the retrieval of extinguished and unextinguished stimulus-outcome associations in a predictive learning task. In this task, participants had to imagine being the doctor of a patient who sometimes suffers from stomach trouble after meals in his favorite restaurants. They were presented with different food stimuli while having to predict the occurrence or non-occurrence of stomach trouble. As extinction memory is modulated by context, we manipulated contextual cues so that initial acquisition of critical associations occurred in context (restaurant frame) A on day one, whereas associations were reversed in context B (extinction, day two). On the third day, participants were either stressed (exposed to the socially evaluated cold pressor task (SECPT); n=21) or subjected to a control condition (n=21) shortly before extinction memory retrieval was tested (in contexts A and B). Salivary cortisol and blood pressure measures as well as subjective ratings indicated that stress induction was successful. When retrieval of extinguished associations was tested on day three, participants' predictions reflected a renewal effect, as indicated by stronger recovery of responding in the acquisition context compared to the extinction context. Compared to controls, stressed participants showed impaired retrieval of extinguished and unextinguished associations. Contextual cues abolished the stress-induced memory impairment for unextinguished but not for extinguished associations. These findings might help to explain why stress leads to the reoccurrence of symptoms in affective disorders.

Bonding after trauma: on the role of social support and the oxytocin system in traumatic stress

This paper outlines the state of affairs in psychobiological research on psychotrauma and PTSD with a focus on the role of the oxytocin system in traumatic stress. With a high prevalence of trauma and PTSD in the Netherlands, new preventive and therapeutic interventions are needed. The focus is on the role of social support and bonding in coming to grips with psychological trauma, about the oxytocin system as a basis for reducing the stress response and creating a feeling of bonding, about binding words to painful emotions in psychotherapy, and about the bonds between researchers and clinicians.

Examining potential contraindications for prolonged exposure therapy for PTSD

Although prolonged exposure (PE) has received the most empirical support of any treatment for post-traumatic stress disorder (PTSD), clinicians are often hesitant to use PE due to beliefs that it is contraindicated for many patients with PTSD. This is especially true for PTSD patients with comorbid problems. Because PTSD has high rates of comorbidity, it is important to consider whether PE is indeed contraindicated for patients with various comorbid problems. Therefore, in this study, we examine the evidence for or against the use of PE with patients with problems that often co-occur with PTSD, including dissociation, borderline personality disorder, psychosis, suicidal behavior and non-suicidal self-injury, substance use disorders, and major depression. It is concluded that PE can be safely and effectively used with patients with these comorbidities, and is often associated with a decrease in PTSD as well as the comorbid problem. In cases with severe comorbidity, however, it is recommended to treat PTSD with PE while providing integrated or concurrent treatment to monitor and address the comorbid problems.