Amygdala-derived-EEG-fMRI-pattern neurofeedback for the treatment of chronic post-traumatic stress disorder. A prospective, multicenter, multinational study evaluating clinical efficacy

We conducted a prospective, single arm, multisite, multinational, open label trial assessing the safety and efficacy of a novel amygdala derived neurofeedback treatment, designated Amygdala-Derived-EFP, for chronic PTSD. Participants, including veterans and civilians, underwent screening, training, 15 neurofeedback sessions over 8 weeks and; baseline, termination (8 weeks) and 3 month post treatment assessments with validated measures. The primary endpoint was more than 50 % of the participants demonstrating a Minimally Clinically Important Difference (MCID) defined as a 6-point reduction, on the Clinician Administered PTSD Scale (CAPS-5) total score at 3 months. Secondary measures included the PCL-5, ERQ, PHQ-9, and CGI. Statistical analyses were performed using SAS®V9.4. The primary endpoint was met, with a CAPS-5 MCID response rate of 66.7 %. The average reduction in CAPS-5 total scores at 3 month follow up was 13.5 points, more than twice the MCID. Changes from baseline in CAPS-5, PCL-5, PHQ-9 scores at 8 weeks and the 3 month follow-up demonstrated statistically significant improvements in response and; demonstrated effect sizes ranging from 0.46 to 1.07. Adverse events were mild and resolved after treatment. This study builds on prior research demonstrating similar outcomes using amygdala-derived neurofeedback. Positive attributes of this therapy include monitoring by non-physician personnel, affordability, accessibility, and tolerability.

Medical cannabis for treatment-resistant combat PTSD

Targeting the endocannabinoid system may have a role in the treatment of post-traumatic stress disorder (PTSD). However, few studies have examined the effectiveness of cannabis on symptoms of PTSD, and more research is needed to ascertain cannabis' effectiveness. In this retrospective naturalistic study, we followed 14 relatively mature (32-68 years of age), treatment-resistant, chronic combat post-traumatic patients who remained severely symptomatic despite treatment with many lines of conventional treatment prior to receiving medicinal cannabis. Our findings show that total sleep score, subjective sleep quality, and sleep duration significantly improved (p < 0.01). Total PTSD symptom score and its subdomains (intrusiveness, avoidance, and alertness) showed improvement (p < 0.05). However, there was no improvement in the frequency of nightmares (p = 0.27). The mean follow-up time was 1.1 ± 0.8 years (range of 0.5 to 3 years).

Are 60-minute prolonged exposure sessions with 20-minute imaginal exposure to traumatic memories sufficient to successfully treat PTSD? A randomized noninferiority clinical trial

The study aims to determine whether 60-minute sessions of prolonged exposure (PE) that include 20 minutes of imaginal exposure (IE) are noninferior to the standard 90-minute sessions that include 40 minutes of IE in treating posttraumatic stress disorder (PTSD) and to explore the relationship of treatment outcome to within- and between-session habituation and change in negative cognitions. Thirty-nine adult veterans with chronic PTSD were randomly assigned to 90-minute (n=19) or 60-minute (n=20) sessions of PE. PTSD symptoms were assessed by an unaware independent evaluator before and after treatment and at 6-month follow-up. Self-reports of depression and negative cognitions were assessed before and after treatment. Participants in both conditions showed significant reductions in PTSD symptoms. Sixty-minute sessions were found to be noninferior to 90-minute sessions in reducing PTSD symptoms, as the upper bound of the 95% confidence interval for the difference between conditions in the PTSD Symptom Scale-Interview (posttreatment: 6.00; follow-up: 6.77) was below the predefined noninferiority margin (7.00). Participants receiving shorter sessions showed less within- and between-session habituation than those receiving longer sessions, but no group differences in reductions in negative cognitions were found. The current findings indicate that the outcomes of 60-minute sessions of PE do not differ from those of 90-minute sessions. In addition, change in trauma-related cognitions and between-session habituation are both potential mechanisms of PE.

Prolonged Exposure for Treating PTSD Among Female Methadone Patients Who Were Survivors of Sexual Abuse in Israel

The aims of this pilot study were: (a) to test the feasibility of prolonged exposure (PE) therapy conducted by a social worker staff on female patients in methadone program clinics who were survivors of child sexual abuse or rape and (b) to examine preliminary outcomes of PE on posttraumatic stress disorder (PTSD), depression, and illicit drug use at pre- and posttreatment, and up to 12-month follow-ups. Twelve female methadone patients who were survivors of child sexual abuse or rape diagnosed with PTSD were enrolled in 13-19 weekly individual PE sessions. Assessments were conducted at pre-, mid-, and posttreatment, as well as at 3, 6, and 12-month follow-ups. The treatment outcomes measures included PTSD symptoms, depressive symptoms, and illicit drug use. Ten of the 12 study patients completed treatment. PTSD and depressive symptoms showed significant reduction. No relapse to illicit drug use was detected. These preliminary results suggest that PE may be delivered by methadone social workers with successful outcomes. Further research should test the efficacy of PE among methadone patients in a randomized control trial with standard care as the control condition.

Acute obsessive compulsive disorder (OCD) in veterans with posttraumatic stress disorder (PTSD)

OBJECTIVES

Posttraumatic obsessions have been reported in a few studies and case series. However, as the patients described were chronic, and the onset of their posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) symptoms was dated some time previously, this hampers interpretation of the temporal, biological and psychological relationship of OCD following traumatic events. In the current paper we describe the emergence of posttraumatic obsessions a short time following the exposure to a traumatic event.

METHODS

The emergence of posttraumatic obsessions, a few months after exposure to trauma, is described for five veterans. All the veterans participated in combat during the summer of 2006 (in the Second Lebanon War).

RESULTS

For all cases, OCD symptoms were initially related to the trauma but later became generalized and independent.

CONCLUSIONS

The course of the symptoms suggests a potential environmental role in the development of OCD following an exposure to a traumatic event. These observations suggest a biological linkage between exposure to trauma and OCD.

High prevalence of obsessive-compulsive disorder among posttraumatic stress disorder patients

Posttraumatic obsessions have been reported in a few studies and case series. However, the magnitude of this phenomenon is still unknown. In the current study we systematically evaluated the prevalence of OCD in a sample of combat and terror related PTSD patients. Out of 44 referrals, 43% of the participants had PTSD with no OCD and 41% were diagnosed also with OCD. Six percent had sub-threshold OC symptoms. No difference was found between PTSD and PTSD-OCD participants' characteristics (including demographics, trauma-related factors, and other psychiatric co-morbidity). The surprisingly high number of OCD found in the current study suggests that PTSD-OCD might be underdiagnosed, signifies the importance of direct assessment of OCD in patients with PTSD, and raise questions regarding the underlying mechanism of post-traumatic OCD.

Exposure-based therapy for post-traumatic stress disorder in children and adults

We review the main components of Cognitive Behavioral Therapy (CBT) in the treatment of Post-traumatic Stress Disorder (PTSD) and the various treatment protocols that were found to be effective in treating this disorder in adult and pediatric populations. We highlight Prolonged Exposure (PE) therapy, which received strong empirical support, and was widely disseminated in Israel. We provide a detailed description of the PE treatment protocol for adults and children, and review studies conducted in Israel. We discuss clinical issues commonly raised by professionals starting to utilize PE and other trauma-focused treatment protocols. Finally, we discuss the open questions in the treatment of PTSD, and suggest some ideas for future research.

Prolonged exposure therapy for chronic combat-related PTSD: a case report of five veterans

Prolonged exposure (PE) therapy has been found efficient in reducing posttraumatic stress disorder (PTSD) symptoms mostly among rape victims, but has not been explored in combat-related PTSD. Five patients with severe chronic PTSD, unresponsive to previous treatment (medication and supportive therapy) are described. Patients were evaluated with the PTSD Symptom Scale-Interview, and Beck Depression Inventory, before and after 10-15 sessions of PE therapy. All five patients showed marked improvement with PE, with a mean decrease of 48% in PTSD Symptom Scale-Interview score and 69% in Beck Depression Inventory score. Moreover, four patients maintained treatment gains or kept improving 6-18 months after the treatment. The results suggest that PE was effective in reducing combat-related chronic PTSD symptoms.

Rhabdomyolysis associated with clozapine treatment in a patient with decreased calcium-dependent potassium permeability of cell membranes

A 21-year-old patient developed rhabdomyolysis during his nineteenth week of treatment with clozapine for drug-resistant schizophrenia. No risk factors for rhabdomyolysis were found, but the calcium-dependent potassium efflux, normally responsible for membrane hyperpolarization and muscle refractoriness, was severely decreased in the patient's red blood cells. Clozapine is speculated to cause rhabdomyolysis in patients with defective calcium-activated K+ channels.

Clozapine for the treatment of agitated-depressed patients with cognitive impairment: a report of three cases

Clozapine, an atypical antipsychotic, is mainly approved for the treatment of resistant schizophrenia. However, a substantial body of evidence suggests that it might be useful in other psychiatric indications, such as treatment-resistant depression, Parkinson's disease, and dementia. In this report we present the cases of three patients hospitalized at the psychiatric division of the Sheba Medical Center, diagnosed with major depressive disorder with cognitive impairment, whose presenting symptom was agitation. These patients were nonresponders to various treatment modalities. However, treatment with clozapine brought about a favorable response.

Mesenteric vein thrombosis. The importance of a second-look operation

Mesenteric vein thrombosis is an abdominal emergency that is rarely diagnosed early. Review of the literature has shown that most cases have been treated by intestinal resection, a few by thrombectomy with or without resection. Three cases of mesenteric vein thrombosis were treated by resection, heparinization, and a second-look operation after 24 hours. When necessary, resection was carried out at the second surgical procedure followed by a third-look operation after 24 hours. After the last inspecting operation without further resection, full heparinization was continued and anticoagulation was ultimately maintained with warafin sodium (Coumadin) for at least three months. The authors believe that optimal treatment for mesenteric vein thrombosis should include anticoagulation with heparin sodium and a mandatory second-look operation.