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Lauten TH, Natour T, Case AJ. Innate and adaptive immune system consequences of post-traumatic stress disorder. Auton Neurosci 2024; 252:103159. [PMID: 38428324 DOI: 10.1016/j.autneu.2024.103159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/06/2024] [Accepted: 02/21/2024] [Indexed: 03/03/2024]
Abstract
In the field of psychiatry, biological markers are rarely, if ever, used in the diagnosis of mental health disorders. Clinicians rely primarily on patient histories and behavioral symptoms to identify specific psychopathologies, which makes diagnosis highly subjective. Moreover, therapies for mental health disorders are aimed specifically at attenuating behavioral manifestations, which overlooks the pathophysiological indices of the disease. This is highly evident in posttraumatic stress disorder (PTSD) where inflammation and immune system perturbations are becoming increasingly described. Further, patients with PTSD possess significantly elevated risks of developing comorbid inflammatory diseases such as autoimmune and cardiovascular diseases, which are likely linked (though not fully proven) to the apparent dysregulation of the immune system after psychological trauma. To date, there is little to no evidence that demonstrates current PTSD therapies are able to reverse the increased risk for psychological trauma-induced inflammatory diseases, which suggests the behavioral and somatic consequences of PTSD may not be tightly coupled. This observation provides an opportunity to explore unique mechanisms outside of the brain that contribute to the long-term pathology of PTSD. Herein, we provide an overview of neuroimmune mechanisms, describe what is known regarding innate and adaptive immunity in PTSD, and suggest new directions that are needed to advance the understanding, diagnosis, and treatment of PTSD moving forward.
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Affiliation(s)
- Tatlock H Lauten
- Department of Psychiatry and Behavioral Sciences, Texas A&M University, Bryan, TX, United States; Department of Medical Physiology, Texas A&M University, Bryan, TX, United States
| | - Tamara Natour
- Department of Psychiatry and Behavioral Sciences, Texas A&M University, Bryan, TX, United States; Department of Medical Physiology, Texas A&M University, Bryan, TX, United States
| | - Adam J Case
- Department of Psychiatry and Behavioral Sciences, Texas A&M University, Bryan, TX, United States; Department of Medical Physiology, Texas A&M University, Bryan, TX, United States.
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2
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He Q, Wang W, Xu D, Xiong Y, Tao C, You C, Ma L, Ma J. Potential causal association between gut microbiome and posttraumatic stress disorder. Transl Psychiatry 2024; 14:67. [PMID: 38296956 PMCID: PMC10831060 DOI: 10.1038/s41398-024-02765-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND The causal effects of gut microbiome and the development of posttraumatic stress disorder (PTSD) are still unknown. This study aimed to clarify their potential causal association using mendelian randomization (MR). METHODS The summary-level statistics for gut microbiome were retrieved from a genome-wide association study (GWAS) of the MiBioGen consortium. As to PTSD, the Freeze 2 datasets were originated from the Psychiatric Genomics Consortium Posttraumatic Stress Disorder Working Group (PGC-PTSD), and the replicated datasets were obtained from FinnGen consortium. Single nucleotide polymorphisms meeting MR assumptions were selected as instrumental variables. The inverse variance weighting (IVW) method was employed as the main approach, supplemented by sensitivity analyses to evaluate potential pleiotropy and heterogeneity and ensure the robustness of the MR results. We also performed reverse MR analyses to explore PTSD's causal effects on the relative abundances of specific features of the gut microbiome. RESULTS In Freeze 2 datasets from PGC-PTSD, eight bacterial traits revealed a potential causal association between gut microbiome and PTSD (IVW, all P < 0.05). In addition, Genus.Dorea and genus.Sellimonas were replicated in FinnGen datasets, in which eight bacterial traits revealed a potential causal association between gut microbiome and the occurrence of PTSD. The heterogeneity and pleiotropy analyses further supported the robustness of the IVW findings, providing additional evidence for their reliability. CONCLUSION Our study provides the potential causal impact of gut microbiomes on the development of PTSD, shedding new light on the understanding of the dysfunctional gut-brain axis in this disorder. Our findings present novel evidence and call for investigations to confirm the association between their links, as well as to illuminate the underlying mechanisms.
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Affiliation(s)
- Qiang He
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Wenjing Wang
- Department of Pharmacy, Institute of Metabolic Diseases and Pharmacotherapy, West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou District, Chengdu, China
| | - Dingkang Xu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Xiong
- Department of Urology, West China Hospital, Sichuan University, Chengdu, China
| | - Chuanyuan Tao
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China
| | - Junpeng Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Lane, Wuhou District, Chengdu, 610041, Sichuan, China.
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Raeder R, Clayton NS, Boeckle M. Narrative-based autobiographical memory interventions for PTSD: a meta-analysis of randomized controlled trials. Front Psychol 2023; 14:1215225. [PMID: 37829075 PMCID: PMC10565228 DOI: 10.3389/fpsyg.2023.1215225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/25/2023] [Indexed: 10/14/2023] Open
Abstract
Introduction The aim of this systematic review and meta-analysis is to evaluate the efficacy of narrative-based interventions (NBIs) for individuals with post-traumatic stress disorder (PTSD). Investigating the efficacy of NBIs should yield insight on autobiographical memory (AM) phenomena implicated in PTSD onset and recovery, leading to improved intervention protocols. Furthermore, by analyzing how NBIs influence maladaptive AM distortions, we hope to shed light on the theorized narrative architecture of AM more generally. Methods A systematic literature search was conducted according to PRISMA and Cochrane guidelines in MEDLINE, EMBASE, PsychINFO, and PubMed. Additional studies were then also identified from the reference lists of other relevant literature and considered for inclusion. Studies were then evaluated for adherence to the inclusion/exclusion criteria and assessed for risk of bias. Various meta-analyses were performed on included studies to understand how NBIs may or may not influence the overall effect size of treatment. Results The results of the meta-analysis of 35 studies, involving 2,596 participants, suggest that NBIs are a viable and effective treatment option for PTSD, yielding a statistically significant within-group effect size and decrease in PTSD symptomatology at both post-treatment [g = 1.73, 95% CI (1.23-2.22)] and 3-9 month follow-up assessments [g = 2.33, 95% CI (1.41-3.26)]. Furthermore, the difference in effect sizes between NBIs compared to active and waitlist controls was statistically significant, suggesting that NBIs are superior. Sub-analyses showed that NET provided a stronger effect size than FORNET, which may be due to the nature of the traumatic event itself and not the treatment protocol. While evidence of small study and publication bias was present, a weight-function model and trim-and-fill method suggested it was not influencing the overall results. Discussion This meta-analysis presents strong evidence supporting the use of NBIs in the treatment of PTSD. Clear similarities can be identified between NBIs included in this analysis that make them distinct from non-NBI interventions, which are reviewed in the discussion. Controlled comparisons between NBIs and non-NBIs would help to further understand AM mechanisms of action implicated in recovery and how various interventions facilitate them. Future research should also aim to elucidate the full range of AM impairment in individuals with PTSD to gain insight on how other memory capabilities, such as the ability to mentally simulate the future, are implicated in the pathogenesis of PTSD.
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Affiliation(s)
- Robert Raeder
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Nicola S. Clayton
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Markus Boeckle
- Scientific Working Group, Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Transitory Psychiatry, University Hospital Tulln, Tulln, Austria
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Olson KE, Mosley RL, Gendelman HE. The potential for treg-enhancing therapies in nervous system pathologies. Clin Exp Immunol 2023; 211:108-121. [PMID: 36041453 PMCID: PMC10019130 DOI: 10.1093/cei/uxac084] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/28/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
While inflammation may not be the cause of disease, it is well known that it contributes to disease pathogenesis across a multitude of peripheral and central nervous system disorders. Chronic and overactive inflammation due to an effector T-cell-mediated aberrant immune response ultimately leads to tissue damage and neuronal cell death. To counteract peripheral and neuroinflammatory responses, research is being focused on regulatory T cell enhancement as a therapeutic target. Regulatory T cells are an immunosuppressive subpopulation of CD4+ T helper cells essential for maintaining immune homeostasis. The cells play pivotal roles in suppressing immune responses to maintain immune tolerance. In so doing, they control T cell proliferation and pro-inflammatory cytokine production curtailing autoimmunity and inflammation. For nervous system pathologies, Treg are known to affect the onset and tempo of neural injuries. To this end, we review recent findings supporting Treg's role in disease, as well as serving as a therapeutic agent in multiple sclerosis, myasthenia gravis, Guillain-Barre syndrome, Parkinson's and Alzheimer's diseases, and amyotrophic lateral sclerosis. An ever-broader role for Treg in the control of neurologic disease has been shown for traumatic brain injury, stroke, neurotrophic pain, epilepsy, and psychiatric disorders. To such ends, this review serves to examine the role played by Tregs in nervous system diseases with a focus on harnessing their functional therapeutic role(s).
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Affiliation(s)
- Katherine E Olson
- Department of Pharmacology and Experimental Neuroscience, Center for Neurodegenerative Disorders, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - R L Mosley
- Department of Pharmacology and Experimental Neuroscience, Center for Neurodegenerative Disorders, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
| | - Howard E Gendelman
- Department of Pharmacology and Experimental Neuroscience, Center for Neurodegenerative Disorders, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
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5
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Goldschen L, Ellrodt J, Amonoo HL, Feldman CH, Case SM, Koenen KC, Kubzansky LD, Costenbader KH. The link between post-traumatic stress disorder and systemic lupus erythematosus. Brain Behav Immun 2023; 108:292-301. [PMID: 36535611 PMCID: PMC10018810 DOI: 10.1016/j.bbi.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 12/03/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous, multisystem autoimmune disorder characterized by unpredictable disease flares. Although the pathogenesis of SLE is complex, an epidemiologic link between posttraumatic stress disorder (PTSD) and the development of SLE has been identified, suggesting that stress-related disorders alter the susceptibility to SLE. Despite the strong epidemiologic evidence connecting PTSD and SLE, gaps remain in our understanding of how the two may be connected. Perturbations in the autonomic nervous system, neuroendocrine system, and at the genomic level may cause and sustain immune dysregulation that could lower the threshold for the development and propagation of SLE. We first describe shared risk factors for SLE and PTSD. We then describe potential biological pathways which may facilitate excessive inflammation in the context of PTSD. Among those genetically predisposed to SLE, systemic inflammation that accompanies chronic stress may fan the flames of smoldering SLE by priming immune pathways. Further studies on the connection between trauma and inflammation will provide important data on pathogenesis, risk factors, and novel treatments for SLE.
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Affiliation(s)
- Lauren Goldschen
- Department of Psychiatry, Brigham and Women's Hospital, 60 Fenwood Road, MA 02115, USA.
| | - Jack Ellrodt
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
| | - Hermioni L Amonoo
- Department of Psychiatry, Brigham and Women's Hospital, 60 Fenwood Road, MA 02115, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Candace H Feldman
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
| | - Siobhan M Case
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
| | - Karestan C Koenen
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Laura D Kubzansky
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA
| | - Karen H Costenbader
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115, USA
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6
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Dawud LM, Holbrook EM, Lowry CA. Evolutionary Aspects of Diverse Microbial Exposures and Mental Health: Focus on "Old Friends" and Stress Resilience. Curr Top Behav Neurosci 2023; 61:93-117. [PMID: 35947354 PMCID: PMC9918614 DOI: 10.1007/7854_2022_385] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The prevalence of inflammatory disease conditions, including allergies, asthma, and autoimmune disorders, increased during the latter half of the twentieth century, as societies transitioned from rural to urban lifestyles. A number of hypotheses have been put forward to explain the increasing prevalence of inflammatory disease in modern urban societies, including the hygiene hypothesis and the "Old Friends" hypothesis. In 2008, Rook and Lowry proposed, based on the evidence that increased inflammation was a risk factor for stress-related psychiatric disorders, that the hygiene hypothesis or "Old Friends" hypothesis may be relevant to psychiatric disorders. Since then, it has become more clear that chronic low-grade inflammation is a risk factor for stress-related psychiatric disorders, including anxiety disorders, mood disorders, and trauma- and stressor-related disorders, such as posttraumatic stress disorder (PTSD). Evidence now indicates that persons raised in modern urban environments without daily contact with pets, relative to persons raised in rural environments in proximity to farm animals, respond with greater systemic inflammation to psychosocial stress. Here we consider the possibility that increased inflammation in persons living in modern urban environments is due to a failure of immunoregulation, i.e., a balanced expression of regulatory and effector T cells, which is known to be dependent on microbial signals. We highlight evidence that microbial signals that can drive immunoregulation arise from phylogenetically diverse taxa but are strain specific. Finally, we highlight Mycobacterium vaccae NCTC 11659, a soil-derived bacterium with anti-inflammatory and immunoregulatory properties, as a case study of how single strains of bacteria might be used in a psychoneuroimmunologic approach for prevention and treatment of stress-related psychiatric disorders.
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Affiliation(s)
- Lamya'a M Dawud
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Evan M Holbrook
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA
| | - Christopher A Lowry
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO, USA.
- Department of Psychology and Neuroscience, University of Colorado Boulder, Boulder, CO, USA.
- Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional VA Medical Center (RMRVAMC), Aurora, CO, USA.
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, CO, USA.
- Center for Neuroscience, University of Colorado Boulder, Boulder, CO, USA.
- Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, USA.
- inVIVO Planetary Health, Worldwide Universities Network (WUN), West New York, NJ, USA.
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7
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Behnke A, Mack M, Fieres J, Christmann M, Bürkle A, Moreno-Villanueva M, Kolassa IT. Expression of DNA repair genes and its relevance for DNA repair in peripheral immune cells of patients with posttraumatic stress disorder. Sci Rep 2022; 12:18641. [PMID: 36333408 PMCID: PMC9636148 DOI: 10.1038/s41598-022-22001-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) involves elevated levels of cellular oxidative stress which jeopardizes the integrity of essential cell compartments. Previously, we demonstrated higher levels of DNA lesions in peripheral blood mononuclear cells (PBMCs) in PTSD. Retaining vital levels of DNA integrity requires cells to mobilize compensatory efforts in elevating their DNA-repair capacity. Accordingly, we hypothesized to find increased expression rates of the DNA-repair genes X-ray repair cross complementing 1 (XRCC1), poly (ADP-ribose) polymerase 1 (PARP1), and polymerase β (Polβ) in PBMCs of PTSD patients as compared to controls, leading to functionally relevant changes in DNA-repair kinetics. In a cohort of 14 refugees with PTSD and 15 without PTSD, we found significantly higher XRCC1 expression in PTSD patients than controls (U = 161.0, p = 0.009, Cohen's r = 0.49), and positive correlations between the severity of PTSD symptoms and the expression of XRCC1 (rS = 0.57, p = 0.002) and PARP1 (rS = 0.43, p = 0.022). Higher XRCC1 (F = 2.39, p = 0.010, η2p = 0.10) and PARP1 (F = 2.15, p = 0.022, η2p = 0.09) expression accounted for slower repair of experimentally X-ray irradiation-induced DNA damage, highlighting the possible physiological relevance of altered DNA-repair gene expression in PTSD. Our study provides first evidence for a compensatory regulation of DNA-repair mechanisms in PTSD. We discuss the implications of increased DNA damage and altered DNA-repair mechanisms in immune senescence, premature aging, and increased physical morbidity in PTSD.
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Affiliation(s)
- Alexander Behnke
- grid.6582.90000 0004 1936 9748Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Albert-Einstein-Allee 47, 89081 Ulm, Germany
| | - Matthias Mack
- grid.6582.90000 0004 1936 9748Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Albert-Einstein-Allee 47, 89081 Ulm, Germany ,grid.9811.10000 0001 0658 7699Molecular Toxicology, Department of Biology, University of Konstanz, 78457 Constance, Germany
| | - Judy Fieres
- grid.9811.10000 0001 0658 7699Molecular Toxicology, Department of Biology, University of Konstanz, 78457 Constance, Germany ,grid.9811.10000 0001 0658 7699Department of Sport Science, Human Performance Research Centre, University of Konstanz, 78457 Constance, Germany
| | - Markus Christmann
- grid.5802.f0000 0001 1941 7111Applied Toxicology, Institute of Toxicology, University of Mainz, 55131 Mainz, Germany
| | - Alexander Bürkle
- grid.9811.10000 0001 0658 7699Molecular Toxicology, Department of Biology, University of Konstanz, 78457 Constance, Germany
| | - María Moreno-Villanueva
- grid.9811.10000 0001 0658 7699Molecular Toxicology, Department of Biology, University of Konstanz, 78457 Constance, Germany ,grid.9811.10000 0001 0658 7699Department of Sport Science, Human Performance Research Centre, University of Konstanz, 78457 Constance, Germany
| | - Iris-Tatjana Kolassa
- grid.6582.90000 0004 1936 9748Clinical and Biological Psychology, Institute of Psychology and Education, Ulm University, Albert-Einstein-Allee 47, 89081 Ulm, Germany ,grid.9811.10000 0001 0658 7699Centre of Excellence for Psychotraumatology, Clinical Psychology and Neuropsychology, University of Konstanz, 78464 Constance, Germany
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8
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The role of IL-6 in TBI and PTSD, a potential therapeutic target? Clin Neurol Neurosurg 2022; 218:107280. [PMID: 35567833 DOI: 10.1016/j.clineuro.2022.107280] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/15/2022] [Accepted: 05/02/2022] [Indexed: 01/14/2023]
Abstract
This literature review focuses on the role of IL-6 in TBI or PTSD-induced neuroinflammation. While TBI and PTSD are widely prevalent, these diagnoses are particularly common amongst veterans. Given the role of IL-6 in neuroprotection acutely, compared to detrimental chronically, targeting this cytokine at specific time points may be beneficial in modulating neuroinflammation. Current treatments for TBI or PTSD are variably affective. By reviewing the role of IL-6 in these two diagnoses, future studies can focus on therapeutics to treat neuroinflammation and ultimately reduce the devastating impacts of neuroinflammation on cognition in PTSD and TBI.
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Oroian BA, Ciobica A, Timofte D, Stefanescu C, Serban IL. New Metabolic, Digestive, and Oxidative Stress-Related Manifestations Associated with Posttraumatic Stress Disorder. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:5599265. [PMID: 34966477 PMCID: PMC8712172 DOI: 10.1155/2021/5599265] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 09/29/2021] [Accepted: 12/04/2021] [Indexed: 12/14/2022]
Abstract
Posttraumatic stress disorder (PTSD) represents a pressing and generally invalidating syndrome that is triggered by a terrifying or stressful experience, relying on recurrently reliving the traumatic event feelings associated to it, which is subsequently linked to ongoing activations of stress-related neurobiological pathways and is often associated with neurodegeneration. In this paper, we examine what lies beneath this disorder, reviewing evidence that connects PTSD with a wide array of mechanisms and its intertwined pathways that can lead to the decompensation of different pathologies, such as cardiovascular disease, gastrointestinal ailments, autoimmune disorders, and endocrine diseases. Also, the significance of the oxidative stress in this frame of reference is debated. Thus, knowing and identifying the main features of the distressing experience, the circumstances around it, as well as the neuropsychological and emotional characteristics of people prone to develop PTSD after going through disturbing incidents can offer an opportunity to anticipate the development of potential destructive consequences in several psychological dimensions: cognitive, affective, relational, behavioral, and somatic. We can also observe more closely the intricate connections of the disorder to other pathologies and their underlying mechanisms such as inflammation, oxidative stress, bacterial overgrowth syndrome, irritable bowel syndrome, metabolic disorders, oxytocin, and cortisol in order to understand it better and to optimize the course of treatment and its management. The complex foundation PTSD possesses is supported by the existing clinical, preclinical, and experimental data encompassed in the current review. Different biological systems and processes such as the hypothalamic-pituitary-adrenal axis, sympathetic nervous system, oxidative stress, inflammation, and microbiome suffer modifications and changes when it comes to PTSD; that is why targeted therapies exert tremendous alleviations of symptoms in patients diagnosed with this disorder. Therefore, this implies that PTSD is not restricted to the psychiatric domain and should be viewed as a systemic condition.
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Affiliation(s)
| | - Alin Ciobica
- Department of Biology, Faculty of Biology, Alexandru Ioan Cuza University, B dul Carol I No. 11 Iasi, Romania
| | - Daniel Timofte
- “Grigore T. Popa” University of Medicine and Pharmacy, 16, Universitatii Street, 700115 Iasi, Romania
| | - Cristinel Stefanescu
- “Grigore T. Popa” University of Medicine and Pharmacy, 16, Universitatii Street, 700115 Iasi, Romania
| | - Ionela Lăcrămioara Serban
- “Grigore T. Popa” University of Medicine and Pharmacy, 16, Universitatii Street, 700115 Iasi, Romania
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Sfera A, Osorio C, Rahman L, Zapata-Martín del Campo CM, Maldonado JC, Jafri N, Cummings MA, Maurer S, Kozlakidis Z. PTSD as an Endothelial Disease: Insights From COVID-19. Front Cell Neurosci 2021; 15:770387. [PMID: 34776871 PMCID: PMC8586713 DOI: 10.3389/fncel.2021.770387] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/11/2021] [Indexed: 12/15/2022] Open
Abstract
SARS-CoV-2 virus, the etiologic agent of COVID-19, has affected almost every aspect of human life, precipitating stress-related pathology in vulnerable individuals. As the prevalence rate of posttraumatic stress disorder in pandemic survivors exceeds that of the general and special populations, the virus may predispose to this disorder by directly interfering with the stress-processing pathways. The SARS-CoV-2 interactome has identified several antigens that may disrupt the blood-brain-barrier by inducing premature senescence in many cell types, including the cerebral endothelial cells. This enables the stress molecules, including angiotensin II, endothelin-1 and plasminogen activator inhibitor 1, to aberrantly activate the amygdala, hippocampus, and medial prefrontal cortex, increasing the vulnerability to stress related disorders. This is supported by observing the beneficial effects of angiotensin receptor blockers and angiotensin converting enzyme inhibitors in both posttraumatic stress disorder and SARS-CoV-2 critical illness. In this narrative review, we take a closer look at the virus-host dialog and its impact on the renin-angiotensin system, mitochondrial fitness, and brain-derived neurotrophic factor. We discuss the role of furin cleaving site, the fibrinolytic system, and Sigma-1 receptor in the pathogenesis of psychological trauma. In other words, learning from the virus, clarify the molecular underpinnings of stress related disorders, and design better therapies for these conditions. In this context, we emphasize new potential treatments, including furin and bromodomains inhibitors.
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Affiliation(s)
- Adonis Sfera
- Department of Psychiatry, Loma Linda University, Loma Linda, CA, United States
- Patton State Hospital, San Bernardino, CA, United States
| | - Carolina Osorio
- Department of Psychiatry, Loma Linda University, Loma Linda, CA, United States
| | - Leah Rahman
- Patton State Hospital, San Bernardino, CA, United States
| | | | - Jose Campo Maldonado
- Department of Medicine, The University of Texas Rio Grande Valley, Edinburg, TX, United States
| | - Nyla Jafri
- Patton State Hospital, San Bernardino, CA, United States
| | | | - Steve Maurer
- Patton State Hospital, San Bernardino, CA, United States
| | - Zisis Kozlakidis
- International Agency For Research On Cancer (IARC), Lyon, France
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Carleial S, Nätt D, Unternährer E, Elbert T, Robjant K, Wilker S, Vukojevic V, Kolassa IT, Zeller AC, Koebach A. DNA methylation changes following narrative exposure therapy in a randomized controlled trial with female former child soldiers. Sci Rep 2021; 11:18493. [PMID: 34531495 PMCID: PMC8445994 DOI: 10.1038/s41598-021-98067-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/02/2021] [Indexed: 02/08/2023] Open
Abstract
The aftermath of traumatization lives on in the neural and epigenetic traces creating a momentum of affliction in the psychological and social realm. Can psychotherapy reorganise these memories through changes in DNA methylation signatures? Using a randomised controlled parallel group design, we examined methylome-wide changes in saliva samples of 84 female former child soldiers from Eastern DR Congo before and six months after Narrative Exposure Therapy. Treatment predicted differentially methylated positions (DMPs) related to ALCAM, RIPOR2, AFAP1 and MOCOS. In addition, treatment associations overlapped at gene level with baseline clinical and social outcomes. Treatment related DMPs are involved in memory formation-the key agent in trauma focused treatments-and enriched for molecular pathways commonly affected by trauma related disorders. Results were partially replicated in an independent sample of 53 female former child soldiers from Northern Uganda. Our results suggest a molecular impact of psychological treatment in women with war-related childhood trauma.Trial registration: Addressing Heightened Levels of Aggression in Traumatized Offenders With Psychotherapeutic Means (ClinicalTrials.gov Identifier: NCT02992561, 14/12/2016).
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Affiliation(s)
- Samuel Carleial
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany
| | - Daniel Nätt
- grid.5640.70000 0001 2162 9922Division of Neurobiology, Department of Biomedical and Clinical Sciences, University of Linköping, Building 463, Room 12.023, Linköping, Sweden
| | - Eva Unternährer
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,grid.6612.30000 0004 1937 0642Child- and Adolescent Research Department, Psychiatric University Hospitals Basel (UPK), University of Basel, Basel, Switzerland
| | - Thomas Elbert
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Katy Robjant
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Sarah Wilker
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany ,grid.7491.b0000 0001 0944 9128Department of Psychology and Sports Science, University of Bielefeld, 33501 Bielefeld, Germany
| | - Vanja Vukojevic
- grid.6612.30000 0004 1937 0642Psychiatric University Clinics, Transfaculty Research Platform, University of Basel, Wilhelm Klein-Strasse 27, CH-4012 Basel, Switzerland
| | - Iris-Tatjana Kolassa
- Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany ,grid.6582.90000 0004 1936 9748Department of Clinical and Biological Psychology, Institute of Psychology & Education, University of Ulm, Ulm University, Ulm, Germany
| | - Anja C. Zeller
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
| | - Anke Koebach
- grid.9811.10000 0001 0658 7699Department of Psychology, Centre for Psychiatry, University of Konstanz, Feuerstein-Strasse. 55, Haus 22, 78479 Konstanz, Germany ,Vivo International E.V., Postbox 5108, 78430 Konstanz, Germany
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12
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Rhein C, Hepp T, Kraus O, von Majewski K, Lieb M, Rohleder N, Erim Y. Interleukin-6 secretion upon acute psychosocial stress as a potential predictor of psychotherapy outcome in posttraumatic stress disorder. J Neural Transm (Vienna) 2021; 128:1301-1310. [PMID: 33988765 DOI: 10.1007/s00702-021-02346-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/28/2021] [Indexed: 01/08/2023]
Abstract
Posttraumatic stress disorder (PTSD) is a severe mental disorder that can develop after a traumatic event. PTSD has been reported to be associated with activation of the innate immune system, as measured by increased levels of pro-inflammatory cytokines. While it is well known that PTSD patients display increased levels of interleukin 6 (IL-6) when compared with healthy controls, the relationship between cytokine secretion and treatment outcome has been hardly investigated yet. The aim of this study was to assess the potential association of inflammatory activation and therapy outcome in PTSD. Before therapeutic intervention, we applied the Trier Social Stress Test (TSST) as a method to elicit psychosocial stress and an acute inflammatory response. IL-6 levels were measured in blood plasma of PTSD patients at different time points before and after the TSST. Severity of depressive, trauma-related, and somatic symptoms was assessed before and 8 weeks after trauma-focused treatment in a multimodal day clinic setting. We showed that high reactivity of IL-6 to psychosocial stress at the beginning of the therapy was associated with a negative therapy outcome in PTSD, especially regarding depressive symptoms. This study suggests plasma IL-6 reactivity as a potential molecular marker to predict treatment outcome in PTSD.
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Affiliation(s)
- Cosima Rhein
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 4, 91054, Erlangen, Germany.
| | - Tobias Hepp
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 4, 91054, Erlangen, Germany
- Institute of Medical Informatics, Biometry and Epidemiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Olga Kraus
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 4, 91054, Erlangen, Germany
- Chair of Health Psychology, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Kristin von Majewski
- Chair of Health Psychology, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Marietta Lieb
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 4, 91054, Erlangen, Germany
| | - Nicolas Rohleder
- Chair of Health Psychology, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Yesim Erim
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 4, 91054, Erlangen, Germany
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13
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Koebach A, Robjant K. NETfacts: a community intervention integrating trauma treatment at the individual and collective level. Eur J Psychotraumatol 2021; 12:1992962. [PMID: 34868485 PMCID: PMC8635579 DOI: 10.1080/20008198.2021.1992962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this article is to present a research-based rationale for NETfacts, a newly developed integrated approach at the individual and the community level in order to mitigate the mental and social sequelae of war and crisis. To this end, we provide a selective review of relevant literature from neuroscience, clinical psychology, and social science. In psychotraumatology, individual avoidance describes the effort to prevent exposure to trauma reminders. Among patients with post-traumatic stress disorder (PTSD), this becomes pathological, exacerbating distress and preventing recovery. This silence resonates in traumatized communities and consequently taboo builds - ultimately to the advantage of the perpetrators. The resulting collective avoidance leads to a fragmented collective memory about trauma or human rights violations in the community so that a shared account of the group's history becomes impossible. The deficient collective memory promotes ambiguous truths and anxiety, enabling a reactive construction of safety based on selective information that leads to an endorsement of extreme opinions. Ongoing insecurity, violence and crime lead to increasing anxiety and fear. The self-interest of the perpetrators and the abnormal behaviour of survivors leads to an escalation in stigma and social exclusion resulting in the prevention or limitation of community exposure to traumatic material, i.e., to reduce tension and protect the construction of safety. The exposure to and recognition of traumatic facts subject to avoidance is key to a coherent collective memory and sense of communion, and to prevent further cycles of violence. The NETfacts health system combines individual and community-based intervention to treat the structure of memory at both the individual and collective levels. Abbreviations: NET: narrative exposure therapy; FORNET: narrative exposure therapy for forensic offender rehabilitation; NETfacts: facts derived from narrative exposure therapy.
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Affiliation(s)
- Anke Koebach
- University of Konstanz, Department of Psychology; and Department of Politics and Public Administation, Konstanz, Germany.,NGO vivo international, Konstanz, Germany
| | - Katy Robjant
- University of Konstanz, Department of Psychology; and Department of Politics and Public Administation, Konstanz, Germany
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14
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Smith AK, Ratanatharathorn A, Maihofer AX, Naviaux RK, Aiello AE, Amstadter AB, Ashley-Koch AE, Baker DG, Beckham JC, Boks MP, Bromet E, Dennis M, Galea S, Garrett ME, Geuze E, Guffanti G, Hauser MA, Katrinli S, Kilaru V, Kessler RC, Kimbrel NA, Koenen KC, Kuan PF, Li K, Logue MW, Lori A, Luft BJ, Miller MW, Naviaux JC, Nugent NR, Qin X, Ressler KJ, Risbrough VB, Rutten BPF, Stein MB, Ursano RJ, Vermetten E, Vinkers CH, Wang L, Youssef NA, Uddin M, Nievergelt CM. Epigenome-wide meta-analysis of PTSD across 10 military and civilian cohorts identifies methylation changes in AHRR. Nat Commun 2020; 11:5965. [PMID: 33235198 PMCID: PMC7686485 DOI: 10.1038/s41467-020-19615-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
Epigenetic differences may help to distinguish between PTSD cases and trauma-exposed controls. Here, we describe the results of the largest DNA methylation meta-analysis of PTSD to date. Ten cohorts, military and civilian, contribute blood-derived DNA methylation data from 1,896 PTSD cases and trauma-exposed controls. Four CpG sites within the aryl-hydrocarbon receptor repressor (AHRR) associate with PTSD after adjustment for multiple comparisons, with lower DNA methylation in PTSD cases relative to controls. Although AHRR methylation is known to associate with smoking, the AHRR association with PTSD is most pronounced in non-smokers, suggesting the result was independent of smoking status. Evaluation of metabolomics data reveals that AHRR methylation associated with kynurenine levels, which are lower among subjects with PTSD. This study supports epigenetic differences in those with PTSD and suggests a role for decreased kynurenine as a contributor to immune dysregulation in PTSD.
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Affiliation(s)
- Alicia K Smith
- Emory University, Department of Gynecology and Obstetrics, Atlanta, GA, USA.
- Emory University, Department of Psychiatry & Behavioral Sciences, Atlanta, GA, USA.
| | | | - Adam X Maihofer
- University of California San Diego, Department of Psychiatry, La Jolla, CA, USA
| | - Robert K Naviaux
- University of California, The Mitochondrial and Metabolic Disease Center, Departments of Medicine, Pediatrics, and Pathology, San Diego, CA, USA
| | - Allison E Aiello
- University of North Carolina, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC, USA
| | - Ananda B Amstadter
- Virginia Commonwealth University, Department of Psychiatry, Richmond, VA, USA
| | - Allison E Ashley-Koch
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, USA
| | - Dewleen G Baker
- University of California San Diego, Department of Psychiatry, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Jean C Beckham
- VA Mid-Atlantic, Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
- Veterans Affairs Durham Healthcare System, Durham, NC, USA
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, USA
| | - Marco P Boks
- University Medical Center Utrecht, Brain Center Rudolf Magnus, Utrecht, The Netherlands
| | - Evelyn Bromet
- State University of New York at Stony Brook, Epidemiology Research Group, Stony Brook, NY, USA
| | - Michelle Dennis
- VA Mid-Atlantic, Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, USA
| | - Sandro Galea
- Boston University, School of Public Health, Boston, MA, USA
| | - Melanie E Garrett
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, USA
| | - Elbert Geuze
- University Medical Center Utrecht, Brain Center Rudolf Magnus, Utrecht, The Netherlands
- Netherlands Ministry of Defence, Brain Research and Innovation Centre, Utrecht, The Netherlands
| | - Guia Guffanti
- McLean Hospital, Division of Depression and Anxiety, Belmont, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Michael A Hauser
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, USA
- Duke University, Department of Medicine, Durham, NC, USA
| | - Seyma Katrinli
- Emory University, Department of Gynecology and Obstetrics, Atlanta, GA, USA
| | - Varun Kilaru
- Emory University, Department of Gynecology and Obstetrics, Atlanta, GA, USA
| | | | - Nathan A Kimbrel
- VA Mid-Atlantic, Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
- Veterans Affairs Durham Healthcare System, Durham, NC, USA
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, NC, USA
| | - Karestan C Koenen
- Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, USA
- Massachusetts General Hospital, Psychiatric and Neurodevelopmental Genetics Unit, Center for Human Genetic Research, and Department of Psychiatry, Boston, MA, USA
- Broad Institute of MIT and Harvard, Stanley Center for Psychiatric Research, Cambridge, MA, USA
| | - Pei-Fen Kuan
- State University of New York at Stony Brook, Department of Applied Mathematics and Statistics, Stony Brook, NY, USA
| | - Kefeng Li
- University of California, The Mitochondrial and Metabolic Disease Center, Department of Medicine, San Diego, CA, USA
| | - Mark W Logue
- National Center for PTSD, Behavioral Science Division at VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Department of Psychiatry, Boston, MA, USA
- Boston University School of Medicine, Department of Medicine (Biomedical Genetics), Boston, MA, USA
- Boston University School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Adriana Lori
- Emory University, Department of Psychiatry & Behavioral Sciences, Atlanta, GA, USA
| | - Benjamin J Luft
- State University of New York at Stony Brook, Department of Medicine, Stony Brook, NY, USA
| | - Mark W Miller
- National Center for PTSD, Behavioral Science Division at VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Department of Psychiatry, Boston, MA, USA
| | - Jane C Naviaux
- University of California, The Mitochondrial and Metabolic Disease Center, Department of Neuroscience, San Diego, CA, USA
| | - Nicole R Nugent
- Brown University, Psychiatry and Human Behavior, Department of Pediatric Research, Providence, RI, USA
| | - Xuejun Qin
- Duke Molecular Physiology Institute, Duke University Medical Center, Durham, NC, USA
| | - Kerry J Ressler
- Emory University, Department of Psychiatry & Behavioral Sciences, Atlanta, GA, USA
- McLean Hospital, Division of Depression and Anxiety, Belmont, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Victoria B Risbrough
- University of California San Diego, Department of Psychiatry, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Bart P F Rutten
- Maastricht University Medical Centre, School for Mental Health and Neuroscience, Department of Psychiatry and Neuropsychology, Maastricht, The Netherlands
| | - Murray B Stein
- University of California San Diego, Department of Psychiatry, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- University of California San Diego, Department of Family Medicine and Public Health, La Jolla, CA, USA
| | - Robert J Ursano
- Uniformed Services University School of Medicine, Center for the Study of Traumatic Stress, Bethesda, MD, USA
| | - Eric Vermetten
- University Medical Center Utrecht, Brain Center Rudolf Magnus, Utrecht, The Netherlands
- Uniformed Services University School of Medicine, Center for the Study of Traumatic Stress, Bethesda, MD, USA
- Leiden University Medical Center, Department of Psychiatry, Leiden, The Netherlands
- Netherlands Defense Department, Research Center, Utrecht, UT, The Netherlands
- Arq Psychotrauma Expert Group, Diemen, The Netherlands
| | - Christiaan H Vinkers
- Amsterdam UMC (location VUmc), Department of Psychiatry, Amsterdam, The Netherlands
- Amsterdam UMC (location VUmc), Department of Anatomy and Neurosciences, Amsterdam, The Netherlands
| | - Lin Wang
- University of California, The Mitochondrial and Metabolic Disease Center, Department of Medicine, San Diego, CA, USA
| | - Nagy A Youssef
- Medical College of Georgia at Augusta University, Department of Psychiatry and Human Behavior and Office of Academic Affairs, Augusta, GA, USA
| | - Monica Uddin
- University of South Florida, College of Public Health, Tampa, FL, USA
| | - Caroline M Nievergelt
- University of California San Diego, Department of Psychiatry, La Jolla, CA, USA
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
- Veterans Affairs Center of Excellence for Stress and Mental Health, San Diego, CA, USA
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15
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Siehl S, Robjant K, Crombach A. Systematic review and meta-analyses of the long-term efficacy of narrative exposure therapy for adults, children and perpetrators. Psychother Res 2020; 31:695-710. [PMID: 33205713 DOI: 10.1080/10503307.2020.1847345] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: Narrative Exposure Therapy (NET) is a short-term trauma-focused intervention originally developed for treating survivors of war and torture. The neurobiological theoretical foundations of NET would suggest that the approach should have long term beneficial effects. We tested this assumption and also provided an extensive overview of all NET studies for adults, for children (KIDNET), and for perpetrators (Forensic Offender Rehabilitation NET; FORNET).Method: Following a systematic literature review, we conducted meta-analyses with all studies that had control conditions, and with all Randomized Controlled Trials (RCTs). We assessed between-groups short- (< 6 months) and long-term (≥ 6 months) effect sizes for symptoms of posttraumatic stress disorder (PTSD) and depression.Results: In a total of 56 studies from 30 countries comparing 1370 participants treated with NET to 1055 controls, we found large between group effect sizes regarding the reduction of PTSD symptoms in favor of NET. Analyses of RCTs with active controls yielded small to medium effect sizes in the short-term, and large effect sizes in the long-term.Conclusions: NET, KIDNET, and FORNET yield beneficial and sustainable treatment results for severely traumatized individuals living in adverse circumstances. Studies in highly developed health care systems comparing NET with other evidence-based trauma-focused interventions are needed.
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Affiliation(s)
- Sebastian Siehl
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany.,Graduate School of Economic and Social Sciences, University of Mannheim, Mannheim, Germany.,Non-Governmental Organization vivo international e.V., Konstanz, Germany
| | - Katy Robjant
- Non-Governmental Organization vivo international e.V., Konstanz, Germany
| | - Anselm Crombach
- Non-Governmental Organization vivo international e.V., Konstanz, Germany.,Department of Psychology at the University of Konstanz, Experimental Clinical Psychology with a Teaching Focus on Clinical Psychology of Childhood and Adolescence.,Non-Governmental Organization Psychologues sans Frontières, Burundi, Bujumbura, Burundi.,Department of Clinical Psychology, Université Lumière de Bujumbura, Bujumbura, Burundi
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16
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Shields GS, Spahr CM, Slavich GM. Psychosocial Interventions and Immune System Function: A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA Psychiatry 2020; 77:1031-1043. [PMID: 32492090 PMCID: PMC7272116 DOI: 10.1001/jamapsychiatry.2020.0431] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Recent estimates suggest that more than 50% of all deaths worldwide are currently attributable to inflammation-related diseases. Psychosocial interventions may represent a potentially useful strategy for addressing this global public health problem, but which types of interventions reliably improve immune system function, under what conditions, and for whom are unknown. OBJECTIVE To address this issue, we conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) in which we estimated associations between 8 different psychosocial interventions and 7 markers of immune system function, and examined 9 potential moderating factors. DATA SOURCES PubMed, Scopus, PsycInfo, and ClinicalTrials.gov databases were systematically searched from February 1, 2017, to December 31, 2018, for all relevant RCTs published through December 31, 2018. STUDY SELECTION Eligible RCTs included a psychosocial intervention, immune outcome, and preintervention and postintervention immunologic assessments. Studies were independently examined by 2 investigators. Of 4621 studies identified, 62 were eligible and 56 included. DATA EXTRACTION AND SYNTHESIS Data were extracted and analyzed from January 1, 2019, to July 29, 2019. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed. Data were extracted by 2 investigators who were blind to study hypotheses and analyses, and were then analyzed using robust variance estimation. Analysis included 8 psychosocial interventions (behavior therapy, cognitive therapy, cognitive behavior therapy [CBT], CBT plus additive treatment or mode of delivery that augmented the CBT, bereavement or supportive therapy, multiple or combined interventions, other psychotherapy, and psychoeducation), 7 immune outcomes (proinflammatory cytokine or marker levels, anti-inflammatory cytokine levels, antibody levels, immune cell counts, natural killer cell activity, viral load, and other immune outcomes), and 9 moderating factors (intervention type, intervention format, intervention length, immune marker type, basal vs stimulated markers, immune marker measurement timing, disease state or reason for treatment, age, and sex). MAIN OUTCOMES AND MEASURES The primary a priori outcomes were pretest-posttest-control (ppc) group effect sizes (ppc g) for the 7 immunologic outcomes investigated. RESULTS Across 56 RCTs and 4060 participants, psychosocial interventions were associated with enhanced immune system function (ppc g = 0.30, 95% CI, 0.21-0.40; t50.9 = 6.22; P < .001). Overall, being randomly assigned to a psychosocial intervention condition vs a control condition was associated with a 14.7% (95% CI, 5.7%-23.8%) improvement in beneficial immune system function and an 18.0% (95% CI, 7.2%-28.8%) decrease in harmful immune system function over time. These associations persisted for at least 6 months following treatment and were robust across age, sex, and intervention duration. These associations were most reliable for CBT (ppc g = 0.33, 95% CI, 0.19-0.47; t27.2 = 4.82; P < .001) and multiple or combined interventions (ppc g = 0.52, 95% CI, 0.17-0.88; t5.7 = 3.63; P = .01), and for studies that assessed proinflammatory cytokines or markers (ppc g = 0.33, 95% CI, 0.19-0.48; t25.6 = 4.70; P < .001). CONCLUSIONS AND RELEVANCE These findings suggest that psychosocial interventions are reliably associated with enhanced immune system function and may therefore represent a viable strategy for improving immune-related health.
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Affiliation(s)
| | - Chandler M. Spahr
- Department of Psychology, San Diego State University, San Diego, California
| | - George M. Slavich
- Cousins Center for Psychoneuroimmunology and Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
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17
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Kaltenbach E, Hermenau K, Schauer M, Dohrmann K, Elbert T, Schalinski I. Trajectories of posttraumatic stress symptoms during and after Narrative Exposure Therapy (NET) in refugees. BMC Psychiatry 2020; 20:312. [PMID: 32552778 PMCID: PMC7298826 DOI: 10.1186/s12888-020-02720-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 06/09/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Trauma-focused therapy approaches are recommended as treatment for posttraumatic stress disorder (PTSD). This includes the treatment of trauma-related suffering in refugee populations. However, there is a lack of knowledge about symptom trajectories in refugees living in volatile conditions. This has led to fear of "retraumatisation" and general skepticism in clinicians concerning the use of exposure therapy. METHODS To test the relevance of this concern, we investigated PTSD symptom trajectories and potentially influencing factors during the course of Narrative Exposure Therapy (NET) in a refugee sample living in Germany. Refugees filled out the PTSD Checklist prior to each treatment session and also during follow-up interviews. Therapists continuously documented positive and negative life events as well as the content of the treatment sessions. Additionally, structured clinical interviews were conducted pre-treatment and at follow-up time points. RESULTS On average, clients presented with substantial decreases in PTSD symptoms already during and after NET. However, symptom trajectories differed and ranged from fast responders to slow responders to no immediate response during treatment. Importantly, a persistent worsening of symptoms was not observed, also not after exposure to the most distressing events. In contrast, stressful life experiences seemed to aggravate PTSD symptoms. CONCLUSIONS Consistent with earlier studies, NET leads to clinically and behaviorally relevant reductions in PTSD symptoms both throughout and following treatment in refugees living in volatile conditions. Concerns about imaginal exposure in refugees were not substantiated. While stressful life events contributed to transient symptom increases, they weren't found to prevent the overall effectiveness of NET. TRIAL REGISTRATION NCT02852616.
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Affiliation(s)
- Elisa Kaltenbach
- Department of Psychology, University of Konstanz, Konstanz, Germany. .,Centre for Research in Family Health, IWK Health Centre, Halifax, NS, Canada. .,Vivo International e.V., Konstanz, Germany.
| | - Katharin Hermenau
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany
| | - Maggie Schauer
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany
| | - Katalin Dohrmann
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany
| | - Thomas Elbert
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany
| | - Inga Schalinski
- grid.9811.10000 0001 0658 7699Department of Psychology, University of Konstanz, Konstanz, Germany ,Vivo International e.V., Konstanz, Germany ,Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Institute of Medical Psychology, Berlin, Germany
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18
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Raghuraman S, Stuttard N, Hunt N. Evaluating narrative exposure therapy for post-traumatic stress disorder and depression symptoms: A meta-analysis of the evidence base. Clin Psychol Psychother 2020; 28:1-23. [PMID: 32525597 DOI: 10.1002/cpp.2486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 05/20/2020] [Accepted: 06/03/2020] [Indexed: 11/07/2022]
Abstract
Narrative exposure therapy (NET) is an intervention for trauma spectrum disorders. Originally developed to treat refugee populations, NET has since been tested for efficacy across different settings. In this review, the NET evidence base is examined through a retrieval, synthesis and appraisal of randomized controlled trials (RCTs) published since 2002. Two independent reviewers (S. R. and N. S.) searched online databases including EMBASE, PsycINFO and PubMed. Twenty-four RCTs were selected for a meta-analysis of three outcomes: post-traumatic stress disorder (PTSD) diagnosis and PTSD and depression symptoms. All outcomes were analysed at short-term (3-4 months), midterm (6-7 months) and long-term (≥12 months) data points. A random-effects model was applied to yield standardized mean differences (SMDs) and odds ratios (ORs) as indicators of NET treatment effect. Subgroup analyses for type of trauma and type of control groups were conducted to examine potential heterogeneity. For the NET group, moderate effect sizes for PTSD symptom severity were observed at midterm and long term and at midterm for depression symptom severity. The number of PTSD diagnoses decreased significantly in the short term for the NET condition, but this was not sustained at the long term. Caution must be exercised when interpreting these results due to high heterogeneity estimates and low quality of evidence across trials. Potential small-study effects further complicate the interpretation of the findings. Recommendations are made for augmenting statistical significance research with qualitative analyses of NET efficacy to better inform clinical practice.
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Affiliation(s)
- Shruti Raghuraman
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nathan Stuttard
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nigel Hunt
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
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19
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Malan-Müller S, de Souza VBC, Daniels WMU, Seedat S, Robinson MD, Hemmings SMJ. Shedding Light on the Transcriptomic Dark Matter in Biological Psychiatry: Role of Long Noncoding RNAs in D-cycloserine-Induced Fear Extinction in Posttraumatic Stress Disorder. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2020; 24:352-369. [PMID: 32453623 DOI: 10.1089/omi.2020.0031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Biological psychiatry scholarship on posttraumatic stress disorder (PTSD) is making strides with new omics technologies. In this context, there is growing recognition that noncoding RNAs are vital for the regulation of gene and protein expression. Long noncoding RNAs (lncRNAs) can modulate splicing, influence RNA editing, messenger RNA (mRNA) stability, translation activation, and microRNA-mRNA interactions, are highly abundant in the brain, and have been implicated in neurodevelopmental disorders. The largest subclass of lncRNAs is long intergenic noncoding RNAs (lincRNAs). We report on lincRNAs and their predicted mRNA targets associated with fear extinction induced by co-administration of D-cycloserine and behavioral fear extinction in a PTSD animal model. Forty-three differentially expressed lincRNAs and 190 differentially expressed mRNAs were found to be associated with fear extinction. Eight lincRNAs were predicted to interact with and regulate 108 of these mRNAs, while seven lincRNAs were predicted to interact with 22 of their pre-mRNA transcripts. Based on the functions of their target mRNAs, we inferred that these lincRNAs bind to nucleotides, ribonucleotides, and proteins; subsequently influence nervous system development, morphology, and immune system functioning; and could be associated with nervous system and mental health disorders. We found the quantitative trait loci that overlapped with fear extinction-related lincRNAs included traits such as serum corticosterone level, neuroinflammation, anxiety, stress, and despair-related responses. To the best of our knowledge, this is the first study to identify lincRNAs and their RNA targets with a putative role in transcriptional regulation during fear extinction in the context of an animal model of PTSD.
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Affiliation(s)
- Stefanie Malan-Müller
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Vladimir B C de Souza
- Department of Molecular Life Sciences and SIB Swiss Institute of Bioinformatics, University of Zurich, Zurich, Switzerland
| | - Willie M U Daniels
- School of Physiology, University of the Witwatersrand, Johannesburg, South Africa
| | - Soraya Seedat
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Mark D Robinson
- Department of Molecular Life Sciences and SIB Swiss Institute of Bioinformatics, University of Zurich, Zurich, Switzerland
| | - Sîan M J Hemmings
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Yang JJ, Jiang W. Immune biomarkers alterations in post-traumatic stress disorder: A systematic review and meta-analysis. J Affect Disord 2020; 268:39-46. [PMID: 32158005 DOI: 10.1016/j.jad.2020.02.044] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/05/2020] [Accepted: 02/26/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Studies have reported the changes of immune biomakers in post-traumatic stress disorder (PTSD), but the results were conflicting. Our aim was to investigate the changes of immune biomarkers in PTSD. METHODS Literatures investigating the changes of immune markers in PTSD published in English were systematically searched through PubMed, Embase and Web of Science. We conducted random effects meta-analyses relating PTSD to immune biomarker concentrations and using subgroup analyses to resolve heterogeneity. RESULTS A total of 2606 articles were screened and 42 samples were included by the systematic review. The levels of interleukin-1β (IL-1β, P = 0.01), IL-2 (P = 0.006), IL-6 (P = 0.0002), interferon-γ (IFN-γ, P = 0.004), tumor necrosis factor-α (TNF-α, P = 0.004), C-reactive protein (CRP, P = 0.0003) and white blood cell (WBC, P = 0.01) were higher in PTSD than healthy controls (HC). Subgroup meta-analyses for psychotropic medication showed the levels of IL-1β and IL-2 were not increased in the PTSD. Subgroup meta-analyses for whether HC exposed to trauma showed the levels of IL-1β and IL-6 were not increased in the PTSD. Egger´s test revealed there was no publication bias. However, there was significant heterogeneity across studies for immune markers other than for WBC (P = 0.14, I2 = 45%). Subgroup analyses based on sex, HC exposed to trauma, PTSD comorbid major depressive disorder, PTSD on psychotropic medications partially or completely resolved heterogeneity for some immune biomarkers. CONCLUSION This meta-analysis provides evidence for elevation of IFN-γ, TNF-α, CRP, and WBC in PTSD.
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Affiliation(s)
- Juan-Juan Yang
- Department of Health Management, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi Provice, China
| | - Wei Jiang
- Department of Oncology, the Second Affiliated Hospital of Xi' an Jiaotong University, Xi'an, 710004, Shaanxi Provice, China.
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Kip A, Priebe S, Holling H, Morina N. Psychological interventions for posttraumatic stress disorder and depression in refugees: A meta-analysis of randomized controlled trials. Clin Psychol Psychother 2020; 27:489-503. [PMID: 32191370 DOI: 10.1002/cpp.2446] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 03/13/2020] [Accepted: 03/13/2020] [Indexed: 12/13/2022]
Abstract
Millions of refugees around the globe suffer from posttraumatic stress disorder (PTSD) and/or depression. We conducted a meta-analysis of randomized controlled trials (RCTs) to determine the efficacy of psychological interventions for PTSD and/or depression in refugees. The meta-analysis was registered on the PROSPERO database (CRD42017071384). A search using the Medline, PsycINFO, and PILOTS databases was conducted in January 2019, resulting in 17 RCTs, of which 14 were conducted with adult refugees (1,108 participants) and 3 with young refugees (<18 years; 151 participants). Further inclusion criteria were at least 10 participants completing an active psychological intervention for PTSD, depression, or both and less than 50% of participants receiving concurrent psychotropic drugs. Random effects models showed that active interventions for adult PTSD yielded a medium to large aggregated effect size (g = 0.77; 95% confidence interval [CI] [0.26, 1.28]) at posttreatment when compared with passive and active control conditions. Active interventions for adult depression also produced large controlled effect sizes at posttreatment (g = 0.82; 95% CI [0.24, 1.40]). The effects appeared to persist over the average follow-up period of 6 months. The findings suggest that psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees. However, the considerable heterogeneity between studies indicates that the efficacy may vary significantly. Future studies should aim to explore the substantial heterogeneity in effect sizes between studies with adult refugees. Additionally, more trials with young refugees suffering from PTSD or depression are needed to determine treatment efficacy for this population.
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Affiliation(s)
- Ahlke Kip
- Institute of Psychology, University of Münster, Münster, Germany
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Heinz Holling
- Institute of Psychology, University of Münster, Münster, Germany
| | - Nexhmedin Morina
- Institute of Psychology, University of Münster, Münster, Germany
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Treatment with a heat-killed preparation of Mycobacterium vaccae after fear conditioning enhances fear extinction in the fear-potentiated startle paradigm. Brain Behav Immun 2019; 81:151-160. [PMID: 31175996 PMCID: PMC6754802 DOI: 10.1016/j.bbi.2019.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/04/2019] [Accepted: 06/04/2019] [Indexed: 12/11/2022] Open
Abstract
The hygiene hypothesis or "Old Friends" hypothesis proposes that inflammatory diseases are increasing in modern urban societies, due in part to reduced exposure to microorganisms that drive immunoregulatory circuits and a failure to terminate inappropriate inflammatory responses. Inappropriate inflammation is also emerging as a risk factor for anxiety disorders, affective disorders, and trauma-and stressor-related disorders, including posttraumatic stress disorder (PTSD), which is characterized as persistent re-experiencing of the trauma after a traumatic experience. Traumatic experiences can lead to long-lasting fear memories and fear potentiation of the acoustic startle reflex. The acoustic startle reflex is an ethologically relevant reflex and can be potentiated in both humans and rats through Pavlovian conditioning. Mycobacterium vaccae is a soil-derived bacterium with immunoregulatory and anti-inflammatory properties that has been demonstrated to enhance fear extinction in the fear-potentiated startle paradigm when given prior to fear conditioning. To determine if immunization with M. vaccae after fear conditioning also has protective effects, adult male Sprague Dawley rats underwent fear conditioning on days -37 and -36 followed by immunizations (3x), once per week beginning 24 h following fear conditioning, with a heat-killed preparation of M. vaccae NCTC 11659 (0.1 mg, s.c., in 100 µl borate-buffered saline) or vehicle, and, then, 3 weeks following the final immunization, were tested in the fear-potentiated startle paradigm (n = 12 per group). Rats underwent fear extinction training on days 1 through 6 followed by spontaneous recovery 14 days later (day 20). Rats were euthanized on day 21 and brain tissue was sectioned for analysis of Tph2, Htr1a, Slc6a4, Slc22a3, and Crhr2 mRNA expression throughout the brainstem dorsal and median raphe nuclei. Immunization with M. vaccae did not affect fear expression on day 1. However, M. vaccae-immunized rats showed enhanced enhanced within-session fear extinction on day 1 and enhanced between-session fear extinction beginning on day 2, relative to vehicle-immunized controls. Immunization with M. vaccae and fear-potentiated startle had minimal effects on serotonergic gene expression when assessed 42 days after the final immunization. Together with previous studies, these data are consistent with the hypothesis that immunoregulatory strategies, such as immunization with M. vaccae, have potential for both prevention and treatment of trauma- and stressor-related psychiatric disorders.
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Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis. Epidemiol Psychiatr Sci 2019; 28:376-388. [PMID: 30739625 PMCID: PMC6669989 DOI: 10.1017/s2045796019000027] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
UNLABELLED AimsIn the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers. METHODS We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason. RESULTS We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = -0.71; 95% confidence interval [CI] -1.01 to -0.41; I2 = 83%; 95% CI 78-88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = -1.02; 95% CI -1.52 to -0.51; I2 = 89%; 95% CI 82-93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = -1.05; 95% CI -1.55 to -0.56; I2 = 87%; 95% CI 79-92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life. CONCLUSIONS Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.
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Kim YK, Amidfar M, Won E. A review on inflammatory cytokine-induced alterations of the brain as potential neural biomarkers in post-traumatic stress disorder. Prog Neuropsychopharmacol Biol Psychiatry 2019; 91:103-112. [PMID: 29932946 DOI: 10.1016/j.pnpbp.2018.06.008] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/17/2018] [Accepted: 06/18/2018] [Indexed: 12/25/2022]
Abstract
The heterogeneity of post-traumatic stress disorder (PTSD) symptoms indicates that multiple neurobiological mechanisms underlie the pathophysiology of the condition. However, no generally accepted PTSD biomarkers in clinical practice currently exist. The sequential responses to recurrent and chronic stress by the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system (ANS) system are considered to play a significant role in the onset and progression of PTSD. Decreased activity of the HPA axis and parasympathetic nervous system, along with increased activity of the sympathetic nervous system, have been observed in PTSD, which may lead to increased levels of proinflammatory cytokines. Such heightened activity of the immune system may cause alterations in the structure and function of brain regions-for example, the amygdala, hippocampus, medial prefrontal cortex, anterior cingulate cortex, and insula-through changes in levels of serotonin and kynurenine pathway metabolites, and direct neurotoxic effects of cytokines. Although chronic inflammation-induced alterations in brain regions critical in controlling emotional behavior and fear regulation may represent a strong candidate biomarker of PTSD, future studies are necessary to further elucidate inflammation-associated neural biomarkers of PTSD. Continued research on therapeutic methods that involve the normalization of the HPA axis, ANS, and immune system is expected to contribute to the development of novel ways to treat PTSD.
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Affiliation(s)
- Yong-Ku Kim
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Meysam Amidfar
- Department of Neuroscience, Fasa University of Medical Sciences, Fasa, Iran
| | - Eunsoo Won
- Department of Psychiatry, College of Medicine, Korea University, Seoul, Republic of Korea.
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Abstract
PURPOSE OF REVIEW Posttraumatic stress disorder is a chronic, heterogeneous disorder for which a multitude of psychotherapies, pharmaceuticals, and immerging treatment programs are available. Majority of efficacy studies focus on Caucasian male military populations, which may be a reason why not all patients respond to treatment with long-term positive outcomes. Additionally, effects of treatment on symptom clusters have been neglected. This work reviews treatment of PTSD and its symptom clusters exclusively in civilian populations, which have been historically under-examined in the literature. RECENT FINDINGS Exposure therapy stands at the forefront of successful PTSD treatment and offers a more cost-effective solution to pharmacotherapy; however, refugees and patients with comorbid depression may not experience such strong benefits. For exposure therapy and other forms of psychotherapy, non-inferiority studies point to promise of internet-delivered and telemedicine-based methods for reaching populations that may not have access to in-person care. SSRIs are the most widely used pharmaceutical treatment for PTSD; moderate initial benefits are observed yet long-term retention and outcomes may be enhanced by adjunct treatment. Again, refugees are a group that experiences lesser benefit. Research has begun to explore efficacy of treatments for individual symptom clusters, with hyperarousal benefiting most from currently available modalities. Avoidance, intrusion, negative thoughts and beliefs, and dissociation are symptoms requiring more research for focused interventions. Treatment of PTSD has evolved to (1) include equivalent proportions of men and women, along with focused female-exclusive cohorts; (2) explore novel methods of treatment online and in various cultural contexts; and (3) less focus on medication as evidenced by current clinical trials. In addition to further efficacy and safety studies in more diverse ethnic populations, work is needed to examine what therapies are best for targeting specific symptom clusters of PTSD. This research will drive precision treatment, and such research is beginning to point towards underlying mechanisms of pathology and change.
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26
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Lely JCG, Smid GE, Jongedijk RA, W Knipscheer J, Kleber RJ. The effectiveness of narrative exposure therapy: a review, meta-analysis and meta-regression analysis. Eur J Psychotraumatol 2019; 10:1550344. [PMID: 31007868 PMCID: PMC6450467 DOI: 10.1080/20008198.2018.1550344] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 10/26/2018] [Accepted: 11/01/2018] [Indexed: 12/21/2022] Open
Abstract
Background: Narrative exposure therapy (NET) is a short-term psychological treatment for post-traumatic stress disorder (PTSD) that has been investigated in various contexts among traumatized refugees and other trauma survivors. Sustained treatment results have been reported, but the methodological quality of the trials needs a more thorough examination. Objective: To evaluate the effectiveness of NET for survivors of trauma, using a quality assessment, an updated meta-analysis, and a meta-regression analysis. Method: Following a systematic literature selection, the methodological quality of the included studies was assessed; Non-controlled and controlled effect sizes (Hedges' g) were estimated using a random effects model. Predictor analyses were performed. Non-controlled effect sizes for PTSD and depression included symptom change at post-treatment and follow-up time-points. Controlled effect sizes included post-treatment comparisons of NET with non-active and active comparators: both trauma-focused (TF) and non-trauma-focused (non-TF) interventions. Results: The selected studies showed high external validity; methodological quality was equivalent to other guideline-supported TF interventions. In 16 randomized controlled trials, involving 947 participants, large non-controlled effect sizes were found for PTSD symptoms, at post-treatment (g = 1.18, 95% confidence interval [0.87; 1.50]) and follow-up (g = 1.37 [0.96; 1.77]). For depression symptoms, medium non-controlled effect sizes were found, at post-treatment (g = 0.47 [0.23; 0.71]) and follow-up (g = 0.60 [0.26; 0.94]). Post-treatment, NET outperformed non-active comparators and non-TF active comparators for PTSD, but not the combined active comparators. For depression, NET only outperformed non-active comparators. Advancing age predicted better treatment results for PTSD and depression symptoms; a history of migration predicted smaller treatment results for depression symptoms. Conclusions:The findings of this meta-analysis suggest that patients and providers may expect sustained treatment results from NET. Controlled comparisons with other guideline-supported TF interventions are not yet available.
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Affiliation(s)
| | | | | | - Jeroen W Knipscheer
- Foundation Centrum '45, Diemen, The Netherlands.,Arq Psychotrauma Expert Group, Diemen, The Netherlands
| | - Rolf J Kleber
- Arq Psychotrauma Expert Group, Diemen, The Netherlands.,Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
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Pape JC, Carrillo-Roa T, Rothbaum BO, Nemeroff CB, Czamara D, Zannas AS, Iosifescu D, Mathew SJ, Neylan TC, Mayberg HS, Dunlop BW, Binder EB. DNA methylation levels are associated with CRF 1 receptor antagonist treatment outcome in women with post-traumatic stress disorder. Clin Epigenetics 2018; 10:136. [PMID: 30390684 PMCID: PMC6215613 DOI: 10.1186/s13148-018-0569-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/17/2018] [Indexed: 02/06/2023] Open
Abstract
Background We have previously evaluated the efficacy of the CRF1 receptor antagonist GSK561679 in female PTSD patients. While GSK561679 was not superior to placebo overall, it was associated with a significantly stronger symptom reduction in a subset of patients with probable CRF system hyperactivity, i.e., patients with child abuse and CRHR1 SNP rs110402 GG carriers. Here, we test whether blood-based DNA methylation levels within CRHR1 and other PTSD-relevant genes would be associated with treatment outcome, either overall or in the high CRF activity subgroup. Results Therefore, we measured CRHR1 genotypes as well as baseline and post-treatment DNA methylation from the peripheral blood in the same cohort of PTSD-diagnosed women treated with GSK561679 (N = 43) or placebo (N = 45). In the same patients, we assessed DNA methylation at the PTSD-relevant genes NR3C1 and FKBP5, shown to predict or associate with PTSD treatment outcome after psychotherapy. We observed significant differences in CRHR1 methylation after GSK561679 treatment in the subgroup of patients with high CRF activity. Furthermore, NR3C1 baseline methylation significantly interacted with child abuse to predict PTSD symptom change following GSK561679 treatment. Conclusions Our results support a possible role of CRHR1 methylation levels as an epigenetic marker to track response to CRF1 antagonist treatment in biologically relevant subgroups. Moreover, pre-treatment NR3C1 methylation levels may serve as a potential marker to predict PTSD treatment outcome, independent of the type of therapy. However, to establish clinical relevance of these markers, our findings require replication and validation in larger studies. Trial registration NCT01018992. Registered 6 November 2009. Electronic supplementary material The online version of this article (10.1186/s13148-018-0569-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julius C Pape
- Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany
| | - Tania Carrillo-Roa
- Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Darina Czamara
- Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany
| | - Anthony S Zannas
- Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Dan Iosifescu
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,New York University School of Medicine, New York, NY, USA.,Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, USA
| | - Sanjay J Mathew
- Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine & Michael E. Debakey VA Medical Center, Houston, TX, USA
| | - Thomas C Neylan
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA.,The San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Helen S Mayberg
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Elisabeth B Binder
- Department of Translational Research in Psychiatry, Max Planck Institute of Psychiatry, Munich, Germany. .,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.
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Krause S, Boeck C, Gumpp AM, Rottler E, Schury K, Karabatsiakis A, Buchheim A, Gündel H, Kolassa IT, Waller C. Child Maltreatment Is Associated with a Reduction of the Oxytocin Receptor in Peripheral Blood Mononuclear Cells. Front Psychol 2018. [PMID: 29535656 PMCID: PMC5835067 DOI: 10.3389/fpsyg.2018.00173] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Child maltreatment (CM) and attachment experiences are closely linked to alterations in the human oxytocin (OXT) system. However, human data about oxytocin receptor (OXTR) protein levels are lacking. Therefore, we investigated oxytocin receptor (OXTR) protein levels in circulating immune cells and related them to circulating levels of OXT in peripheral blood. We hypothesized reduced OXTR protein levels, associated with both, experiences of CM and an insecure attachment representation. Methods: OXTR protein expressions were analyzed by western blot analyses in peripheral blood mononuclear cells (PBMC) and plasma OXT levels were determined by radioimmunoassay (RIA) in 49 mothers. We used the Childhood Trauma Questionnaire (CTQ) to assess adverse childhood experiences. Attachment representations (secure vs. insecure) were classified using the Adult Attachment Projective Picture System (AAP) and levels of anxiety and depression were assessed with the German version of the Hospital Depression and Anxiety scale (HADS-D). Results: CM-affected women showed significantly lower OXTR protein expression with significantly negative correlations between the OXTR protein expression and the CTQ sum score, whereas plasma OXT levels showed no significant differences in association with CM. Lower OXTR protein expression in PBMC were particularly pronounced in the group of insecurely attached mothers compared to the securely attached group. Anxiety levels were significantly higher in CM-affected women. Conclusion: This study demonstrated a significant association between CM and an alteration of OXTR protein expression in human blood cells as a sign for chronic, long-lasting alterations in this attachment-related neurobiological system.
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Affiliation(s)
- Sabrina Krause
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University, Ulm, Germany
| | - Christina Boeck
- Department of Clinical and Biological Psychology, Ulm University, Germany
| | - Anja M Gumpp
- Department of Clinical and Biological Psychology, Ulm University, Germany
| | - Edit Rottler
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University, Ulm, Germany
| | - Katharina Schury
- Department of Clinical and Biological Psychology, Ulm University, Germany
| | | | - Anna Buchheim
- Institute of Psychology, University of Innsbruck, Innsbruck, Austria
| | - Harald Gündel
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University, Ulm, Germany
| | | | - Christiane Waller
- Department of Psychosomatic Medicine and Psychotherapy, Ulm University, Ulm, Germany
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Malan-Muller S, Valles-Colomer M, Raes J, Lowry CA, Seedat S, Hemmings SM. The Gut Microbiome and Mental Health: Implications for Anxiety- and Trauma-Related Disorders. ACTA ACUST UNITED AC 2018; 22:90-107. [DOI: 10.1089/omi.2017.0077] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Stefanie Malan-Muller
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Mireia Valles-Colomer
- Department of Microbiology and Immunology, Rega Institute, KU Leuven–University of Leuven, Leuven, Belgium
- VIB, Center for Microbiology, Leuven, Belgium
| | - Jeroen Raes
- Department of Microbiology and Immunology, Rega Institute, KU Leuven–University of Leuven, Leuven, Belgium
- VIB, Center for Microbiology, Leuven, Belgium
| | - Christopher A. Lowry
- Department of Integrative Physiology and Center for Neuroscience, University of Colorado Boulder, Boulder, Colorado
- Military and Veteran Microbiome: Consortium for Research and Education (MVM-Core), Aurora, Colorado
- Department of Psychiatry, Neurology & Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, Colorado
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Denver, Colorado
- Center for Neuroscience, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Soraya Seedat
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Sian M.J. Hemmings
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
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Abstract
OBJECTIVE Inadequate immunoregulation and elevated inflammation may be risk factors for posttraumatic stress disorder (PTSD), and microbial inputs are important determinants of immunoregulation; however, the association between the gut microbiota and PTSD is unknown. This study investigated the gut microbiome in a South African sample of PTSD-affected individuals and trauma-exposed (TE) controls to identify potential differences in microbial diversity or microbial community structure. METHODS The Clinician-Administered PTSD Scale for DSM-5 was used to diagnose PTSD according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Microbial DNA was extracted from stool samples obtained from 18 individuals with PTSD and 12 TE control participants. Bacterial 16S ribosomal RNA gene V3/V4 amplicons were generated and sequenced. Microbial community structure, α-diversity, and β-diversity were analyzed; random forest analysis was used to identify associations between bacterial taxa and PTSD. RESULTS There were no differences between PTSD and TE control groups in α- or β-diversity measures (e.g., α-diversity: Shannon index, t = 0.386, p = .70; β-diversity, on the basis of analysis of similarities: Bray-Curtis test statistic = -0.033, p = .70); however, random forest analysis highlighted three phyla as important to distinguish PTSD status: Actinobacteria, Lentisphaerae, and Verrucomicrobia. Decreased total abundance of these taxa was associated with higher Clinician-Administered PTSD Scale scores (r = -0.387, p = .035). CONCLUSIONS In this exploratory study, measures of overall microbial diversity were similar among individuals with PTSD and TE controls; however, decreased total abundance of Actinobacteria, Lentisphaerae, and Verrucomicrobia was associated with PTSD status.
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History of child maltreatment and telomere length in immune cell subsets: Associations with stress- and attachment-related hormones. Dev Psychopathol 2017; 30:539-551. [PMID: 28803568 DOI: 10.1017/s0954579417001055] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Experiencing maltreatment during childhood can have long-lasting consequences for both mental and physical health. Immune cell telomere length (TL) shortening might be one link between child maltreatment (CM) experiences and adverse health outcomes later in life. While the stress hormone cortisol has been associated with TL attrition, the attachment-related hormone oxytocin may promote resilience. In 15 mothers with and 15 age- and body mass index-matched mothers without CM, we assessed TL in peripheral blood mononuclear cells and selected immune cell subsets (monocytes, naive, and memory cytotoxic T cells) by quantitative fluorescence in situ hybridization, as well as peripheral cortisol and oxytocin levels. Memory cytotoxic T cells showed significantly shorter TL in association with CM, whereas TL in monocytes and naive cytotoxic T cells did not significantly differ between the two groups. Across both groups, cortisol was negatively associated with TL, while oxytocin was positively associated with TL in memory cytotoxic T cells. These results indicate that long-lived memory cytotoxic T cells are most affected by the increased biological stress state associated with CM. Keeping in mind the correlational and preliminary nature of the results, the data suggest that cortisol may have a damaging and oxytocin a protective function on TL.
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Köbach A, Schaal S, Hecker T, Elbert T. Psychotherapeutic Intervention in the Demobilization Process: Addressing Combat-related Mental Injuries with Narrative Exposure in a First and Second Dissemination Stage. Clin Psychol Psychother 2017; 24:807-825. [PMID: 26676201 PMCID: PMC5573918 DOI: 10.1002/cpp.1986] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 08/10/2015] [Accepted: 09/21/2015] [Indexed: 11/05/2022]
Abstract
BACKGROUND Depending on the exposure to traumatic stressors and combat, 20% to 50% of ex-combatants present with trauma-related disorders, and more than half of the members of armed groups have a proclivity to violence. Therefore, psychotherapeutic assistance should address both, trauma-related suffering and the lowered threshold for aggressive behaviour. OBJECTIVE Supporting the demobilization process of ex-combatants in the eastern DR-Congo, we implemented a version of Narrative Exposure Therapy adapted for Forensic Offender Rehabilitation (FORNET). METHOD In two successive dissemination stages (DS), local counsellors conducted FORNET. In DS1, they were trained by clinical experts, and in DS2, the by then experienced counsellors trained and supervised a second group of local counsellors (DS2). The training consisted of a 3-week workshop covering theoretical concepts and practical therapeutic skills. In DS1 and DS2, a total of 98 demobilizing combatants received an intervention; treatment-as-usual served as the control condition. Posttraumatic stress disorder, appetitive aggression, depression severity and drug dependence were assessed prior to the intervention and 6 and 12 months later; additionally, we assessed reintegration success. RESULTS Six months post-intervention, FORNET significantly reduced Posttraumatic stress disorder symptoms but had less effect on the trait of appetitive aggression; moreover, beneficial effects were found for depression severity and drug dependence as well as for reintegration indices. Treatment gains were retained at 12 months. CONCLUSIONS Individuals without previous training in psychotherapy can learn to effectively apply the brief intervention FORNET and support the demobilization process in ongoing conflicts. The study suggests that it is possible to pass down psychotherapeutic techniques over generations of counsellors. © 2015 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd. KEY PRACTITIONER MESSAGE Posttraumatic stress symptoms, depression and clinically relevant levels of drug dependence can effectively be reduced with a version of Narrative Exposure Therapy (NET) adapted for Forensic Offender Rehabilitation (FORNET). The intervention is effective in the context of ongoing conflict. Individuals without previous training in psychotherapy can learn to effectively apply the brief intervention FORNET. It is possible to pass down psychotherapeutic techniques like FORNET over generations of counsellors. Psychotherapeutic interventions like FORNET may facilitate the transition to peace in war-torn regions.
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Affiliation(s)
- Anke Köbach
- Department of PsychologyUniversity of KonstanzKonstanzGermany
- vivo internationalKonstanzGermany
| | - Susanne Schaal
- vivo internationalKonstanzGermany
- Department of PsychologyUniversity of UlmUlmGermany
| | - Tobias Hecker
- vivo internationalKonstanzGermany
- Department of PsychologyUniversity of ZürichZürichSwitzerland
| | - Thomas Elbert
- Department of PsychologyUniversity of KonstanzKonstanzGermany
- vivo internationalKonstanzGermany
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Nosè M, Ballette F, Bighelli I, Turrini G, Purgato M, Tol W, Priebe S, Barbui C. Psychosocial interventions for post-traumatic stress disorder in refugees and asylum seekers resettled in high-income countries: Systematic review and meta-analysis. PLoS One 2017; 12:e0171030. [PMID: 28151992 PMCID: PMC5289495 DOI: 10.1371/journal.pone.0171030] [Citation(s) in RCA: 120] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/13/2017] [Indexed: 11/27/2022] Open
Abstract
Treatment of post-traumatic stress disorder (PTSD) in refugees and asylum seekers resettled in high-income countries presents specific challenges. This systematic review examined the effectiveness of psychosocial interventions for this group. We searched the Cochrane Central Register of randomised trials, CINAHL, EMBASE, PILOTS, PsycINFO, PubMed and Web of Science up to July 2016. Studies included randomised and controlled clinical trials comparing psychosocial interventions with waiting list or treatment as usual in adult refugees and asylum seekers with PTSD resettled in high-income countries. PTSD symptoms post-intervention was the primary outcome. We computed standardized mean differences (SMD) with 95% confidence intervals (CI). This study is registered with PROSPERO: CRD42015027843. Twelve studies were included in the meta-analysis. Psychosocial interventions were effective in decreasing PTSD symptoms relative to control groups (SMD -1·03, 95% CI -1·55 to -0·51; number needed to treat 4·4; I2 86%; 95% CI 77 to 91). Narrative exposure therapy, a manualized short-term variant of cognitive behavioural therapy with a trauma focus, was the best-supported intervention (5 RCTs, 187 participants, SMD -0·78, 95% CI -1·18 to -0·38, I2 37%; 95% CI 0 to 77). Methodological quality of the included studies was limited. Overall, psychosocial interventions for asylum seekers and refugees with PTSD resettled in high-income countries were found to provide significant benefits in reducing PTSD symptoms. Yet, the number of studies is small and their methodological quality limited, so that more rigorous trials should be conducted in the future.
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Affiliation(s)
- Michela Nosè
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Francesca Ballette
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Irene Bighelli
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Giulia Turrini
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Marianna Purgato
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Wietse Tol
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, WHO Collaborating Centre for Mental Health Services Development, Queen Mary University of London, London, United Kingdom
| | - Corrado Barbui
- WHO Collaborating Centre for Research and Training in Mental Health and Service Evaluation, Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
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Wang Z, Caughron B, Young MRI. Posttraumatic Stress Disorder: An Immunological Disorder? Front Psychiatry 2017; 8:222. [PMID: 29163241 PMCID: PMC5681483 DOI: 10.3389/fpsyt.2017.00222] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/23/2017] [Indexed: 12/15/2022] Open
Abstract
Patients with posttraumatic stress disorder (PTSD) exhibit an increased state of inflammation. Various animal models for PTSD have shown some of the same immune imbalances as have been shown in human subjects with PTSD, and some of these studies are discussed in this review. However, animal studies can only indirectly implicate immune involvement in PTSD in humans. This review of mainly studies with human subjects focuses on dissecting the immunological role in the pathogenesis of PTSD following initial trauma exposure. It addresses both the inflammatory state associated with PTSD and the immune imbalance between stimulatory and inhibitory immune mediators, as well as variables that can lead to discrepancies between analyses. The concept of immunological treatment approaches is proposed for PTSD, as new treatments are needed for this devastating disorder that is affecting unprecedented numbers of Veterans from the long-standing wars in the Middle East and which affects civilians following severe trauma.
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Affiliation(s)
- Zhewu Wang
- Mental Health Service, Ralph H. Johnson VA Medical Center, Charleston, SC, United States.,Department of Psychiatry, Medical University of South Carolina, Charleston, SC, United States
| | - Blaine Caughron
- Research Service, Ralph H. Johnson VA Medical Center, Charleston, SC, United States
| | - M Rita I Young
- Research Service, Ralph H. Johnson VA Medical Center, Charleston, SC, United States.,Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, United States
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Reber SO, Langgartner D, Foertsch S, Postolache TT, Brenner LA, Guendel H, Lowry CA. Chronic subordinate colony housing paradigm: A mouse model for mechanisms of PTSD vulnerability, targeted prevention, and treatment-2016 Curt Richter Award Paper. Psychoneuroendocrinology 2016; 74:221-230. [PMID: 27676359 DOI: 10.1016/j.psyneuen.2016.08.031] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/31/2016] [Indexed: 01/22/2023]
Abstract
There is considerable individual variability in vulnerability for developing posttraumatic stress disorder (PTSD); evidence suggests that this variability is related in part to genetic and environmental factors, including adverse early life experience. Interestingly, recent studies indicate that induction of chronic low-grade inflammation may be a common mechanism underlying gene and environment interactions that increase the risk for development of PTSD symptoms, and, therefore, may be a target for novel interventions for prevention or treatment of PTSD. Development of murine models with face, construct, and predictive validity would provide opportunities to investigate in detail complex genetic, environmental, endocrine, and immunologic factors that determine vulnerability to PTSD-like syndromes, and furthermore may provide mechanistic insight leading to development of novel interventions for both prevention and treatment of PTSD symptoms. Here we describe the potential use of the chronic subordinate colony housing (CSC) paradigm in mice as an adequate animal model for development of a PTSD-like syndrome and describe recent studies that suggest novel interventions for the prevention and treatment of PTSD.
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Affiliation(s)
- Stefan O Reber
- Laboratory for Molecular Psychosomatics, Clinic for Psychosomatic Medicine and Psychotherapy, University Ulm, 89081 Ulm, Germany.
| | - Dominik Langgartner
- Laboratory for Molecular Psychosomatics, Clinic for Psychosomatic Medicine and Psychotherapy, University Ulm, 89081 Ulm, Germany.
| | - Sandra Foertsch
- Laboratory for Molecular Psychosomatics, Clinic for Psychosomatic Medicine and Psychotherapy, University Ulm, 89081 Ulm, Germany.
| | - Teodor T Postolache
- University of Maryland School of Medicine, Baltimore MD, MD 21201, USA; Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), University of Colorado, Anschutz Medical Campus, Denver, CO 80220, USA; Military and Veteran Microbiome Consortium for Research and Education (MVM-CoRE), Denver, CO 80220, USA.
| | - Lisa A Brenner
- Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), University of Colorado, Anschutz Medical Campus, Denver, CO 80220, USA; Military and Veteran Microbiome Consortium for Research and Education (MVM-CoRE), Denver, CO 80220, USA.
| | - Harald Guendel
- Laboratory for Molecular Psychosomatics, Clinic for Psychosomatic Medicine and Psychotherapy, University Ulm, 89081 Ulm, Germany.
| | - Christopher A Lowry
- Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), University of Colorado, Anschutz Medical Campus, Denver, CO 80220, USA; Military and Veteran Microbiome Consortium for Research and Education (MVM-CoRE), Denver, CO 80220, USA; Department of Integrative Physiology and Center for Neuroscience, University of Colorado Boulder, Boulder, CO 80309, USA; Center for Neuroscience, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA.
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Wang Z, Young MRI. PTSD, a Disorder with an Immunological Component. Front Immunol 2016; 7:219. [PMID: 27375619 PMCID: PMC4893499 DOI: 10.3389/fimmu.2016.00219] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 05/23/2016] [Indexed: 12/27/2022] Open
Abstract
Post-traumatic stress disorder (PTSD) has been associated with an inflammatory state. However, few studies have addressed the mechanisms underlying this immune imbalance that favors inflammation or how this imbalance contributes to PTSD. Whether the immune imbalance influences responsiveness or unresponsiveness of patients to PTSD treatments is currently not known. This review brings forward an immune emphasis to a mental health disorder that is unprecedented in its prevalence among combat Veterans of the ongoing conflicts in Iraq and Afghanistan and which also afflicts civilians who have undergone extreme traumatic experiences, such as following natural disasters, serious accidents, or assaults. Included is an overview of the correlative associations in human subjects between PTSD and inflammation and studies in animal models of PTSD, demonstrating causal contributions of inflammation and immune dysregulation to PTSD-like behavior following stress exposure.
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Affiliation(s)
- Zhewu Wang
- Mental Health Service, Ralph H. Johnson VA Medical Center, Charleston, SC, USA; Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA
| | - M Rita I Young
- Research Service, Ralph H. Johnson VA Medical Center, Charleston, SC, USA; Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
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Korotana LM, Dobson KS, Pusch D, Josephson T. A review of primary care interventions to improve health outcomes in adult survivors of adverse childhood experiences. Clin Psychol Rev 2016; 46:59-90. [DOI: 10.1016/j.cpr.2016.04.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 02/18/2016] [Accepted: 04/17/2016] [Indexed: 12/18/2022]
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Immunization with a heat-killed preparation of the environmental bacterium Mycobacterium vaccae promotes stress resilience in mice. Proc Natl Acad Sci U S A 2016; 113:E3130-9. [PMID: 27185913 DOI: 10.1073/pnas.1600324113] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The prevalence of inflammatory diseases is increasing in modern urban societies. Inflammation increases risk of stress-related pathology; consequently, immunoregulatory or antiinflammatory approaches may protect against negative stress-related outcomes. We show that stress disrupts the homeostatic relationship between the microbiota and the host, resulting in exaggerated inflammation. Repeated immunization with a heat-killed preparation of Mycobacterium vaccae, an immunoregulatory environmental microorganism, reduced subordinate, flight, and avoiding behavioral responses to a dominant aggressor in a murine model of chronic psychosocial stress when tested 1-2 wk following the final immunization. Furthermore, immunization with M. vaccae prevented stress-induced spontaneous colitis and, in stressed mice, induced anxiolytic or fear-reducing effects as measured on the elevated plus-maze, despite stress-induced gut microbiota changes characteristic of gut infection and colitis. Immunization with M. vaccae also prevented stress-induced aggravation of colitis in a model of inflammatory bowel disease. Depletion of regulatory T cells negated protective effects of immunization with M. vaccae on stress-induced colitis and anxiety-like or fear behaviors. These data provide a framework for developing microbiome- and immunoregulation-based strategies for prevention of stress-related pathologies.
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PTSD is associated with an increase in aged T cell phenotypes in adults living in Detroit. Psychoneuroendocrinology 2016; 67:133-41. [PMID: 26894484 PMCID: PMC4826331 DOI: 10.1016/j.psyneuen.2016.01.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/27/2016] [Accepted: 01/27/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Psychosocial stress is thought to play a key role in the acceleration of immunological aging. This study investigated the relationship between lifetime and past-year history of post-traumatic stress disorder (PTSD) and the distribution of T cell phenotypes thought to be characteristic of immunological aging. METHODS Data were from 85 individuals who participated in the community-based Detroit Neighborhood Health Study. Immune markers assessed included the CD4:CD8 ratio, the ratio of late-differentiated effector (CCR7-CD45RA+CD27-CD28-) to naïve (CCR7+CD45RA+CD27+CD28+) T cells, the percentage of KLRG1-expressing cells, and the percentage of CD57-expressing cells. RESULTS In models adjusted for age, gender, race/ethnicity, education, smoking status, and medication use, we found that past-year PTSD was associated with statistically significant differences in the CD8+ T cell population, including a higher ratio of late-differentiated effector to naïve T cells, a higher percentage of KLRG1+ cells, and a higher percentage of CD57+ cells. The percentage of CD57+ cells in the CD4 subset was also significantly higher and the CD4:CD8 ratio significantly lower among individuals who had experienced past-year PTSD. Lifetime PTSD was also associated with differences in several parameters of immune aging. CONCLUSIONS PTSD is associated with an aged immune phenotype and should be evaluated as a potential catalyzer of accelerated immunological aging in future studies.
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Thomaes K, de Kloet C, Wilker S, El-Hage W, Schäfer I, Kleim B, Schmahl C, van Zuiden M. Investigating biological traces of traumatic stress in changing societies: challenges and directions from the ESTSS Task Force on Neurobiology. Eur J Psychotraumatol 2016; 7:29453. [PMID: 26996535 PMCID: PMC4800281 DOI: 10.3402/ejpt.v7.29453] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 11/14/2022] Open
Abstract
Traumatic stress can have severe consequences for both mental and physical health. Furthermore, both psychological and biological traces of trauma increase as a function of accumulating traumatic experiences. Neurobiological research may aid in limiting the impact of traumatic stress, by leading to advances in preventive and treatment interventions. To promote the possibility for clinical implementation of novel research findings, this brief review describes timely conceptual and methodological challenges and directions in neurobiological trauma research on behalf of the Task Force "Neurobiology of Traumatic Stress" of the European Society for Traumatic Stress Studies (ESTSS). The most important conceptual challenges are the heterogeneity of disorders and existence of subtypes across diagnostic categories: differential latent profiles and trajectories regarding symptom expression and neural correlates are being unraveled; however, similar latent classes' approaches for treatment response and neurobiological data remain scarce thus far. The key to improving the efficacy of currently available preventive interventions and treatments for trauma-related disorders lies in a better understanding and characterization of individual differences in response to trauma and interventions. This could lead to personalized treatment strategies for trauma-related disorders, based on objective information indicating whether individuals are expected to benefit from them. The most important methodological challenge identified here is the need for large consortia and meta-analyses or, rather, mega-analyses on existent data as a first step. In addition, large multicenter studies, combining novel methods for repeated sampling with more advanced statistical modeling techniques, such as machine learning, should aim to translate identified disease mechanisms into molecular blood-based biomarker combinations to predict disorder vulnerability and treatment responses.
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Affiliation(s)
- Kathleen Thomaes
- GGZ inGeest/Department of Psychiatry & Anatomy and neurosciences, VU University Medical Center, Amsterdam, The Netherlands;
| | - Carien de Kloet
- Arq Psychotrauma Expert Group, Foundation Centrum '45, Oegstgeest, The Netherlands
| | - Sarah Wilker
- Department of Clinical and Biological Psychology, Ulm University, Ulm, Germany
| | - Wissam El-Hage
- Department of Psychiatry, CHRU de Tours, Inserm U930, University of Tours, Tours, France
| | - Ingo Schäfer
- Department of Psychiatry, University Medical Center Hamburg-Eppendorf, University of Hamburg, Hamburg, Germany
| | - Birgit Kleim
- Department of Psychology, University of Zurich, Zürich, Switzerland.,Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, Zurich, Switzerland
| | - Christian Schmahl
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Mirjam van Zuiden
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Patel N, Kellezi B, Williams ACDC. Psychological, social and welfare interventions for psychological health and well-being of torture survivors. Cochrane Database Syst Rev 2014; 2014:CD009317. [PMID: 25386846 PMCID: PMC11026826 DOI: 10.1002/14651858.cd009317.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Torture is widespread, with potentially broad and long-lasting impact across physical, psychological, social and other areas of life. Its complex and diverse effects interact with ethnicity, gender, and refugee experience. Health and welfare agencies offer varied rehabilitation services, from conventional mental health treatment to eclectic or needs-based interventions. This review is needed because relatively little outcome research has been done in this field, and no previous systematic review has been conducted. Resources are scarce, and the challenges of providing services can be considerable. OBJECTIVES To assess beneficial and adverse effects of psychological, social and welfare interventions for torture survivors, and to compare these effects with those reported by active and inactive controls. SEARCH METHODS Randomised controlled trials (RCTs) were identified through a search of PsycINFO, MEDLINE, EMBASE, Web of Science, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Depression, Anxiety and Neurosis Specialised Register (CCDANCTR), the Latin American and Caribbean Health Science Information Database (LILACS), the Open System for Information on Grey Literature in Europe (OpenSIGLE), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and Published International Literature On Traumatic Stress (PILOTS) all years to 11 April 2013; searches of Cochrane resources, international trial registries and the main biomedical databases were updated on 20 June 2014. We also searched the Online Library of Dignity (Danish Institute against Torture), reference lists of reviews and included studies and the most frequently cited journals, up to April 2013 but not repeated for 2014. Investigators were contacted to provide updates or details as necessary. SELECTION CRITERIA Full publications of RCTs or quasi-RCTs of psychological, social or welfare interventions for survivors of torture against any active or inactive comparison condition. DATA COLLECTION AND ANALYSIS We included all major sources of grey literature in our search and used standard methodological procedures as expected by The Cochrane Collaboration for collecting data, evaluating risk of bias and using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods to assess the quality of evidence. MAIN RESULTS Nine RCTs were included in this review. All were of psychological interventions; none provided social or welfare interventions. The nine trials provided data for 507 adults; none involved children or adolescents. Eight of the nine studies described individual treatment, and one discussed group treatment. Six trials were conducted in Europe, and three in different African countries. Most people were refugees in their thirties and forties; most met the criteria for post-traumatic stress disorder (PTSD) at the outset. Four trials used narrative exposure therapy (NET), one cognitive-behavioural therapy (CBT) and the other four used mixed methods for trauma symptoms, one of which included reconciliation methods. Five interventions were compared with active controls, such as psychoeducation; four used treatment as usual or waiting list/no treatment; we analysed all control conditions together. Duration of therapy varied from one hour to longer than 20 hours with a median of around 12 to 15 hours. All trials reported effects on distress and on PTSD, and two reported on quality of life. Five studies followed up participants for at least six months.No immediate benefits of psychological therapy were noted in comparison with controls in terms of our primary outcome of distress (usually depression), nor for PTSD symptoms, PTSD caseness, or quality of life. At six-month follow-up, three NET and one CBT study (86 participants) showed moderate effect sizes for intervention over control in reduction of distress (standardised mean difference (SMD) -0.63, 95% confidence interval (CI) -1.07 to -0.19) and of PTSD symptoms (SMD -0.52, 95% CI -0.97 to -0.07). However, the quality of evidence was very low, and risk of bias resulted from researcher/therapist allegiance to treatment methods, effects of uncertain asylum status of some people and real-time non-standardised translation of assessment measures. No measures of adverse events were described, nor of participation, social functioning, quantity of social or family relationships, proxy measures by third parties or satisfaction with treatment. Too few studies were identified for review authors to attempt sensitivity analyses. AUTHORS' CONCLUSIONS Very low-quality evidence suggests no differences between psychological therapies and controls in terms of immediate effects on post-traumatic symptoms, distress or quality of life; however, NET and CBT were found to confer moderate benefits in reducing distress and PTSD symptoms over the medium term (six months after treatment). Evidence was of very low quality, mainly because non-standardised assessment methods using interpreters were applied, and sample sizes were very small. Most eligible trials also revealed medium to high risk of bias. Further, attention to the cultural appropriateness of interventions or to their psychometric qualities was inadequate, and assessment measures used were unsuitable. As such, these findings should be interpreted with caution.No data were available on whether symptom reduction enabled improvements in quality of life, participation in community life, or in social and family relationships in the medium term. Details of adverse events and treatment satisfaction were not available immediately after treatment nor in the medium term. Future research should aim to address these gaps in the evidence and should include larger sample sizes when possible. Problems of torture survivors need to be defined far more broadly than by PTSD symptoms, and recognition given to the contextual influences of being a torture survivor, including as an asylum seeker or refugee, on psychological and social health.
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Affiliation(s)
- Nimisha Patel
- University of East LondonSchool of PsychologyRomford Road, StratfordLondonUKE15 4LZ
- International Centre for Health and Human RightsLondonUK
| | - Blerina Kellezi
- University of NottinghamSchool of Medicine, Division of Primary CareTower Building, University ParkNottinghamUKNG7 2RD
- Univeristy of OxfordCentre for CriminologyOxfordUK
| | - Amanda C de C Williams
- International Centre for Health and Human RightsLondonUK
- University College LondonResearch Department of Clinical, Educational & Health PsychologyGower StreetLondonUKWC1E 6BT
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