Long-term follow-up of a randomised controlled trial of prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: a task-shifted intervention

BACKGROUND

Empirical evidence on the longer-term effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed. The aim of the study was to evaluate the maintenance of treatment gains achieved in a comparative study of effectiveness of prolonged exposure therapy for adolescents (PE-A) and supportive counselling (SC) in adolescents with PTSD up to 24-months post-treatment.

METHOD

Sixty-three adolescents (13-18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7-14 sessions of treatment provided by trained and supervised non-specialist health workers (NSHWs). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale, at pretreatment, post-treatment, and at 3-, 6-, 12- and 24-months post-treatment follow-up (FU) evaluations.

RESULTS

Participants in both the prolonged exposure and SC treatment groups attained a significant reduction in PTSD symptoms and maintained this reduction in PTSD symptoms at 12- and 24-month assessment. Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving SC at 12-months FU [difference in PE-A v. SC mean scores = 9.24, 95% CI (3.66-14.83), p < 0.001; g = 0.88] and at 24-months FU [difference in PE-A v. SC mean scores = 9.35, 95% CI (3.53-15.17), p = 0.002; g = 0.68].

CONCLUSIONS

Adolescents with PTSD continued to experience greater benefit from prolonged exposure treatment than SC provided by NSHWs in a community setting 12 and 24 months after completion of treatment.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Factor Structure and Psychometric Properties of the Peritraumatic and Posttraumatic Emotions Questionnaires Among Active Duty Military Personnel With Posttraumatic Stress Disorder

The Peritraumatic Emotions Questionnaire (Peri-TEQ) and Posttraumatic Emotions Questionnaire (Post-TEQ) are self-report measures of emotions experienced during and after a traumatic event, respectively. The factor structure and psychometric properties of the Peri- and Post-TEQ were investigated among 474 military personnel with posttraumatic stress disorder (PTSD) following deployment. Exploratory factor analysis and confirmatory factor analysis were conducted to test the factor structure of the scales. Internal consistency, composite reliability, convergent validity, and discriminant validity were also assessed. Four factors were identified for the Peri-TEQ (Fear, Humiliation, Anger, and Sadness), and three factors were identified for the Post-TEQ (Fear, Anger-Hurt, and Humiliation). The full scales and all subscales demonstrated adequate-to-good internal consistency, Cronbach's αs = .722-.893. The subscales demonstrated adequate-to-good composite reliability, Cronbach's αs = .763-.861. The Peri- and Post-TEQ demonstrated good convergent validity with measures of PTSD symptoms, rs = .229-.601, ps < .001, and depressive symptoms, rs = .284-.470, ps < .001, and good discriminate validity with measures of resilience, ps = .116-.940, and unit cohesion, Peri-TEQ, p = .304 and Post-TEQ, r = -.123, p = .008. The Humiliation subscales demonstrated good convergent validity with guilt cognitions, rs = .315-.341, ps < .001, and the Anger subscales demonstrated good convergent validity with state anger, rs = .260-.347, ps < .001. The Peri- and Post-TEQ are reliable, valid self-report measures of emotions during and in response to remembering a trauma. The results support the use of these measures in research investigating trauma-related emotions.

Prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: task-shifting randomised controlled trial

BACKGROUND

Empirical evidence on the effectiveness of evidence-based treatments for adolescents with post-traumatic stress disorder (PTSD) in low-resource settings is needed.AimsTo evaluate the comparative effectiveness of prolonged exposure and supportive counselling in adolescents with PTSD.

METHOD

Sixty-three adolescents (13-18 years) with PTSD were randomly assigned to receive either of the interventions comprising 7-14 sessions of treatment (trial registration in the Pan African Clinical Trials Registry: PACTR201511001345372). The primary outcome measure was PTSD symptom severity, as independently assessed on the Child PTSD Symptom Scale at pre-treatment, post-treatment, and at 3- and 6-month follow-up.

RESULTS

Participants receiving prolonged exposure experienced greater improvement on the PTSD symptom severity scale than those receiving supportive counselling (between group differences at post-intervention, mean 12.49, 95% CI 6.82-18.17, P<0.001; d = 1.22). A similar effect size was maintained at 3-month (d = 0.85) and 6-month (d = 1.02) follow-up assessments.

CONCLUSIONS

Adolescents with PTSD experienced greater benefit from prolonged exposure treatment when provided by non-specialist health workers (nurses) in a community setting.Declaration of interestNone.

Prolonged exposure therapy and supportive counselling for posttraumatic stress disorder in adolescents in a community-based sample, including experiences of stakeholders: study protocol for a comparative randomized controlled trial using task-shifting

BACKGROUND

There is a dearth of empirical evidence on the effectiveness of pharmacological and non-pharmacological treatments for adolescents with posttraumatic stress disorder (PTSD) in developing countries. The primary aim of the study is to examine the effects of prolonged exposure therapy compared with supportive counseling for adolescents with PTSD delivered by nurses trained as counselors.

METHODS/DESIGN

A single-blind randomized clinical trial comprising 90 adolescents with PTSD using a permuted block design will be utilized. Nurses previously naïve to prolonged exposure and supportive counselling will be trained to provide these treatments at the adolescents' high schools. Data collection will last from March 2014 to December 2017 and annually thereafter, dependent on the availability of funding. Participants will receive seven to fourteen 60 min sessions of prolonged exposure treatment (n = 45) or supportive counselling (n = 45). All assessments will be conducted before treatment, at mid-treatment, immediately after treatment completion, at 3-, 6-, and 12-month follow-up, and annually thereafter. It is hypothesized that PE-A will be superior to SC in reducing PTSD symptoms at post-treatment as measured by the CPSS-I administered by an independent evaluator. It is further hypothesized that PE-A treatment gains will be maintained at 3-, 6- and 12-month follow-ups and annually thereafter.

DISCUSSION

While early indications are that PE-A is an effective treatment for PTSD in adolescents, this study will help determine the effectiveness of PE-A in a South African, community setting (school-based) when task-shifted to nurses, as compared to SC.

TRIAL REGISTRATION

Pan African Clinical Trials Registry: PACTR201511001345372 , retrospectively registered 11 November 2015.

Adolescent and nurse perspectives of psychotherapeutic interventions for PTSD delivered through task-shifting in a low resource setting

BACKGROUND

This investigation compared the perceived effectiveness of supportive counselling (SC) and prolonged exposure for adolescents (PE-A) by treatment users (adolescents with PTSD) and non-specialist treatment providers (supervised nurses).

METHOD

Adolescent participants and nurse providers were purposively recruited to share their experiences of trial participation through face to face semi-structured in-depth interviews and treatment-specific focus groups (all recorded). Twelve adolescent participant transcripts (ten interviews and two focus groups) and three nurse provider transcripts were doubly transcribed. Thematic content analysis was applied using Atlas.ti software. Two emerging themes are presented in this paper: 1) Perceptions of the intervention and 2) Usefulness of the intervention.

RESULTS

Regardless of treatment arm, adolescents experienced warm counselling relationships and described the process of extending trust to the counselor. Adolescents in the PE-A arm provided clear descriptions of session structure and treatment rationale compared with adolescents receiving SC. The most helpful tools were breathing retraining and imaginal exposure for PE-A and creation of distraction strategies during non-directive SC. Adolescents in both arms continued to use the techniques acquired during treatment and reported symptom improvement. Participants who received SC acknowledged ongoing reexperiencing. Nurses perceived SC to be an immediately transferable skill, but feedback on their preference for one intervention over the other was inconclusive.

CONCLUSION

Both PTSD treatment strategies, implemented by non-specialists, were perceived as helpful. Overall, adolescents reported warm therapeutic relationships and a reduction in PTSD symptoms. Nurses stated that they would require institutional support to ensure delivery of these interventions in a scalable and sustainable manner.

Effect of Prolonged Exposure Therapy Delivered Over 2 Weeks vs 8 Weeks vs Present-Centered Therapy on PTSD Symptom Severity in Military Personnel: A Randomized Clinical Trial

IMPORTANCE

Effective and efficient treatment is needed for posttraumatic stress disorder (PTSD) in active duty military personnel.

OBJECTIVE

To examine the effects of massed prolonged exposure therapy (massed therapy), spaced prolonged exposure therapy (spaced therapy), present-centered therapy (PCT), and a minimal-contact control (MCC) on PTSD severity.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted at Fort Hood, Texas, from January 2011 through July 2016 and enrolling 370 military personnel with PTSD who had returned from Iraq, Afghanistan, or both. Final follow-up was July 11, 2016.

INTERVENTIONS

Prolonged exposure therapy, cognitive behavioral therapy involving exposure to trauma memories/reminders, administered as massed therapy (n = 110; 10 sessions over 2 weeks) or spaced therapy (n = 109; 10 sessions over 8 weeks); PCT, a non-trauma-focused therapy involving identifying/discussing daily stressors (n = 107; 10 sessions over 8 weeks); or MCC, telephone calls from therapists (n = 40; once weekly for 4 weeks).

MAIN OUTCOMES AND MEASURES

Outcomes were assessed before and after treatment and at 2-week, 12-week, and 6-month follow-up. Primary outcome was interviewer-assessed PTSD symptom severity, measured by the PTSD Symptom Scale-Interview (PSS-I; range, 0-51; higher scores indicate greater PTSD severity; MCID, 3.18), used to assess efficacy of massed therapy at 2 weeks posttreatment vs MCC at week 4; noninferiority of massed therapy vs spaced therapy at 2 weeks and 12 weeks posttreatment (noninferiority margin, 50% [2.3 points on PSS-I, with 1-sided α = .05]); and efficacy of spaced therapy vs PCT at posttreatment.

RESULTS

Among 370 randomized participants, data were analyzed for 366 (mean age, 32.7 [SD, 7.3] years; 44 women [12.0%]; mean baseline PSS-I score, 25.49 [6.36]), and 216 (59.0%) completed the study. At 2 weeks posttreatment, mean PSS-I score was 17.62 (mean decrease from baseline, 7.13) for massed therapy and 21.41 (mean decrease, 3.43) for MCC (difference in decrease, 3.70 [95% CI,0.72 to 6.68]; P = .02). At 2 weeks posttreatment, mean PSS-I score was 18.03 for spaced therapy (decrease, 7.29; difference in means vs massed therapy, 0.79 [1-sided 95% CI, -∞ to 2.29; P = .049 for noninferiority]) and at 12 weeks posttreatment was 18.88 for massed therapy (decrease, 6.32) and 18.34 for spaced therapy (decrease, 6.97; difference, 0.55 [1-sided 95% CI, -∞ to 2.05; P = .03 for noninferiority]). At posttreatment, PSS-I scores for PCT were 18.65 (decrease, 7.31; difference in decrease vs spaced therapy, 0.10 [95% CI, -2.48 to 2.27]; P = .93).

CONCLUSIONS AND RELEVANCE

Among active duty military personnel with PTSD, massed therapy (10 sessions over 2 weeks) reduced PTSD symptom severity more than MCC at 2-week follow-up and was noninferior to spaced therapy (10 sessions over 8 weeks), and there was no significant difference between spaced therapy and PCT. The reductions in PTSD symptom severity with all treatments were relatively modest, suggesting that further research is needed to determine the clinical importance of these findings.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01049516.

Impediments and catalysts to task-shifting psychotherapeutic interventions for adolescents with PTSD: perspectives of multi-stakeholders

BACKGROUND

This qualitative study was nested within a randomized controlled trial (RCT) where two psychotherapeutic interventions (supportive counselling and prolonged exposure for adolescents) were provided by supervised nurses (who served as 'nurse counsellors') to adolescents with PTSD in school settings. This paper describes the perspectives of nurse counsellors (NCs) and school liaisons (SLs). SLs were teachers or administrative personnel at the schools who coordinated the study visits of participants with the NCs. We focus on the impediments and catalysts to and recommendations for treatment implementation.

METHODS

NCs (n = 3) and SLs (n = 3) who participated in the RCT during 2014 were purposively recruited by telephone and participated in face-to-face semi-structured in-depth interviews that were recorded and doubly transcribed. Thematic content analysis was applied using Atlas.ti software to identify emerging themes. This paper describes the impediments and catalysts to provide psychotherapy by task-shifting in a community setting across three sub-themes: personal, community, and collaborative care.

RESULTS

Although nurses were initially resistant to supervision it was central to personally coping with complex interventions, managing traumatic content, and working apart from a multi-disciplinary team. Delivering the interventions in the community presented multiple logistical impediments (e.g. transport, communication, venue suitability) which required creative solutions. In light of resource shortages, networking is central to effective delivery and uptake of the interventions. Collaboration between government departments of health and education may have a major impact on providing school-based psychotherapy through task-shifting.

CONCLUSIONS

Impediments to implementation are not insurmountable. This article provides recommendations to maximize the success of task-shifting interventions should they be rolled out.

Treatment of Adolescent PTSD: The Impact of Prolonged Exposure Versus Client-Centered Therapy on Co-Occurring Emotional and Behavioral Problems

The present study evaluated secondary emotional and behavioral outcomes among adolescents who received prolonged exposure (PE-A) or client-centered therapy (CCT) for posttraumatic stress disorder (PTSD) in a randomized controlled trial. Participants were 61 adolescent girls (age: M = 15.33, SD = 1.50 years) with sexual abuse related PTSD seeking treatment at a community mental health clinic. Multilevel modeling was employed to evaluate group differences on the Youth Self-Report (YSR) over acute treatment and 12-month follow-up. Both treatment groups showed significant improvements on all YSR scales from baseline to 12-month follow-up. Adolescents who received PE-A showed significantly greater reductions than those receiving CCT on the Externalizing subscale (d = 0.70), rule-breaking behavior (d = 0.63), aggressive behavior (d = 0.62), and conduct problems (d = 0.78). No treatment differences were found on the Internalizing subscale or among other YSR problem areas. Both PE-A and CCT effectively reduced many co-occurring problems among adolescents with PTSD. Although PE-A focuses on PTSD and not on disruptive behaviors, PE-A was associated with greater sustained changes in externalizing symptoms, supporting broad effects of trauma-focused treatment on associated problem areas.

A pilot and feasibility randomised controlled study of Prolonged Exposure Treatment and supportive counselling for post-traumatic stress disorder in adolescents: a third world, task-shifting, community-based sample

BACKGROUND

There is a dearth of empirical evidence on the effectiveness of pharmacological and nonpharmacological treatments for adolescents with post-traumatic stress disorder (PTSD) in developing country settings. The primary aim of this study was to demonstrate that Prolonged Exposure Treatment for Adolescents (PE-A) and supportive counselling (SC) are implementable by nurses in a South African context. A secondary aim was to perform a preliminary analysis of the effectiveness of registered nurses delivering either PE-A or SC treatment to adolescents with PTSD. It is hypothesised that PE-A will be superior to SC in terms of improvements in PTSD symptoms and depression.

METHOD

A pilot, single-blind, randomised clinical trial of 11 adolescents with PTSD. Nurses previously naïve to Prolonged Exposure (PE) Treatment and SC provided these treatments at the adolescents' high schools. Data collection lasted from March 2013 to October 2014. Participants received twelve 60-90-min sessions of PE (n = 6) or SC (n = 5). All outcomes were assessed before treatment, at mid-treatment, immediately after treatment completion and at 12-month follow-up. The primary outcome, PTSD symptom severity, was assessed with the Child PTSD Symptom Scale-Interview (CPSS-I) (range, 0-51; higher scores indicate greater severity). The secondary outcome, depression severity, was assessed with the Beck Depression Inventory (BDI) (range, 0-41; higher scores indicate greater severity).

RESULTS

Data were analysed as intention to treat. During treatment, participants in both the PE-A and SC treatment arms experienced significant improvement on the CPSS-I as well as on the BDI. There was a significant difference between the PE-A and SC groups in maintaining PTSD and depression at the 12-month post-treatment assessment, with the participants in the PE-A group maintaining their gains both on PTSD and depression measures.

CONCLUSION

The treatment was adequately implemented by the nurses and well-tolerated by the participants. Preliminary results suggest that the delivery of either intervention led to a significant improvement in PTSD and depression symptoms immediately post treatment. The important difference was that improvement gains in PTSD and depression in the PE-A group were maintained at 12-month follow-up. The results of this pilot and feasibility study are discussed.

TRIAL REGISTRATION

Pan African Clinical Trials Registry: PACTR201511001345372 , registered on 11 November 2015.

Single unit activity in the lateral septum and central nucleus of the amygdala in the elevated plus-maze: a model of exposure therapy?

The central nucleus of the amygdala (CeA) is a major output region of the amygdala involved in organizing the expression of fear. There is also evidence that the lateral septum (LS) provides inhibitory control of neurons in CeA and is involved in the relief of fear. This study examined single unit activity in the lateral septum (LS) and the central nucleus of the amygdala (CeA) in the open and closed arms of the elevated plus-maze, a highly validated animal model of fear and anxiety. The general presumption is that animals normally avoid the open arms because the open arms are relatively more anxiety provoking than the closed arms which represent relative safety. It was expected that neurons in CeA would increase their activity in the open arms relative to the closed arms indicative of increased anxiety and that LS neurons would decrease their activity on the open arms. Contrary to expectations it was found that the preponderance of units in CeA decreased their firing rates on the open arms compared to the closed arms. An increase in firing rates in LS was seen in the open arms compared to the closed arms. The data suggest that when animals are placed on the open arms a compensatory process takes place to suppress fear so that the animal can engage in adaptive behavior. We liken this process to that which takes place in exposure therapy for phobias in humans which involves the inhibition of fear resulting from Pavlovian extinction.

Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD

Obsessive-compulsive disorder (OCD) is a highly debilitating disorder. Fortunately there are treatments that help the majority of OCD sufferers. The behavioral treatment with the most empirical support for its efficacy is exposure and response prevention (EX/RP). Over the years in our supervision meetings and in our clinical practice we have noted a number of relatively common therapist pitfalls that decrease the effectiveness of EX/RP. These pitfalls include not encouraging patients to approach the most distressing situations, doing imaginal exposure when in vivo is called for (and vice versa), encouraging distraction during exposure, providing reassurance, failing to address the core fear, ineffective handling of mental compulsions, and difficulty working with close others in the patient's life. In the current article we describe these common pitfalls and how to avoid them.

Prolonged exposure versus dynamic therapy for adolescent PTSD: a pilot randomized controlled trial

OBJECTIVE

To examine the efficacy and maintenance of developmentally adapted prolonged exposure therapy for adolescents (PE-A) compared with active control time-limited dynamic therapy (TLDP-A) for decreasing posttraumatic and depressive symptoms in adolescent victims of single-event traumas.

METHOD

Thirty-eight adolescents (12 to 18 years old) were randomly assigned to receive PE-A or TLDP-A.

RESULTS

Both treatments resulted in decreased posttraumatic stress disorder and depression and increased functioning. PE-A exhibited a greater decrease of posttraumatic stress disorder and depression symptom severity and a greater increase in global functioning than did TDLP-A. After treatment, 68.4% of adolescents beginning treatment with PE-A and 36.8% of those beginning treatment with TLDP-A no longer met diagnostic criteria for posttraumatic stress disorder. Treatment gains were maintained at 6- and 17-month follow-ups.

CONCLUSIONS

Brief individual therapy is effective in decreasing posttraumatic distress and behavioral trauma-focused components enhance efficacy. CLINICAL TRIAL REGISTRY INFORMATION: Prolonged Exposure Therapy Versus Active Psychotherapy in Treating Post-Traumatic Stress Disorder in Adolescents, URL: http://clinicaltrials.gov, unique identifier: NCT00183690.

Changes in reported physical health symptoms and social function with prolonged exposure therapy for chronic posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with significant health risk, illness, and functional impairment, e.g., Green and Kimerling [2004: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association] Kimerling et al. [2000: Trauma and Health: J Trauma Stress 13:115-128].

METHODS

These analyses examined whether negative health perceptions and general social functioning change with treatment of chronic PTSD among women from a randomized controlled study comparing prolonged exposure (PE; n=48) or PE combined with cognitive restructuring (PE/CR; n=40) to waitlist (n=19; Foa et al., 2005: J Consult Clin Psychol 73:953-964].

RESULTS

Self- reported physical health difficulties were significantly reduced in the PE and PE/CR conditions compared to the waitlist condition. These reductions did not demonstrate significant change during the 12 month follow-up period. Self-reported discomfort associated with physical health difficulties did not demonstrate significant change over treatment. No difference was detected between the active treatment and waitlist conditions. Both the PE and PE/CR groups reported improved social functioning at post treatment compared to the waitlist. Additional improvement in general social functioning was found between 3 and 12 month follow-up assessments. Changes in PTSD and depressive symptoms over treatment accounted for 29% of the variance in reduction of reported health problems and 30% of the variance in improvement of general social functioning. Importantly, only changes in PTSD symptoms significantly contribute to the model predicting change in physical health problems with depression associated only at a trend level. However, collinearity between PTSD and depression makes interpretation difficult.

CONCLUSIONS

Negative health perceptions and general social function improve with PE. Changes in depression and PTSD with treatment are related to these changes.

The OCI-R: validation of the subscales in a clinical sample

The psychometric properties of the Obsessive-Compulsive Inventory-Revised (OCI-R) subscales have not been validated in a clinical sample of individuals diagnosed with obsessive-compulsive disorder (OCD). Data were collected on 186 patients diagnosed with OCD and 17 patients diagnosed with generalized anxiety disorder (GAD) using the OCI-R and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Confirmatory factor analysis revealed an acceptable factor structure. Patients with a given primary symptom subtype were elevated on the corresponding subscale of the OCI-R compared to other OCD patients and patients with GAD. In addition, patients who acknowledged that symptom subtype as present but not primary on the Y-BOCS had elevated OCI-R scores on that scale compared to patients who did not endorse that symptom subtype and patients with GAD. Results indicate that the subscales of the OCI-R are valid measures of six symptom subtypes of OCD. The OCI-R is a psychometrically sound, brief instrument. The current data combined with previous efforts suggest that it is appropriate for clinical and non-clinical populations, and for clinical and research purposes. Further research should examine the sensitivity of the specific subscales to treatment effects, and the potential for adding more items to account for other symptom domains of OCD.

Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics

Female assault survivors (N=171) with chronic posttraumatic stress disorder (PTSD) were randomly assigned to prolonged exposure (PE) alone, PE plus cognitive restructuring (PE/CR), or wait-list (WL). Treatment, which consisted of 9-12 sessions, was conducted at an academic treatment center or at a community clinic for rape survivors. Evaluations were conducted before and after therapy and at 3-, 6-, and 12-month follow-ups. Both treatments reduced PTSD and depression in intent-to-treat and completer samples compared with the WL condition; social functioning improved in the completer sample. The addition of CR did not enhance treatment outcome. No site differences were found: Treatment in the hands of counselors with minimal cognitive- behavioral therapy (CBT) experience was as efficacious as that of CBT experts. Treatment gains were maintained at follow-up, although a minority of patients received additional treatment.

Effects of chlordiazepoxide on single-unit activity in the septal region of the freely moving rat: aversive vs. non-aversive contexts

Evidence suggests that stimuli that have the property of inhibiting fear in a Pavlovian fear conditioning paradigm increase cellular activity in the lateral septum, a result consistent with the idea that the lateral septum is actively involved in the inhibition of fear. The experiments reported here were designed to determine if an anxiolytic drug with fear-inhibiting properties would also increase neuronal activity in the lateral septum in a manner that might relate to its mechanism of action as an anxiolytic. An experiment was performed to compare the effects of the benzodiazepine anxiolytic chlordiazepoxide (CDP) upon single-unit activity in the septal region of the rat brain during Pavlovian aversive conditioning with the effects of CDP in a non-aversive context. During Pavlovian conditioning there was a decrease in unit activity in the more lateral regions of the septum, the dorsolateral and ventrolateral nuclei, when a stimulus signaling footshock (CS+) was presented. This conditioned suppression of unit activity was blocked by an intraperitoneal injection of CDP. Additionally, CDP increased baseline unit activity in these regions in the absence of conditioned stimuli. In the more medial regions of the septum, the intermediate lateral septum, we observed few consistent changes either to the conditioned stimuli or to the drug. In a non-aversive context CDP had either no effect at low to moderate doses, or a suppressant effect at a higher dose. The results support a fear-relief hypothesis of lateral septal functioning and suggest the lateral septum as a possible site for the anxiolytic action of benzodiazepines.

Stimulation of the lateral septum attenuates immobilization-induced stress ulcers

Rats with electrodes implanted in their dorsolateral septal area underwent a cold-immobilization restraint procedure during which the experimental group received electrical stimulation while the control group did not. Electrical stimulation of the dorsolateral septal region clearly reduced the number of gastric ulcers formed during the cold-immobilization stress procedure. The pattern of results with septal stimulation contrasts with that seen by other investigators after stimulation of the central amygdaloid nucleus. The mitigation of stress-induced ulceration after lateral septal stimulation is consistent with the proposed function for the lateral septal area in relief from aversive emotional states.

Effect of prenatal cocaine on dopamine receptor-G protein coupling in mesocortical regions of the rabbit brain

The effects of in utero exposure to cocaine on dopamine receptors in the frontal and cingulate areas of the developing rabbit cortex were assessed by examining receptor-mediated stimulations in GTP binding to alpha-subunits of G proteins. Pregnant Dutch-belted rabbits received intravenous injections of 4 mg/kg of cocaine HCl twice a day on gestational days 8-29, cortical membranes were prepared from their progenies on postnatal days 10-100 and dopamine-stimulated [35S] guanosine-5'-[gamma-thio]triphosphate (GTP gamma S) binding to membrane G alpha proteins was measured. Dopamine increased [35S]GTP gamma S binding to G alpha s and G alpha i. These increases in [35S]GTP gamma S binding reflect the stimulation of D1- and D2-dopamine receptors, respectively. The ability of dopamine to stimulate the binding of [35S]GTP gamma S to G alpha s but not to G alpha i was reduced in both frontal and cingulate cortices obtained from cocaine-exposed animals when examined at 10, 50 or 100 days of age. Prenatal cocaine exposure was also shown to reduce dopamine-stimulated [alpha-32P]GTP binding to G alpha s without influencing binding to G alpha i. The muscarinic cholinergic receptor-evoked increases in [35S]GTP gamma S binding to G alpha i and G alpha o were not altered. Immunoblot analyses revealed no differences in the levels of these alpha subunits in membranes from cocaine-exposed animals vs controls. Furthermore, prenatal cocaine did not affect [3H]8-chloro-2,3,4,5-tetrahydro-3-methyl-5-phenyl-1H-3-benzazepin-7- olhemimaleate binding to cortical D1 dopamine receptors. The results suggest that prenatal exposure of rabbits to cocaine selectively uncouples the D1 dopamine receptor from its G protein in mesocortical brain areas and that this change persists through postnatal day 100.

Prenatal exposure to cocaine selectively reduces D1 dopamine receptor-mediated activation of striatal Gs proteins

The effect of in utero exposure to cocaine on striatal dopamine receptors was assessed at postnatal days 10 through 100 by examining receptor-mediated increases in GTP binding to G alpha proteins. Pregnant Dutch-belted rabbits were injected with 4 mg/kg i.v. of cocaine HCl twice a day on gestational days 8 through 29, and striatal membranes were prepared from their progenies on days 10 through 100. Dopamine-stimulated [35S]GTP gamma S binding to membrane alpha subunits was measured and found to increase binding to G alpha s and G alpha i. Pharmacological characterization of the dopamine response revealed that enhanced [35S]GTP gamma S binding to G alpha s is associated with D1 receptor stimulation, whereas binding to G alpha i is linked to D2 receptor activation. The abilities of dopamine to stimulate the binding of [35S]GTP gamma S to G alpha s but not to G alpha i was reduced in striata obtained from cocaine-exposed animals when examined at 10, 50 or 100 days of age. Similarly, prenatal cocaine exposure also reduced dopamine-stimulated [alpha-32P]GTP binding to G alpha s without influencing binding to G alpha i. Fetal cocaine exposure did not change carbachol-induced increases in [35S]GTP gamma S binding to G alpha i and G alpha o. Immunoblot analyses showed no changes in the amounts of these alpha subunits in membranes from cocaine-exposed animals vs. controls. Moreover, prenatal cocaine did not affect [3H]SCH23390 binding to D1 dopamine receptors in the caudate, putamen or substantia nigra.(ABSTRACT TRUNCATED AT 250 WORDS)

Anticonflict action of chlordiazepoxide in rats with combined lesions

Lesions of brain areas thought to promote anxiety do not diminish the anticonflict effects of benzodiazepines (BZDs). After initial training in the lick-suppression conflict test, eight rats received electrolytic lesions of the amygdala, dorsal raphe, locus coeruleus, and mammillary bodies. Ten others received sham lesions. Postoperative testing revealed a significant increase in punished licking at two stages after surgery in lesioned animals when compared with their own preoperative baseline levels and with the punished licking of control animals. Systemic administration of chlordiazepoxide (CDP, 2.5-10.0 mg/kg) resulted in a comparable dose-dependent increase in punished licking in both groups. These results suggest that the several structures lesioned need not be intact for CDP to have an antianxiety effect. It appears that sites of anxiolytic action are much more widely spread than currently believed and that other brain areas should be considered.

The role of the lateral septum in anxiolysis

Behavior of rats in the water-lick conflict test was examined during stimulation, and after lesions of the lateral septal nucleus. Continuous low-current stimulation resulted in an anxiolytic effect, an increase in the number of licks, and hence in the number of shocks, during a signaled, punished period. This effect is similar to the one seen with peripheral administration of benzodiazepine and other anxiolytic agents. Rewarding medial forebrain stimulation did not have this effect. Conversely, septal lesions resulted in an anxiogenic effect, a significant decrease in the number of licks during the punished period. Lesions had this effect when the conflict behavior was already well established. Septal lesions performed before acquisition of the conflict behavior resulted in initial retardation of acquisition. The results suggest an important role for the lateral septum in the inhibition of anxiety and in the acquisition of behaviors reinforced by alleviation of anxiety.

Spontaneous alternation behavior: an animal model for obsessive-compulsive disorder?

This study entailed the adoption of a well-established behavioral paradigm, spontaneous alternation, as a possible animal model for some of the symptoms observed in obsessive-compulsive disorder (OCD) in humans. Food-deprived rats were run in a T-maze in which both a black and a white goal box were equally baited with a small amount of chocolate milk. Each rat was given 7 trials every other day during which it was placed in the start box and allowed to make a choice. The mean number of choices until an alternation occurred was recorded. After a stable baseline of spontaneous alternation was achieved the effects of manipulating the serotonergic system were tested. Both the nonselective 5-HT agonist 5-MeODMT (1.25 mg/kg) and the more selective 5-HT1A agonist 8-OH-DPAT (2 mg/kg) disrupted spontaneous alternation. A course of chronic treatment (2 x 5 mg/kg for 21 days) with the selective 5-HT uptake blocking agent fluoxetine had a protective effect on the 5-MeODMT-induced disruption of spontaneous alternation behavior. Serotonergic manipulations of spontaneous alternation may be a simple animal model for the perseverative symptoms or indecisiveness seen in people diagnosed with OCD.

Septal unit activity during classical conditioning: a regional comparison

Single unit activity was recorded from the lateral and medial septum of rats during aversive Pavlovian differential conditioning. One conditioned stimulus (CS+) was consistently paired with and another (CS-) was explicitly unpaired with a brief shock unconditioned stimulus (US). In the lateral septum single unit activity generally increased in the presence of a conditioned inhibitor of fear (CS-), while unit activity generally decreased in the presence of a conditioned excitor of fear (CS+). Responses in the medial septum were more heterogeneous. Many cells did not show plastic changes to the CSs, others showed responses to the conditioned stimuli opposite to that seen in the lateral septum. A small group of cells showed responses similar to that seen in the lateral septum. Finally, theta bursting cells were seen in the medial septum with some evidence of increased theta activity in the presence of a conditioned inhibitor of fear (CS-). The results were interpreted as consistent with the proposition that the lateral septum mediates the inhibition of aversive emotional states. The medial septum may have some involvement with the activation of fear or anxiety.

Anxiolytic effects of benzodiazepines in amygdala-lesioned rats

The role of the amygdala in the anxiolytic action of benzodiazepines was examined. Performance on a water-licking conflict paradigm was tested in rats with localized damage to the central nucleus of the amygdala (ACE) or with general damage to the entire amygdaloid complex. The effects of the benzodiazepine chlordiazepoxide (2.5-20.0 mg/kg) on conflict behavior in these animals was also examined. Electrolytic lesions of either ACE or of the entire amygdaloid complex resulted in a pronounced increase of punished responding, an effect that persisted for at least 12 sessions postoperatively. After shock levels were adjusted in the lesioned groups to match their baseline punished behavior to that of the controls, various doses of chlordiazepoxide were administered. Not only did the lesioned animals show an increase in punished behavior in response to the drug, they were more sensitive than controls to the lower drug doses. A complete model of anxiolytic action may have to include both mechanisms that block anxiogenic regions and those that activate anxiolytic regions.

Unit activity in the medial septum during differential appetitive conditioning

Unit activity in the medial septal area of the rat was studied during pavlovian appetitive differential conditioning. The firing pattern of cells in the medial septum is that of suppression to presentation of the conditioned excitor and no significant increase to the presentation of the conditioned inhibitor. This pattern is discussed in the context of a comparison with the pattern found in the lateral septal area and assesses the significance of the motivational value of the stimuli.

Forebrain origins and terminations of the medial forebrain bundle metabolically activated by rewarding stimulation or by reward-blocking doses of pimozide

Using [14C]-2-deoxyglucose autoradiography, we determined which forebrain and diencephalic areas showed metabolic alterations in response to unilateral electrical stimulation of the posterior medial forebrain bundle at parameters chosen to produce a just-submaximal rewarding effect. At these parameters, only a few areas were activated. There was no detectable activation anterior or dorsal to the genu of the corpus callosum. Just anterior to the anterior commissure, there was strong activation of the vertical limb of the diagonal band of Broca, with a focus in the nucleus of the diagonal band. Just posterior to the anterior commissure, there was strong activation of compartment "c" of the medial forebrain bundle (MFB), with weaker activation of the bed nucleus of the stria terminalis and the medial preoptic area. At midhypothalamic levels, the dorsolateral, dorsomedial, and ventral MFB all showed activation. There was bilateral suppression of activity in the lateral habenula. Activation appeared to end in the anterior ventral tegmental area of Tsai. Reward-blocking doses of the neuroleptic pimozide activated the caudate and the lateral habenula but did not alter any of the unilateral effects of stimulation. Using longer pulse durations and/or shifting the site of stimulation to the substantia nigra activated many of the systems not activated in the first experiment, including all of the major dopaminergic projection systems, proving the capacity of the technique to reveal activation of these systems. The results permit one to define a discrete projection system that merits electrophysiological investigation as a likely substrate for the rewarding effect of MFB stimulation. They also suggest that dopaminergic projection systems may not form part of the reward pathway itself.

Unilaterally activated systems in rats self-stimulating at sites in the medial forebrain bundle, medial prefrontal cortex, or locus coeruleus

Rats with electrodes in either the posterior medial forebrain bundle (MFB), the anterior MFB, the medial prefrontal cortex, or the locus coeruleus self-stimulated during a 45 min period following the injection of [14C]2-deoxyglucose. They were then sacrificed and their brains prepared for autoradiography. The autoradiographs were analyzed for unilaterally activated neural systems, using a computerized image analyzing system to compare the darkness of neural structures on the stimulated side with the darkness of the same structures on the unstimulated side. There was extensive overlap in the neural structures unilaterally activated by stimulation in the anterior and posterior MFB; but there was no overlap between the structures activated by MFB stimulation and the structures activated by stimulation at either of the extradiencephalic sites; nor did the forebrain, diencephalic, and midbrain sites have any readily apparent bilateral effects in common. If there is a substrate common to MFB self-stimulation and extradiencephalic self-stimulation, its activation is not revealed by 2-deoxyglucose autoradiography.

An animal model to detect learning deficits following treatment of the immature brain. Studies using radiation and methotrexate

Learning deficits have been noted in children with acute leukemia given methotrexate (MTX) with and without cranial irradiation (RT) for prophylaxis. A rat model has been developed to assess treatment effects on learning. The test used was altered performance of a simultaneous discrimination task in a standard operant conditioning box, employing the mean number of days needed to score 80% correct responses as the criterion. An illustrative experiment distributed suckling rats among four groups: (1) 36 controls; (2) 14 cranial RT (1,000 R); (3) 14 MTX (5 mg/kg i.p.); (4) 36 RT + MTX 24 h later, and (5) 12 undernourished controls (to match poor weight gain patterns of treated animals). Survivors were tested 10-12 weeks later: values for groups 1-5 in order were 3.9, 4.1, 4.7, 5.0 and 4.0 days. Only group 4 results were significantly different from group 1 (p = less than 0.05).

Computer assisted analysis of 2-DG autoradiographs

A computerized image processing system is described that assists the neurobiologists in analyzing data from 2-DG autoradiography by providing for: (1) Rapid fine-scale digitization of gray levels using a TV camera (2) The recognition of and verification of subtle differences in optical density with the aid of color windows (3) the superimposition of the autoradiographic image upon the histological image, so that the activity seen in the autoradiograph can be accurately assigned to anatomically defined structures (4) The production of numerical data suitable for statistical analysis and line drawings suitable for black on white publication (5) The relating of local gray level to a norm for the image as a whole, so as to remove the variability introduced by variations in section thickness, in the amount of 2-DG seen by the brain during incorporation, in level of anesthesia, etc. If the localized darkening in autoradiographic images is being used as an index of localized functional activity rather than as a measure of metabolism, normalization obviates the need to obtain arterial blood samples. These routines permit anatomically accurate numerical analysis of autoradiographs without any constraints on the experimental situation.

Septal correlates of conditioned inhibition and excitation in rats

Multiple-unit activity was recorded in the lateral septum of rats during Pavlovian differential conditioning. In Experiment 1, one group of animals received a classical aversive discrimination paradigm, while another group was presented with a control procedure in which the unconditioned stimuli (shocks) were administered randomly with regard to the conditioned stimuli. Septal unit activity increased during presentations of the conditioned inhibitor and was markedly suppressed during presentations of the conditioned excitor in the conditioning-group animals and not in the control animals. Baseline activity remained unchanged in the conditioning group but was suppressed in the random control group. Furthermore, termination of the aversive stimuli was marked by a burst of firing in the conditioning group, but no such rebound was seen in the control group. In Experiment 2, a classical appetitive discrimination paradigm was given, in which septal unit activity was found to increase in the presence of the conditioned excitor and was suppressed in the presence of the conditioned inhibitor. The results are interpreted as indicating a role for the septum in the relief of aversive states.