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Burback L, Brémault-Phillips S, Nijdam MJ, McFarlane A, Vermetten E. Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review. Curr Neuropharmacol 2024; 22:557-635. [PMID: 37132142 PMCID: PMC10845104 DOI: 10.2174/1570159x21666230428091433] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/19/2023] [Accepted: 02/23/2023] [Indexed: 05/04/2023] Open
Abstract
This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.
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Affiliation(s)
- Lisa Burback
- Department of Psychiatry, University of Alberta, Edmonton, Canada
| | | | - Mirjam J. Nijdam
- ARQ National Psychotrauma Center, Diemen, The Netherlands
- Department of Psychiatry, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Department of Psychiatry, New York University Grossman School of Medicine, New York, USA
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2
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Nieto-Quero A, Infantes-López MI, Zambrana-Infantes E, Chaves-Peña P, Gavito AL, Munoz-Martin J, Tabbai S, Márquez J, Rodríguez de Fonseca F, García-Fernández MI, Santín LJ, Pedraza C, Pérez-Martín M. Unveiling the Secrets of the Stressed Hippocampus: Exploring Proteomic Changes and Neurobiology of Posttraumatic Stress Disorder. Cells 2023; 12:2290. [PMID: 37759512 PMCID: PMC10527244 DOI: 10.3390/cells12182290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/28/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
Intense stress, especially traumatic stress, can trigger disabling responses and in some cases even lead to the development of posttraumatic stress disorder (PTSD). PTSD is heterogeneous, accompanied by a range of distress symptoms and treatment-resistant disorders that may be associated with a number of other psychopathologies. PTSD is a very heterogeneous disorder with different subtypes that depend on, among other factors, the type of stressor that provokes it. However, the neurobiological mechanisms are poorly understood. The study of early stress responses may hint at the way PTSD develops and improve the understanding of the neurobiological mechanisms involved in its onset, opening the opportunity for possible preventive treatments. Proteomics is a promising strategy for characterizing these early mechanisms underlying the development of PTSD. The aim of the work was to understand how exposure to acute and intense stress using water immersion restraint stress (WIRS), which could be reminiscent of natural disaster, may induce several PTSD-associated symptoms and changes in the hippocampal proteomic profile. The results showed that exposure to WIRS induced behavioural symptoms and corticosterone levels reminiscent of PTSD. Moreover, the expression profiles of hippocampal proteins at 1 h and 24 h after stress were deregulated in favour of increased inflammation and reduced neuroplasticity, which was validated by histological studies and cytokine determination. Taken together, these results suggest that neuroplastic and inflammatory dysregulation may be a therapeutic target for the treatment of post-traumatic stress disorders.
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Affiliation(s)
- Andrea Nieto-Quero
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - María Inmaculada Infantes-López
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain; (P.C.-P.); (J.M.-M.)
| | - Emma Zambrana-Infantes
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Patricia Chaves-Peña
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain; (P.C.-P.); (J.M.-M.)
| | - Ana L. Gavito
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Jose Munoz-Martin
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain; (P.C.-P.); (J.M.-M.)
| | - Sara Tabbai
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Javier Márquez
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
- Departamento de Biología Molecular y Bioquímica, Canceromics Lab, Universidad de Málaga, 29010 Malaga, Spain
| | - Fernando Rodríguez de Fonseca
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - María Inmaculada García-Fernández
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
- Departamento de Fisiología Humana, Histología Humana, Anatomía Patológica y Educación Física y Deportiva, Universidad de Málaga, 29010 Malaga, Spain
| | - Luis J. Santín
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Carmen Pedraza
- Departamento de Psicobiología y Metodología de las Ciencias del Comportamiento, Universidad de Málaga, 29010 Malaga, Spain; (A.N.-Q.); (E.Z.-I.); (S.T.); (L.J.S.)
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
| | - Margarita Pérez-Martín
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29590 Malaga, Spain; (M.I.I.-L.); (A.L.G.); (J.M.); (F.R.d.F.); (M.I.G.-F.)
- Departamento de Biología Celular, Genética y Fisiología, Universidad de Málaga, 29010 Malaga, Spain; (P.C.-P.); (J.M.-M.)
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Carmi L, Zohar J, Juven-Wetzler A, Desarnaud F, Makotkine L, Bierer LM, Cohen H, Yehuda R. Promoter methylation of the glucocorticoid receptor following trauma may be associated with subsequent development of PTSD. World J Biol Psychiatry 2023; 24:578-586. [PMID: 36748398 PMCID: PMC10440098 DOI: 10.1080/15622975.2023.2177342] [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: 09/11/2022] [Revised: 01/22/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The ability to identify persons at elevated risk for post-traumatic stress disorder (PTSD) soon after exposure to trauma, could aid clinical decision-making and treatment. In this study, we explored whether cytosine methylation of the 1 F promoter of the NR3C1 (glucocorticoid receptor [GR]) gene obtained immediately following a trauma could predict PTSD. METHODS Our sample comprised 52 trauma survivors (28 women, 24 men), presenting to the Emergency Department (ED) within six hours of a traumatic event and followed for 13 months. Blood samples were taken at intake (n = 42) and again at the end of the study (13 months later, n = 27) to determine NR3C1-1F promoter methylation as well as plasma levels of cortisol, adrenocorticotropic-hormone (ACTH), and neuropeptide-Y (NPY). RESULTS At the 13-month follow-up, participants who met the PTSD criteria (n = 4) showed significantly lower NR3C1-1F promoter sum percent methylation compared to the non-PTSD group (n = 38). Further, NR3C1-1F methylation at ED intake was inversely correlated with PTSD severity 13 months later, indicating that lower NR3C1-1F promoter methylation in the immediate aftermath of trauma was associated with the development of PTSD. CONCLUSION To the extent that reduced promoter methylation is associated with greater GR expression and responsivity, this finding is consistent with the hypothalamic-pituitary-adrenal dysregulation previously described for PTSD.
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Affiliation(s)
- Lior Carmi
- Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan, Israel
- The Data Science Institution, Reichman University, Herzliya, Israel
| | - Joseph Zohar
- Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan, Israel
- Tel Aviv University, Tel Aviv, Israel
| | | | - Frank Desarnaud
- Traumatic Stress Studies Division, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, Mental Health Care Center, PTSD Clinical Research Program & Laboratory of Clinical Neuroendocrinology and Neurochemistry, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Louri Makotkine
- Traumatic Stress Studies Division, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, Mental Health Care Center, PTSD Clinical Research Program & Laboratory of Clinical Neuroendocrinology and Neurochemistry, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Linda M Bierer
- Traumatic Stress Studies Division, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, Mental Health Care Center, PTSD Clinical Research Program & Laboratory of Clinical Neuroendocrinology and Neurochemistry, James J. Peters Veterans Affairs Medical Center, Bronx, New York
| | - Hagit Cohen
- Beer-Sheva Mental Health Center, Ministry of Health, Anxiety and Stress Research Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Rachel Yehuda
- Traumatic Stress Studies Division, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, Mental Health Care Center, PTSD Clinical Research Program & Laboratory of Clinical Neuroendocrinology and Neurochemistry, James J. Peters Veterans Affairs Medical Center, Bronx, New York
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Cohen H, Ephraim‐Oluwanuga OT, Akintunde OT, Gureje O, Matar MA, Todder D, Zohar J. The potential beneficial effect of sleep deprivation following traumatic events to preventing PTSD: Review of current insight regarding sleep, memory, and trauma resonating with ancient rituals-Àìsùn Oku (African) and Tsuya (Japanese). Neuropsychopharmacol Rep 2023; 43:2-11. [PMID: 36622038 PMCID: PMC10009425 DOI: 10.1002/npr2.12311] [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: 09/11/2022] [Revised: 11/17/2022] [Accepted: 12/05/2022] [Indexed: 01/10/2023] Open
Abstract
Sleep figures in numerous ancient texts, for example, Epic of Gilgamesh, and has been a focus for countless mystical and philosophical texts. Even in the present century, sleep remains one of the most complex behaviors whose function still remains to be further explored. Current hypotheses suggest that among other functions, sleep contributes to memory processes. Memory is a core topic of study in post-traumatic stress disorder (PTSD) and other stress-related phenomena. It is widely accepted that sleep plays a major role in the consolidation of newly encoded hippocampus-dependent memories to pre-existing knowledge networks. Conversely, sleep deprivation disrupts consolidation and impairs memory retrieval. Along this line, sleep deprivation following a potentially traumatic event may interfere with the consolidation of event-related memories and, thereby, may reduce long-term post-traumatic stress-related symptoms. This review consolidates clinical and animal studies on the relationships between sleep, sleep deprivation, memory processes, and trauma exposure while introducing new contemporary insights into an ancient African tribal ritual (Àìsùn Oku) and Japanese ceremony ritual (Tsuya). We propose that these findings, focusing specifically on the effects of sleep deprivation in the immediate aftermath of traumatic events, may be explored as a possible therapeutic measure. Along with a summary of the field questions on whether sleep is performed "to remember" or "to forget" we lay the rationale for using sleep deprivation as a clinical tool. A tool that may partially prevent the long-term persistence of these traumatic events' memory and thereby, at least partly, attenuating the development of PTSD.
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Affiliation(s)
- Hagit Cohen
- Ministry of Health, Anxiety and Stress Research Unit, Faculty of Health Sciences, Beer‐Sheva Mental Health CenterBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | | | - Orunmuyi T. Akintunde
- Department of Nuclear Medicine, College of MedicineUniversity of IbadanIbadanNigeria
| | - Oye Gureje
- Department of PsychiatryCollege of Health Sciences University of AbujaAbujaNigeria
| | - Michael A. Matar
- Ministry of Health, Anxiety and Stress Research Unit, Faculty of Health Sciences, Beer‐Sheva Mental Health CenterBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Doron Todder
- Ministry of Health, Anxiety and Stress Research Unit, Faculty of Health Sciences, Beer‐Sheva Mental Health CenterBen‐Gurion University of the NegevBeer‐ShevaIsrael
| | - Joseph Zohar
- Post‐Trauma Center, Sheba Medical CenterTel Aviv UniversityTel AvivIsrael
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5
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Breindahl N, Strange KF, Østergaard D, Collatz Christensen H. Evaluation of a critical incident management system on mental health in lifeguard organisations: a retrospective study. BMJ Open Sport Exerc Med 2023; 9:e001499. [PMID: 36704713 PMCID: PMC9872474 DOI: 10.1136/bmjsem-2022-001499] [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] [Accepted: 01/12/2023] [Indexed: 01/25/2023] Open
Abstract
Background Lifeguards may face many life-threatening situations during their careers and may be at increased risk of post-traumatic stress disorder (PTSD). Minimal evidence concerning critical incident management systems in lifeguard organisations exists. Objectives To develop, implement and evaluate an operational system for critical incident management in lifeguard organisations. Methods This retrospective study included data on occupational injury reports from 2013 to 2022 in TrygFonden Surf Lifesaving Denmark. All active lifeguards were invited to evaluate the system and the individual steps using an online questionnaire with three questions rated on a 5-point Likert scale. Primary outcome was a change in the frequency of psychological injury reports after system implementation in 2020. The secondary outcome was the lifeguards' satisfaction with the system. Results After implementation, the average annual number of psychological injury reports increased 6.5-fold from 2 (2013-2019) to 13 (2020-2022), without changes to the number of critical incidents attended by the lifeguards. Sixty-six (33.8%) active lifeguards answered the questionnaire and agreed that follow-up after critical incidents was very important (mean score 4.7/5). Satisfaction with steps 1-2 and 3 of critical incident management among involved lifeguards was high (mean score 4.4/5 and 4.6/5, respectively). The system included an operational workflow diagram and incident report template presented in this study. Conclusions The operational system for critical incident management may improve early recognition of symptoms for the prevention of PTSD. It may be used as a screening and decision tool for referral to a mental health professional.
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Affiliation(s)
- Niklas Breindahl
- Prehospital Center Region Zealand, Naestved Hospital, Naestved, Denmark,Department of Neonatal and Pediatric Intensive Care, Rigshospitalet, Copenhagen, Denmark,International Life Saving Federation, Leuven, Belgium,TrygFonden Surf Lifesaving Denmark, Hvidovre, Denmark
| | - Kirstine Friderichsen Strange
- TrygFonden Surf Lifesaving Denmark, Hvidovre, Denmark,Hammel Neurorehabilitation and Research Centre, Regional Hospital Hammel Neurocenter, Hammel, Denmark
| | - Doris Østergaard
- Copenhagen Academy for Medical Education and Simulation, Herlev Hospital, Herlev, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Helle Collatz Christensen
- Prehospital Center Region Zealand, Naestved Hospital, Naestved, Denmark,Copenhagen Emergency Medical Services, Region Hovedstaden, Ballerup, Denmark,Danish Clinical Quality Program (RKKP), National Clinical Registries, Denmark, Copenhagen, Denmark
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6
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Pedraza LK, Sierra RO, de Oliveira Alvares L. Systems consolidation and fear memory generalisation as a potential target for trauma-related disorders. World J Biol Psychiatry 2022; 23:653-665. [PMID: 35001808 DOI: 10.1080/15622975.2022.2027010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Fear memory generalisation is a central hallmark in the broad range of anxiety and trauma-related disorders. Recent findings suggest that fear generalisation is closely related to hippocampal dependency during retrieval. In this review, we describe the current understanding about memory generalisation and its potential influence in fear attenuation through pharmacological and behavioural interventions. In light of systems consolidation framework, we propose that keeping memory precision could be a key step to enhance therapeutic outcomes.
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Affiliation(s)
- Lizeth K Pedraza
- Laboratório de Neurobiologia da Memória, Biophysics Department, Biosciences Institute, 91.501-970, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Department of Physiology, University of Szeged, Szeged, Hungary
| | - Rodrigo O Sierra
- Laboratório de Neurobiologia da Memória, Biophysics Department, Biosciences Institute, 91.501-970, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Department of Physiology, University of Szeged, Szeged, Hungary
| | - Lucas de Oliveira Alvares
- Laboratório de Neurobiologia da Memória, Biophysics Department, Biosciences Institute, 91.501-970, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Graduate Program in Neuroscience, Institute of Health Sciences, Porto Alegre, Brazil
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A Public Health Perspective of Post-Traumatic Stress Disorder. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116474. [PMID: 35682057 PMCID: PMC9180718 DOI: 10.3390/ijerph19116474] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 11/25/2022]
Abstract
Trauma exposure is one of the most important and prevalent risk factors for mental and physical ill-health. Prolonged or excessive stress exposure increases the risk of a wide variety of mental and physical symptoms, resulting in a condition known as post-traumatic stress disorder (PTSD). The diagnosis might be challenging due to the complex pathophysiology and co-existence with other mental disorders. The prime factor for PTSD development is exposure to a stressor, which variably, along with peritraumatic conditions, affects disease progression and severity. Additionally, many factors are thought to influence the response to the stressor, and hence reshape the natural history and course of the disease. With sufficient knowledge about the disease, preventive and intervenient methods can be implemented to improve the quality of life of the patients and to limit both the medical and economic burden of the disease. This literature review provides a highlight of up-to-date literature on traumatic stress, with a focus on causes or triggers of stress, factors that influence response to stress, disease burden, and the application of the social-ecological public health model of disease prevention. In addition, it addresses therapeutic aspects, ethnic differences in traumatic stress, and future perspectives, including potential biomarkers.
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8
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Lesmana CBJ, Suryani LK, Tiliopoulos N. The biobehavioural effectiveness of spiritual-hypnosis-assisted therapy in PTSD with childhood trauma. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00475-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Posttraumatic Stress Disorder (PTSD) is a serious psychological trauma disorder. Treatment of psychological trauma tends to focus on patients' memory. Clinical Spiritual-Hypnosis Assisted Therapy is a culturally sensitive treatment that combines elements of psychodynamic hypnosis, cognitive–behavioral and humanistic therapies.
Methods
The current interventional single-blind randomized control study assessed the biobehavioural effectiveness of spiritual-hypnosis on cortisol and PTSD symptomatology in adults with childhood trauma. Participants were divided into spiritual hypnosis (n = 15) and a control group (n = 14) that received fluoxetine. This study used PCL-C & CTQ to screen the presence and severity of PTSD symptoms.
Results
Spiritual hypnosis was significantly better than fluoxetine at reducing PTSD symptoms, while both treatments had similar effects on cortisol modification.
Conclusions
Spiritual-Hypnosis Assisted Therapy for PTSD patients with childhood trauma appears to have a noteworthy effect in reducing PTSD clinical symptoms and results in a comparable to the pharmacological treatment modification of the HPA axis cortisol markers.
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Duran ÉP, Hemanny C, Vieira R, Nascimento O, Machado L, de Oliveira IR, Demarzo M. A Randomized Clinical Trial to Assess the Efficacy of Online-Treatment with Trial-Based Cognitive Therapy, Mindfulness-Based Health Promotion and Positive Psychotherapy for Post-Traumatic Stress Disorder during the COVID-19 Pandemic: A Study Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:819. [PMID: 35055641 PMCID: PMC8775699 DOI: 10.3390/ijerph19020819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/22/2021] [Accepted: 01/07/2022] [Indexed: 12/10/2022]
Abstract
BACKGROUND Research suggests the use of different forms of therapy as a way of decreasing dropout rates in the treatment of post-traumatic stress disorder (PTSD). The psychotherapies to be assessed in this study are trial-based cognitive therapy (TBCT), mindfulness-based health promotion (MBHP) and positive psychotherapy (PPT). OBJECTIVES (1) to assess the online efficacy of TBCT compared to MBHP and PPT to reduce the symptoms of PTSD in the context of the Coronavirus Disease 2019 (COVID-19) pandemic; (2) to compare the efficacy of these psychotherapies in improving anxiety, depression, guilt and in promoting well-being; and (3) to describe how professionals perceive online treatment. METHODS A randomized, multicenter, single-blind clinical trial will be conducted, with three separate arms. An estimated sample of 135 patients will receive either TBCT, MBHP or PPT and will be treated through online, individual, weekly visits, totaling 14 sessions. The primary outcome will be CAPS-5 and secondary outcomes will be HADS and WHO-5. The variables used to mediate these outcomes will be the Trauma-Related Guilt Inventory (TRGI), Negative Core Beliefs Inventory (NCBI) and the California Psychotherapy Alliance Scale (CALPAS-P). EXPECTED RESULTS PTSD symptoms are expected to be reduced after TBCT, MBHP and PPT. No statistical difference is expected to be found among the three. DISCUSSION The present study will evaluate and contribute towards the development of new psychotherapeutic options for patients with PTSD. The results of this study will allow the dissemination of new effective and adaptable interventions for patients with PTSD.
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Affiliation(s)
- Érica Panzani Duran
- Postgraduate Program of Interactive Processes of Organs and Systems, Health Sciences Institute, Department of Neuroscience and Mental Health, Federal University of Bahia, Salvador 40110-060, Brazil; (C.H.); (R.V.); (I.R.d.O.)
| | - Curt Hemanny
- Postgraduate Program of Interactive Processes of Organs and Systems, Health Sciences Institute, Department of Neuroscience and Mental Health, Federal University of Bahia, Salvador 40110-060, Brazil; (C.H.); (R.V.); (I.R.d.O.)
| | - Renata Vieira
- Postgraduate Program of Interactive Processes of Organs and Systems, Health Sciences Institute, Department of Neuroscience and Mental Health, Federal University of Bahia, Salvador 40110-060, Brazil; (C.H.); (R.V.); (I.R.d.O.)
| | - Orlando Nascimento
- Mente Aberta—Brazilian Center for Mindfulness and Health Promotion, Department of Preventive Medicine, Universidade Federal de São Paulo (UNIFESP), Sao Paulo 04753-060, Brazil; (O.N.); (M.D.)
| | - Leonardo Machado
- Postgraduate Program in Neuropsychiatry and Behavioral Sciences, Center for Medical Sciences, Department of Neuropsychiatry, Federal University of Pernambuco (POSNEURO-CCM-UFPE), Recife 50070-460, Brazil;
| | - Irismar Reis de Oliveira
- Postgraduate Program of Interactive Processes of Organs and Systems, Health Sciences Institute, Department of Neuroscience and Mental Health, Federal University of Bahia, Salvador 40110-060, Brazil; (C.H.); (R.V.); (I.R.d.O.)
| | - Marcelo Demarzo
- Mente Aberta—Brazilian Center for Mindfulness and Health Promotion, Department of Preventive Medicine, Universidade Federal de São Paulo (UNIFESP), Sao Paulo 04753-060, Brazil; (O.N.); (M.D.)
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Azizi M, Bidaki R, Ebadi A, Ostadtaghizadeh A, Tafti AD, Hajebi A, Alizadeh A, Khankeh HR. Psychological distress Management in Iranian emergency prehospital providers: A Qualitative study. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2021; 10:442. [PMID: 35071648 PMCID: PMC8719565 DOI: 10.4103/jehp.jehp_351_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/04/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Emergency prehospital providers (EPHP) who are constantly providing medical care in threatening conditions are more at risk of displaying psychological distress presentations in disaster situations. Problem-solving strategies are essential for effective and efficient management of event position. Therefore, the present study aimed to explore psychological distress promotion in Iranian EPHP. MATERIALS AND METHODS A qualitative content analysis study was conducted based on 24 semi-structured interviews. A purposeful sampling method was applied until reaching data saturation. Interviews were transcribed verbatim, and then, data condensing, labeling, coding, and defining categories were performed by the qualitative content analysis recommended by the Landman and Graneheim approach. RESULTS Based on the experience of study participants, two main themes with six categories developed. The main themes included emotion-based management and problem-based management when confronting with incidence scene. CONCLUSION The main problems of EPHP in confronting with incidence and disasters scenes are psychological distress which some rescuers have emotional reactions while some others who are more resilience and experience manage this problem in the form of problem-based approach. It is recommended these practical strategies to be taught to less experienced rescuers for avoiding emotional-based reactions and better management of disaster scene.
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Affiliation(s)
- Maryam Azizi
- School of Public Health, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Reza Bidaki
- Research Center of Addiction and Behavioral Sciences, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Life Style Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Abbas Ostadtaghizadeh
- Department of Disaster and Emergency Health, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbasali Dehghani Tafti
- School of Public Health, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Ahmad Hajebi
- Research Center for Addiction and Risky Behaviors (ReCARB), Pychiatric Department, Iran University of Medical Siences, Tehran, Iran
| | - Azizeh Alizadeh
- PhD in Military Psychology, Psychology Department of Hajar Hospital, Tehran, Iran
| | - Hamid Reza Khankeh
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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A randomized clinical trial to assess the efficacy of trial-based cognitive therapy compared to prolonged exposure for post-traumatic stress disorder: preliminary findings. CNS Spectr 2021; 26:427-434. [PMID: 32450928 DOI: 10.1017/s1092852920001455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is a prevalent mental health condition that is often associated with psychiatric comorbidities and changes in quality of life. Prolonged exposure therapy (PE) is considered the gold standard psychological treatment for PTSD, but treatment resistance and relapse rates are high. Trial-based cognitive therapy (TBCT) is an effective treatment for depression and social anxiety disorder, and its structure seems particularly promising for PTSD. Therefore, we evaluated the efficacy of TBCT compared to PE in patients with PTSD. METHODS Ninety-five patients (77.6% females) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria for PTSD were randomly assigned to receive either TBCT (n = 44) or PE (n = 51). Patients were evaluated before and after treatment, and at follow-up 3 months after treatment. The primary outcome was improvement in PTSD symptoms as assessed by the Davidson Trauma Scale (DTS). Secondary outcomes were depression, anxiety, and dysfunctional attitudes assessed by the Beck Depression/Anxiety Inventories and Dysfunctional Attitudes Scale, as well as the dropout rate. RESULTS A significant reduction in DTS scores was observed in both arms, but no significant difference between treatments. Regarding the secondary outcomes, we found significant differences in depressive symptoms in favor of TBCT, and the dropout rate was lower in the TBCT group than the PE group. CONCLUSION Our preliminary results suggest that TBCT may be an effective alternative for treating PTSD. Further research is needed to better understand its role and the mechanisms of change in the treatment of this disorder.
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12
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Repeated cocaine exposure prior to fear conditioning induces persistency of PTSD-like symptoms and enhancement of hippocampal and amygdala cell density in male rats. Brain Struct Funct 2021; 226:2219-2241. [PMID: 34195855 DOI: 10.1007/s00429-021-02320-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/11/2021] [Indexed: 12/29/2022]
Abstract
Pre- and post-trauma drug use can interfere with recovery from post-traumatic stress disorder (PTSD). However, the biological underpinnings of this interference are poorly understood. Here we examined the effect of pre-fear conditioning cocaine self-administration on PTSD-like symptoms in male rats, and defined impairment of fear extinction as difficulty to recover from PTSD. We also examined cell density changes in brain regions suspected of being involved in resistance to PTSD recovery. Before footshock stress testing, rats were trained to self-administer cocaine during 20 consecutive days, after which they were exposed to footshocks, while other rats continued to self-administer cocaine until the end of the experiment. Upon assessment of three PTSD-like symptoms (fear during situational reminders, anxiety-like behavior, and impairment of recognition memory) and fear extinction learning and memory, changes in cell density were measured in the medial prefrontal cortex, hippocampus, and amygdala. Results show that pre-footshock cocaine exposure did not affect fear during situational reminders. Fear conditioning did not lead to an increase in cocaine consumption. However, in footshock stressed rats, cocaine induced a reduction of anxiety-like behavior, an aggravation of recognition memory decline, and an impairment of extinction memory. These behavioral alterations were associated with increased cell density in the hippocampal CA1, CA2, and CA3 regions and basolateral amygdala, but not in the medial prefrontal cortex. Our findings suggest that enhancement of cell density in the hippocampus and amygdala may be changes associated with drug use, interfering with PTSD recovery.
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13
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Danan D, Todder D, Zohar J, Cohen H. Is PTSD-Phenotype Associated with HPA-Axis Sensitivity? Feedback Inhibition and Other Modulating Factors of Glucocorticoid Signaling Dynamics. Int J Mol Sci 2021; 22:ijms22116050. [PMID: 34205191 PMCID: PMC8200046 DOI: 10.3390/ijms22116050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 01/12/2023] Open
Abstract
Previously, we found that basal corticosterone pulsatility significantly impacts the vulnerability for developing post-traumatic stress disorder (PTSD). Rats that exhibited PTSD-phenotype were characterized by blunted basal corticosterone pulsatility amplitude and a blunted corticosterone response to a stressor. This study sought to identify the mechanisms underlining both the loss of pulsatility and differences in downstream responses. Serial blood samples were collected manually via jugular vein cannula at 10-min intervals to evaluate suppression of corticosterone following methylprednisolone administration. The rats were exposed to predator scent stress (PSS) after 24 h, and behavioral responses were assessed 7 days post-exposure for retrospective classification into behavioral response groups. Brains were harvested for measurements of the glucocorticoid receptor, mineralocorticoid receptor, FK506-binding protein-51 and arginine vasopressin in specific brain regions to assess changes in hypothalamus–pituitary–adrenal axis (HPA) regulating factors. Methylprednisolone produced greater suppression of corticosterone in the PTSD-phenotype group. During the suppression, the PTSD-phenotype rats showed a significantly more pronounced pulsatile activity. In addition, the PTSD-phenotype group showed distinct changes in the ventral and dorsal CA1, dentate gyrus as well as in the paraventricular nucleus and supra-optic nucleus. These results demonstrate a pre-trauma vulnerability state that is characterized by an over-reactivity of the HPA and changes in its regulating factors.
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Affiliation(s)
- Dor Danan
- Anxiety and Stress Research Unit, Beer-Sheva Mental Health Center, Ministry of Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84170, Israel; (D.D.); (D.T.)
| | - Doron Todder
- Anxiety and Stress Research Unit, Beer-Sheva Mental Health Center, Ministry of Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84170, Israel; (D.D.); (D.T.)
| | - Joseph Zohar
- Post-Trauma Center, Sheba Medical Center, Tel Aviv 52621, Israel;
| | - Hagit Cohen
- Anxiety and Stress Research Unit, Beer-Sheva Mental Health Center, Ministry of Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84170, Israel; (D.D.); (D.T.)
- Correspondence: ; Tel.: +972-544-369106
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Gargot T, Kisand H, Miguel A, Tanyeri S, Soron TR, Serene B, Feron G, Žaja N, Valdés-Florido MJ, Soto-Angona Ó, Frankova I. Preventing Post Traumatic Stress Disorder in the general population induced by trauma during the COVID pandemic: A simple brief intervention based on cognitive science that could be delivered digitally. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2021; 5:100193. [PMID: 38620807 PMCID: PMC7833821 DOI: 10.1016/j.ejtd.2020.100193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/12/2020] [Accepted: 12/27/2020] [Indexed: 11/16/2022]
Abstract
Most of the recent studies indicated the prevalence of Post-Traumatic Stress Symptoms (PTSS) are increasing after the COVID pandemic around the world. Bo et al. reported PTSS prevalence of 96.2% among the COVID-19-infected people. The sociocultural and individual vulnerability and protective factors may influence onset and maintenance of the symptoms. However, there is significant lack in understanding the risk factors and preventive factors that influence the maintenance of Post-Traumatic Stress symptoms that defines Post-Traumatic Stress Disorder (PTSD). The digital technology gives us the unique opportunity to assess this risk, to monitor and track this evolution longitudinally. In this research project we aimed to design and develop a smartphone application for longitudinal data collection enabling to (1) predict and follow the evolution of PTSS toward PTSD, (2) assess the relative efficacy of several methods to prevent the evolution of PTSS right after exposure to trauma (1-24 h), (3) educate people about psychological effects that can occur during and after trauma, normalize acute distress and refer to professional help if a disorder is constituted. We hope that this research project will help to understand how to maximize the self help support during the acute phase (golden hours) after trauma to prevent the transition from PTSS to PTSD. A video abstract can be found on https://www.youtube.com/watch?v=RZJehj3J8go&feature=emb_title.
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Affiliation(s)
- Thomas Gargot
- Child and Adolescent Psychiatry, Excellence Center in Autism and neurodevelopmental disorders - Tours ExAC-T, CHRU Tours
- ISIR, Sorbonne Université, CHART Laboratory-EA 4004, Paris, France
- THIM, Paris 8 University, Saint Denis, France
| | - Helena Kisand
- University of Tatru, Estonia. EFPT Psychotherapy Working Group
| | - Ana Miguel
- Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Selin Tanyeri
- Ege University, School of Medicine, Psychiatry Department, Turkey
| | | | | | | | - Nikola Žaja
- University Psychiatric Hospital Vrapče, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | - Óscar Soto-Angona
- Department of Psychiatry, Vall d'Hebron University Hospital, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Catalonia, Spain
| | - Iryna Frankova
- Bogomolets National Medical University, Medical Psychology, Psychosomatic Medicine and Psychotherapy Department, Kyiv, Ukraine
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15
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Rajkumar RP. Harnessing the Neurobiology of Resilience to Protect the Mental Well-Being of Healthcare Workers During the COVID-19 Pandemic. Front Psychol 2021; 12:621853. [PMID: 33815205 PMCID: PMC8012770 DOI: 10.3389/fpsyg.2021.621853] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/22/2021] [Indexed: 01/26/2023] Open
Abstract
Healthcare workers are at a high risk of psychological morbidity in the face of the COVID-19 pandemic. However, there is significant variability in the impact of this crisis on individual healthcare workers, which can be best explained through an appreciation of the construct of resilience. Broadly speaking, resilience refers to the ability to successfully adapt to stressful or traumatic events, and thus plays a key role in determining mental health outcomes following exposure to such events. A proper understanding of resilience is vital in enabling a shift from a reactive to a proactive approach for protecting and promoting the mental well-being of healthcare workers. Research in the past decade has identified six areas that provide promising leads in understanding the biological basis of individual variations in resilience. These are: (1) the key role played by the monoamines noradrenaline and serotonin, (2) the centrality of the hypothalamic-pituitary-adrenal axis in influencing stress vulnerability and resilience, (3) the intimate links between the immune system and stress sensitivity, (4) the role of epigenetic modulation of gene expression in influencing the stress response, (5) the role played by certain neuropeptides as a natural “brake” mechanism in the face of stress, and (6) the neurobiological mechanisms by which environmental factors, such as exercise, diet, and social support, influence resilience to subsequent life events. Though much of this research is still in its early stages, it has already provided valuable information on which strategies – including dietary changes, lifestyle modification, environmental modification, psychosocial interventions, and even pharmacological treatments – may prove to be useful in fostering resilience in individuals and groups. This paper examines the above evidence more closely, with a specific focus on the challenges faced by healthcare workers during the COVID-19 pandemic, and provides suggestions regarding how it may be translated into real-world interventions, as well as how the more tentative hypotheses advanced in this field may be tested during this critical period.
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Affiliation(s)
- Ravi Philip Rajkumar
- Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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16
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Bryant RA. A critical review of mechanisms of adaptation to trauma: Implications for early interventions for posttraumatic stress disorder. Clin Psychol Rev 2021; 85:101981. [PMID: 33588312 DOI: 10.1016/j.cpr.2021.101981] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 11/23/2020] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
Although many attempts have been made to limit development of posttraumatic stress disorder (PTSD) by early intervention after trauma exposure, these attempts have achieved only modest success. This review critiques the biological and cognitive strategies used for early intervention and outlines the extent to which they have prevented PTSD. The major predictors of PTSD are reviewed, with an emphasis on potential mechanisms that may underpin the transition from acute stress reaction to development of PTSD. This review highlights that there is a wide range of biological and cognitive factors that have been shown to predict PTSD. Despite this, the major attempts at early intervention have focused on strategies that attempt to augment extinction processes or alter appraisals in the acute period. The documented predictors of PTSD indicate that a broader range of potential strategies could be explored to limit PTSD. The evidence that people follow different trajectories of stress response following trauma and there is a wide array of acute predictors of PTSD indicates that a flexible and tailored approach needs to be investigated to evaluate more effective early intervention strategies.
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17
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Schultebraucks K, Chang BP. The opportunities and challenges of machine learning in the acute care setting for precision prevention of posttraumatic stress sequelae. Exp Neurol 2021; 336:113526. [PMID: 33157093 PMCID: PMC7856033 DOI: 10.1016/j.expneurol.2020.113526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 11/25/2022]
Abstract
Personalized medicine is among the most exciting innovations in recent clinical research, offering the opportunity for tailored screening and management at the individual level. Biomarker-enriched clinical trials have shown increased efficiency and informativeness in cancer research due to the selective exclusion of patients unlikely to benefit. In acute stress situations, clinically significant decisions are often made in time-sensitive manners and providers may be pressed to make decisions based on abbreviated clinical assessments. Up to 30% of trauma survivors admitted to the Emergency Department (ED) will develop long-lasting posttraumatic stress psychopathologies. The long-term impact of those survivors with posttraumatic stress sequelae are significant, impacting both long-term psychological and physiological recovery. An accurate prognostic model of who will develop posttraumatic stress symptoms does not exist yet. Additionally, no scalable and cost-effective method that can be easily integrated into routine care exists, even though especially the acute care setting provides a critical window of opportunity for prevention in the so-called golden hours when preventive measures are most effective. In this review, we aim to discuss emerging machine learning (ML) applications that are promising for precisely risk stratification and targeted treatments in the acute care setting. The aim of this narrative review is to present examples of digital health innovations and to discuss the potential of these new approaches for treatment selection and prevention of posttraumatic sequelae in the acute care setting. The application of artificial intelligence-based solutions have already had great success in other areas and are rapidly approaching the field of psychological care as well. New ways of algorithm-based risk predicting, and the use of digital phenotypes provide a high potential for predicting future risk of PTSD in acute care settings and to go new steps in precision psychiatry.
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Affiliation(s)
- Katharina Schultebraucks
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, United States of America; Data Science Institute, Columbia University, New York, NY, United States of America.
| | - Bernard P Chang
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY, United States of America
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Pharmacological prevention and early treatment of post-traumatic stress disorder and acute stress disorder: a systematic review and meta-analysis. Transl Psychiatry 2019; 9:334. [PMID: 31819037 PMCID: PMC6901463 DOI: 10.1038/s41398-019-0673-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 12/29/2022] Open
Abstract
Post-traumatic stress disorder (PTSD) is a common mental disorder associated with significant distress and reduced functioning. Its occurrence after a severe traumatic event and association with characteristic neurobiological changes make PTSD a good candidate for pharmacological prevention and early treatment. The primary aim for this systematic review and meta-analysis was to assess whether pharmacological interventions when compared to placebo, or other pharmacological/psychosocial interventions resulted in a clinically significant reduction or prevention of symptoms, improved functioning or quality of life, presence of disorder, or adverse effects. A systematic search was undertaken to identify RCTs, which used early pharmacotherapy (within three months of a traumatic event) to prevent and treat PTSD and acute stress disorder (ASD) in children and adults. Using Cochrane Collaboration methodology, RCTs were identified and rated for risk of bias. Available data was pooled to calculate risk ratios (RR) for PTSD prevalence and standardised mean differences (SMD) for PTSD severity. 19 RCTs met the inclusion criteria; 16 studies with adult participants and three with children. The methodological quality of most trials was low. Only hydrocortisone in adults was found to be superior to placebo (3 studies, n = 88, RR: 0.21 (CI 0.05 to 0.89)) although this was in populations with severe physical illness, raising concerns about generalisability. No significant effects were found for the other pharmacotherapies investigated (propranolol, oxytocin, gabapentin, fish oil (1470 mg DHA/147 mg EPA), fish oil (224 mg DHA/22.4 mg EPA), dexamethasone, escitalopram, imipramine and chloral hydrate). Hydrocortisone shows the most promise, of pharmacotherapies subjected to RCTs, as an emerging intervention in the prevention of PTSD within three months after trauma and should be a target for further investigation. The limited evidence for hydrocortisone and its adverse effects mean it cannot be recommended for routine use, but, it could be considered as a preventative intervention for people with severe physical illness or injury, shortly after a traumatic event, as long as there are no contraindications. More research is needed using larger, high quality RCTs to establish the most efficacious use of hydrocortisone in different populations and optimal dosing, dosing window and route. There is currently a lack of evidence to suggest that other pharmacological agents are likely to be effective.
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19
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Shaked G, Shaked D, Sebbag G, Czeiger D. The effect of steroid treatment on whiplash associated syndrome: a controlled randomized prospective trial. Eur J Trauma Emerg Surg 2019; 47:1115-1122. [PMID: 31811333 DOI: 10.1007/s00068-019-01282-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE There is significant evidence in the literature that low or relatively low cortisol concentrations near the time of an accident are associated with more severe forms of whiplash-associated disorders. We hypothesized that treating patients that were involved in a motor vehicle accident with hydrocortisone would alleviate the incidence and severity of these disabling disorders. METHODS A prospective, randomized, double-blind, placebo-controlled clinical trial. Blunt trauma patients that underwent a motor vehicle crash were allocated into a study group that received a single bolus of hydrocortisone and a control group that received saline. The patients were followed for 1 month. The incidence and severity of whiplash associated disorder, functional disturbances, and post-traumatic stress disorder were compared between the two groups. The analyses were repeated for sub-divisions into groups of high and low admission cortisol. RESULTS The more severe forms of whiplash-associated disorders on the day of accident were associated with low cortisol levels; mean cortisol concentration of the lower grade of whiplash patients (13.09 ± 7.35 µg%) was higher than that of whiplash syndrome of the severe forms (8.33 ± 3.45 µg), p = 0.001. There were no differences between study and control groups regarding whiplash-associated disorders, functional tests, and severity of stress disorder 1 month after the accident. Significant differences were evident between high and low cortisol sub-groups. Those who had low cortisol level on admission and received hydrocortisone had worse outcomes. CONCLUSION Steroid treatment of patients with whiplash might be harmful to those who present with low cortisol concentrations (< 9.5 μg/dL). TRIAL REGISTRATION Clinical Trials: Association between low cortisol levels and whiplash syndrome. Date of registration: March 18, 2014. Date the first participant was enrolled: May 10, 2014. TRIAL REGISTRATION NUMBER NCT02090309. URL: https://clinicaltrials.gov/ct2/show/NCT02090309 .
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Affiliation(s)
- Gad Shaked
- Department of General Surgery and Trauma Unit, Soroka University Medical Center and Ben-Gurion University, Wingate St. 64, 84101, Beer Sheva, Israel.
| | - Daniela Shaked
- Physical Therapy Department, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel
| | - Gilbert Sebbag
- Department of General Surgery and Trauma Unit, Soroka University Medical Center and Ben-Gurion University, Wingate St. 64, 84101, Beer Sheva, Israel
| | - David Czeiger
- Department of General Surgery and Trauma Unit, Soroka University Medical Center and Ben-Gurion University, Wingate St. 64, 84101, Beer Sheva, Israel
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Early Risk and Resiliency Factors Predict Chronic Posttraumatic Stress Disorder in Caregivers of Patients Admitted to a Neuroscience ICU. Crit Care Med 2019; 46:713-719. [PMID: 29384786 DOI: 10.1097/ccm.0000000000002988] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Informal caregivers-that is, close family and friends providing unpaid emotional or instrumental care-of patients admitted to ICUs are at risk for posttraumatic stress disorder. As a first step toward developing interventions to prevent posttraumatic stress disorder in ICU caregivers, we examined the predictive validity of psychosocial risk screening during admission for caregiver posttraumatic stress disorder at 3 and 6 months post hospitalization. DESIGN An observational, prospective study. PARTICIPANTS Ninety-nine caregivers were recruited as part of a longitudinal research program of patient-caregiver dyads in a neuroscience ICU. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Caregiver posttraumatic stress disorder symptoms were assessed during admission (baseline), 3 months, and 6 months post hospitalization. We 1) characterized prevalence of clinically significant symptoms at each time point 2); calculated sensitivity and specificity of baseline posttraumatic stress disorder screening in predicting posttraumatic stress disorder at 3 and 6 months; and 3) used recursive partitioning to select potential baseline factors and examine the extent to which they helped predict clinically significant posttraumatic stress disorder symptoms at each time point. Rates of caregiver posttraumatic stress disorder remained relatively stable over time (16-22%). Screening for posttraumatic stress disorder at baseline predicted posttraumatic stress disorder at 3 and 6 months with moderate sensitivity (75-80%) and high specificity (92-95%). Screening for posttraumatic stress disorder at baseline was associated with caregiver anxiety, mindfulness (i.e., ability to be aware of one's thoughts and feelings in the moment), and bond with patient. Furthermore, baseline posttraumatic stress disorder screening was the single most relevant predictor of posttraumatic stress disorder at 3 and 6 months, such that other baseline factors did not significantly improve predictive ability. CONCLUSIONS Screening neuroscience ICU caregivers for clinically significant posttraumatic stress disorder symptoms during admission is the single most important way to identify the majority of those likely to suffer from chronic posttraumatic stress disorder following discharge. Addressing early posttraumatic stress disorder symptoms and their psychosocial correlates during admission may help prevent chronic posttraumatic stress disorder in these at-risk caregivers.
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Abstract
Defensive motivation, broadly defined as the orchestrated optimization of defensive functions, encapsulates core components of threat-related psychopathology. The exact relationship between defensive functions and stress-induced symptoms, however, is not entirely clear. Here we review how some of the most important behavioral and neurological findings related to threat-related disorders -- lowering response threshold to threats, facilitated learning and generalization to new threatening cues, reduced appetitive sensitivity, and resistance to extinction of the defensive state -- map onto defensive motivational states, highlighting evidence that supports conjecturing threat-related disorders as persistent motivational states. We propose a mechanism for the perpetuation of the motivational state, progressively converting temporary defensive functions into persistent defensive states associated with distress and impairment.
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Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits and Alternatives. J Clin Med 2018; 7:jcm7020017. [PMID: 29385731 PMCID: PMC5852433 DOI: 10.3390/jcm7020017] [Citation(s) in RCA: 120] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 01/09/2018] [Accepted: 01/10/2018] [Indexed: 01/27/2023] Open
Abstract
Benzodiazepines are some of the most commonly prescribed medications in the world. These sedative-hypnotics can provide rapid relief for symptoms like anxiety and insomnia, but are also linked to a variety of adverse effects (whether used long-term, short-term, or as needed). Many patients take benzodiazepines long-term without ever receiving evidence-based first-line treatments (e.g., psychotherapy, relaxation techniques, sleep hygiene education, serotonergic agents). This review discusses the risks and benefits of, and alternatives to benzodiazepines. We discuss evidence-based indications and contraindications, and the theoretical biopsychosocial bases for effectiveness, ineffectiveness and harm. Potential adverse effects and drug-drug interactions are summarized. Finally, both fast-acting/acute and delayed-action/chronic alternative treatments for anxiety and/or insomnia are discussed. Response to treatment-whether benzodiazepines, other pharmacological agents, or psychotherapy-should be determined based on functional recovery and not merely sedation.
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Carmassi C, Gesi C, Corsi M, Cremone IM, Bertelloni CA, Massimetti E, Olivieri MC, Conversano C, Santini M, Dell'Osso L. Exploring PTSD in emergency operators of a major University Hospital in Italy: a preliminary report on the role of gender, age, and education. Ann Gen Psychiatry 2018; 17:17. [PMID: 29755579 PMCID: PMC5935923 DOI: 10.1186/s12991-018-0184-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 04/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency services personnel face frequent exposure to potentially traumatic events, with the potential for chronic symptomatic distress. The DSM-5 recently recognized a particular risk for post-traumatic stress disorder (PTSD) among first responders (criterion A4) but data are still scarce on prevalence rates and correlates. OBJECTIVE The aim of the present study was to explore the possible role of age, gender, and education training in a sample of emergency personnel diagnosed with DSM-5 PTSD. METHODS The Trauma and Loss Spectrum-Self-Report (TALS-SR) and the Work and Social Adjustment Scale (WSAS) were administered to 42 between nurses and health care assistants, employed at the emergency room of a major University Hospital (Pisa) in Italy. RESULTS 21.4% of the sample reported DSM-5 PTSD with significantly higher scores in the TALS-SR domain exploring the acute reaction to trauma and losses among health care assistants, older, and non-graduated subjects. A significant correlation between the number of the TALS-SR symptoms endorsed, corresponding to DSM-5 PTSD diagnostic criteria emerged in health care assistants. CONCLUSIONS Despite further studies are needed in larger samples, our data suggest a high risk for PTSD and post-traumatic stress spectrum symptoms in nurses and health care workers operating in an emergency department, particularly among health care assistants, women, older, and non-graduated operators.
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Affiliation(s)
- Claudia Carmassi
- 1Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Camilla Gesi
- 1Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Martina Corsi
- 1Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Ivan M Cremone
- 1Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Carlo A Bertelloni
- 1Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Enrico Massimetti
- 1Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | | | - Ciro Conversano
- 1Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
| | - Massimo Santini
- Emergency Medicine and Emergency Room Unit, AOUP, Pisa, Italy
| | - Liliana Dell'Osso
- 1Section of Psychiatry, Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy
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Liang L, Zhou H, Zhang S, Yuan J, Wu H. Effects of gut microbiota disturbance induced in early life on the expression of extrasynaptic GABA-A receptor α5 and δ subunits in the hippocampus of adult rats. Brain Res Bull 2017; 135:113-119. [DOI: 10.1016/j.brainresbull.2017.09.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 09/21/2017] [Accepted: 09/26/2017] [Indexed: 12/26/2022]
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Aisenberg N, Serova L, Sabban EL, Akirav I. The effects of enhancing endocannabinoid signaling and blocking corticotrophin releasing factor receptor in the amygdala and hippocampus on the consolidation of a stressful event. Eur Neuropsychopharmacol 2017; 27:913-927. [PMID: 28663121 DOI: 10.1016/j.euroneuro.2017.06.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 04/20/2017] [Accepted: 06/10/2017] [Indexed: 11/18/2022]
Abstract
Current clinical and pre-clinical data suggest that both cannabinoid agents and blockage of CRF through corticotrophin releasing factor receptor type 1 (CRFr1) may offer therapeutic benefits for post-traumatic stress disorder (PTSD). Here we aim to determine whether they are more effective when combined when microinjected into the basolateral amygdala (BLA) or CA1 area of the hippocampus after exposure to a stressful event in the shock/reminders rat model for PTSD. Injection of the fatty acid amide hydrolase (FAAH) inhibitor URB597 after the shock into either the BLA or CA1 facilitated extinction, and attenuated startle response and anxiety-like behavior. These preventive effects of URB597 were found to be mediated by the CB1 receptor. Intra-BLA and intra-CA1 microinjection of the CRFr1 antagonist, CP-154,526 attenuated startle response. When microinjected into the BLA, CP-154,526 also attenuated freezing behavior during exposure to the first reminder and decreased anxiety-like behavior. The combined treatment of URB597 and CP-154,526 was not more effective than the separate treatments. Finally, mRNA levels of CRF, CRFr1 and CB1r were significantly higher in the BLA of rats exposed to shock and reminders compared to non-shocked rats almost one month after the shock. Taken together, the results show that enhancing endocannabinoid signaling in the amygdala and hippocampus produced a more favorable spectrum of effects than those caused by the CRFr1 antagonist. The findings suggest that FAAH inhibitors may be used as a novel treatment for stress-related anxiety disorders.
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MESH Headings
- Amidohydrolases/antagonists & inhibitors
- Amidohydrolases/metabolism
- Animals
- Anxiety/drug therapy
- Anxiety/metabolism
- Basolateral Nuclear Complex/drug effects
- Basolateral Nuclear Complex/metabolism
- Benzamides/pharmacology
- CA1 Region, Hippocampal/drug effects
- CA1 Region, Hippocampal/metabolism
- Carbamates/pharmacology
- Disease Models, Animal
- Endocannabinoids/metabolism
- Male
- Memory Consolidation/drug effects
- Memory Consolidation/physiology
- Nootropic Agents/pharmacology
- Pyrimidines/pharmacology
- Pyrroles/pharmacology
- RNA, Messenger/metabolism
- Rats, Sprague-Dawley
- Receptor, Cannabinoid, CB1/metabolism
- Receptors, Corticotropin-Releasing Hormone/antagonists & inhibitors
- Receptors, Corticotropin-Releasing Hormone/metabolism
- Reflex, Startle/drug effects
- Reflex, Startle/physiology
- Stress Disorders, Post-Traumatic/drug therapy
- Stress Disorders, Post-Traumatic/metabolism
- Stress, Psychological/drug therapy
- Stress, Psychological/metabolism
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Affiliation(s)
- Nurit Aisenberg
- Department of Psychology, University of Haifa, Haifa 3498838, Israel
| | - Lidia Serova
- Department of Biochemistry and Molecular Biology, New York Medical College, Valhalla, NY 10595, USA
| | - Esther L Sabban
- Department of Biochemistry and Molecular Biology, New York Medical College, Valhalla, NY 10595, USA
| | - Irit Akirav
- Department of Psychology, University of Haifa, Haifa 3498838, Israel.
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26
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Shoshan N, Segev A, Abush H, Mizrachi Zer-Aviv T, Akirav I. Cannabinoids prevent the differential long-term effects of exposure to severe stress on hippocampal- and amygdala-dependent memory and plasticity. Hippocampus 2017; 27:1093-1109. [DOI: 10.1002/hipo.22755] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/22/2017] [Accepted: 06/20/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Noa Shoshan
- Department of Psychology; University of Haifa; Haifa 3498838 Israel
| | - Amir Segev
- Department of Psychology; University of Haifa; Haifa 3498838 Israel
| | - Hila Abush
- Department of Psychology; University of Haifa; Haifa 3498838 Israel
| | | | - Irit Akirav
- Department of Psychology; University of Haifa; Haifa 3498838 Israel
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27
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Extinction of avoidance behavior by safety learning depends on endocannabinoid signaling in the hippocampus. J Psychiatr Res 2017; 90:46-59. [PMID: 28222356 DOI: 10.1016/j.jpsychires.2017.02.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/24/2017] [Accepted: 02/02/2017] [Indexed: 12/29/2022]
Abstract
The development of exaggerated avoidance behavior is largely responsible for the decreased quality of life in patients suffering from anxiety disorders. Studies using animal models have contributed to the understanding of the neural mechanisms underlying the acquisition of avoidance responses. However, much less is known about its extinction. Here we provide evidence in mice that learning about the safety of an environment (i.e., safety learning) rather than repeated execution of the avoided response in absence of negative consequences (i.e., response extinction) allowed the animals to overcome their avoidance behavior in a step-down avoidance task. This process was context-dependent and could be blocked by pharmacological (3 mg/kg, s.c.; SR141716) or genetic (lack of cannabinoid CB1 receptors in neurons expressing dopamine D1 receptors) inactivation of CB1 receptors. In turn, the endocannabinoid reuptake inhibitor AM404 (3 mg/kg, i.p.) facilitated safety learning in a CB1-dependent manner and attenuated the relapse of avoidance behavior 28 days after conditioning. Safety learning crucially depended on endocannabinoid signaling at level of the hippocampus, since intrahippocampal SR141716 treatment impaired, whereas AM404 facilitated safety learning. Other than AM404, treatment with diazepam (1 mg/kg, i.p.) impaired safety learning. Drug effects on behavior were directly mirrored by drug effects on evoked activity propagation through the hippocampal trisynaptic circuit in brain slices: As revealed by voltage-sensitive dye imaging, diazepam impaired whereas AM404 facilitated activity propagation to CA1 in a CB1-dependent manner. In line with this, systemic AM404 enhanced safety learning-induced expression of Egr1 at level of CA1. Together, our data render it likely that AM404 promotes safety learning by enhancing information flow through the trisynaptic circuit to CA1.
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Dirven BCJ, Homberg JR, Kozicz T, Henckens MJAG. Epigenetic programming of the neuroendocrine stress response by adult life stress. J Mol Endocrinol 2017; 59:R11-R31. [PMID: 28400482 DOI: 10.1530/jme-17-0019] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/17/2017] [Indexed: 12/11/2022]
Abstract
The hypothalamic-pituitary-adrenal (HPA) axis is critically involved in the neuroendocrine regulation of stress adaptation, and the restoration of homeostasis following stress exposure. Dysregulation of this axis is associated with stress-related pathologies like major depressive disorder, post-traumatic stress disorder, panic disorder and chronic anxiety. It has long been understood that stress during early life can have a significant lasting influence on the development of the neuroendocrine system and its neural regulators, partially by modifying epigenetic regulation of gene expression, with implications for health and well-being in later life. Evidence is accumulating that epigenetic plasticity also extends to adulthood, proposing it as a mechanism by which psychological trauma later in life can long-lastingly affect HPA axis function, brain plasticity, neuronal function and behavioural adaptation to neuropsychological stress. Further corroborating this claim is the phenomenon that these epigenetic changes correlate with the behavioural consequences of trauma exposure. Thereby, epigenetic modifications provide a putative molecular mechanism by which the behavioural phenotype and transcriptional/translational potential of genes involved in HPA axis regulation can change drastically in response to environmental challenges, and appear an important target for treatment of stress-related disorders. However, improved insight is required to increase their therapeutic (drug) potential. Here, we provide an overview of the growing body of literature describing the epigenetic modulation of the (primarily neuroendocrine) stress response as a consequence of adult life stress and interpret the implications for, and the challenges involved in applying this knowledge to, the identification and treatment of stress-related psychiatric disorders.
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MESH Headings
- Animals
- Anxiety/genetics
- Anxiety/metabolism
- Anxiety/physiopathology
- Brain/metabolism
- Brain/physiopathology
- DNA Methylation
- Depressive Disorder, Major/genetics
- Depressive Disorder, Major/metabolism
- Depressive Disorder, Major/physiopathology
- Epigenesis, Genetic
- Histones/genetics
- Histones/metabolism
- Homeostasis
- Humans
- Hypothalamo-Hypophyseal System/metabolism
- Hypothalamo-Hypophyseal System/physiopathology
- MicroRNAs/genetics
- MicroRNAs/metabolism
- Neurons/metabolism
- Neurons/pathology
- Neurotransmitter Agents/metabolism
- Pituitary-Adrenal System/metabolism
- Pituitary-Adrenal System/physiopathology
- Receptors, Glucocorticoid/genetics
- Receptors, Glucocorticoid/metabolism
- Receptors, Mineralocorticoid/genetics
- Receptors, Mineralocorticoid/metabolism
- Stress, Psychological/genetics
- Stress, Psychological/metabolism
- Stress, Psychological/physiopathology
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Affiliation(s)
- B C J Dirven
- Department of AnatomyDonders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Cognitive NeuroscienceDonders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J R Homberg
- Department of Cognitive NeuroscienceDonders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - T Kozicz
- Department of AnatomyDonders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - M J A G Henckens
- Department of Cognitive NeuroscienceDonders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
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Effects of Traumatic Stress Induced in the Juvenile Period on the Expression of Gamma-Aminobutyric Acid Receptor Type A Subunits in Adult Rat Brain. Neural Plast 2017; 2017:5715816. [PMID: 28352479 PMCID: PMC5352903 DOI: 10.1155/2017/5715816] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/18/2017] [Accepted: 02/15/2017] [Indexed: 12/04/2022] Open
Abstract
Studies have found that early traumatic experience significantly increases the risk of posttraumatic stress disorder (PTSD). Gamma-aminobutyric acid (GABA) deficits were proposed to be implicated in development of PTSD, but the alterations of GABA receptor A (GABAAR) subunits induced by early traumatic stress have not been fully elucidated. Furthermore, previous studies suggested that exercise could be more effective than medications in reducing severity of anxiety and depression but the mechanism is unclear. This study used inescapable foot-shock to induce PTSD in juvenile rats and examined their emotional changes using open-field test and elevated plus maze, memory changes using Morris water maze, and the expression of GABAAR subunits (γ2, α2, and α5) in subregions of the brain in the adulthood using western blotting and immunohistochemistry. We aimed to observe the role of GABAAR subunits changes induced by juvenile trauma in the pathogenesis of subsequent PTSD in adulthood. In addition, we investigated the protective effects of exercise for 6 weeks and benzodiazepine (clonazepam) for 2 weeks. This study found that juvenile traumatic stress induced chronic anxiety and spatial memory loss and reduced expression of GABAAR subunits in the adult rat brains. Furthermore, exercise led to significant improvement as compared to short-term BZ treatment.
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Thomas E, Stein DJ. Novel pharmacological treatment strategies for posttraumatic stress disorder. Expert Rev Clin Pharmacol 2016; 10:167-177. [PMID: 27835034 DOI: 10.1080/17512433.2017.1260001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION A wide range of medications have been studied for posttraumatic stress disorder (PTSD) and a number are registered for this indication. Nevertheless, current pharmacotherapies are only partially effective in some patients, and are minimally effective in others. Thus novel treatment avenues need to be explored. Areas covered: In considering novel pharmacological agents for the treatment of PTSD, this paper takes a translational approach. We outline how advances in our understanding of the underlying neurobiology of PTSD may inform the identification of potential new treatment targets, including glutamatergic, noradrenergic and opioid pathways. Expert commentary: Continued investigation of the neural substrates and signalling pathways involved in responses to trauma may inform the development of novel treatment targets for future drug development for PTSD. However, the translation of preclinical findings to clinical practice is likely to be complex and gradual.
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Affiliation(s)
- Eileen Thomas
- a Division of Consultation Liaison, Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
| | - Dan J Stein
- b US/UCT MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry and Mental Health , University of Cape Town , Cape Town , South Africa
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Mindlis I, Morales-Raveendran E, Goodman E, Xu K, Vila-Castelar C, Keller K, Crawford G, James S, Katz CL, Crowley LE, de la Hoz RE, Markowitz S, Wisnivesky JP. Post-traumatic stress disorder dimensions and asthma morbidity in World Trade Center rescue and recovery workers. J Asthma 2016; 54:723-731. [PMID: 27905829 DOI: 10.1080/02770903.2016.1263650] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Using data from a cohort of World Trade Center (WTC) rescue and recovery workers with asthma, we assessed whether meeting criteria for post-traumatic stress disorder (PTSD), sub-threshold PTSD, and for specific PTSD symptom dimensions are associated with increased asthma morbidity. METHODS Participants underwent a Structured Clinical Interview for Diagnostic and Statistical Manual to assess the presence of PTSD following DSM-IV criteria during in-person interviews between December 2013 and April 2015. We defined sub-threshold PTSD as meeting criteria for two of three symptom dimensions: re-experiencing, avoidance, or hyper-arousal. Asthma control, acute asthma-related healthcare utilization, and asthma-related quality of life data were collected using validated scales. Unadjusted and multiple regression analyses were performed to assess the relationship between sub-threshold PTSD and PTSD symptom domains with asthma morbidity measures. RESULTS Of the 181 WTC workers with asthma recruited into the study, 28% had PTSD and 25% had sub-threshold PTSD. Patients with PTSD showed worse asthma control, higher rates of inpatient healthcare utilization, and poorer asthma quality of life than those with sub-threshold or no PTSD. After adjusting for potential confounders, among patients not meeting the criteria for full PTSD, those presenting symptoms of re-experiencing exhibited poorer quality of life (p = 0.003). Avoidance was associated with increased acute healthcare use (p = 0.05). Sub-threshold PTSD was not associated with asthma morbidity (p > 0.05 for all comparisons). CONCLUSIONS There may be benefit in assessing asthma control in patients with sub-threshold PTSD symptoms as well as those with full PTSD to more effectively identify ongoing asthma symptoms and target management strategies.
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Affiliation(s)
- I Mindlis
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - E Morales-Raveendran
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - E Goodman
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - K Xu
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - C Vila-Castelar
- b The Graduate Center, City University of New York , New York , NY , USA.,c Queens College, City University of New York , Flushing , NY , USA
| | - K Keller
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - G Crawford
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - S James
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - C L Katz
- d Department of Psychiatry , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - L E Crowley
- e Department of Preventive Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - R E de la Hoz
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA.,f Division of Pulmonary , Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai , New York , NY , USA
| | - S Markowitz
- c Queens College, City University of New York , Flushing , NY , USA
| | - J P Wisnivesky
- a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA.,f Division of Pulmonary , Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai , New York , NY , USA
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Cannabinoids and post-traumatic stress disorder: clinical and preclinical evidence for treatment and prevention. Behav Pharmacol 2016; 27:561-9. [DOI: 10.1097/fbp.0000000000000253] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Bohström D, Carlström E, Sjöström N. Managing stress in prehospital care: Strategies used by ambulance nurses. Int Emerg Nurs 2016; 32:28-33. [PMID: 27665426 DOI: 10.1016/j.ienj.2016.08.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 08/06/2016] [Accepted: 08/17/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ambulance nurses display stress symptoms, resulting from their work with patients in an emergency service. Certain individuals seem, however, to handle longstanding stress better than others and remain in exposed occupations such as ambulance services for many years. This paper examines stress inducing and stress defusing factors among ambulance nurses. METHODS A qualitative descriptive design using critical incident technique was used. A total of 123 critical incidents were identified, and a total of 61 strategies dealing with stress were confirmed. In all, 13 sub-categories (seven stress factors and five stress reducing factors) were merged into four categories (two stress categories and two stress reducing categories). RESULTS AND CONCLUSION The study shows that ambulance nurses in general experience emergency calls as being stressful. Unclear circumstances increase the stress level, with cases involving children and childbirth being especially stressful. Accurate information and assistance from the dispatch centre reduced the stress. Having discussions with colleagues directly after the assignment were particularly stress reducing. Advanced team collaboration with teammates was viewed as effective means to decrease stress, in addition to simple rituals to defuse stress such as taking short breaks during the workday. The study confirmed earlier studies that suggest the benefits of defusing immediately after stress reactions.
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Affiliation(s)
- Dan Bohström
- University of Gothenburg, The Sahlgrenska Academy, Institute of Health and Care Sciences, PO Box 457, SE-405 30 Gothenburg, Sweden
| | - Eric Carlström
- University of Gothenburg, The Sahlgrenska Academy, Institute of Health and Care Sciences, PO Box 457, SE-405 30 Gothenburg, Sweden
| | - Nils Sjöström
- University of Gothenburg, The Sahlgrenska Academy, Institute of Health and Care Sciences, PO Box 457, SE-405 30 Gothenburg, Sweden.
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Posttraumatic Stress Disorder after Vaginal Delivery at Primiparous Women. Sci Rep 2016; 6:27554. [PMID: 27271544 PMCID: PMC4897652 DOI: 10.1038/srep27554] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 05/18/2016] [Indexed: 11/08/2022] Open
Abstract
Although severe gynaecological pathology during delivery and negative outcome have been shown to be related with posttraumatic stress disorder (PTSD) little is known about traumatic experiences following regular delivery, at the expected time and with a healthy child. The objective of our study was to determine the prevalence of PTSD during postpartum period after vaginal delivery and its risk factors. The sample included 126 primiparous women. Monthly, for the next three months, the women were assessed for PTSD using the gold standard interview for PTSD, Clinician-Administered PTSD Scale (CAPS). Risk factors were assessed including sociodemographic variables, personal medical history and clinical variables. After the first month, 2.4% women had acute full PTSD and another 9.5% had clinically significant level of PTSD symptoms. Following the second and the third month, partial PTSD was found in 5.9% and 1.3% of the women, respectively, and none of participants had full PTSD. Obstetrical interventions were the only significant risk factor for the development of PTSD. Symptoms of postpartum PTSD are not rare after a traumatic delivery, and associated with specific obstetrical risk factors. Awareness of these risk factors may stimulate interventions to prevent this important and neglected postpartum disorder.
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35
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Diazepam effects on aversive memory retrieval and extinction: Role of anxiety levels. Pharmacol Biochem Behav 2016; 141:42-9. [DOI: 10.1016/j.pbb.2015.11.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/24/2015] [Accepted: 11/27/2015] [Indexed: 11/22/2022]
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36
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Frijling JL, van Zuiden M, Koch SBJ, Nawijn L, Veltman DJ, Olff M. Effects of intranasal oxytocin on amygdala reactivity to emotional faces in recently trauma-exposed individuals. Soc Cogn Affect Neurosci 2015; 11:327-36. [PMID: 26382634 DOI: 10.1093/scan/nsv116] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 09/14/2015] [Indexed: 12/15/2022] Open
Abstract
UNLABELLED There is a need for effective, early post-trauma preventive interventions for post-traumatic stress disorder (PTSD). Attenuating amygdala hyperreactivity early post-trauma, a likely PTSD vulnerability factor, may decrease PTSD risk. Since oxytocin modulates amygdala reactivity to emotional stimuli, oxytocin administration early post-trauma may be a promising candidate for PTSD prevention. In a randomized double-blind placebo-controlled fMRI study, we investigated effects of a single intranasal oxytocin administration (40 IU) on amygdala reactivity to happy, neutral and fearful faces in 41 recently trauma-exposed men and women showing moderate to high distress after initial post-trauma screening. We explored treatment interactions with sex. Participants were scanned within 11 days post-trauma. Compared with placebo, oxytocin significantly increased right amygdala reactivity to fearful faces. There was a significant treatment by sex interaction on amygdala reactivity to neutral faces, with women showing increased left amygdala reactivity after oxytocin. These findings indicate that a single oxytocin administration may enhance fearful faces processing in recently trauma-exposed individuals and neutral faces processing in recently trauma-exposed women. These observations may be explained by oxytocin-induced increased salience processing. Clinical implications of these findings for PTSD prevention should be further investigated. TRIAL REGISTER Netherlands Trial Registry; Boosting Oxytocin after trauma: Neurobiology and the Development of Stress-related psychopathology (BONDS); NTR3190; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC = 3190.
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Affiliation(s)
- Jessie L Frijling
- Department of Psychiatry and Brain Imaging Center, Academic Medical Center, Amsterdam, The Netherlands,
| | | | - Saskia B J Koch
- Department of Psychiatry and Brain Imaging Center, Academic Medical Center, Amsterdam, The Netherlands
| | - Laura Nawijn
- Department of Psychiatry and Brain Imaging Center, Academic Medical Center, Amsterdam, The Netherlands
| | - Dick J Veltman
- VU University Medical Center, Department of Psychiatry, Amsterdam, The Netherlands, and
| | - Miranda Olff
- Department of Psychiatry and Arq Psychotrauma Expert Group, Diemen, The Netherlands
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Prevention of posttraumatic stress disorder with propranolol: A meta-analytic review. J Psychosom Res 2015; 79:89-93. [PMID: 25972056 DOI: 10.1016/j.jpsychores.2015.04.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 04/15/2015] [Accepted: 04/16/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE PTSD is associated with significant morbidity and its prevention could reduce a significant burden of individual and societal suffering. The aim of this study is to conduct a systematic review of the literature on the prevention of PTSD by using propranolol following exposure to a traumatic event. METHODS Authors searched all studies published in the MEDLINE database up to November 2014 and reviewed textbooks and reference lists. Authors of relevant articles were contacted. Clinical trials and observational studies were included if they investigated the effect of propranolol in the acute post-trauma phase to prevent PTSD symptoms for subjects 18 years of age or older. PTSD was diagnosed according to DSM or widely accepted and validated diagnostic tools. A random-effects model was used to perform meta-analysis. RESULTS Five studies were included in the review for meta-analysis. Heterogeneity was not significant (τ2=0.0, S.E=0.247; Cochran's Q(4)=1.870, p=0.760; I2=0%). Relative risk point estimate to the effect of propranolol to prevent PTSD was 0.92 (95% CI: 0.55-1.55). Asymmetry was not significant under the Egger test (z=-1.34; p=0.180). CONCLUSIONS The findings suggest that propranolol treatment after the traumatic event did not alter the incidence of PTSD, although physiological responses are generally attenuated. The studies included small sample sizes, which can preclude the detection of significant results. Authors believe future studies should achieve larger sample sizes and longer follow-up periods.
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38
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Abstract
OBJECTIVE Although benzodiazepines (BZDs) are commonly used in the treatment of posttraumatic stress disorder (PTSD), no systematic review or meta-analysis has specifically examined this treatment. The goal of this study was to analyze and summarize evidence concerning the efficacy of BZDs in treating PTSD. METHODS The review protocol was undertaken according to the principles recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and is registered with the PROSPERO international prospective register of systematic reviews (http://www.crd.york.ac.uk/PROSPERO, registration number CRD42014009318). Two authors independently conducted a search of all relevant articles using multiple electronic databases and independently abstracted information from studies measuring PTSD outcomes in patients using BZDs. Eighteen clinical trials and observational studies were identified, with a total of 5236 participants. Outcomes were assessed using qualitative and quantitative syntheses, including meta-analysis. RESULTS BZDs are ineffective for PTSD treatment and prevention, and risks associated with their use tend to outweigh potential short-term benefits. In addition to adverse effects in general populations, BZDs are associated with specific problems in patients with PTSD: worse overall severity, significantly increased risk of developing PTSD with use after recent trauma, worse psychotherapy outcomes, aggression, depression, and substance use. Potential biopsychosocial explanations for these results are proposed based on studies that have investigated BZDs, PTSD, and relevant animal models. CONCLUSIONS The results of this systematic review suggest that BZDs should be considered relatively contraindicated for patients with PTSD or recent trauma. Evidence-based treatments for PTSD should be favored over BZDs.
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Porcheret K, Holmes EA, Goodwin GM, Foster RG, Wulff K. Psychological Effect of an Analogue Traumatic Event Reduced by Sleep Deprivation. Sleep 2015; 38:1017-25. [PMID: 26118556 DOI: 10.5665/sleep.4802] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 01/09/2015] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVE To examine the effect of sleep deprivation compared to sleep, immediately after experimental trauma stimuli on the development of intrusive memories to that trauma stimuli. DESIGN Participants were exposed to a film with traumatic content (trauma film). The immediate response to the trauma film was assessed, followed by either total sleep deprivation (sleep deprived group, N = 20) or sleep as usual (sleep group, N = 22). Twelve hours after the film viewing the initial psychological effect of the trauma film was measured and for the subsequent 6 days intrusive emotional memories related to the trauma film were recorded in daily life. SETTING Academic sleep laboratory and participants' home environment. PARTICIPANTS Healthy paid volunteers. MEASUREMENTS AND RESULTS On the first day after the trauma film, the psychological effect as assessed by the Impact of Event Scale - Revised was lower in the sleep deprived group compared to the sleep group. In addition, the sleep deprived group reported fewer intrusive emotional memories (mean 2.28, standard deviation [SD] 2.91) compared to the sleep group (mean 3.76, SD 3.35). Because habitual sleep/circadian patterns, psychological health, and immediate effect of the trauma film were similar at baseline for participants of both groups, the results cannot be accounted for by pre-existing inequalities between groups. CONCLUSIONS Our findings suggest that sleep deprivation on one night, rather than sleeping, reduces emotional effect and intrusive memories following exposure to experimental trauma.
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Affiliation(s)
- Kate Porcheret
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Emily A Holmes
- MRC Cognition and Brain Sciences Unit, Cambridge, UK.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Guy M Goodwin
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Russell G Foster
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Katharina Wulff
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Mouthaan J, Sijbrandij M, Reitsma JB, Luitse JSK, Goslings JC, Gersons BPR, Olff M. The role of early pharmacotherapy in the development of posttraumatic stress disorder symptoms after traumatic injury: an observational cohort study in consecutive patients. Gen Hosp Psychiatry 2015; 37:230-5. [PMID: 25805128 DOI: 10.1016/j.genhosppsych.2015.02.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 02/26/2015] [Accepted: 02/27/2015] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Pharmacological intervention during traumatic memory consolidation has been suggested to prevent posttraumatic stress disorder (PTSD). The aim of this study was to examine the association between prescription of early pharmacotherapy and the risk of developing PTSD symptoms following traumatic injury. METHOD The use of opiate analgesics, beta-adrenergic blockers, corticosteroids and benzodiazepines within 48 h postinjury was documented based on hospital charts for 629 Level 1 trauma center patients. PTSD symptoms were assessed using structured clinical interviews. Primary outcome was 6-week PTSD symptoms. Secondary outcomes were PTSD diagnoses at 6 weeks and during 1 year posttrauma. RESULTS Linear regression analyses showed that opiate administration within 48 h was negatively associated with PTSD symptoms at 6 weeks (β=-0.14, P=.009) after controlling for demographic and injury-related characteristics and concurrent pharmacotherapy. Fewer patients with opiates had a PTSD diagnosis at 6 weeks (P=.047) and during 1 year posttrauma (P=.013) than patients with none of the specified pharmacotherapies. Low prescription frequency of beta-blockers (3.8%), corticosteroids (2.2%) and benzodiazepines (7.8%) precluded further examination of their role in the development of PTSD symptoms because of limited statistical power. CONCLUSIONS This study suggests a possible beneficial influence of opiate administration within 48 h posttrauma on the development of PTSD symptoms. Future studies may evaluate the effectiveness of inhospital opiate analgesics compared to placebo in preventing PTSD and may focus on the mechanisms underlying the effect of opiates in preventing PTSD.
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Affiliation(s)
- Joanne Mouthaan
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, The Netherlands; Department of Clinical Psychology, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands.
| | - Marit Sijbrandij
- Department of Clinical Psychology, VU University, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands; EMGO Institute for Health and Care Research, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
| | - Johannes B Reitsma
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
| | - Jan S K Luitse
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - J Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Berthold P R Gersons
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, The Netherlands; Arq Psychotrauma Expert Group, Nienoord 5, 1112 XE Diemen, The Netherlands.
| | - Miranda Olff
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Meibergdreef 5, 1105 AZ Amsterdam, The Netherlands; Arq Psychotrauma Expert Group, Nienoord 5, 1112 XE Diemen, The Netherlands.
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Kapfhammer HP. Patient-reported outcomes in post-traumatic stress disorder. Part II: focus on pharmacological treatment. DIALOGUES IN CLINICAL NEUROSCIENCE 2015. [PMID: 25152660 PMCID: PMC4140515 DOI: 10.31887/dcns.2014.16.2/hkapfhammer] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Post-traumatic stress disorder (PTSD) may be associated with long-lasting psychological suffering, distressing psychosocial disability, markedly reduced health-related quality of life, and increased morbidity and mortality in a subgroup of individuals in the aftermath of serious traumatic events. Both etiopathogenesis and treatment modalities of PTSD are best conceptualized within a biopsychosotial model. Pharmacotherapy may lay claim to a major role in the multimodal treatment approaches. Here we outline two different pharmacotherapeutic trends that aim to modify the encoding, consolidation, and rehearsal of traumatic memory in order to reduce the risk of PTSD immediately after trauma exposure on the one hand, and that endeavor to treat the clinical state of PTSD on the other. The theoretical rationales of both pharmacological strategies are the complex neurobiological underpinnings that characterize traumatic memory organization and clinical PTSD. Meanwhile, promising data from randomized controlled trials have been obtained for both approaches. Empirical evidence may inform clinicians in their clinical efforts for this special group of patients. The efficacy of several classes of drugs that have been investigated within a context of research should be evaluated critically and still have to stand the test of effectiveness in daily clinical practice. From a patient perspective, empirical results may serve as a psychoeducative guideline to what pharmacotherapeutic approaches may realistically achieve, what their risks and benefits are, and what their limits are in contributing to reducing the often major chronic suffering caused by serious traumatic events. Ethical issues have to be considered, particularly in the context of pharmacological strategies projected to prevent PTSD in the aftermath of traumatic exposure.
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Affiliation(s)
- Hans-Peter Kapfhammer
- Department of Psychiatry, Medical University of Graz, 31, 8036 Graz, Austria Austria
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Escitalopram in the prevention of posttraumatic stress disorder: a pilot randomized controlled trial. BMC Psychiatry 2015; 15:24. [PMID: 25885650 PMCID: PMC4337322 DOI: 10.1186/s12888-015-0391-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/15/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A small literature suggests that pharmacotherapy may be useful in the prophylaxis of posttraumatic stress disorder in patients presenting with major trauma. There is relatively little data, however, on the use of selective serotonin reuptake inhibitors (SSRIs) in this context. METHODS 24 week, double-blind placebo controlled study. 31 participants presenting immediately after trauma, and meeting diagnostic criteria for full or partial acute stress disorder were randomized to treatment with 10-20 mg of escitalopram or placebo daily for 24 weeks. 2 participants were excluded from the analysis due to early drop out, leaving 29 participants (escitalopram = 12, placebo = 17) for inclusion in an intent- to- treat analysis. Participants were followed up until 56 weeks, and assessed with the Clinician Administered PTSD Scale (CAPS). A mixed model repeated measures analysis of variance (RMANOVA) was undertaken to determine the efficacy of the intervention on the CAPS score. RESULTS There was a significant reduction in CAPS score over the course of treatment (F(7, 142) = 41. 58, p < 0.001) in both the escitalopram and placebo groups, with a greater reduction in CAPS score in the placebo group F(7, 142) = 2.12, p = 0.045. There were improvements on all secondary measures, including the Clinical Global Impressions scale, and scales assessing depression, anxiety and disability. Only functional disability outcomes (F(7, 141) = 2.13, p = .04), were significantly different between treatment and placebo groups. In the sample as a whole, improvement in scores were maintained at the 52 week follow-up. Side effects were comparable between the groups. CONCLUSIONS These data are consistent with other recent work indicating that the SSRIs may not be efficacious in the prevention of PTSD. Nevertheless, the small sample size and baseline differences between groups limit the explanatory power of the study. Although a consideration of the possibility of medication prophylaxis in PTSD remains important, both from conceptual and clinical perspectives, caution is needed with regards to the use of SSRIs until their efficacy can be proven. TRIAL REGISTRATION Clinical Trials NCT00300313.
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Levkovitz Y, Fenchel D, Kaplan Z, Zohar J, Cohen H. Early post-stressor intervention with minocycline, a second-generation tetracycline, attenuates post-traumatic stress response in an animal model of PTSD. Eur Neuropsychopharmacol 2015; 25:124-32. [PMID: 25487770 DOI: 10.1016/j.euroneuro.2014.11.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 11/02/2014] [Accepted: 11/20/2014] [Indexed: 12/11/2022]
Abstract
We assessed the effects of minocycline, a tetracycline with anti-inflammatory, anti-apoptotic and neuroprotective capacities, in an animal model of post-traumatic stress disorder (PTSD). Rats were exposed to psychogenic stress and treated 1h later with minocycline or saline. Behavioral measures included the elevated plus-maze (EPM) and acoustic startle response (ASR) 7 days post stress-exposure. One day after behavioral testing, animals were exposed to a trauma cue and freezing response was assessed. Local levels of cytokines interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in the hippocampus, frontal cortex (FC) and hypothalamus were then examined. Minocycline attenuated anxious-like behaviors in stress-exposed rats. In addition, decreased levels of cytokines were measured in exposed rats treated with minocycline compared to their counterparts treated with saline. This study suggests a potential use of minocycline in preventing physiological and behavioral alternations resulting from acute exposure to psychological stress. As this is the first study to report beneficial outcomes for minocycline treatment in an animal model of PTSD, further investigations of the use of minocycline in stress-related conditions with emphasis on PTSD is needed.
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Affiliation(s)
- Yechiel Levkovitz
- Beer-Yaakov Mental Health Center, Beer-Yaakov, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Daphna Fenchel
- Beer-Yaakov Mental Health Center, Beer-Yaakov, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Zeev Kaplan
- Beer-Sheva Mental Health Center, Ministry of Health, Anxiety and Stress Research Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
| | - Joseph Zohar
- Division of Psychiatry, Ministry of Health, The Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hagit Cohen
- Beer-Sheva Mental Health Center, Ministry of Health, Anxiety and Stress Research Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel
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44
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Roque AP. Pharmacotherapy as prophylactic treatment of post-traumatic stress disorder: a review of the literature. Issues Ment Health Nurs 2015; 36:740-51. [PMID: 26440879 DOI: 10.3109/01612840.2015.1057785] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Post-traumatic stress disorder has a lifetime prevalence of almost 9% in the United States. The diagnosis is associated with increased rates of comorbid substance abuse and increased rates of depression. Providers are taught how to diagnose and treat PTSD, but little discussion is devoted to how to prevent the disorder. Behavioral research in animal studies has provided some evidence for the use of medications in decreasing the fear response and the reconsolidation of memories. A heightened fear response and the re-experience of traumatic memory are key components for diagnosis. The purpose of this literature review is to examine the evidence for pharmacotherapy as prophylactic treatment in acute stress/trauma in order to prevent the development of post-traumatic stress disorder. The body of the review includes discussions on medications, medications as adjunct to script-driven imagery, and special considerations for military, first responders, and women. This article concludes with implications for practice and recommendations for future research. The key words used for the literature search were "prophylactic treatment of PTSD," "pharmacotherapy and trauma," "pharmacological prevention of PTSD," "beta blockers and the prevention of PTSD," "acute stress and prevention of PTSD," "propranolol and PTSD," "secondary prevention of PTSD," and "medications used to prevent PTSD." Findings were categorized by medications and medications as adjunct to script-driven imagery. The literature suggests that hydrocortisone, propranolol, and morphine may decrease symptoms and diagnosis of post-traumatic stress disorder.
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Affiliation(s)
- Autumn Pearl Roque
- a University of Kentucky, College of Nursing , Lexington , Kentucky , USA
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Korem N, Akirav I. Cannabinoids prevent the effects of a footshock followed by situational reminders on emotional processing. Neuropsychopharmacology 2014; 39:2709-22. [PMID: 24897957 PMCID: PMC4200492 DOI: 10.1038/npp.2014.132] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/06/2014] [Accepted: 05/30/2014] [Indexed: 01/04/2023]
Abstract
Posttraumatic stress disorder (PTSD) can develop following exposure to a traumatic event. Hence, what we do in the first few hours after trauma exposure may alter the trajectory of PTSD. We examined whether cannabinoids can prevent the effects of a single footshock followed by situational reminders (SRs) on emotional processing. Rats were exposed to a footshock (1.5 mA, 10 s) on day 1 followed by exposure to SRs of the shock on days 3 and 5. The CB1/2 receptor agonist WIN55,212-2 or vehicle were injected intraperitoneally 2 h after the shock. After 1 week, PTSD-like symptoms were examined. Exposure to SRs exacerbated the effects of the shock as rats exposed to shock and SRs, but not shock alone, showed impaired extinction of the traumatic event, impaired plasticity in the hippocmapal-accumbens pathway, enhanced latency to startle, and altered expression of CB1 receptors (CB1r) and glucocorticoid receptors (GRs) in the CA1, basolateral amygdala (BLA) and prefrontal cortex (PFC). WIN55,212-2 prevented the effects of the shock and SRs on extinction, plasticity, and startle response. WIN55,212-2 normalized the shock/SR-induced upregulation in CB1r in the PFC, and CA1 and GRs in the CA1, with no effect on BLA downregulation of CB1r and GRs. Shock and SRs caused lasting (1 week) alterations in emotional processing associated with changes in GR and CB1r expression in brain areas related to PTSD. WIN55,212-2 administered after trauma exposure prevented these alterations via PFC- and CA1-CB1r and CA1-GRs.
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Affiliation(s)
- Nachshon Korem
- Department of Psychology, University of Haifa, Haifa, Israel
| | - Irit Akirav
- Department of Psychology, University of Haifa, Haifa, Israel,Department of Psychology, University of Haifa, Mount Carmel, Haifa 31905, Israel, Tel: +972 4 8288268, Fax: +972 4 8263157, E-mail:
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The role of acute cortisol and DHEAS in predicting acute and chronic PTSD symptoms. Psychoneuroendocrinology 2014; 45:179-86. [PMID: 24845188 DOI: 10.1016/j.psyneuen.2014.04.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 04/01/2014] [Accepted: 04/01/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Decreased activation of the hypothalamus-pituitary-adrenal (HPA) axis in response to stress is suspected to be a vulnerability factor for posttraumatic stress disorder (PTSD). Previous studies showed inconsistent findings regarding the role of cortisol in predicting PTSD. In addition, no prospective studies have examined the role of dehydroepiandrosterone (DHEA), or its sulfate form DHEAS, and the cortisol-to-DHEA(S) ratio in predicting PTSD. In this study, we tested whether acute plasma cortisol, DHEAS and the cortisol-to-DHEAS ratio predicted PTSD symptoms at 6 weeks and 6 months post-trauma. METHODS Blood samples of 397 adult level-1 trauma center patients, taken at the trauma resuscitation room within hours after the injury, were analyzed for cortisol and DHEAS levels. PTSD symptoms were assessed at 6 weeks and 6 months post-trauma with the Clinician Administered PTSD Scale. RESULTS Multivariate linear regression analyses showed that lower cortisol predicted PTSD symptoms at both 6 weeks and 6 months, controlling for age, gender, time of blood sampling, injury, trauma history, and admission to intensive care. Higher DHEAS and a smaller cortisol-to-DHEAS ratio predicted PTSD symptoms at 6 weeks, but not after controlling for the same variables, and not at 6 months. CONCLUSIONS Our study provides important new evidence on the crucial role of the HPA-axis in response to trauma by showing that acute cortisol and DHEAS levels predict PTSD symptoms in survivors of recent trauma.
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Lotan A, Lifschytz T, Slonimsky A, Broner EC, Greenbaum L, Abedat S, Fellig Y, Cohen H, Lory O, Goelman G, Lerer B. Neural mechanisms underlying stress resilience in Ahi1 knockout mice: relevance to neuropsychiatric disorders. Mol Psychiatry 2014; 19:243-52. [PMID: 24042478 DOI: 10.1038/mp.2013.123] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Revised: 07/19/2013] [Accepted: 08/08/2013] [Indexed: 02/06/2023]
Abstract
The Abelson helper integration site 1 (AHI1) gene has a pivotal role in brain development. Studies by our group and others have demonstrated association of AHI1 with schizophrenia and autism. To elucidate the mechanism whereby alteration in AHI1 expression may be implicated in the pathogenesis of neuropsychiatric disorders, we studied Ahi1 heterozygous knockout (Ahi1(+/-)) mice. Although their performance was not different from wild-type mice on tests that model classical schizophrenia-related endophenotypes, Ahi1(+/-) mice displayed an anxiolytic-like phenotype across different converging modalities. Using behavioral paradigms that involve exposure to environmental and social stress, significantly decreased anxiety was evident in the open field, elevated plus maze and dark-light box, as well as during social interaction in pairs. Assessment of core temperature and corticosterone secretion revealed a significantly blunted response of the autonomic nervous system and the hypothalamic-pituitary-adrenal axis in Ahi1(+/-) mice exposed to environmental and visceral stress. However, response to centrally acting anxiogenic compounds was intact. On resting-state functional MRI, connectivity of the amygdala with other brain regions involved in processing of anxiogenic stimuli and inhibitory avoidance learning, such as the lateral entorhinal cortex, ventral hippocampus and ventral tegmental area, was significantly reduced in the mutant mice. Taken together, our data link Ahi1 under-expression with a defect in the process of threat detection. Alternatively, the results could be interpreted as representing an anxiety-related endophenotype, possibly granting the Ahi1(+/-) mouse relative resilience to various types of stress. The current knockout model highlights the contribution of translational approaches to understanding the genetic basis of emotional regulation and its associated neurocircuitry, with possible relevance to neuropsychiatric disorders.
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Affiliation(s)
- A Lotan
- Biological Psychiatry Laboratory, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - T Lifschytz
- Biological Psychiatry Laboratory, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - A Slonimsky
- Biological Psychiatry Laboratory, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - E C Broner
- Biological Psychiatry Laboratory, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - L Greenbaum
- Biological Psychiatry Laboratory, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - S Abedat
- Cardiovascular Research Center, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Y Fellig
- Department of Pathology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - H Cohen
- Anxiety and Stress Research Unit, Ben-Gurion University of the Negev, Beersheba, Israel
| | - O Lory
- MRI Lab, Medical Biophysics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Goelman
- MRI Lab, Medical Biophysics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - B Lerer
- Biological Psychiatry Laboratory, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Pryor K, Root J. III. Intraoperative awareness: a pound of prevention, an ounce of cure? Br J Anaesth 2013; 111:529-31. [DOI: 10.1093/bja/aet156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
Medically ill adolescents are at increased risk for psychological distress and/or functional impairment. However, there are few research studies examining the optimal psychiatric treatments for this population. Psychiatric medication recommendations are largely based on studies of youth with a primary psychiatric disorder, adult studies, hypothesized mechanisms of action, and/or clinical experience. This paper provides evidence-informed recommendations for the psychopharmacological treatment of acutely medically ill adolescents suffering from significant psychological distress and/or functional impairment. Representing the most common problems among medically ill adolescents that are treated with psychiatric medications, recommendations are provided for anxiety and depression; iatrogenic medical trauma, inadequate sleep and insomnia; and, delirium.
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Speck V, Noble A, Kollmar R, Schenk T. Diagnosis of spontaneous cervical artery dissection may be associated with increased prevalence of posttraumatic stress disorder. J Stroke Cerebrovasc Dis 2013; 23:335-42. [PMID: 23849487 DOI: 10.1016/j.jstrokecerebrovasdis.2013.03.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 03/08/2013] [Accepted: 03/29/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Receiving information that one has a dissected cervical artery, which can cause a stroke at any time, is obviously traumatic, but details about the psychiatric and psychosocial sequelae are not known. We investigated the prevalence of and risk factors for posttraumatic stress disorder (PTSD) in patients with spontaneous cervical artery dissection (CD) and the impact of PTSD on their psychosocial functioning. METHODS Patients admitted because of CD between 2006 and 2010 were retrospectively examined using a diagnostic PTSD measure (Posttraumatic Diagnostic Scale). Patients between 2011 and 2012 were examined prospectively. To identify potential predictors for PTSD, we examined all patients' stress coping strategies (brief COPE inventory), anxiety and depression (Hospital Anxiety and Depression Scale), impairment by preventive medication, time since diagnosis and their neurologic (modified Rankin Scale) and cognitive status. To identify the psychosocial impact of PTSD, we examined quality of life (Short-Form 36). RESULTS Data of 47 retrospectively contacted patients and 15 prospectively examined patients were included. Twenty-eight patients (45.2%) met the diagnostic criteria for PTSD. A significantly reduced health-related quality of life (HRQoL) was found in 27 patients (43.5%) for mental health and in 8 patients (12.9%) for physical health. Results of logistic regression analysis revealed that the use of maladaptive coping strategies was predictive of the disorder (P < .0001). Age, sex, mRS score, impairment caused by medication, and time since diagnosis were not predictive for PTSD. The presence of PTSD itself was the only significant predictor for reduced mental HRQol (P = .0004). Age, sex, mRS score, impairment caused by medication, and total Hospital Anxiety and Depression Scale score were not predictive for reduced mental HRQoL. CONCLUSIONS PTSD seems to occur frequently in patients with CD and is associated with reduced mental HRQoL. Because the presence of a maladaptive coping style is correlated with PTSD, teaching patients better coping skills might be helpful.
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Affiliation(s)
- Verena Speck
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Adam Noble
- Institute for Psychiatry, King's College London, London, United Kingdom
| | - Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Thomas Schenk
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany.
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