1
|
Askovic M, Soh N, Elhindi J, Harris AW. Neurofeedback for post-traumatic stress disorder: systematic review and meta-analysis of clinical and neurophysiological outcomes. Eur J Psychotraumatol 2023; 14:2257435. [PMID: 37732560 PMCID: PMC10515677 DOI: 10.1080/20008066.2023.2257435] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/22/2023] [Indexed: 09/22/2023] Open
Abstract
Background: Posttraumatic stress disorder (PTSD) is a debilitating condition affecting millions of people worldwide. Existing treatments often fail to address the complexity of its symptoms and functional impairments resulting from severe and prolonged trauma. Electroencephalographic Neurofeedback (NFB) has emerged as a promising treatment that aims to reduce the symptoms of PTSD by modulating brain activity.Objective: We conducted a systematic review and meta-analysis of ten clinical trials to answer the question: how effective is NFB in addressing PTSD and other associated symptoms across different trauma populations, and are these improvements related to neurophysiological changes?Method: The review followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. We considered all published and unpublished randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) involving adults with PTSD as a primary diagnosis without exclusion by type of trauma, co-morbid diagnosis, locality, or sex. Ten controlled studies were included; seven RCTs and three NRSIs with a total number of participants n = 293 (128 male). Only RCTs were included in the meta-analysis (215 participants; 88 male).Results: All included studies showed an advantage of NFB over control conditions in reducing symptoms of PTSD, with indications of improvement in symptoms of anxiety and depression and related neurophysiological changes. Meta-analysis of the pooled data shows a significant reduction in PTSD symptoms post-treatment SMD of -1.76 (95% CI -2.69, -0.83), and the mean remission rate was higher in the NFB group (79.3%) compared to the control group (24.4%). However, the studies reviewed were mostly small, with heterogeneous populations and varied quality.Conclusions: The effect of NFB on the symptoms of PTSD was moderate and mechanistic evidence suggested that NFB leads to therapeutic changes in brain functioning. Future research should focus on more rigorous methodological designs, expanded sample size and longer follow-up.
Collapse
Affiliation(s)
- Mirjana Askovic
- New South Wales Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS), Sydney, NSW, Australia
- Specialty of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Brain Dynamics Centre, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Nerissa Soh
- Specialty of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - James Elhindi
- Research and Education Network, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Anthony W.F. Harris
- Specialty of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Brain Dynamics Centre, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
2
|
Stevens ES, Funkhouser CJ, Auerbach RP, Talati A, Gameroff MG, Posner JE, Weissman MM, Shankman SA. Inhibition Predicts the Course of Depression and Anxiety Symptoms Among Adolescents: The Moderating Role of Familial Risk. J Nerv Ment Dis 2023; 211:100-107. [PMID: 36044650 PMCID: PMC9892173 DOI: 10.1097/nmd.0000000000001584] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Numerous theoretical models suggest that inhibition difficulties-the inability to moderate automatic responses-contribute to the onset and/or maintenance of internalizing symptoms. Inhibition deficits and internalizing disorders run in families and share overlapping genetic risk factors, suggesting that inhibition deficits may be particularly prognostic of internalizing symptoms in those with high familial risk. This study tested this hypothesis in a longitudinal sample during the transition from adolescence to early adulthood. As hypothesized, prospective associations between inhibition and anxiety and depressive symptoms 8 years later were moderated by familial risk for depression. Specifically, poorer inhibition prospectively predicted greater anxiety and depressive symptoms in those at high (but not low) familial risk for major depressive disorder. These findings provide preliminary support for impaired inhibition as an indicator of risk for later internalizing symptoms in those at high familial risk.
Collapse
Affiliation(s)
- Elizabeth S. Stevens
- University of Illinois at Chicago, Department of Psychology, 1007 W. Harrison Street, Chicago, IL 60607
| | - Carter J. Funkhouser
- University of Illinois at Chicago, Department of Psychology, 1007 W. Harrison Street, Chicago, IL 60607
| | - Randy P. Auerbach
- Columbia University, Vagelos College of Physicians and Surgeon, Department of Psychiatry, 1051 Riverside Drive, New York, NY 10032
- New York State Psychiatric Institute, Division of Translational Epidemiology, 1051 Riverside Drive, New York, NY 10032
| | - Ardesheer Talati
- Columbia University, Vagelos College of Physicians and Surgeon, Department of Psychiatry, 1051 Riverside Drive, New York, NY 10032
- New York State Psychiatric Institute, Division of Translational Epidemiology, 1051 Riverside Drive, New York, NY 10032
| | - Marc G. Gameroff
- Columbia University, Vagelos College of Physicians and Surgeon, Department of Psychiatry, 1051 Riverside Drive, New York, NY 10032
- New York State Psychiatric Institute, Division of Translational Epidemiology, 1051 Riverside Drive, New York, NY 10032
| | - Jonathan E. Posner
- Columbia University, Vagelos College of Physicians and Surgeon, Department of Psychiatry, 1051 Riverside Drive, New York, NY 10032
- New York State Psychiatric Institute, Division of Translational Epidemiology, 1051 Riverside Drive, New York, NY 10032
| | - Myrna M. Weissman
- Columbia University, Vagelos College of Physicians and Surgeon, Department of Psychiatry, 1051 Riverside Drive, New York, NY 10032
- New York State Psychiatric Institute, Division of Translational Epidemiology, 1051 Riverside Drive, New York, NY 10032
| | - Stewart A. Shankman
- Northwestern University, Department of Psychiatry and Behavioral Sciences, 680 N. Lake Shore Drive, Chicago, IL 60611
| |
Collapse
|
3
|
Kotler S, Mannino M, Kelso S, Huskey R. First few seconds for flow: A comprehensive proposal of the neurobiology and neurodynamics of state onset. Neurosci Biobehav Rev 2022; 143:104956. [PMID: 36368525 DOI: 10.1016/j.neubiorev.2022.104956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/22/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022]
Abstract
Flow is a cognitive state that manifests when there is complete attentional absorption while performing a task. Flow occurs when certain internal as well as external conditions are present, including intense concentration, a sense of control, feedback, and a balance between the challenge of the task and the relevant skillset. Phenomenologically, flow is accompanied by a loss of self-consciousness, seamless integration of action and awareness, and acute changes in time perception. Research has begun to uncover some of the neurophysiological correlates of flow, as well as some of the state's neuromodulatory processes. We comprehensively review this work and consider the neurodynamics of the onset of the state, considering large-scale brain networks, as well as dopaminergic, noradrenergic, and endocannabinoid systems. To accomplish this, we outline an evidence-based hypothetical situation, and consider the flow state in a broader context including other profound alterations in consciousness, such as the psychedelic state and the state of traumatic stress that can induce PTSD. We present a broad theoretical framework which may motivate future testable hypotheses.
Collapse
Affiliation(s)
| | | | - Scott Kelso
- Human Brain & Behavior Laboratory, Center for Complex Systems and Brain Sciences, Florida Atlantic University, United States; Intelligent Systems Research Centre, Ulster University, Derry∼Londonderry, North Ireland
| | - Richard Huskey
- Cognitive Communication Science Lab, Department of Communication, University of California Davis, United States; Cognitive Science Program, University of California Davis, United States; Center for Mind and Brain, University of California Davis, United States.
| |
Collapse
|
4
|
Lorenz RC, Butler O, Willmund G, Wesemann U, Zimmermann P, Gallinat J, Kühn S. Effects of stress on neural processing of combat-related stimuli in deployed soldiers: an fMRI study. Transl Psychiatry 2022; 12:483. [PMID: 36396623 DOI: 10.1038/s41398-022-02241-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022] Open
Abstract
Severe trauma exposure may lead to symptoms of both posttraumatic stress disorder and depression. Neuroanatomical theories suggest that both disorders may share imbalances in fronto-limbic circuits. Longitudinal studies are necessary to better understand the impact of a stressful life situation on potential long-term fronto-limbic imbalances. Here we investigated soldiers neural processing of combat-related stimuli versus negative affective stimuli before and after the deployment in different war zones. In the final analysis we included 104 deployed soldiers (combat group) and 36 soldiers that were not deployed (control group). Behaviorally, we found a significant group by time interaction regarding depression symptom scores with an increase in the combat group. Depressive symptoms were subclinical. On the neural level, neither the whole brain analysis nor the region of interest (ROI) analyses including frontal and limbic ROIs revealed any significant results in the group by time interaction. However, extracted ROI values of the group by time interaction of amygdala and hippocampus were positively associated with the change in depression symptom scores in the combat group, but not in the control group. These results highlight the role of depression in individuals that experience stressful life situations. Future studies may need to investigate the role of depressive symptoms after trauma exposure with different tasks that may be particularly sensitive to changes due to depressive symptoms.
Collapse
|
5
|
Ressler KJ, Berretta S, Bolshakov VY, Rosso IM, Meloni EG, Rauch SL, Carlezon WA. Post-traumatic stress disorder: clinical and translational neuroscience from cells to circuits. Nat Rev Neurol 2022; 18:273-288. [PMID: 35352034 PMCID: PMC9682920 DOI: 10.1038/s41582-022-00635-8] [Citation(s) in RCA: 90] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 01/16/2023]
Abstract
Post-traumatic stress disorder (PTSD) is a maladaptive and debilitating psychiatric disorder, characterized by re-experiencing, avoidance, negative emotions and thoughts, and hyperarousal in the months and years following exposure to severe trauma. PTSD has a prevalence of approximately 6-8% in the general population, although this can increase to 25% among groups who have experienced severe psychological trauma, such as combat veterans, refugees and victims of assault. The risk of developing PTSD in the aftermath of severe trauma is determined by multiple factors, including genetics - at least 30-40% of the risk of PTSD is heritable - and past history, for example, prior adult and childhood trauma. Many of the primary symptoms of PTSD, including hyperarousal and sleep dysregulation, are increasingly understood through translational neuroscience. In addition, a large amount of evidence suggests that PTSD can be viewed, at least in part, as a disorder that involves dysregulation of normal fear processes. The neural circuitry underlying fear and threat-related behaviour and learning in mammals, including the amygdala-hippocampus-medial prefrontal cortex circuit, is among the most well-understood in behavioural neuroscience. Furthermore, the study of threat-responding and its underlying circuitry has led to rapid progress in understanding learning and memory processes. By combining molecular-genetic approaches with a translational, mechanistic knowledge of fear circuitry, transformational advances in the conceptual framework, diagnosis and treatment of PTSD are possible. In this Review, we describe the clinical features and current treatments for PTSD, examine the neurobiology of symptom domains, highlight genomic advances and discuss translational approaches to understanding mechanisms and identifying new treatments and interventions for this devastating syndrome.
Collapse
Affiliation(s)
- Kerry J Ressler
- SPARED Center, Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, USA.
| | - Sabina Berretta
- SPARED Center, Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - Vadim Y Bolshakov
- SPARED Center, Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - Isabelle M Rosso
- SPARED Center, Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward G Meloni
- SPARED Center, Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott L Rauch
- SPARED Center, Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - William A Carlezon
- SPARED Center, Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
6
|
Crum KI, Hwang S, Blair KS, Aloi JM, Meffert H, White SF, Tyler PM, Leibenluft E, Pope K, Blair RJR. Interaction of irritability and anxiety on emotional responding and emotion regulation: a functional MRI study. Psychol Med 2021; 51:2778-2788. [PMID: 32584213 PMCID: PMC7759590 DOI: 10.1017/s0033291720001397] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 04/17/2020] [Accepted: 04/29/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Irritability and anxiety frequently co-occur in pediatric populations. Studies separately looking at the neural correlates of these symptoms have identified engagement of similar neural systems - particularly those implicated in emotional processing. Both irritability and anxiety can be considered negative valence emotional states that might relate to emotion dysregulation. However, previous work has not examined the neural responding during the performance of an emotion regulation task as a function of interaction between irritability and anxiety simultaneously. METHODS This fMRI study involved 155 participants (90 with significant psychopathologies and 92 male) who performed the Affective Stroop Task, designed to engage emotion regulation as a function of task demands. The Affective Reactivity Index (ARI) was used to index irritability and the Screen for Child Anxiety Related Emotional Disorders (SCARED) was used to index anxiety. RESULTS Levels of irritability, but not anxiety, was positively correlated with responses to visual images within the right rostro-medial prefrontal cortex and left anterior cingulate cortex during view trials. The second region of ventral anterior cingulate cortex showed a condition-by-emotion-by-ARI score-by-SCARED score interaction. Specifically, anxiety level was significantly correlated with a decreased differential BOLD response to negative relative to neutral view trials but only in the presence of relatively high irritability. CONCLUSIONS Atypical maintenance of emotional stimuli within the rostro-medial prefrontal cortex may exacerbate the difficulties faced by adolescents with irritability. Moreover, increased anxiety combined with significant irritability may disrupt an automatic emotional conflict-based form of emotion regulation that is particularly associated with the ventral anterior cingulate cortex.
Collapse
Affiliation(s)
- Kathleen I. Crum
- Medical University of South Carolina, Charleston, South Carolina, USA
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska, USA
| | - Soonjo Hwang
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Karina S. Blair
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska, USA
| | | | | | - Stuart F. White
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska, USA
| | - Patrick M. Tyler
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska, USA
| | - Ellen Leibenluft
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland, USA
| | - Kayla Pope
- Medical College of Wisconsin, Northeastern Wisconsin Psychiatry Training Program, Winnebago, Wisconsin, USA
| | - R. J. R. Blair
- Center for Neurobehavioral Research, Boys Town National Research Hospital, Boys Town, Nebraska, USA
| |
Collapse
|
7
|
Roeckner AR, Oliver KI, Lebois LAM, van Rooij SJH, Stevens JS. Neural contributors to trauma resilience: a review of longitudinal neuroimaging studies. Transl Psychiatry 2021; 11:508. [PMID: 34611129 PMCID: PMC8492865 DOI: 10.1038/s41398-021-01633-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 09/02/2021] [Accepted: 09/14/2021] [Indexed: 12/15/2022] Open
Abstract
Resilience in the face of major life stressors is changeable over time and with experience. Accordingly, differing sets of neurobiological factors may contribute to an adaptive stress response before, during, and after the stressor. Longitudinal studies are therefore particularly effective in answering questions about the determinants of resilience. Here we provide an overview of the rapidly-growing body of longitudinal neuroimaging research on stress resilience. Despite lingering gaps and limitations, these studies are beginning to reveal individual differences in neural circuit structure and function that appear protective against the emergence of future psychopathology following a major life stressor. Here we outline a neural circuit model of resilience to trauma. Specifically, pre-trauma biomarkers of resilience show that an ability to modulate activity within threat and salience networks predicts fewer stress-related symptoms. In contrast, early post-trauma biomarkers of subsequent resilience or recovery show a more complex pattern, spanning a number of major circuits including attention and cognitive control networks as well as primary sensory cortices. This novel synthesis suggests stress resilience may be scaffolded by stable individual differences in the processing of threat cues, and further buttressed by post-trauma adaptations to the stressor that encompass multiple mechanisms and circuits. More attention and resources supporting this work will inform the targets and timing of mechanistic resilience-boosting interventions.
Collapse
Affiliation(s)
- Alyssa R. Roeckner
- grid.189967.80000 0001 0941 6502Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA USA
| | - Katelyn I. Oliver
- grid.189967.80000 0001 0941 6502Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA USA
| | - Lauren A. M. Lebois
- grid.240206.20000 0000 8795 072XDivision of Depression and Anxiety Disorders, McLean Hospital, Belmont, MA USA ,grid.38142.3c000000041936754XDepartment of Psychiatry, Harvard Medical School, Boston, MA USA
| | - Sanne J. H. van Rooij
- grid.189967.80000 0001 0941 6502Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA USA
| | - Jennifer S. Stevens
- grid.189967.80000 0001 0941 6502Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA USA
| |
Collapse
|
8
|
Abstract
Abstract
Purpose of Review
Anhedonia is a transdiagnostic symptom comprising reduced subjective reward or pleasure. Anhedonia influences subjective anticipation and in-the-moment experiences. This review draws together affective learning and engagement evidence for anhedonia affecting subjective experiences of social environments.
Recent Findings
While social engagement is diminished consistently, subjective appraisals of social contexts vary across different mental health disorders. Low positive affect during social experiences or stimuli is reported in PTSD, mood, schizophrenia, and anxiety disorders. Diminished neural reward networks underpin the anticipation of social experiences in ADHD, schizophrenia spectrum, and autistic spectrum disorders. Multiple theories exist to explain how anhedonia might interfere with social environments.
Summary
Anhedonia is a barrier to engagement, motivation, and enjoyment of social contexts. While many studies characterize experiences during social contexts, learning theories provide the most promise for developing targeted interventions.
Collapse
|
9
|
Breukelaar IA, Bryant RA, Korgaonkar MS. The functional connectome in posttraumatic stress disorder. Neurobiol Stress 2021; 14:100321. [PMID: 33912628 PMCID: PMC8065342 DOI: 10.1016/j.ynstr.2021.100321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/15/2021] [Accepted: 03/18/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Previous fMRI studies of posttraumatic stress disorder (PTSD) have investigated region-specific alterations in intrinsic connectivity but connectome-wide changes in connectivity are yet to be characterized. Understanding the neurobiology of this is important to develop novel treatment interventions for PTSD. This study aims to identify connectome-wide disruptions in PTSD to provide a more comprehensive analysis of nseural networks in this disorder. METHODS A functional MRI scan was completed by 138 individuals (67 PTSD and 71 non-trauma-exposed healthy controls [HC]). For every individual, inter-regional intrinsic functional connectivity was estimated between 436 brain regions, comprising intra and inter-network connectivity of eight large-scale brain networks. Group-wise differences between PTSD and HC were investigated using network-based statistics at a family-wise error rate of p < 0.05. Significant network differences were then further investigated in 27 individuals with trauma exposure but no PTSD [TC]). RESULTS Compared to HC, PTSD displayed lower intrinsic functional connectivity in a network of 203 connections between 420 regions within and between mid-posterior default mode, central executive, limbic, visual and somatomotor regions. Additionally, PTSD displayed higher connectivity across a network of 50 connections from thalamic and limbic to sensory and default-mode regions. Connectivity in TC in both these networks was intermediate and significantly different to PTSD and HC. CONCLUSION A large-scale imbalance between hypoconnectivity of higher-order cortical networks and hyperconnectivity of emotional and arousal response systems seems to occur on a sliding scale from trauma exposure to clinical manifestation as PTSD. Novel interventions that target this systemic functional imbalance could provide potential mitigation of PTSD.
Collapse
Affiliation(s)
- Isabella A. Breukelaar
- Brain Dynamics Centre, Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, Australia
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Richard A. Bryant
- Brain Dynamics Centre, Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, Australia
- School of Psychology, University of New South Wales, Sydney, Australia
| | - Mayuresh S. Korgaonkar
- Brain Dynamics Centre, Westmead Institute for Medical Research, University of Sydney, Westmead, NSW, Australia
- Discipline of Psychiatry, Sydney Medical School, Westmead, NSW, Australia
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
10
|
Nicholson AA, Ros T, Jetly R, Lanius RA. Regulating posttraumatic stress disorder symptoms with neurofeedback: Regaining control of the mind. Journal of Military, Veteran and Family Health 2020. [DOI: 10.3138/jmvfh.2019-0032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neurofeedback is emerging as a psychophysiological treatment where self-regulation is achieved through online feedback of neural states. Novel personalized medicine approaches are particularly important for the treatment of posttraumatic stress disorder (PTSD), as symptom presentation of the disorder, as well as responses to treatment, are highly heterogeneous. Learning to achieve control of specific neural substrates through neurofeedback has been shown to display therapeutic evidence in patients with a wide variety of psychiatric disorders, including PTSD. This article outlines the neural mechanisms underlying neurofeedback and examines converging evidence for the efficacy of neurofeedback as an adjunctive treatment for PTSD via both electroencephalography (EEG) and real-time functional magnetic resonance imaging (fMRI) modalities. Further, implications for the treatment of PTSD via neurofeedback in the military member and Veteran population is examined.
Collapse
Affiliation(s)
- Andrew A. Nicholson
- Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
- Neurology and Imaging of Cognition Lab, University of Geneva, Geneva, Switzerland
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
- Department of Psychology, Western University, London, Ontario
| | - Tomas Ros
- Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
- Neurology and Imaging of Cognition Lab, University of Geneva, Geneva, Switzerland
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
- Department of Psychology, Western University, London, Ontario
| | - Rakesh Jetly
- Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
- Neurology and Imaging of Cognition Lab, University of Geneva, Geneva, Switzerland
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
- Department of Psychology, Western University, London, Ontario
| | - Ruth A. Lanius
- Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
- Neurology and Imaging of Cognition Lab, University of Geneva, Geneva, Switzerland
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
- Department of Psychology, Western University, London, Ontario
| |
Collapse
|
11
|
Nicholson AA, McKinnon MC, Jetly R, Lanius RA. Uncovering the heterogeneity of posttraumatic stress disorder: Towards a personalized medicine approach for military members and Veterans. Journal of Military, Veteran and Family Health 2020. [DOI: 10.3138/jmvfh.2019-0031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introduction: Recently, there has been substantial interest in exploring the heterogeneity of posttraumatic stress disorder (PTSD) on a neurobiological level, as individuals with PTSD, including military members and Veterans, vary in their presentation of symptoms. Methods: Critically, a dissociative subtype of PTSD (PTSD+DS) has been defined, where a large body of evidence suggests that the unique presentation of symptoms among PTSD+DS patients is associated with aberrant neurobiological underpinnings. Results: PTSD+DS is often characterized by emotion overmodulation, with increased top-down activation from emotion regulation areas, which is associated with emotional detachment, depersonalization, and derealization. This is in stark contrast to the symptoms commonly observed in individuals with PTSD, who exhibit emotion undermodulation, which involves decreased top-down regulation of hyperactive emotion generation areas and is associated with vivid re-experiencing of trauma memories and hyperarousal. Discussion: This article examines a clinical case example that clearly illustrates this heterogeneous presentation of PTSD symptomatology and psychopathology. It discusses the implications this evidence base holds for a neurobiologically-informed, personalized medicine approach to treatment for military members and Veterans.
Collapse
Affiliation(s)
- Andrew A. Nicholson
- Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, Hamilton
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton
- Homewood Research Institute, Guelph, Ontario
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
| | - Margaret C. McKinnon
- Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, Hamilton
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton
- Homewood Research Institute, Guelph, Ontario
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
| | - Rakesh Jetly
- Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, Hamilton
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton
- Homewood Research Institute, Guelph, Ontario
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
| | - Ruth A. Lanius
- Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
- Mood Disorders Program, St. Joseph’s Healthcare Hamilton, Hamilton
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton
- Homewood Research Institute, Guelph, Ontario
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
| |
Collapse
|
12
|
Bickel KE, Kennedy R, Levy C, Burgio KL, Bailey FA. The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis. J Gen Intern Med 2020; 35:505-513. [PMID: 31792872 PMCID: PMC7018872 DOI: 10.1007/s11606-019-05538-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 08/06/2019] [Accepted: 10/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization. OBJECTIVES To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration. DESIGN Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center. SUBJECTS Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011. MAIN MEASURES Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life. KEY RESULTS Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194-2.138). CONCLUSIONS PTSD's association with increased end-of-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients. TRIAL REGISTRATION NCT00234286.
Collapse
Affiliation(s)
- Kathleen E Bickel
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA.
- Rocky Mountain Veterans Affairs Medical Center, Aurora, USA.
| | - Richard Kennedy
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cari Levy
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA
- Rocky Mountain Veterans Affairs Medical Center, Aurora, USA
| | - Kathryn L Burgio
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - F Amos Bailey
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| |
Collapse
|
13
|
Fani N, King TZ, Clendinen C, Hardy RA, Surapaneni S, Blair JR, White SF, Powers A, Ely TD, Jovanovic T, Ressler KJ, Bradley B. Attentional control abnormalities in posttraumatic stress disorder: Functional, behavioral, and structural correlates. J Affect Disord 2019; 253:343-51. [PMID: 31078834 DOI: 10.1016/j.jad.2019.04.098] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/19/2019] [Accepted: 04/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Attentional disruptions are common in PTSD, but findings across neuropsychological and neuroimaging studies have been variable. Few PTSD studies have investigated abnormalities in attention networks using a multi-modal imaging approach and attentional tasks that include emotionally-salient images. This study combined a behavioral task that included these images (emotional Stroop) with functional and structural neuroimaging (fMRI and diffusion tensor imaging; DTI) methods to comprehensively investigate attentional control abnormalities in a highly-traumatized civilian sample. METHODS 48 traumatized women with and without PTSD received clinical assessments, fMRI and DTI. During fMRI, the Affective Stroop (AS), an attentional control task that includes emotionally-salient distractor images (trauma-relevant, positive, neutral) and variable task demands, was administered. RESULTS In response to more difficult AS trials, participants with PTSD demonstrated lower activation in the dorsal and rostral anterior cingulate cortex and greater activation in the insula. This group also showed comparatively poorer performance on positive AS distractor trials, even after adjusting for trauma exposure. Performance on these trials inversely correlated with structural integrity of the cingulum bundle and uncinate fasciculus. CONCLUSIONS Even after adjusting for trauma exposure, participants with PTSD showed worse performance on an attentional control task in the context of emotional stimuli. They also showed relatively lower cognitive control network activation and greater salience network activation. Fronto-parietal and fronto-limbic white matter connectivity corresponded with AS performance. Our findings indicate that attentional control impairments in PTSD are most evident in the context of emotional cues, and are related to decrements in function and structure of cognitive control and salience networks.
Collapse
|
14
|
Ford JD. Trauma Memory Processing in Posttraumatic Stress Disorder Psychotherapy: A Unifying Framework. J Trauma Stress 2018; 31:933-942. [PMID: 30444287 DOI: 10.1002/jts.22344] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 09/05/2018] [Accepted: 09/08/2018] [Indexed: 12/19/2022]
Abstract
Trauma memory processing (TMP) is an empirically supported approach to psychotherapy for posttraumatic stress disorder (PTSD). However, TMP is not a single, uniform intervention but instead a paradigm that can be operationalized through a variety of component procedures that have not been systematically elucidated and formally tested. Based on findings from phenomenological/structural and neuroimaging research, a central feature of PTSD is theorized to be the involuntary immersion in trauma memories with diminished awareness or negative appraisals of self and current context. Such intrusive reexperiencing-which is epitomized by, but not limited to, flashbacks-is postulated to underlie PTSD's avoidance, altered emotions and cognitions, dissociative, and hyperarousal/hypervigilance symptoms; it is thus a logical target for TMP. The varied approaches to TMP for PTSD are conceptualized as having the common goal of activation of the neural networks in the brain that underlie two key capacities disrupted by intrusive reexperiencing in PTSD: intentional self-referential retrieval of memories and suppression of memory retrieval. Therefore, TMP is postulated to involve two core functions (purposeful reflective remembering and memory awareness in situ) and three essential types (in vivo, imaginal, and cognitive reappraisal). Several implications of this framework for clinical practice and research on TMP for PTSD are discussed.
Collapse
Affiliation(s)
- Julian D Ford
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| |
Collapse
|
15
|
Ogoh S, Yoo JK, Badrov MB, Parker RS, Anderson EH, Wiblin JL, North CS, Suris A, Fu Q. Cerebral blood flow regulation and cognitive function in women with posttraumatic stress disorder. J Appl Physiol (1985) 2018; 125:1627-1635. [DOI: 10.1152/japplphysiol.00502.2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is associated with structural and functional alterations in a number of interacting brain regions, but the physiological mechanism for the high risk of cerebrovascular disease or impairment in brain function remains unknown. Women are more likely to develop PTSD after a trauma than men. We hypothesized that cerebral blood flow (CBF) regulation is impaired in women with PTSD, and it is associated with impairment in cognitive function. To test our hypothesis, we examined dynamic cerebral autoregulation (CA) and cognitive function by using a transfer function analysis between arterial pressure and middle cerebral artery blood velocity and the Stroop Color and Word test (SCWT), respectively. We did not observe any different responses in these hemodynamic variables between women with PTSD ( n = 15) and healthy counterparts (all women; n = 8). Cognitive function was impaired in women with PTSD; specifically, reaction time for the neutral task of SCWT was longer in women with PTSD compared with healthy counterparts ( P = 0.011), but this cognitive dysfunction was not affected by orthostatic stress. On the other hand, transfer function phase, gain, and coherence were not different between groups in either the supine or head-up tilt (60°) position, or even during the cognitive challenge, indicating that dynamic CA was well maintained in women with PTSD. In addition, there was no relationship between cognitive function and dynamic CA. These findings suggest that PTSD-related cognitive dysfunction may not be due to compromised CBF regulation. NEW & NOTEWORTHY Cognitive function was impaired; however, dynamic cerebral autoregulation (CA) as an index of cerebral blood flow regulation was not impaired during supine and 60° head-up tilt in women with PTSD compared with healthy females. In addition, there was no relationship between cognitive function and dynamic CA. These findings suggest that the mechanism of PTSD-related cognitive dysfunction may not be due to CBF regulation.
Collapse
Affiliation(s)
- Shigehiko Ogoh
- Department of Biomedical Engineering, Toyo University, Kawagoe-Shi, Saitama, Japan
| | - Jeung-Ki Yoo
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark B. Badrov
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rosemary S. Parker
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Texas
| | - Elizabeth H. Anderson
- University of Texas Southwestern Medical Center, Dallas, Texas
- Veterans Affairs North Texas Health Care System, Dallas, Texas
| | - Jessica L. Wiblin
- University of Texas Southwestern Medical Center, Dallas, Texas
- Veterans Affairs North Texas Health Care System, Dallas, Texas
| | - Carol S. North
- Metrocare Services and the University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alina Suris
- University of Texas Southwestern Medical Center, Dallas, Texas
- Veterans Affairs North Texas Health Care System, Dallas, Texas
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Texas
- University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|