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Zeifman RJ, Landy MSH, Liebman RE, Fitzpatrick S, Monson CM. Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy. Clin Psychol Rev 2021; 86:102030. [PMID: 33894491 DOI: 10.1016/j.cpr.2021.102030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is a severe and complicated clinical presentation characterized by especially high rates of suicide, healthcare utilization, and psychosocial impairment. Although guidelines exist for treating each of these disorders alone, there remains limited guidance on the optimal treatment in cases where BPD and PTSD co-occur. Therefore, this systematic review synthesizes the existing research on the treatment of BPD-PTSD with the aim of optimizing treatment for this population. First, the prevalence and clinical severity of comorbid BPD-PTSD is reviewed. Next, we describe the results of our systematic review, which identified 21 articles that examined treatment outcomes in the context of BPD-PTSD or subclinical BPD-PTSD. Based on our results, we describe existing psychotherapeutic approaches, including BPD-specific treatments, trauma-focused and non-trauma-focused treatments for PTSD, and stage-based treatments for BPD-PTSD. We also summarize BPD-PTSD treatment outcomes, including whether each disorder interferes with treatment and recovery of the other. Results related to treatment safety and concerns regarding conducting trauma-focused treatment for BPD-PTSD are addressed. We end by highlighting important gaps in the literature and provide recommendations for further research.
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Affiliation(s)
| | - Meredith S H Landy
- Department of Psychology, Ryerson University, Toronto, Canada; Mind Beacon Health Inc., Toronto, Canada
| | - Rachel E Liebman
- Department of Psychology, Ryerson University, Toronto, Canada; Department of Psychology, York University, Toronto, Canada
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Abdullahi PR, Raeis-Abdollahi E, Sameni H, Vafaei AA, Ghanbari A, Rashidy-Pour A. Protective effects of morphine in a rat model of post-traumatic stress disorder: Role of hypothalamic-pituitary-adrenal axis and beta- adrenergic system. Behav Brain Res 2020; 395:112867. [PMID: 32827567 DOI: 10.1016/j.bbr.2020.112867] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 07/18/2020] [Accepted: 08/12/2020] [Indexed: 11/25/2022]
Abstract
Post-traumatic stress disorder (PTSD) arises after tremendous traumatic experiences. Recently, we have reported that morphine has time-dependent protective effects against behavioral and morphological deficits in the single prolonged stress (SPS) as an experimental model of PTSD in adult male rats. To find the mechanisms underlying the protective effects of morphine against SPS-induced PTSD-like symptoms, the present study investigated the interaction between morphine and hypothalamic-pituitary-adrenal (HPA) axis and beta - adrenergic system, which crucially involved in the stress response, on PTSD-like symptoms in male rats. The animals were exposed to the SPS procedure (restraint for 2 h, forced swimming for 20 min, and ether anesthesia) and morphine (10 mg/kg) or saline was injected 24 h following the SPS. The glucocorticoid receptor antagonist RU486 (20 mg/kg), the mineralocorticoid receptor antagonist spironolactone (50 mg/kg), and the corticosterone synthesis inhibitor metyrapone (50 mg/kg) were injected 90 min before morphine administration to block the HPA axis activity. The beta - adrenergic receptor blocker propranolol (10 mg/kg) and the peripheral beta-adrenergic receptor blocker nadolol (5 mg/kg) were administered 30 min before morphine injection to block the beta - adrenergic system. Anxiety-like behaviors were evaluated using the elevated plus maze (EPM) 11 days after the SPS. After that, animals were conditioned in a fear-conditioning task and extinction training was performed on days 1, 2, 3, 4 and 11 after fear conditioning. SPS increased anxiety-like behaviors and impaired fear extinction. Morphine injection 24 h after SPS significantly improved anxiety-like behaviors and enhanced fear extinction. The RU486, spironolactone and metyrapone prevented the protective effects of morphine on both SPS-induced anxiety-like behaviors and impaired fear extinction. The propranolol, and nadolol did not prevent the effect of morphine on anxiety-like behaviors, but the propranolol prevented morphine effects on fear extinction in SPS animals. These findings together suggest that the protective effects of morphine on PTSD-like symptoms in rats require a certain level of the HPA axis and central beta - adrenergic activity and any alteration in the function of these systems can impede the protective effects of morphine.
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Affiliation(s)
| | - Ehsan Raeis-Abdollahi
- Department of Physiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Sameni
- Nervous System Stem Cells Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Abbas Ali Vafaei
- Research Center of Physiology, Semnan University of Medical Sciences, Semnan, Iran
| | - Ali Ghanbari
- Research Center of Physiology, Semnan University of Medical Sciences, Semnan, Iran
| | - Ali Rashidy-Pour
- Research Center of Physiology, Semnan University of Medical Sciences, Semnan, Iran.
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Santiago J, Akeman E, Kirlic N, Clausen AN, Cosgrove KT, McDermott TJ, Mathis B, Paulus M, Craske MG, Abelson J, Martell C, Wolitzky-Taylor K, Bodurka J, Thompson WK, Aupperle RL. Protocol for a randomized controlled trial examining multilevel prediction of response to behavioral activation and exposure-based therapy for generalized anxiety disorder. Trials 2020; 21:17. [PMID: 31907032 PMCID: PMC6943897 DOI: 10.1186/s13063-019-3802-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/11/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Only 40-60% of patients with generalized anxiety disorder experience long-lasting improvement with gold standard psychosocial interventions. Identifying neurobehavioral factors that predict treatment success might provide specific targets for more individualized interventions, fostering more optimal outcomes and bringing us closer to the goal of "personalized medicine." Research suggests that reward and threat processing (approach/avoidance behavior) and cognitive control may be important for understanding anxiety and comorbid depressive disorders and may have relevance to treatment outcomes. This study was designed to determine whether approach-avoidance behaviors and associated neural responses moderate treatment response to exposure-based versus behavioral activation therapy for generalized anxiety disorder. METHODS/DESIGN We are conducting a randomized controlled trial involving two 10-week group-based interventions: exposure-based therapy or behavioral activation therapy. These interventions focus on specific and unique aspects of threat and reward processing, respectively. Prior to and after treatment, participants are interviewed and undergo behavioral, biomarker, and neuroimaging assessments, with a focus on approach and avoidance processing and decision-making. Primary analyses will use mixed models to examine whether hypothesized approach, avoidance, and conflict arbitration behaviors and associated neural responses at baseline moderate symptom change with treatment, as assessed using the Generalized Anxiety Disorder-7 item scale. Exploratory analyses will examine additional potential treatment moderators and use data reduction and machine learning methods. DISCUSSION This protocol provides a framework for how studies may be designed to move the field toward neuroscience-informed and personalized psychosocial treatments. The results of this trial will have implications for approach-avoidance processing in generalized anxiety disorder, relationships between levels of analysis (i.e., behavioral, neural), and predictors of behavioral therapy outcome. TRIAL REGISTRATION The study was retrospectively registered within 21 days of first participant enrollment in accordance with FDAAA 801 with ClinicalTrials.gov, NCT02807480. Registered on June 21, 2016, before results.
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Affiliation(s)
- J Santiago
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA
| | - E Akeman
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA
| | - N Kirlic
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA
| | - A N Clausen
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC, USA
- Duke University Brain Imaging and Analysis Center, Durham, NC, USA
| | - K T Cosgrove
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA
- Department of Psychology, University of Tulsa, Tulsa, OK, USA
| | - T J McDermott
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA
- Department of Psychology, University of Tulsa, Tulsa, OK, USA
| | - B Mathis
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA
| | - M Paulus
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA
- School of Community Medicine, University of Tulsa, Tulsa, OK, USA
| | - M G Craske
- Psychology, Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - J Abelson
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - C Martell
- Department of Psychological and Brain Sciences, University of Massachusetts-Amherst, Amherst, MA, USA
| | - K Wolitzky-Taylor
- Psychology, Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - J Bodurka
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA
- Stephenson School of Biomedical Engineering, The University of Oklahoma, Norman, OK, USA
| | - W K Thompson
- Family Medicine and Public Health, University of California, San Diego, San Diego, CA, USA
| | - Robin L Aupperle
- Laureate Institute for Brain Research, 6655 South Yale Avenue, Tulsa, OK, 74136, USA.
- School of Community Medicine, University of Tulsa, Tulsa, OK, USA.
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Room to move: Plasticity in early auditory information processing and auditory learning in schizophrenia revealed by acute pharmacological challenge. Schizophr Res 2018; 199:285-291. [PMID: 29627173 PMCID: PMC6151271 DOI: 10.1016/j.schres.2018.03.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/22/2018] [Accepted: 03/26/2018] [Indexed: 11/23/2022]
Abstract
Many patients with chronic psychotic disorders including schizophrenia (SZ) maintain meaningful levels of plasticity (i.e., capacity for change) within neurocognition-relevant brain mechanisms, as evidenced by gains in neurocognition and function after interventions such as targeted cognitive training. However, like many clinical features of these disorders, therapeutic responses in SZ are heterogeneous, and prospectively identifying treatment-sensitive individuals and individualized treatment modalities remains an unmet challenge. We propose that available plasticity in neurocognition-relevant brain mechanisms in individual SZ patients can be detected by gains in laboratory measures of early auditory information processing (EAIP) and auditory learning after a single challenge-dose of a pharmacologic agent; here, we present supportive data for this strategy with the non-competitive NMDA antagonist, memantine, and the psychostimulant, amphetamine. We describe a novel therapeutic model where this "challenge dose" strategy is used to prospectively identify a sensitive cohort of patients, and in these patients, a therapeutic response is elicited by pairing drug-enhanced EAIP and auditory learning with auditory-based targeted cognitive training.
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Enhancing Endocannabinoid Neurotransmission Augments The Efficacy of Extinction Training and Ameliorates Traumatic Stress-Induced Behavioral Alterations in Rats. Neuropsychopharmacology 2018; 43:1284-1296. [PMID: 29265107 PMCID: PMC5916373 DOI: 10.1038/npp.2017.305] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 12/09/2017] [Accepted: 12/15/2017] [Indexed: 12/19/2022]
Abstract
Exposure to a traumatic event may result in the development of post-traumatic stress disorder (PTSD). Endocannabinoids are crucial modulators of the stress response, interfere with excessive retrieval and facilitate the extinction of traumatic memories. Exposure therapy, combined with pharmacotherapy, represents a promising tool for PTSD treatment. We investigated whether pharmacological manipulations of the endocannabinoid system during extinction learning ameliorates the behavioral changes induced by trauma exposure. Rats were exposed to inescapable footshocks paired with social isolation, a risk factor for PTSD. One week after trauma, rats were subjected to three spaced extinction sessions, mimicking human exposure therapy. The anandamide hydrolysis inhibitor URB597, the 2-arachidonoylglycerol hydrolysis inhibitor JZL184 or the cannabinoid agonist WIN55,212-2 were administered before or after the extinction sessions. Rats were tested for extinction retention 16 or 36 days after trauma and 24-h later for social interaction. Extinction training alone reduced fear of the trauma-associated context but did not restore normal social interaction. Traumatized animals not exposed to extinction sessions exhibited reductions in hippocampal anandamide content with respect to home-cage controls. Noteworthy, all drugs exerted beneficial effects, but URB597 (0.1 mg/kg) induced the best improvements by enhancing extinction consolidation and restoring normal social behavior in traumatized rats through indirect activation of CB1 receptors. The ameliorating effects remained stable long after treatment and trauma exposure. Our findings suggest that drugs potentiating endocannabinoid neurotransmission may represent promising tools when combined to exposure-based psychotherapies in the treatment of PTSD.
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Browne CA, Falcon E, Robinson SA, Berton O, Lucki I. Reversal of Stress-Induced Social Interaction Deficits by Buprenorphine. Int J Neuropsychopharmacol 2017; 21:164-174. [PMID: 29020387 PMCID: PMC5793841 DOI: 10.1093/ijnp/pyx079] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/22/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with post-traumatic stress disorder frequently report persistent problems with social interactions, emerging after a traumatic experience. Chronic social defeat stress is a widely used rodent model of stress that produces robust and sustained social avoidance behavior. The avoidance of other rodents can be reversed by 28 days of treatment with selective serotonin reuptake inhibitors, the only pharmaceutical class approved by the U.S. Food and Drug Administration for treating post-traumatic stress disorder. In this study, the sensitivity of social interaction deficits evoked by 10 days of chronic social defeat stress to prospective treatments for post-traumatic stress disorder was examined. METHODS The effects of acute and repeated treatment with a low dose of buprenorphine (0.25 mg/kg/d) on social interaction deficits in male C57BL/6 mice by chronic social defeat stress were studied. Another cohort of mice was used to determine the effects of the selective serotonin reuptake inhibitor fluoxetine (10 mg/kg/d), the NMDA antagonist ketamine (10 mg/kg/d), and the selective kappa opioid receptor antagonist CERC-501 (1 mg/kg/d). Changes in mRNA expression of Oprm1 and Oprk1 were assessed in a separate cohort. RESULTS Buprenorphine significantly reversed social interaction deficits produced by chronic social defeat stress following 7 days of administration, but not after acute injection. Treatment with fluoxetine for 7 days, but not 24 hours, also reinstated social interaction behavior in mice that were susceptible to chronic social defeat. In contrast, CERC-501 and ketamine failed to reverse social avoidance. Gene expression analysis found: (1) Oprm1 mRNA expression was reduced in the hippocampus and increased in the frontal cortex of susceptible mice and (2) Oprk1 mRNA expression was reduced in the amygdala and increased in the frontal cortex of susceptible mice compared to non-stressed controls and stress-resilient mice. CONCLUSIONS Short-term treatment with buprenorphine and fluoxetine normalized social interaction after chronic social defeat stress. In concert with the changes in opioid receptor expression produced by chronic social defeat stress, we speculate that buprenorphine's efficacy in this model of post-traumatic stress disorder may be associated with the ability of this compound to engage multiple opioid receptors.
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Affiliation(s)
| | | | | | | | - Irwin Lucki
- Departments of Psychiatry, Philadelphia, Pennsylvania,Systems Pharmacology and Translational Therapeutics, Philadelphia, Pennsylvania,University of Pennsylvania, Philadelphia, Pennsylvania,Correspondence: Irwin Lucki, PhD, Department of Pharmacology and Molecular Therapeutics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 ()
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Yan T, Xie Q, Zheng Z, Zou K, Wang L. Different frequency repetitive transcranial magnetic stimulation (rTMS) for posttraumatic stress disorder (PTSD): A systematic review and meta-analysis. J Psychiatr Res 2017; 89:125-135. [PMID: 28278422 DOI: 10.1016/j.jpsychires.2017.02.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 01/18/2017] [Accepted: 02/09/2017] [Indexed: 01/11/2023]
Abstract
Posttraumatic stress disorder (PTSD) is a psychiatric disorder. Repetitive transcranial magnetic stimulation (rTMS) has been found to be effective for treating PTSD, but whether different frequencies have different effects remains controversial. We conducted this systematic review and meta-analysis to address this question. We searched the literature for studies written in English or Chinese in 9 electronic databases from the databases' inception to August 1, 2016. Additional articles were identified from the reference lists of identified studies and from personal reference collections. Eighteen articles were included, and 11 were suitable for the meta-analysis (Combined sample size was 377 (217 in active rTMS groups, 160 in sham-controlled groups)). Low-frequency (LF) rTMS resulted in a significant reduction in the PTSD total score and the depression score (1. PTSD total score: pooled SMD, 0.92; CI, 0.11-1.72; 2. Depression: pooled SMD, 0.54; CI, 0.08-1.00). High-frequency (HF) rTMS showed the following results: 1. PTSD total score: pooled SMD, 3.24; CI, 2.24-4.25; 2. re-experiencing: pooled SMD, -1.77; CI, -2.49-(-1.04); 3. Avoidance: pooled SMD, -1.57; CI, -2.50-(-0.84); 4. hyperarousal: pooled SMD, -1.32; CI, -2.17-(-0.47); 5. depression: pooled SMD, 1.92; CI, 0.80-3.03; and 6. Anxiety: pooled SMD, 2.67; CI, 1.82-3.52. Therefore, both HF and LF rTMS can alleviate PTSD symptoms. Although the evidence is extremely limited, LF rTMS can reduce overall PTSD and depression symptoms. HF rTMS can improve the main and related symptoms of PTSD. However, additional research is needed to substantiate these findings.
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Affiliation(s)
- Tingting Yan
- Department of Disaster Medical Science, Sichuan University, Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, 610041, PR China.
| | - Qinglian Xie
- Department of Psychiatry, West China Hospital, Sichuan University, Chengdu, 610041, PR China
| | - Zhong Zheng
- Department of Neurobiological Examine Centre, West China Hospital, Sichuan University, Chengdu, 610041, PR China
| | - Ke Zou
- Department of Neurobiological Examine Centre, West China Hospital, Sichuan University, Chengdu, 610041, PR China
| | - Lijuan Wang
- Department of Neurology, Sichuan Academy of Medical Sciences & Sichuan Provincial Peoples Hospital, Chengdu, 610041, PR China
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Effects of moderate treadmill exercise and fluoxetine on behavioural and cognitive deficits, hypothalamic-pituitary-adrenal axis dysfunction and alternations in hippocampal BDNF and mRNA expression of apoptosis – related proteins in a rat model of post-traumatic stress disorder. Neurobiol Learn Mem 2017; 139:165-178. [DOI: 10.1016/j.nlm.2017.01.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 12/14/2016] [Accepted: 01/21/2017] [Indexed: 12/15/2022]
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The endocannabinoid system and Post Traumatic Stress Disorder (PTSD): From preclinical findings to innovative therapeutic approaches in clinical settings. Pharmacol Res 2016; 111:668-678. [DOI: 10.1016/j.phrs.2016.07.024] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/30/2016] [Accepted: 07/21/2016] [Indexed: 02/01/2023]
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Abstract
Increasing plasticity in neurons of the prefrontal cortex (PFC) has been proposed as a possible therapeutic tool to enhance extinction, a process that is impaired in post-traumatic stress disorder, schizophrenia, and addiction. To test this hypothesis, we generated transgenic mice that overexpress neurogranin (a calmodulin-binding protein that facilitates long-term potentiation) in the PFC. Neurogranin overexpression in the PFC enhanced long-term potentiation and increased the rates of extinction learning of both fear conditioning and sucrose self-administration. Our results indicate that elevated neurogranin function within the PFC can enhance local plasticity and increase the rate of extinction learning across different behavioral tasks. Thus, neurogranin can provide a molecular link between enhanced plasticity and enhanced extinction.
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Xia J, Du Y, Han J, Liu G, Wang X. D-cycloserine augmentation in behavioral therapy for obsessive-compulsive disorder: a meta-analysis. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:2101-17. [PMID: 25960632 PMCID: PMC4410826 DOI: 10.2147/dddt.s68994] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate the overall effect of D-cycloserine (DCS) augmentation on exposure and response prevention (ERP) therapy for obsessive-compulsive disorder (OCD). METHODS Clinical studies on the effect of DCS augmentation on ERP therapy for OCD compared to placebo were included for meta analysis. The primary outcome was the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Meta-analyses were performed with a random-effect model or a fixed-effect model using the Cochrane Review Manager (RevMan, version 5.2) to calculate the odds ratio and the mean difference, with their corresponding 95% confidence intervals. RESULTS A total of six studies was included in the current meta-analyses, and their data were extracted. Among them, four were for analyses of DCS and Y-BOCS at midtreatment, six for analysis at posttreatment, and four at 3-month follow-up. Besides, three of the six eligible studies were included in the meta-analysis of the DCS and Clinical Global Impression-Severity Scale at posttreatment, and three in the meta-analysis of DCS and proportions of treatment responders and of subjects attaining clinical remission status criteria at posttreatment. Our meta-analyses do not reveal a significant effect of DCS augmentation in ERP therapy for OCD patients, except when measured at midtreatment. Compared to the placebo group, DCS augmentation did show a trend toward significantly lower/decreased Y-BOCS; when measured at posttreatment and in the subpopulation of DCS taken before some of the ERP sessions, DCS augmentation showed a trend toward significantly lower/decreased Y-BOCS. CONCLUSION Our result suggested that with the careful optimization of DCS-augmented ERP therapy by fine-tuning timing and dosing of DCS administration and number and frequency of ERP sessions, DCS may enhance the efficacy of ERP therapy in reducing the symptomatic severity of OCD patients, especially at early stage of the treatment; therefore, DCS augmentation could possibly reduce treatment cost, reduce treatment drop and refusal rate, and help to improve access to the limited number of experienced therapists.
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Affiliation(s)
- Jing Xia
- Department of Psychiatry, Shengjing Hospital of China Medical University, Heping District Shenyang, Liaoning, People's Republic of China
| | - Yanqiu Du
- Department of Medicine, Shenyang Ninth People's Hospital, Tiexi District, Shenyang, Liaoning, People's Republic of China
| | - Jiyang Han
- Department of Psychiatry, Shengjing Hospital of China Medical University, Heping District Shenyang, Liaoning, People's Republic of China
| | - Guo Liu
- Department of Psychiatry, Shengjing Hospital of China Medical University, Heping District Shenyang, Liaoning, People's Republic of China
| | - Xumei Wang
- Department of Psychiatry, Shengjing Hospital of China Medical University, Heping District Shenyang, Liaoning, People's Republic of China
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Neuromodulation Approaches for the Treatment of Post-Traumatic Stress Disorder: Stimulating the Brain Following Exposure-based Therapy. Curr Behav Neurosci Rep 2015. [DOI: 10.1007/s40473-015-0042-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Sethna F, Wang H. Pharmacological enhancement of mGluR5 facilitates contextual fear memory extinction. ACTA ACUST UNITED AC 2014; 21:647-50. [PMID: 25403451 PMCID: PMC4236415 DOI: 10.1101/lm.035857.114] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Behavioral exposure therapy, which involves extinction of the previously acquired fear, has been used to treat anxiety-related symptoms such as post-traumatic stress disorder. It has been hypothesized that proextinction pharmacotherapeutics may enhance the efficacy of exposure therapy. Systemic administration of the metabotropic glutamate receptor 5 (mGluR5)-positive allosteric modulator 3-cyano-N-(1,3-diphenyl-1H-pyrazol-5-yl)benzamide (CDPPB) facilitated the extinction of contextual fear memory. Notably, CDPPB also enhanced the initial fear memory formation, and had no effect on memory retrieval. Our data suggest that positive regulation of mGluR5 may offer a new method to enhance exposure therapy through facilitating extinction without adversely affecting other aspects of memory process.
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Affiliation(s)
- Ferzin Sethna
- Genetics Program, Michigan State University, East Lansing, Michigan 48824, USA
| | - Hongbing Wang
- Department of Physiology, Michigan State University, East Lansing, Michigan 48824, USA Neuroscience Program, Michigan State University, East Lansing, Michigan 48824, USA
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Glenn DE, Minor TR, Vervliet B, Craske MG. The effect of glucose on hippocampal-dependent contextual fear conditioning. Biol Psychiatry 2014; 75:847-54. [PMID: 24199667 DOI: 10.1016/j.biopsych.2013.09.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 09/17/2013] [Accepted: 09/20/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The metabolic challenge of trauma disrupts hippocampal functioning, which is necessary for processing the complex co-occurring elements comprising the traumatic context. Poor contextual memory of trauma may subsequently contribute to intrusive memories and overgeneralization of fear. Glucose consumption following trauma may be a means to protect hippocampal functioning and contextual fear learning. This study experimentally examined the effect of glucose on hippocampal-dependent contextual learning versus cued fear learning in humans. METHODS Forty-two male participants underwent cued conditioning with an unconditional stimulus (US) (shock) paired with a discrete conditional stimulus (geometric shape) and context conditioning (requiring hippocampal processing) with a US unpredictably paired with a background context (picture of room). Participants were then blindly randomized to consume either a 25 g glucose or sweet-tasting placebo drink and returned for a test phase 24 hours later. Measures included acoustic startle response, US expectancy, blood glucose levels, and arousal ratings. RESULTS The glucose group showed superior retention of hippocampal-dependent contextual learning at test relative to the placebo group, as demonstrated by acoustic startle response and US expectancy ratings. Glucose and placebo groups did not differ on any measure of cued fear learning at test. CONCLUSIONS This study provides experimental evidence that in mildly stressed humans postconditioning glucose consumption improves retention of hippocampal-dependent contextual learning but not cued learning. Ultimately, glucose consumption following trauma may be a means of improving learning about the traumatic context, thereby preventing subsequent development of symptoms of posttraumatic stress.
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Affiliation(s)
- Daniel E Glenn
- Department of Psychology, University of California, Los Angeles, California.
| | - Thomas R Minor
- Department of Psychology, University of California, Los Angeles, California
| | - Bram Vervliet
- Department of Psychology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michelle G Craske
- Department of Psychology, University of California, Los Angeles, California
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Abstract
Whereas fear memories are rapidly acquired and enduring over time, extinction memories are slow to form and are susceptible to disruption. Consequently, behavioral therapies that involve extinction learning (e.g., exposure therapy) often produce only temporary suppression of fear and anxiety. This review focuses on the factors that are known to influence the relapse of extinguished fear. Several phenomena associated with the return of fear after extinction are discussed, including renewal, spontaneous recovery, reacquisition, and reinstatement. Additionally, this review describes recent work, which has focused on the role of psychological stress in the relapse of extinguished fear. Recent developments in behavioral and pharmacological research are examined in light of treatment of pathological fear in humans.
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de Kleine RA, Rothbaum BO, van Minnen A. Pharmacological enhancement of exposure-based treatment in PTSD: a qualitative review. Eur J Psychotraumatol 2013; 4:21626. [PMID: 24147208 PMCID: PMC3800126 DOI: 10.3402/ejpt.v4i0.21626] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 08/01/2013] [Accepted: 09/11/2013] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Rianne A de Kleine
- Behavioral Science Institute, Radboud University Nijmegen, Nijmegen, the Netherlands ; Overwaal, Centre for Anxiety Disorders (Pro Persona), Nijmegen, the Netherlands ; NijCare, Nijmegen, the Netherlands
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Wangelin BC, Powers MB, Smits JAJ, Tuerk PW. Enhancing exposure therapy for PTSD with yohimbine HCL: protocol for a double-blind, randomized controlled study implementing subjective and objective measures of treatment outcome. Contemp Clin Trials 2013; 36:319-26. [PMID: 23939512 DOI: 10.1016/j.cct.2013.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 07/30/2013] [Accepted: 08/03/2013] [Indexed: 02/06/2023]
Abstract
Prolonged exposure (PE) therapy is considered a gold standard protocol for the treatment of PTSD, and it is associated with large treatment effect sizes in combat veteran samples. However, considering high rates of PTSD in the present veteran population, ongoing research work is important toward improving treatment efficiency by decreasing time to symptom amelioration and increasing the amount of symptom amelioration. The proposed research aims to enhance exposure therapy outcomes for veterans with PTSD via combination treatment with PE and yohimbine hydrochloride (HCL), an alpha-2 adrenergic receptor antagonist. The proposed investigation entails a randomized, placebo-controlled trial investigating the effect of a single administration of yohimbine HCL (paired with the first session of imaginal exposure) on outcome of PE in 40 veterans with PTSD. An additional goal is to establish a pragmatic method of tracking psychophysiological measures over the course of therapy for incorporation into future clinical psychotherapy trials. Thus, in addition to traditional self- and clinician-reported psychological outcomes, heart rate and skin conductance reactivity will be measured during a standard trauma-specific imagery task before, during, and after PE treatment. We will further investigate whether changes in psychophysiological measures predict changes in patient- and clinician-reported outcome measures.
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Affiliation(s)
- Bethany C Wangelin
- Mental Health Service Line, Ralph H. Johnson Veterans Affairs Medical Center, 109 Bee St., Charleston, SC, United States; Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St., Charleston, SC 29401, United States.
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Isserles M, Shalev AY, Roth Y, Peri T, Kutz I, Zlotnick E, Zangen A. Effectiveness of Deep Transcranial Magnetic Stimulation Combined with a Brief Exposure Procedure in Post-Traumatic Stress Disorder – A Pilot Study. Brain Stimul 2013; 6:377-83. [DOI: 10.1016/j.brs.2012.07.008] [Citation(s) in RCA: 169] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 07/27/2012] [Accepted: 07/29/2012] [Indexed: 02/06/2023] Open
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Macdonald K, Feifel D. Helping oxytocin deliver: considerations in the development of oxytocin-based therapeutics for brain disorders. Front Neurosci 2013; 7:35. [PMID: 23508240 PMCID: PMC3597931 DOI: 10.3389/fnins.2013.00035] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 02/28/2013] [Indexed: 11/13/2022] Open
Abstract
Concerns regarding a drought in psychopharmacology have risen from many quarters. From one perspective, the wellspring of bedrock medications for anxiety disorders, depression, and schizophrenia was serendipitously discovered over 30 year ago, the swell of pharmaceutical investment in drug discovery has receded, and the pipeline's flow of medications with unique mechanisms of action (i.e., glutamatergic agents, CRF antagonists) has slowed to a trickle. Might oxytocin (OT)-based therapeutics be an oasis? Though a large basic science literature and a slowly increasing number of studies in human diseases support this hope, the bulk of extant OT studies in humans are single-dose studies on normals, and do not directly relate to improvements in human brain-based diseases. Instead, these studies have left us with a field pregnant with therapeutic possibilities, but barren of definitive treatments. In this clinically oriented review, we discuss the extant OT literature with an eye toward helping OT deliver on its promise as a therapeutic agent. To this end, we identify 10 key questions that we believe future OT research should address. From this overview, several conclusions are clear: (1) the OT system represents an extremely promising target for novel CNS drug development; (2) there is a pressing need for rigorous, randomized controlled clinical trials targeting actual patients; and (3) in order to inform the design and execution of these vital trials, we need further translational studies addressing the questions posed in this review. Looking forward, we extend a cautious hope that the next decade of OT research will birth OT-targeted treatments that can truly deliver on this system's therapeutic potential.
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Affiliation(s)
- K Macdonald
- Department of Psychiatry, University of California, San Diego San Diego, CA, USA
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20
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d-Cycloserine administered directly to infralimbic medial prefrontal cortex enhances extinction memory in sucrose-seeking animals. Neuroscience 2013; 230:24-30. [DOI: 10.1016/j.neuroscience.2012.11.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 11/01/2012] [Accepted: 11/03/2012] [Indexed: 01/13/2023]
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Maccani MA, Delahanty DL, Nugent NR, Berkowitz SJ. Pharmacological secondary prevention of PTSD in youth: challenges and opportunities for advancement. J Trauma Stress 2012; 25:543-50. [PMID: 23073974 PMCID: PMC4019220 DOI: 10.1002/jts.21731] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Child and adolescent posttraumatic stress disorder (PTSD) is associated with an increased risk for a number of deleterious mental and physical health outcomes that if untreated may persist throughout the life course. Efficacious interventions applied soon after trauma exposure have the potential to reduce or prevent the development of PTSD symptoms and their associated impact on behavior and physical health. We review extant research related to treatment-modifiable peritraumatic predictors of pediatric PTSD, which have informed an emerging field of pharmacologic secondary prevention (i.e., occurring shortly following trauma exposure) of PTSD. Challenges and opportunities for early posttrauma PTSD prevention are described. Finally, we offer new models for biologically informed integration of pharmacologic and psychosocial secondary prevention intervention strategies for children and adolescents.
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Affiliation(s)
- Matthew A. Maccani
- Division of Behavioral Genetics, Rhode Island Hospital, Providence, Rhode Island, USA,Center for Alcohol and Addiction Studies, Brown University, Providence, Rhode Island, USA
| | - Douglas L. Delahanty
- Department of Psychology, Kent State University, Kent, Ohio, USA,Northeastern Ohio University College of Medicine, Rootstown, Ohio, USA,Medical Research, Summa Health System, Akron, Ohio, USA
| | - Nicole R. Nugent
- Division of Behavioral Genetics, Rhode Island Hospital, Providence, Rhode Island, USA,Alpert Brown Medical School and Bradley/Hasbro Children’s Research Center, Providence, Rhode Island, USA
| | - Steven J. Berkowitz
- Department of Psychiatry, University of Pennsylvania, School of Medicine Philadelphia, Pennsylvania, USA,Yale University Child Study Center, Yale University, New Haven, Connecticut, USA
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Geyer MA, Olivier B, Joëls M, Kahn RS. From antipsychotic to anti-schizophrenia drugs: role of animal models. Trends Pharmacol Sci 2012; 33:515-21. [PMID: 22810174 PMCID: PMC3461097 DOI: 10.1016/j.tips.2012.06.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 06/14/2012] [Accepted: 06/15/2012] [Indexed: 01/24/2023]
Abstract
Current drugs for treating schizophrenia are mostly variations on a theme that was started over 50 years ago. Sadly, clinical efficacy has not improved substantially over the years. We argue that both clinical and preclinical researchers have focused too much on psychosis, which is only one of the hallmarks of schizophrenia. This narrow focus has hampered the development of relevant animal models and human experimental medicine paradigms. Other fields in psychiatry, most notably in the realms of addiction and anxiety, have prospered from results obtained in parallel studies using animal models and experimental human studies. Lessons to be learned from those models and recent genetic and cognitive insights in schizophrenia can be utilized to develop better animal and human models and, potentially, novel treatment strategies.
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Affiliation(s)
- Mark A Geyer
- Department of Psychiatry, University of California San Diego, La Jolla, San Diego, CA, USA.
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Cain CK, Maynard GD, Kehne JH. Targeting memory processes with drugs to prevent or cure PTSD. Expert Opin Investig Drugs 2012; 21:1323-50. [PMID: 22834476 DOI: 10.1517/13543784.2012.704020] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Post-traumatic stress disorder (PTSD) is a chronic debilitating psychiatric disorder resulting from exposure to a severe traumatic stressor and an area of great unmet medical need. Advances in pharmacological treatments beyond the currently approved SSRIs are needed. AREAS COVERED Background on PTSD, as well as the neurobiology of stress responding and fear conditioning, is provided. Clinical and preclinical data for investigational agents with diverse pharmacological mechanisms are summarized. EXPERT OPINION Advances in the understanding of stress biology and mechanisms of fear conditioning plasticity provide a rationale for treatment approaches that may reduce hyperarousal and dysfunctional aversive memories in PTSD. One challenge is to determine if these components are independent or reflect a common underlying neurobiological alteration. Numerous agents reviewed have potential for reducing PTSD core symptoms or targeted symptoms in chronic PTSD. Promising early data support drug approaches that seek to disrupt dysfunctional aversive memories by interfering with consolidation soon after trauma exposure, or in chronic PTSD, by blocking reconsolidation and/or enhancing extinction. Challenges remain for achieving selectivity when attempting to alter aversive memories. Targeting the underlying traumatic memory with a combination of pharmacological therapies applied with appropriate chronicity, and in combination with psychotherapy, is expected to substantially improve PTSD treatment.
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Andero R, Ressler KJ. Fear extinction and BDNF: translating animal models of PTSD to the clinic. GENES BRAIN AND BEHAVIOR 2012; 11:503-12. [PMID: 22530815 DOI: 10.1111/j.1601-183x.2012.00801.x] [Citation(s) in RCA: 184] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Brain-derived neurotrophic factor (BDNF) is the most studied neurotrophin involved in synaptic plasticity processes that are required for long-term learning and memory. Specifically, BDNF gene expression and activation of its high-affinity tropomyosin-related kinase B (TrkB) receptor are necessary in the amygdala, hippocampus and prefrontal cortex for the formation of emotional memories, including fear memories. Among the psychiatric disorders with altered fear processing, there is post-traumatic stress disorder (PTSD) which is characterized by an inability to extinguish fear memories. Since BDNF appears to enhance extinction of fear, targeting impaired extinction in anxiety disorders such as PTSD via BDNF signalling may be an important and novel way to enhance treatment efficacy. The aim of this review is to provide a translational point of view that stems from findings in the BDNF regulation of synaptic plasticity and fear extinction. In addition, there are different systems that seem to alter fear extinction through BDNF modulation like the endocannabinoid system and the hypothalamic-pituitary adrenal axis. Recent work also finds that the pituitary adenylate cyclase-activating polypeptide and PAC1 receptor, which are upstream of BDNF activation, may be implicated in PTSD. Especially interesting are data that exogenous fear extinction enhancers such as antidepressants, histone deacetylases inhibitors and D-cycloserine, a partial N-methyl d-aspartate agonist, may act through or in concert with the BDNF-TrkB system. Finally, we review studies where recombinant BDNF and a putative TrkB agonist, 7,8-dihydroxyflavone, may enhance extinction of fear. These approaches may lead to novel agents that improve extinction in animal models and eventually humans.
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Affiliation(s)
- R Andero
- Department of Psychiatry and Behavioral Sciences, Yerkes National Primate Research Center, Emory University School of Medicine, Atlanta, GA, USA
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Lebron-Milad K, Milad MR. Sex differences, gonadal hormones and the fear extinction network: implications for anxiety disorders. BIOLOGY OF MOOD & ANXIETY DISORDERS 2012; 2:3. [PMID: 22738383 PMCID: PMC3384233 DOI: 10.1186/2045-5380-2-3] [Citation(s) in RCA: 191] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 02/07/2012] [Indexed: 01/11/2023]
Abstract
Convergent data from rodents and human studies have led to the development of models describing the neural mechanisms of fear extinction. Key components of the now well-characterized fear extinction network include the amygdala, hippocampus, and medial prefrontal cortical regions. These models are fueling novel hypotheses that are currently being tested with much refined experimental tools to examine the interactions within this network. Lagging far behind, however, is the examination of sex differences in this network and how sex hormones influence the functional activity and reactivity of these brain regions in the context of fear inhibition. Indeed, there is a large body of literature suggesting that sex hormones, such as estrogen, do modulate neural plasticity within the fear extinction network, especially in the hippocampus.After a brief overview of the fear extinction network, we summarize what is currently known about sex differences in fear extinction and the influence of gonadal hormones on the fear extinction network. We then go on to propose possible mechanisms by which sex hormones, such as estrogen, may influence neural plasticity within the fear extinction network. We end with a discussion of how knowledge to be gained from developing this line of research may have significant ramifications towards the etiology, epidemiology and treatment of anxiety disorders.
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Affiliation(s)
- Kelimer Lebron-Milad
- Department of Psychiatry, Harvard Medical School & Massachusetts General Hospital, Boston, MA, USA.
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Glutamate abnormalities in obsessive compulsive disorder: neurobiology, pathophysiology, and treatment. Pharmacol Ther 2011; 132:314-32. [PMID: 21963369 DOI: 10.1016/j.pharmthera.2011.09.006] [Citation(s) in RCA: 222] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Accepted: 08/29/2011] [Indexed: 11/22/2022]
Abstract
Obsessive compulsive disorder is prevalent, disabling, incompletely understood, and often resistant to current therapies. Established treatments consist of specialized cognitive-behavioral psychotherapy and pharmacotherapy with medications targeting serotonergic and dopaminergic neurotransmission. However, remission is rare, and more than a quarter of OCD sufferers receive little or no benefit from these approaches, even when they are optimally delivered. New insights into the disorder, and new treatment strategies, are urgently needed. Recent evidence suggests that the ubiquitous excitatory neurotransmitter glutamate is dysregulated in OCD, and that this dysregulation may contribute to the pathophysiology of the disorder. Here we review the current state of this evidence, including neuroimaging studies, genetics, neurochemical investigations, and insights from animal models. Finally, we review recent findings from small clinical trials of glutamate-modulating medications in treatment-refractory OCD. The precise role of glutamate dysregulation in OCD remains unclear, and we lack blinded, well-controlled studies demonstrating therapeutic benefit from glutamate-modulating agents. Nevertheless, the evidence supporting some important perturbation of glutamate in the disorder is increasingly strong. This new perspective on the pathophysiology of OCD, which complements the older focus on monoaminergic neurotransmission, constitutes an important focus of current research and a promising area for the ongoing development of new therapeutics.
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