Increased neural response to trauma scripts in posttraumatic stress disorder following paroxetine treatment: A pilot study

Antidepressants in the acute treatment of post-traumatic stress disorder in adults: a systematic review and meta-analysis

Currently, there are few pharmacotherapy options for clinicians treating post-traumatic stress disorder (PTSD), and antidepressants are usually the medication of choice. This meta-analysis aimed to review the efficacy of antidepressants in the acute treatment of PTSD in adults while investigating the contribution of study design and placebo response to the findings of these studies. Randomized, double-blind, placebo-controlled clinical trials that compared antidepressants with placebo for acute treatment of PTSD were selected. Standardized mean difference (SMD) in change in Clinician-Administered PTSD Scale scores were pooled after examining for heterogeneity. A random-effects meta-analysis was performed. Twenty-nine antidepressant-placebo comparisons, involving 4575 subjects, were analyzed. The SMD among all studies was 0.25, a small to medium effect size, lower than that in studies of antidepressants in adult major depressive disorder. The SMDs for low and high mean placebo responses, were 0.27 and 0.22, respectively. The overall SMD for paroxetine studies was in the moderate range (0.43) and that for sertraline studies was in the small range (0.12). Our findings suggest that antidepressants have modest efficacy in alleviating PTSD symptoms. Patient-level meta-analyses are required to further explore the potential clinical relevance of sertraline for PTSD.

Neural correlates of PTSD in women with childhood sexual abuse with and without PTSD and response to paroxetine treatment: A placebo-controlled, double-blind trial

Objective

Childhood sexual abuse is the leading cause of posttraumatic stress disorder (PTSD) in women, and is a prominent cause of morbidity and loss of function for which limited treatments are available. Understanding the neurobiology of treatment response is important for developing new treatments. The purpose of this study was to assess neural correlates of personalized traumatic memories in women with childhood sexual abuse with and without PTSD, and to assess response to treatment.

Methods

Women with childhood sexual abuse with (N = 28) and without (N = 17) PTSD underwent brain imaging with High-Resolution Positron Emission Tomography scanning with radiolabeled water for brain blood flow measurements during exposure to personalized traumatic scripts and memory encoding tasks. Women with PTSD were randomized to paroxetine or placebo followed by three months of double-blind treatment and repeat imaging with the same protocol.

Results

Women with PTSD showed decreases in areas involved in the Default Mode Network (DMN), a network of brain areas usually active when the brain is at rest, hippocampus and visual processing areas with exposure to traumatic scripts at baseline while women without PTSD showed increased activation in superior frontal gyrus and other areas (p < 0.005). Treatment of women with PTSD with paroxetine resulted in increased anterior cingulate activation and brain areas involved in the DMN and visual processing with scripts compared to placebo (p < 0.005).

Conclusion

PTSD related to childhood sexual abuse in women is associated with alterations in brain areas involved in memory and the stress response and treatment with paroxetine results in modulation of these areas.

Functional brain changes after alternative pharmacological interventions in posttraumatic stress disorder: A systematic review of clinical trials

BACKGROUND

Posttraumatic stress disorder (PTSD) is a complex and heterogeneous mental health condition that can develop after exposure to a traumatic event. Clinical trials have used alternative pharmacological agents to treat PTSD, but their associated neural correlates remain unclear. The present systematic review aims to summarize the changes in brain function associated with the use of these alternative pharmacological agents in PTSD.

METHODS

Clinical trials using functional magnetic resonance imaging, either at rest or during the performance of tasks, were included if they compared the effects of alternative pharmacological agents between PTSD patients and either trauma-exposed controls or never-exposed healthy controls.

RESULTS

Sixteen studies were included, of which 11 used intranasal oxytocin, 2 used hydrocortisone, and 3 used delta-9-tetrahydrocannabinol (THC). Oxytocin administration was associated with the normalization of functional connectivity between the ventromedial prefrontal cortex and amygdala as well as enhanced the function of brain regions specifically involved in emotion processing (e.g., amygdala), working memory (e.g., dorsolateral prefrontal cortex), and reward (e.g., putamen). Hydrocortisone did not influence brain function at rest or during the performance of an autobiographical memory task, whereas THC was associated with the reduction of the amygdala and increased medial prefrontal cortex activation.

CONCLUSIONS

This systematic review identified preliminary evidence for normalizing brain function after the use of alternative pharmacological agents. Importantly, sex-specific differences were noted, in particular when using oxytocin, that will require further investigation.

Validation of a new impedance cardiography analysis algorithm for clinical classification of stress states

Pre-ejection period (PEP) is an index of sympathetic nervous system activity that can be computed from electrocardiogram (ECG) and impedance cardiogram (ICG) signals, but sensitive to speech/motion artifact. We sought to validate an ICG noise removal method, three-stage ensemble-average algorithm (TEA), in data acquired from a clinical trial comparing active versus sham non-invasive vagal nerve stimulation (tcVNS) after standardized speech stress. We first compared TEA's performance versus the standard conventional ensemble-average algorithm (CEA) approach to classify noisy ICG segments. We then analyzed ECG and ICG data to measure PEP and compared group-level differences in stress states with each approach. We evaluated 45 individuals, of whom 23 had post-traumatic stress disorder (PTSD). We found that the TEA approach identified artifact-corrupted beats with intraclass correlation coefficient > 0.99 compared to expert adjudication. TEA also resulted in higher group-level differences in PEP between stress states than CEA. PEP values were lower in the speech stress (vs. baseline rest) group using both techniques, but the differences were greater using TEA (12.1 ms) than CEA (8.0 ms). PEP differences in groups divided by PTSD status and tcVNS (active vs. sham) were also greater when using the TEA versus CEA method, although the magnitude of the differences was lower. In conclusion, TEA helps to accurately identify noisy ICG beats during speaking stress, and this increased accuracy improves sensitivity to group-level differences in stress states compared to CEA, suggesting greater clinical utility.

Protocol for individual participant data meta-analysis of interventions for post-traumatic stress

INTRODUCTION

Several evidence-based treatments are effective for post-traumatic stress disorder (PTSD), yet a substantial proportion of patients do not respond or dropout of treatment. We describe the protocol for a systematic review and individual participant data meta-analysis (IPD-MA) aimed at assessing the effectiveness and adverse effects of psychotherapy and pharmacotherapy interventions for treating PTSD. Additionally, we seek to examine moderators and predictors of treatment outcomes.

METHOD AND ANALYSIS

This IPD-MA includes randomised controlled trials comparing psychotherapy and pharmacotherapy interventions for PTSD. PubMed, Embase, PsycINFO, PTSDpubs and CENTRAL will be screened up till the 11th of January 2021. The target population is adults with above-threshold baseline PTSD symptoms on any standardised self-report measure. Trials will only be eligible if at least 70% of the study sample have been diagnosed with PTSD by means of a structured clinical interview. The primary outcomes of this IPD-MA are PTSD symptom severity, and response rate. Secondary outcomes include treatment dropout and adverse effects. Two independent reviewers will screen major bibliographic databases and past reviews. Authors will be contacted to contribute their participant-level datasets. Datasets will be merged into a master dataset. A one-stage IPD-MA will be conducted focusing on the effects of psychological and pharmacological interventions on PTSD symptom severity, response rate, treatment dropout and adverse effects. Subsequent analyses will focus on examining the effect of moderators and predictors of treatment outcomes. These will include sociodemographic, treatment-related, symptom-related, resilience, intervention, trauma and combat-related characteristics. By determining the individual factors that influence the effectiveness of specific PTSD treatments, we will gain insight into personalised treatment options for PTSD.

ETHICS AND DISSEMINATION

Specific ethics approval for an IPD-MA is not required as this study entails secondary analysis of existing anonymised data. The results of this study will be published in peer-reviewed scientific journals and presentations.

Neurobiological Alterations in Females With PTSD: A Systematic Review

Most females experience at least one traumatic event in their lives, but not all develop PTSD. Despite considerable research, our understanding of the key factors that constitute risk for PTSD among females is limited. Previous research has largely focused on sex differences, neglecting within group comparisons, thereby obviating differences between females who do and do not develop PTSD following exposure to trauma. In this systematic review, we conducted a search for the extent of existing research utilizing magnetic resonance imaging (MRI) to examine neurobiological differences among females of all ages, with and without PTSD. Only studies of females who met full diagnostic criteria for PTSD were included. Fifty-six studies were selected and reviewed. We synthesized here findings from structural MRI (sMRI), functional MRI (fMRI), diffusion tensor imaging (DTI), and resting state functional connectivity (rs-FC MRI) studies, comparing females with and without PTSD. A range of biopsychosocial constructs that may leave females vulnerable to PTSD were discussed. First, the ways timing and type of exposure to trauma may impact PTSD risk were discussed. Second, the key role that cognitive and behavioral mechanisms may play in PTSD was described, including rumination, and deficient fear extinction. Third, the role of specific symptom patterns and common comorbidities in female-specific PTSD was described, as well as sex-specific implications on treatment and parenting outcomes. We concluded by identifying areas for future research, to address the need to better understand developmental aspects of brain alterations, the differential impact of trauma types and timing, the putative role of neuroendocrine system in neurobiology of PTSD among females, and the impact of social and cultural factors on neurobiology in females with PTSD.

Application of a Conducting Poly-Methionine/Gold Nanoparticles-Modified Sensor for the Electrochemical Detection of Paroxetine

This work demonstrates a facile electropolymerization of a dl-methionine (dl-met) conducting polymeric film on a gold nanoparticle (AuNPs)-modified glassy carbon electrode (GCE). The resulting sensor was successfully applied for the sensitive detection of paroxetine·HCl (PRX), a selective serotonin (5-HT) reuptake inhibitor (SSRIs), in its pharmaceutical formulations. The sensor was characterized morphologically using scanning electron microscopy (SEM) with energy dispersive X-ray spectroscopy (EDX) and atomic force microscopy (AFM) and electrochemical techniques such as differential pulse voltammetry (DPV), electrochemical impedance spectroscopy (EIS) and cyclic voltammetry (CV). The proposed sensor, poly (dl-met)/AuNPs-GCE, exhibited a linear response range from 5 × 10⁻¹¹ to 5 × 10⁻⁸ M and from 5 × 10⁻⁸ to 1 × 10⁻⁴ M using DPV with lowest limit of detection (LOD = 1 × 10⁻¹¹ M) based on (S/N = 3). The poly (dl-met)/AuNPs-GCE sensor was successfully applied for PRX determination in three different pharmaceutical formulations with percent recoveries between 96.29% and 103.40% ± SD (±0.02 and ±0.58, respectively).

The effects of laser stimulation at acupoint ST36 on anxiety-like behaviors and anterior cingulate cortex c-Fos expression in a rat post-traumatic stress disorder model

Post-traumatic stress disorder (PTSD) is a mental disorder that is linked with the onset of multiple anxiety-like behaviors. This study was designed to assess how these behaviors and anterior cingulate cortex (ACC) c-Fos expression were impacted by 10.6-μm laser stimulation at acupoint ST36 a rat model of PTSD. A rat model of PTSD was prepared via prolonged exposure of animals to a stressor, followed by a 7-day period during which animals were allowed to rest undisturbed in their cages. Rats were randomized into four experimental groups (n = 12/group): the control, PTSD, LS, and sham LS groups. Control group animals were not subjected to SPS procedures prior to behavioral testing. LS and sham LS animals were administered LS treatment at bilateral ST36 acupoints or non-acupoints, respectively, for a 7-day period. Animals were then assessed for performance in elevated plus maze (EPM) tests and open-field tests (OFT), and their plasma corticosterone levels were measured. In addition, c-Fos-positive nuclei in the ACC were detected via immunohistochemical staining. Relative to sham LS treatment and PTSD model control rats, LS was associated with increased time spent in both open EPM test arms and in the central area in the OFT (P < 0.05). The PTSD model group exhibited a significant reduction in ACC c-Fox expression, while LS treatment significantly increased this expression (P < 0.001). In addition, a correlation was detected between anxiety-like behaviors and altered ACC neuronal activation. The results of this study indicate that LS at acupoint ST36 can have a previously unreported effect on anxiety-like behaviors in the context of PTSD, with ACC neuronal activation potentially being implicated as a driver of this effect.

Activation of ventrolateral orbital cortex improves mouse neuropathic pain-induced anxiodepression

Depression and anxiety are frequently observed in patients suffering from neuropathic pain. The underlying mechanisms remained unclear. The ventrolateral orbital cortex (VLO) has attracted considerable interest in its role in antidepressive effect in rodents. In the present study, we further investigated the role of the VLO in the anxiodepressive consequences of neuropathic pain in a chronic constriction injury of infraorbital nerve-induced trigeminal neuralgia (TN) mouse model. Elevated plus maze, open field, forced swimming, tail suspension, and sucrose preference tests were used to evaluate anxiodepressive-like behaviors. The results show that chemogenetic activation of bilateral VLO neurons, especially CaMK2A+ pyramidal neurons, blocked the TN-induced anxiodepressive-like behaviors. Chemogenetic and optogenetic activation of VGLUT2+ or inhibition of VGAT+ VLO neurons was sufficient to produce an antianxiodepressive effect in TN mice. Pharmacological activation of D1-like receptors (D1Rs) but not D2Rs in the VLO significantly alleviated TN-induced depressive-like behaviors. Electrophysiological recordings revealed a decreased excitability of VLO excitatory neurons following neuropathic pain. Furthermore, activation of submedius thalamic nucleus-VLO (Sm-VLO) projection mimicked the antianxiodepressive effect of VLO excitation. Conversely, activation of VLO-periaqueductal gray matter (PAG) projection had no effect on TN-induced anxiodepressive behaviors. This study provides a potentially novel mechanism-based therapeutic strategy for the anxiodepressive consequences of neuropathic pain.

Application of Noninvasive Vagal Nerve Stimulation to Stress-Related Psychiatric Disorders

BACKGROUND

Vagal Nerve Stimulation (VNS) has been shown to be efficacious for the treatment of depression, but to date, VNS devices have required surgical implantation, which has limited widespread implementation.

METHODS

New noninvasive VNS (nVNS) devices have been developed which allow external stimulation of the vagus nerve, and their effects on physiology in patients with stress-related psychiatric disorders can be measured with brain imaging, blood biomarkers, and wearable sensing devices. Advantages in terms of cost and convenience may lead to more widespread implementation in psychiatry, as well as facilitate research of the physiology of the vagus nerve in humans. nVNS has effects on autonomic tone, cardiovascular function, inflammatory responses, and central brain areas involved in modulation of emotion, all of which make it particularly applicable to patients with stress-related psychiatric disorders, including posttraumatic stress disorder (PTSD) and depression, since dysregulation of these circuits and systems underlies the symptomatology of these disorders.

RESULTS

This paper reviewed the physiology of the vagus nerve and its relevance to modulating the stress response in the context of application of nVNS to stress-related psychiatric disorders.

CONCLUSIONS

nVNS has a favorable effect on stress physiology that is measurable using brain imaging, blood biomarkers of inflammation, and wearable sensing devices, and shows promise in the prevention and treatment of stress-related psychiatric disorders.

Improving Research Practice for Studying Borderline Personality Disorder: Lessons From the Clinic

Borderline personality disorder is an often misunderstood and underdiagnosed mental illness characterized in part by affective lability. Clinicians’ unique understanding of the disorder has allowed them to develop disorder-specific approaches to treatment. In this review, we highlight how borderline personality disorder research can benefit from greater engagement with key disorder-specific features, including symptom variability and interpersonal sensitivity. In addition, we propose that research which employs interactive tasks will be more reflective of the kinds of volatility found in the real-life situations. Finally, we discuss how mixed-methodology can serve as a way for recovery-oriented research to practice the very ideals and recommendations it suggests. We use a patient case to contextualize each section. As interest in borderline personality disorder continues to grow, an intentional emphasis on a person-centered, recovery-focused, and disorder-specific approach to research is needed.

Neurocognition in PTSD: Treatment Insights and Implications

Post-traumatic stress disorder (PTSD) is classified as a traumatic stress-related condition and is most often discussed in terms of emotional dysfunction. However, given that cognitive and emotional processes are intricately intertwined, implemented by overlapping brain networks, and effectively integrated in at least some of the same regions (e.g., prefrontal cortex, for a review, see Crocker et al. 2013), an abundance of literature now highlights the key role that cognitive functioning plays in both the development and maintenance (or exacerbation) of PTSD symptoms (Aupperle et al. 2012a; Verfaellie et al. 2012). Findings from this body of work detail objective impairment in neuropsychological function in those with PTSD (Brandes et al. 2002; Hayes et al. 2012a; Koenen et al. 2001). Yet despite the impact of neurocognition on PTSD treatment engagement and success (e.g., Haaland et al. 2016; Nijdam et al. 2015) and conversely, the role of PTSD treatment in normalizing cognitive dysfunction, a much smaller literature exists on neurocognitive changes following treatment for PTSD. Even aside from its role in treatment, cognitive functioning in PTSD has significant implications for daily functioning for individuals with this disorder, as cognition is predictive of school achievement, obtaining and maintaining employment, job advancement, maintaining relationships, greater wealth, and better health and quality of life (e.g., Diamond and Ling 2016).

Evidenced-Based Treatment of Posttraumatic Stress Disorder: An Updated Review of Validated Psychotherapeutic and Pharmacological Approaches

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate psychotherapeutic and pharmacologic approaches to treating patients with posttraumatic stress disorder.

ABSTRACT

A strong evidence base exists for psychological and pharmacological interventions for the treatment of posttraumatic stress disorder (PTSD). The published literature investigating the effectiveness of these treatments in reducing the symptoms and impairments associated with PTSD has expanded substantially in recent years. This review provides a concise overview of the empirical literature examining these treatment approaches. Evidence-based, trauma-focused therapies are recommended as first-line interventions, with the most support for cognitive- and exposure-based approaches. Prolonged exposure and cognitive processing therapy are the two most cited and rigorously investigated. Various other evidence-supported protocols are discussed. Pharmacotherapies can be used when evidence-based psychotherapies are not available or are ineffective, or on the basis of patient preference. Pharmacotherapy with the most support for PTSD includes selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Evidence supports the implementation of these interventions across genders, populations, and settings. Given that little research directly compares the effectiveness of different PTSD interventions and their mechanisms of action, it remains uncertain how to best select and tailor treatments to optimize individual outcomes. Future directions and novel, ongoing research are discussed.

Brain mechanisms of stress and depression in coronary artery disease

INTRODUCTION

Major depression is associated with an increased risk for and mortality from coronary artery disease (CAD), however the mechanisms by which this occurs are not clear. Depression, which is linked to stress, is associated with changes in brain areas involved in memory and the stress response, and it is likely that these regions play an important role in this increased risk. This study assessed the effects of stress on brain and cardiac function in patients with CAD with and without depression.

METHODS

CAD patients with (N = 17) and without (N = 21) major depression based on the Structured Clinical Interview for DSM-IV (DSM-IV) and/or a Hamilton Depression Scale score of nine or greater underwent imaging of the brain with high resolution positron emission tomography (HR-PET) and [O-15] water and imaging of the heart with single photon emission tomography (SPECT) and [Tc-99 m] sestamibi during mental stress (mental arithmetic) and control conditions.

RESULTS

Patients with CAD and major depression showed increased parietal cortex activation and a relative failure of medial prefrontal/anterior cingulate activation during mental stress compared to CAD patients without depression. Depressed CAD patients with stress-induced myocardial ischemia, however, when compared to depressed CAD patients without showed increased activation in rostral portions of the anterior cingulate.

CONCLUSIONS

These findings are consistent with a role for brain areas implicated in stress and depression in the mechanism of increased risk for CAD morbidity and mortality in CAD patients with the diagnosis of major depression.

rTMS Ameliorates PTSD Symptoms in Rats by Enhancing Glutamate Transmission and Synaptic Plasticity in the ACC via the PTEN/Akt Signalling Pathway

Repetitive transcranial magnetic stimulation (rTMS) is a novel physiological therapy that has been adopted to clinically treat psychiatric disorders. Our previous study indicated the potential therapeutic effect of rTMS on posttraumatic stress disorder (PTSD). However, the exact molecular mechanism is elusive. Currently, using the single prolonged stress (SPS) rat model for PTSD, we investigated the glutamatergic transmission and neural plasticity changes in the anterior cingulate cortex (ACC) after SPS induction and explored the protective effects and mechanism of rTMS treatment. We found that high-frequency rTMS (HrTMS, 15 Hz) treatment significantly relieved the impaired glutamatergic receptors in the ACC after SPS treatment by significantly increasing NMDAR and AMPAR expression. Simultaneously, HrTMS blocked inhibited neuronal phosphatase and tensin homologue on chromosome 10 (PTEN)/Akt signalling in the ACC after SPS treatment by decreasing PTEN expression and increasing Akt phosphorylation, which is critically involved in the regulation of memory and synaptic plasticity. The PTEN inhibitors bpV and small interfering RNA and the Akt inhibitor wortmannin were stereotaxically administered to the ACC after SPS treatment to advance the mechanistic study. Analysis by Western blot, double immunofluorescence, Golgi staining and behavioural tests demonstrated that the effects of rTMS on PTEN/Akt activation, glutamatergic receptor expression, neuronal synaptic plasticity and PTSD-related behaviours induced by SPS treatment were enhanced by PTEN inhibition and blocked by Akt inhibition in the ACC. Our study provides convincing evidence for the effectiveness of rTMS treatment on PTSD and suggests that its potential mechanism involves remodelling neuronal synaptic plasticity via the PTEN/Akt signalling pathway.

Diminished medial prefrontal cortex activation during the recollection of stressful events is an acquired characteristic of PTSD

BACKGROUND

Previous research has shown relatively diminished medial prefrontal cortex activation and heightened psychophysiological responses during the recollection of personal events in post-traumatic stress disorder (PTSD), but the origin of these abnormalities is unknown. Twin studies provide the opportunity to determine whether such abnormalities reflect familial vulnerabilities, result from trauma exposure, or are acquired characteristics of PTSD.

METHODS

In this case-control twin study, 26 male identical twin pairs (12 PTSD; 14 non-PTSD) discordant for PTSD and combat exposure recalled and imagined trauma-unrelated stressful and neutral life events using a standard script-driven imagery paradigm during functional magnetic resonance imaging and concurrent skin conductance measurement.

RESULTS

Diminished activation in the medial prefrontal cortex during Stressful v. Neutral script-driven imagery was observed in the individuals with PTSD, relative to other groups.

CONCLUSIONS

Diminished medial prefrontal cortex activation during Stressful v. Neutral script-driven imagery may be an acquired characteristic of PTSD. If replicated, this finding could be used prospectively to inform diagnosis and the assessment of treatment response.

Memory Retention Involves the Ventrolateral Orbitofrontal Cortex: Comparison with the Basolateral Amygdala

The orbitofrontal cortex (OFC) is thought to link stimuli and actions with anticipated outcomes in order to sustain flexible behavior in an ever-changing environment. How it retains these associations to guide future behavior is less well-defined. Here we focused on one subregion of this heterogeneous structure, the ventrolateral OFC (VLO). CaMKII-driven inhibitory Gi-coupled designer receptors exclusively activated by designer drugs (DREADDs) were infused and subsequently activated by their ligand Clozapine-N-oxide (CNO) in conjunction with fear extinction training (a form of aversive conditioning) and response-outcome conditioning (a form of appetitive conditioning). Gi-DREADD-mediated inactivation of the VLO during extinction conditioning interfered with fear extinction memory, resulting in sustained freezing when mice were later tested drug-free. Similarly, Gi-DREADD-mediated inactivation in conjunction with response-outcome conditioning caused a later decay in goal-directed responding-that is, mice were unable to select actions based on the likelihood that they would be rewarded in a sustainable manner. By contrast, inhibitory Gi-DREADDs in the basolateral amygdala (BLA) impaired the acquisition of both conditioned fear extinction and response-outcome conditioning, as expected based on prior studies using other inactivation techniques. Meanwhile, DREADD-mediated inhibition of the dorsolateral striatum enhanced response-outcome conditioning, also in line with prior reports. Together, our findings suggest that learning-related neuroplasticity in the VLO may be necessary for memory retention in both appetitive and aversive domains.

Pre-treatment Resting-State Functional MR Imaging Predicts the Long-Term Clinical Outcome After Short-Term Paroxtine Treatment in Post-traumatic Stress Disorder

Background: The chronic phase of post-traumatic stress disorder (PTSD) and the limited effectiveness of existing treatments creates the need for the development of potential biomarkers to predict response to antidepressant medication at an early stage. However, findings at present focus on acute therapeutic effect without following-up the long-term clinical outcome of PTSD. So far, studies predicting the long-term clinical outcome of short-term treatment based on both pre-treatment and post-treatment functional MRI in PTSD remains limited. Methods: Twenty-two PTSD patients were scanned using resting-state functional MRI (rs-fMRI) before and after 12 weeks of treatment with paroxetine. Twenty patients were followed up using the same psychopathological assessments 2 years after they underwent the second MRI scan. Based on clinical outcome, the follow-up patients were divided into those with remitted PTSD or persistent PTSD. Amplitude of low-frequency fluctuations (ALFF) and degree centrality (DC) derived from pre-treatment and post-treatment rs-fMRI were used as classification features in a support vector machine (SVM) classifier. Results: Prediction of long-term clinical outcome by combined ALFF and DC features derived from pre-treatment rs-fMRI yielded an accuracy rate of 72.5% (p < 0.005). The most informative voxels for outcome prediction were mainly located in the precuneus, superior temporal area, insula, dorsal medial prefrontal cortex, frontal orbital cortex, supplementary motor area, lingual gyrus, and cerebellum. Long-term outcome could not be successfully classified by post-treatment imaging features with accuracy rates <50%. Conclusions: Combined information from ALFF and DC from rs-fMRI data before treatment could predict the long-term clinical outcome of PTSD, which is critical for defining potential biomarkers to customize PTSD treatment and improve the prognosis.

A Pilot Study of the Effects of Mindfulness-Based Stress Reduction on Post-traumatic Stress Disorder Symptoms and Brain Response to Traumatic Reminders of Combat in Operation Enduring Freedom/Operation Iraqi Freedom Combat Veterans with Post-traumatic Stress Disorder

OBJECTIVE

Brain imaging studies in patients with post-traumatic stress disorder (PTSD) have implicated a circuitry of brain regions including the medial prefrontal cortex, amygdala, hippocampus, parietal cortex, and insula. Pharmacological treatment studies have shown a reversal of medial prefrontal deficits in response to traumatic reminders. Mindfulness-based stress reduction (MBSR) is a promising non-pharmacologic approach to the treatment of anxiety and pain disorders. The purpose of this study was to assess the effects of MBSR on PTSD symptoms and brain response to traumatic reminders measured with positron-emission tomography (PET) in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans with PTSD. We hypothesized that MBSR would show increased prefrontal response to stress and improved PTSD symptoms in veterans with PTSD.

METHOD

Twenty-six OEF/OIF combat veterans with PTSD who had recently returned from a combat zone were block randomized to receive eight sessions of MBSR or present-centered group therapy (PCGT). PTSD patients underwent assessment of PTSD symptoms with the Clinician-Administered PTSD Scale (CAPS), mindfulness with the Five Factor Mindfulness Questionnaire (FFMQ) and brain imaging using PET in conjunction with exposure to neutral and Iraq combat-related slides and sound before and after treatment. Nine patients in the MBSR group and 8 in the PCGT group completed all study procedures.

RESULTS

Post-traumatic stress disorder patients treated with MBSR (but not PCGT) had an improvement in PTSD symptoms measured with the CAPS that persisted for 6 months after treatment. MBSR also resulted in an increase in mindfulness measured with the FFMQ. MBSR-treated patients had increased anterior cingulate and inferior parietal lobule and decreased insula and precuneus function in response to traumatic reminders compared to the PCGT group.

CONCLUSION

This study shows that MBSR is a safe and effective treatment for PTSD. Furthermore, MBSR treatment is associated with changes in brain regions that have been implicated in PTSD and are involved in extinction of fear responses to traumatic memories as well as regulation of the stress response.

PSYCHOTHERAPY VERSUS PHARMACOTHERAPY FOR POSTTRAUMATIC STRESS DISORDER: SYSTEMIC REVIEW AND META-ANALYSES TO DETERMINE FIRST-LINE TREATMENTS

BACKGROUND

Current clinical practice guidelines (CPGs) for posttraumatic stress disorder (PTSD) offer contradictory recommendations regarding use of medications or psychotherapy as first-line treatment. Direct head-to-head comparisons are lacking.

METHODS

Systemic review of Medline, EMBASE, PILOTS, Cochrane Central Register of Controlled Trials, PsycINFO, and Global Health Library was conducted without language restrictions. Randomized clinical trials ≥8 weeks in duration using structured clinical interview-based outcome measures, active-control conditions (e.g. supportive psychotherapy), and intent-to-treat analysis were selected for analyses. Independent review, data abstraction, and bias assessment were performed using standardized processes. Study outcomes were grouped around conventional follow-up time periods (3, 6, and 9 months). Combined effect sizes were computed using meta-analyses for medication versus control, medication pre-/posttreatment, psychotherapy versus control, and psychotherapy pre-/posttreatment.

RESULTS

Effect sizes for trauma-focused psychotherapies (TFPs) versus active control conditions were greater than medications versus placebo and other psychotherapies versus active controls. TFPs resulted in greater sustained benefit over time than medications. Sertraline, venlafaxine, and nefazodone outperformed other medications, although potential for methodological biases were high. Improvement following paroxetine and fluoxetine treatment was small. Venlafaxine and stress inoculation training (SIT) demonstrated large initial effects that decreased over time. Bupropion, citalopram, divalproex, mirtazapine, tiagabine, and topiramate failed to differentiate from placebo. Aripiprazole, divalproex, guanfacine, and olanzapine failed to differentiate from placebo when combined with an antidepressant.

CONCLUSIONS

Study findings support use of TFPs over nontrauma-focused psychotherapy or medication as first-line interventions. Second-line interventions include SIT, and potentially sertraline or venlafaxine, rather than entire classes of medication, such as SSRIs. Future revisions of CPGs should prioritize studies that utilize active controls over waitlist or treatment-as-usual conditions. Direct head-to-head trials of TFPs versus sertraline or venlafaxine are needed.

Real-Time fMRI Neurofeedback with War Veterans with Chronic PTSD: A Feasibility Study

Many patients with post-traumatic stress disorder (PTSD), especially war veterans, do not respond to available treatments. Here, we describe a novel neurofeedback (NF) intervention using real-time functional magnetic resonance imaging for treating and studying PTSD. The intervention involves training participants to control amygdala activity after exposure to personalized trauma scripts. Three combat veterans with chronic PTSD participated in this feasibility study. All three participants tolerated well the NF training. Moreover, two participants, despite the chronicity of their symptoms, showed clinically meaningful improvements, while one participant showed a smaller symptom reduction. Examination of changes in resting-state functional connectivity patterns revealed a normalization of brain connectivity consistent with clinical improvement. These preliminary results support feasibility of this novel intervention for PTSD and indicate that larger, well-controlled studies of efficacy are warranted.

Functional network topology associated with posttraumatic stress disorder in veterans

Posttraumatic stress disorder (PTSD) is a disabling disorder associated with resting state functional connectivity alterations. However, whether specific brain regions are altered in PTSD or whether the whole brain network organization differs remains unclear. PTSD can be treated with trauma-focused therapy, although only half of the patients recover after treatment. In order to better understand PTSD psychopathology our aim was to study resting state networks in PTSD before and after treatment. Resting state functional magnetic resonance images were obtained from veterans with PTSD (n = 50) and controls (combat and civilian controls; n = 54) to explore which network topology properties (degree and clustering coefficient) of which brain regions are associated with PTSD. Then, PTSD-associated brain regions were investigated before and after treatment. PTSD patients were subdivided in persistent (n = 22) and remitted PTSD patients (n = 17), and compared with combat controls (n = 22), who were also reassessed. Prior to treatment associations with PTSD were found for the degree of orbitofrontal, and temporoparietal brain regions, and for the clustering coefficient of the anterior cingulate cortex. No significant effects were found over the course of treatment. Our results are in line with previous resting state studies, showing resting state connectivity alterations in the salience network and default mode network in PTSD, and also highlight the importance of other brain regions. However, network metrics do not seem to change over the course of treatment. This study contributes to a better understanding of the psychopathology of PTSD.

Treatment Outcome-Related White Matter Differences in Veterans with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a debilitating disorder that has been associated with brain abnormalities, including white matter alterations. However, little is known about the effect of treatment on these brain alterations. To investigate the course of white matter alterations in PTSD, we used a longitudinal design investigating treatment effects on white matter integrity using diffusion tensor imaging (DTI). Diffusion tensor and magnetization transfer images were obtained pre- and posttreatment from veterans with (n=39) and without PTSD (n=22). After treatment, 16 PTSD patients were remitted, and 23 had persistent PTSD based on PTSD diagnosis. The dorsal and hippocampal cingulum bundle, stria terminalis, and fornix were investigated as regions of interest. Exploratory whole-brain analyses were also performed. Groups were compared with repeated-measures ANOVA for fractional anisotropy (FA), and magnetization transfer ratio. Persistently symptomatic PTSD patients had increasing FA of the dorsal cingulum over time, and at reassessment these FA values were higher than both combat controls and the remitted PTSD group. Group-by-time interactions for FA were found in the hippocampal cingulum, fornix, and stria terminalis, posterior corona radiata, and superior longitudinal fasciculus. Our results indicate that higher FA of the dorsal cingulum bundle may be an acquired feature of persistent PTSD that develops over time. Furthermore, treatment might have differential effects on the hippocampal cingulum, fornix, stria terminalis, posterior corona radiata, and superior longitudinal fasciculus in remitted vs persistent PTSD patients. This study contributes to a better understanding of the neural underpinnings of PTSD treatment outcome.

Altered spontaneous neuronal activity in chronic posttraumatic stress disorder patients before and after a 12-week paroxetine treatment

BACKGROUND

Abnormal functional brain activity has been revealed in patients with Posttraumatic Stress Disorder (PTSD) in recent years, while the recovery neuromechanism of PTSD has not yet been elucidated. The aim of this study was to investigate the altered spontaneous brain activity in treatment-naïve chronic PTSD patients before and after 12 weeks׳ treatment with paroxetine.

METHODS

Twenty-one earthquake-related PTSD patients and seventeen traumatized controls underwent a resting functional magnetic resonance imaging (Rs-fMRI) scan at baseline. Amplitude of low-frequency fluctuation (ALFF) was calculated and compared between PTSD patients and controls. Then, the PTSD group completed 12 weeks of treatment with paroxetine, and Rs-fMRI was repeated to compare with the baseline. Lastly, correlation analyses of ALFF values within altered brain areas were conducted.

RESULTS

Hyperactive function of visual cortex was observed in PTSD patients before and after treatment. After treatment, significantly increased ALFF values were observed in the left orbitofrontal cortex (OFC), while decreased ALFF values were found in the precuneus. Interestingly, a negative correlation between the mean ALFF values of OFC and those of precuneus and visual cortex was only observed in controls, but not in PTSD patients pre- or post-treatment.

LIMITATIONS

A corresponding control condition was absent in this study.

CONCLUSION

The findings showed that manipulating regional spontaneous activity of precuneus and OFC could be a potential prognostic indicator of PTSD. However, hyperactive function of visual cortex and disrupted connections between OFC, precuneus and visual cortex did not reverse after treatment, which could be a potential target for further treatment.

Disrupted amygdala-prefrontal functional connectivity in civilian women with posttraumatic stress disorder

Many features of posttraumatic stress disorder (PTSD) can be linked to exaggerated and dysregulated emotional responses. Central to the neurocircuitry regulating emotion are functional interactions between the amygdala and the ventromedial prefrontal cortex (vmPFC). Findings from human and animal studies suggest that disruption of this circuit predicts individual differences in emotion regulation. However, only a few studies have examined amygdala-vmPFC connectivity in the context of emotional processing in PTSD. The aim of the present research was to investigate the hypothesis that PTSD is associated with disrupted functional connectivity of the amygdala and vmPFC in response to emotional stimuli, extending previous findings by demonstrating such links in an understudied, highly traumatized, civilian population. 40 African-American women with civilian trauma (20 with PTSD and 20 non-PTSD controls) were recruited from a large urban hospital. Participants viewed fearful and neutral face stimuli during functional magnetic resonance imaging (fMRI). Relative to controls, participants with PTSD showed an increased right amygdala response to fearful stimuli (p(corr) < .05). Right amygdala activation correlated positively with the severity of hyperarousal symptoms in the PTSD group. Participants with PTSD showed decreased functional connectivity between the right amygdala and left vmPFC (p(corr) < .05). The findings are consistent with previous findings showing PTSD is associated with an exaggerated response of amygdala-mediated emotional arousal systems. This is the first study to show that the amygdala response may be accompanied by disruption of an amygdala-vmPFC functional circuit that is hypothesized to be involved in prefrontal cortical regulation of amygdala responsivity.