Changes in trauma-potentiated startle with treatment of posttraumatic stress disorder in combat Veterans

Emotional Processing Theory proposes that habituation to trauma-related stimuli is an essential component of PTSD treatment. However, the mechanisms underlying treatment-related habituation are not well understood. We examined one psychophysiological measure that holds potential for elucidating the biological processes involved in treatment response: trauma-potentiated startle response. Seventeen OEF/OIF combat Veterans participated in the study and completed three assessments using a trauma-potentiated startle paradigm over PTSD treatment. Results revealed different patterns of trauma-potentiated startle across treatment for responders and nonresponders, but no differences in within task habituation. Responders showed an increase followed by a decrease in trauma-potentiated startle, whereas nonresponders showed a relatively flat response profile. Results suggested that PTSD patients who engage with emotional content as demonstrated by greater startle reactivity may be more likely to respond to PTSD treatment. Furthermore, trauma-potentiated startle shows promise as an objective measure of psychophysiological responses involved in PTSD recovery.     

Multicomponent behavioral treatment for chronic combat-related posttraumatic stress disorder: a randomized controlled trial

This study examined the efficacy of a multicomponent cognitive-behavioral therapy, Trauma Management Therapy, which combines exposure therapy and social emotional rehabilitation, to exposure therapy only in a group of male combat veterans with chronic posttraumatic stress disorder (PTSD). Thirty-five male Vietnam veterans with PTSD were randomly assigned to receive either Trauma Management Therapy (TMT) or Exposure Therapy Only (EXP). Participants were assessed at pre-treatment, mid-treatment, and post-treatment. Primary clinical outcomes were reduction of PTSD symptoms and improved social emotional functioning. Results indicated that veterans in both conditions showed statistically significant and clinically meaningful reductions in PTSD symptoms from pre- to post-treatment, though consistent with a priori hypotheses there were no group differences on PTSD variables. However, compared to the EXP group, participants in the TMT group showed increased frequency in social activities and greater time spent in social activities. These changes occurred from mid-treatment (after completion of exposure therapy) to post-treatment (after completion of the social emotional rehabilitation component); supporting the hypothesis that TMT alone would result in improved social functioning. Although the TMT group also had a significant decrease in episodes of physical rage, that change occurred prior to introduction of the social emotional component of TMT. This study demonstrates efficacy of exposure therapy for treating the core symptoms of PTSD among combat veterans with a severe and chronic form of this disorder. Moreover, multi-component CBT shows promise for improving social functioning beyond that provided by exposure therapy alone, particularly by increasing social engagement/interpersonal functioning in a cohort of veterans with severe and chronic PTSD.     

Progress towards understanding the genetics of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a complex syndrome that occurs following exposure to a potentially life threatening traumatic event. This review summarises the literature on the genetics of PTSD including gene–environment interactions (GxE), epigenetics and genetics of treatment response. Numerous genes have been shown to be associated with PTSD using candidate gene approaches. Genome-wide association studies have been limited due to the large sample size required to reach statistical power. Studies have shown that GxE interactions are important for PTSD susceptibility. Epigenetics plays an important role in PTSD susceptibility and some of the most promising studies show stress and child abuse trigger epigenetic changes. Much of the molecular genetics of PTSD remains to be elucidated. However, it is clear that identifying genetic markers and environmental triggers has the potential to advance early PTSD diagnosis and therapeutic interventions and ultimately ease the personal and financial burden of this debilitating disorder.     

A comparative study of trauma and posttraumatic stress disorder prevalence in epilepsy patients and psychogenic nonepileptic seizure patients

PURPOSE: This study tests the hypothesis that trauma histories, including histories of physical and sexual abuse, and posttraumatic stress disorder (PTSD) are more prevalent in psychogenic non-epileptic seizure (NES) patients than in epilepsy patients. METHODS: Thirty-five inpatients with intractable seizures were evaluated for trauma history and PTSD. After these assessments, patients were diagnosed as having either epileptic or nonepileptic seizures through EEG monitoring. RESULTS: NES diagnosis correlated with PTSD and total number of lifetime traumas, adult traumas, and abuse traumas. Contrary to previous hypotheses, reported childhood sexual abuse (CSA) did not correlate significantly with NES diagnosis. However, CSA predicted PTSD in a discriminant analysis. CONCLUSIONS: We found evidence for the hypothesized relations between trauma, abuse, PTSD, and NES diagnosis. However, elevated levels in both seizure-disorder groups suggest that routine assessment for abuse, trauma, and PTSD might facilitate medical care and treatment for all intractable seizure patients.     

Affective lability predicts decreased habituation in posttraumatic stress symptom responding during a single laboratory session of imaginal exposure

Affective lability, or the instability of emotional states, is associated with heightened levels of trauma-related emotional responding and posttraumatic stress disorder (PTSD) symptoms. However, the impact of affective lability, specifically on habituation to idiographic trauma cues, has yet to be examined among trauma-exposed individuals. The current study examined differential response trajectories to trauma-related imaginal exposure as a function of affective lability. Specifically, 72 women with a history of sexual victimization participated in a laboratory-based study involving a single session of repeated imaginal exposures to idiographic traumatic event cues. As hypothesized, participants higher in affective lability reported less reduction in trauma-cue elicited posttraumatic stress symptoms across exposure trials. Given these results, it will be important to continue to extend these laboratory findings to better understand how elevated affective lability is related to response to trauma-focused exposure therapy among individuals with PTSD or other trauma-related psychopathology (e.g., borderline personality disorder).     

Elevated plasma arginine vasopressin levels in veterans with posttraumatic stress disorder

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with altered hypothalamic-pituitary-adrenal (HPA) axis functioning. Arginine vasopressin (AVP), in conjunction with corticotrophin releasing hormone, has shown to be an important modulator of the HPA axis. In order to evaluate the effect of trauma and PTSD on central AVP secretion we assessed plasma AVP levels in equally trauma exposed veterans with and without PTSD and a non-traumatized healthy control group. METHODS: Assessment of plasma AVP in 29 male veterans with PTSD, 29 traumatized veterans without PTSD, matched for age, gender, year and region of deployment (trauma controls), and 26 age matched healthy controls. RESULTS: Plasma AVP levels were higher in PTSD patients compared to both healthy controls (p = 0.004) and trauma controls (p < 0.001). In PTSD patients without a comorbid MDD a significant correlation was observed between plasma AVP levels and symptoms of avoidance measured with the Clinician Administered PTSD Scale (CAPS). CONCLUSION: Elevated plasma AVP levels are specifically related to PTSD and not to exposure to traumatic stress during deployment. Our results indicate that AVP may play a role as an anxiogenic factor, but they do not support a role for AVP in the altered response to dexamethasone in PTSD.     

Disgust and the development of posttraumatic stress among soldiers deployed to Afghanistan

Although the DSM-IV recognizes that events can traumatize by evoking horror, not just fear, the role of disgust in the development of posttraumatic stress disorder (PTSD) has received little research attention. In a study of soldiers deployed to Afghanistan, we examined whether reports of peritraumatic disgust and trait disgust vulnerability factors (disgust propensity and disgust sensitivity) predict PTSD-symptoms, independently of peritraumatic fear, neuroticism, and anxiety sensitivity. Participants (N = 174) enrolled in this study before deployment, and were retested around 6 months (N = 138; 79%) and, again, 15 months (N = 107; 62%) after returning home. The results showed that (1) greater peritraumatic disgust and fear independently predicted PTSD-symptom severity at 6 months, (2) greater disgust propensity predicted more peritraumatic disgust, but not PTSD-symptom severity, and (3) disgust sensitivity moderated the relationship between peritraumatic disgust and PTSD-symptom severity. Implications of these findings for broadening the affective vulnerabilities that may contribute to PTSD will be discussed.     

Grey matter reduction associated with posttraumatic stress disorder and traumatic stress

In recent decades, many imaging studies have reported brain structural alterations in posttraumatic stress disorder (PTSD). However, due to differences in the selection of control subjects, it is difficult to conclude whether the observed alterations were related to disease or traumatic stress. The present study was to provide a quantitative voxelwise meta-analysis of grey matter (GM) changes in PTSD relative to either trauma-exposed controls without PTSD (TEC) or non-traumatised healthy controls (HC) separately and to conduct a systematic review of voxel-based morphometry (VBM) studies that compared trauma-exposed individuals with HC to explore the effect of traumatic stress. GM reduction was identified in the medial prefrontal cortex in PTSD compared to both TEC and HC. Additional GM reduction was also observed in PTSD in the left hippocampus, left middle temporal gyrus and right superior frontal gyrus compared with TEC. Additionally, GM decreased in the left occipital cortex in PTSD compared with HC. The present study delimited the significant differences among VBM results in PTSD research when different control groups were chosen.     

Association between flashbacks and structural brain abnormalities in posttraumatic stress disorder

Objective

Posttraumatic stress disorder (PTSD) is reliably associated with reduced brain volume relative to healthy controls, in areas similar to those found in depression. We investigated whether in a PTSD sample brain volumes in these areas were related to reporting specific symptoms of PTSD or to overall symptom severity.

Method

Structural MRI scans were obtained from 28 participants diagnosed with PTSD according to DSM-IV-TR. Participants reported the extent of individual PTSD symptoms using the Posttraumatic Diagnostic Scale. Voxel-based morphometry applying the Dartel algorithm implemented within SPM5 was used to identify volumetric changes, related to PTSD total, symptom cluster, and individual symptom scores.

Results

Brain volume was unrelated to overall PTSD severity, but greater reexperiencing scores predicted reduced volumes in the middle temporal and inferior occipital cortices. Increased reports of flashbacks predicted reduced volume in the insula/parietal operculum and in the inferior temporal gyrus.

Conclusion

The data illustrate the value of analyses at the symptom level within a patient population to supplement group comparisons of patients and healthy controls. Areas identified were consistent with a neurobiological account of flashbacks implicating specific abnormalities in the ventral visual stream.     

Resting-state functional connectivity of anterior and posterior hippocampus in posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) has been associated with altered resting-state functional connectivity (rs-FC) of several brain regions within the salience (SN) and default-mode (DMN) networks, including the hippocampus. However, most rs-FC studies have not focused primarily on the hippocampus, nor have they appreciated its structural heterogeneity, despite clear evidence for a dissociation between posterior and anterior hippocampal connectivity. Here, we examine rs-FC of anterior and posterior hippocampus with key regions in the SN (amygdala, insula, and dorsal anterior cingulate cortex/pre-supplementary motor area) and DMN (ventromedial prefrontal cortex, posterior cingulate cortex, and precuneus) previously implicated in PTSD, using a seed-based approach. Resting-state magnetic resonance images were obtained from 48 PTSD patients and 34 trauma-exposed healthy participants (TEHC). Results indicated no group differences when examining the hippocampus as a whole. However, examining the anterior and posterior hippocampus revealed a loss of anterior to posterior connectivity differentiation in PTSD patients. The PTSD group also demonstrated lower negative connectivity of the posterior hippocampus-precuneus pathway compared with the TEHC group. Finally, as differences in anterior and posterior hippocampus connectivity have been also related to age, we performed a secondary analysis exploring the association between age and posterior- and anterior-hippocampus connectivity in both groups. Results showed that among PTSD patients, increased age had the effect of normalizing posterior hippocampus-precuneus and hippocampus-posterior cingulate cortex connectivity, whereas no such effect was noted for the control group. These findings highlight the need for PTSD connectivity research to consider sub-parts of the hippocampus and to account for age-related connectivity differences.     

Comorbidity in the prediction of Cognitive Processing Therapy treatment outcomes for combat-related posttraumatic stress disorder

This paper examines clinical predictors of posttraumatic stress disorder (PTSD) treatment outcomes following Cognitive Processing Therapy (CPT) in Australian military veterans. Fifty nine treatment seeking veterans were enrolled in a randomized controlled trial comparing 12 sessions of CPT (n = 30) with usual treatment (n = 29) at three community-based veterans counseling centers. PTSD and key co-morbidities (depression, anxiety, anger and alcohol use) were measured. Growth curve modeling was used to examine factors which influenced PTSD severity post-treatment. For the CPT condition, baseline anger was the only co-morbidity predictive of change in PTSD severity over time. Participants with higher anger scores showed less of a decrease in PTSD severity over time. Higher anxiety in participants in treatment as usual was significantly associated with better treatment gains. This research suggests that veterans experiencing high levels of anger might benefit from targeted anger reduction strategies to increase the effectiveness of CPT treatment for PTSD.     

The association of posttraumatic stress disorder,complex posttraumatic stress disorder,and borderline personality disorder from a network analytical perspective

BackgroundPosttraumatic Stress Disorder (PTSD), Complex PTSD, and Borderline Personality Disorder (BPD) share etiological risk factors and an overlapping set of associated symptoms. Since the ICD-11 proposal for trauma-related disorders, the relationship of these disorders has to be clarified. A novel approach to psychopathology, network analysis, allows for a detailed analysis of comorbidity on symptom level.MethodsSymptoms were assessed in adult survivors of childhood abuse (N = 219) using the newly developed ICD-11 Trauma-Questionnaire and the SCID-II. The psychopathological network was analyzed using the network approach.ResultsPTSD and Complex PTSD symptoms were strongly connected within disorders and to a lesser degree between disorders. Symptoms of BPD were weakly connected to others. Re-experiencing and dissociation were the most central symptoms.ConclusionsMental disorders are no discrete entities, clear boundaries are unlikely to be found. The psychopathological network revealed central symptoms that might be important targets for specific first interventions.     

Posttraumatic stress disorder symptoms in trauma-exposed college students: the role of trauma-related cognitions, gender, and negative affect

Considerable evidence indicates a prominent role for trauma-related cognitions in the development and maintenance of posttraumatic stress disorder (PTSD) symptoms. The present study utilized regression analysis to examine the unique relationships between various trauma-related cognitions and PTSD symptoms after controlling for gender and measures of general affective distress in a large sample of trauma-exposed college students. In terms of trauma-related cognitions, only negative cognitions about the self were related to PTSD symptom severity. Gender and anxiety symptoms were also related to PTSD symptom severity. Theoretical implications of the results are discussed.     

Diminished rostral anterior cingulate activity in response to threat-related events in posttraumatic stress disorder

BACKGROUND: Previous brain imaging studies have reported hyperactivation of the amygdala and hypoactivation of the anterior cingulate in posttraumatic stress disorder (PTSD) patients, which is believed to be an underlying neural mechanism of the PTSD symptoms. The current study specifically focuses on the abnormal activity of the rostral anterior cingulate, using a paradigm which elicits an unexpected processing conflict caused by salient emotional stimuli. METHODS: Twelve survivors (seven men and five women) of the Taegu subway fire in 2003, who later developed PTSD, agreed to participate in this study. Twelve healthy volunteers (seven men and five women) were recruited for comparison. Functional brain images of all participants were acquired using functional magnetic resonance imaging while performing a same-different judgment task, which was modified to elicit an unexpected emotional processing conflict. RESULTS: PTSD patients, compared to comparison subjects, showed a decreased rostral anterior cingulate functioning when exposed to situations which induce an unexpected emotional processing conflict. Moreover, PTSD symptom severity was negatively correlated to the level of decrease in the rostral anterior cingulate activity. CONCLUSIONS: The results of this study provide evidence that the rostral anterior cingulate functioning is impaired in PTSD patients during response-conflict situations that involve emotional stimuli.     

Behavioral and experiential avoidance in patients with hoarding disorder

Background and objectives

This study examined the relationship between experiential and behavioral avoidance and hoarding symptom severity, controlling for anxiety and depression symptoms, in 66 adult individuals (M age = 61.41; SD = 9.03) with HD.

Methods

Hierarchical regression was used to test the associations between hoarding severity, as defined by the Savings Inventory-Revised (SI-R) total and its three subscales, and avoidance, as defined by the Acceptance and Action Questionnaire II (AAQ-II) and two scales from the Brief COPE (Self-Distraction and Behavioral Disengagement) when controlling for anxiety and depression symptoms.

Results

Experiential avoidance (AAQ-II) and behavioral avoidance (Brief COPE subscales Self-Distraction and Behavioral Disengagement) uniquely accounted for aspects of hoarding severity (SI-R) in regression models. Behavioral avoidance contributed significant additional variance to the SI-R Clutter subscale, whereas experiential avoidance was uniquely predictive of additional variance in the SI-R Difficulty Discarding and the SI-R Acquisition subscales.

Limitations

Future research should examine the effect of experiential avoidance on hoarding behaviors experimentally.

Conclusions

Given that the AAQ-II and Self-Distraction and Behavioral Disengagement subscales were not correlated, these findings suggest that experiential and behavioral avoidance are two distinct processes contributing to the severity of specific HD. Results support the utility of avoidance in the cognitive-behavioral model for HD.     

The impact of pre- and post-trauma financial problems on posttraumatic stress symptoms,anxiety and depression symptoms,and emotional support: A prospective population-based comparative study

Potentially traumatic events (PTEs) are associated with a higher risk of mental health problems and a lack of emotional support. The extent to which pre- and/or post-trauma financial problems further increase this risk, while controlling for pre-trauma mental health problems and lack of support and compared to nonvictims, is largely unknown. To better understand this risk, data was extracted from four surveys of VICTIMS study using the Dutch population-based longitudinal LISS-panel. Multivariate logistic regression analyses (MLRA) showed that nonvictims (n^{nonvictims total}=5003) with persistent financial problems (present at T1 and present at T2 one year later) more often suffered from severe anxiety and depression symptoms (ADS; Adjusted OR (aOR)= 1.72) and lack of emotional support (aOR=1.96) than nonvictims without these problems, and that victims of PTEs (n^{victims total}=872) with persistent financial problems more often suffered moderate ADS (aOR=2.10) than nonvictims with persistent financial problems. MLRA showed that victims with pre- and/or post-trauma financial problems were more at risk of probable PTSD than victims without financial problems (aORs ≥ 2.02). Victim services and (mental) health care professionals should screen for pre- and post-trauma financial problems and, when found, refer the victims to relevant professionals since these problems can significantly hinder recovery.     

Enhanced sensitivity to glucocorticoids in peripheral mononuclear leukocytes in posttraumatic stress disorder.

BACKGROUND: The aim of this study was to determine whether there is increased responsiveness to corticosteroids in posttraumatic stress disorder (PTSD) by examining the differential effects of dexamethasone (DEX) on the inhibition of lysozyme activity. METHODS: 60 mL of blood was withdrawn at 8:00 am, and mononuclear leukocytes were isolated from the blood of 26 men with, and 18 men without, PTSD. An aliquot of live cells was incubated with a series of concentrations of DEX to determine the rate of inhibition of lysozyme activity; a portion of cells was frozen for the determination of glucocorticoid receptors (GR). RESULTS: Subjects with PTSD showed evidence of a greater sensitivity to glucocorticoids as reflected by a significantly lower mean concentration (nmol/L) of dexamethasone at which 50% of lysozyme activity is inhibited (IC(50-DEX)) (PTSD+ = 4.9 +/-.53; PTSD- group = 7.2 +/-.64). The lysozyme IC(50-DEX) was significantly correlated with age at exposure to the first traumatic event in subjects with PTSD (r =.44, n = 26, p =.025). The number of cytosolic glucocorticoid receptors was also correlated with age at exposure to the focal traumatic event (r = -.44, n = 25, p =.03) in PTSD. CONCLUSIONS: This is the first in vitro demonstration of an alteration in target tissue sensitivity to glucocorticoids in PTSD. The lower lysozyme IC(50-DEX) might be related to the risk factor of prior exposure to trauma.     

Evaluation of smoking characteristics among community-recruited daily smokers with and without posttraumatic stress disorder and panic psychopathology

The present investigation compared 123 community-recruited daily smokers with posttraumatic stress disorder (PTSD), panic disorder (PD), nonclinical panic attacks (PA), or no current Axis I psychopathology (controls; C) in terms of nicotine dependence, smoking rate, quit history, severity of symptoms during past quit attempts, and motivation for and expectancies about smoking. No differences were observed between groups in regard to smoking rate or nicotine dependence. The PTSD group reported making more lifetime quit attempts than the other groups, and the PTSD and PD groups perceived more severe symptoms during past quit attempts. The PD and PTSD groups reported greater motivation to smoke to reduce negative affect. Individuals with PTSD endorsed a stronger expectation that smoking would alleviate negative mood states and would produce negative consequences. Overall, results suggest that smokers with PD or PTSD differ from other smoking groups in a number of clinically significant ways.     

The association of traumatic experiences and posttraumatic stress disorder with health care utilization in the elderly - a German population based study

Objective

Traumatic experiences (TE) and posttraumatic stress disorder (PTSD) are related to impaired mental and physical health and to increased health care utilization (HCU). However, general population studies simultaneously investigating the association of TE and PTSD with HCU in the elderly are lacking to date.

Methods

A representative sample of 1456 people aged 60-85 years from the German general population was examined using self-rating instruments for TE, PTSD, HCU and physical health (PH).

Results

In regression analyses including age and gender, TE are significantly associated with increased probability of visits to specialists and to mental health professionals, and of hospitalization, but not with the frequency of HCU. Current PTSD is significantly associated with increased probability of visits to mental health professionals and of hospitalization, and with increased frequency of general practitioner visits, of specialist visits, and of visits to mental health professionals. In two mediation models, the relationships between TE and PTSD, respectively, with HCU were weakened but remained significant after including PTSD and physical morbidity, respectively.

Conclusion

These results indicate that both trauma and PTSD are positively associated to some indicators of HCU. Posttraumatic stress disorder has a weak mediating role in the association of TE and HCU. Physical health has a weak mediating role in the association of PTSD and HCU.     

The utility of college student samples in research on trauma and posttraumatic stress disorder: A critical review

There is a widespread notion of the ‘college sophomore problem’ in social science research that posits that college student samples are samples of convenience with little generalizability to the general population. To address this concern, we conducted a critical review of the literature on college student samples in trauma research. Specifically, we reviewed how college student samples differ from non-college samples in four key areas of trauma research: (1) exposure rates to potentially traumatic events (PTEs), (2) prevalence of posttraumatic stress disorder (PTSD) symptoms, (3) factor structure of PTSD symptoms, and (4) PTSD’s relation with common markers, correlates, and consequences. Lastly, we discussed the value and advantages of using college student samples in trauma research. Results of the critical review indicated similar trends of trauma-related findings (Points 1–4) between college student samples and both U.S. nationally collected and treatment-seeking samples; specifically, we identified a comparable lifetime PTE exposure rate, comparable rates of PTSD, a comparable factor structure of PTSD symptoms, and a comparable pattern of associations between PTSD symptoms and post-trauma markers/correlates/consequences. Although trauma-exposed college student samples are biased in some key areas, they may be no more biased than other commonly used trauma samples (e.g. epidemiological, treatment-seeking). Results of this critical review highlight the need to re-examine potentially unfounded biases on the part of the trauma research community, as well as the need to consider advantages of using college student samples in trauma research.