steven e. bruce, ph.d. - traumatic...

ALTEREDEMOTIONALINTERFERENCEPROCESSINGINWOMENWITHPOST-TRAUMATICSTRESSDISORDER.NEURALIMPROVEMENTSAFTERCOGNITIVEPROCESSINGTHERAPY.

StevenE.Bruce,Ph.D.

University of Missouri-St. Louis

Washington University School of Medicine

PTSDNeuroplasGcity

•  PreviousresearchhasfoundalteraGonsinneuralacGvityaLerexperiencingatraumaGceventandthedevelopmentofPTSD

Rauch 96 Shin 99

Liberzon 99 Bremner 99

Shin 97 Bremner 99

Rauch 00

Semple 00

Bruce 12

HIPPOCAMPUS Bremner 99

MEDIAL PFC & Ant Cingulate Bremner 99 Lanius 00

Bremner 99 Shin 01

Shin 97 Semple 00

Shin 99

AMYGDALA

Insula Etkin 07

Lanius 05

Bruce 12

PTSDNeuroplasGcity

•  CanintervenGonstargeGngPTSDsymptomsreversetheseneuralalteraGons?

CurrentStudy•  Baseline–  45womenwithPTSD(basedonDSM-IV-TR)

– Historyofinterpersonaltrauma(childhoodoradult)

–  22“Healthy”controls•  Pre-post–  23PTSDparGcipantshavecompletedCPTandaTime2fMRIscan

Methods•  InclusionCriteria

–  Womenaged18-55–  RightHanded–  Exposuretoaninterpersonaltrauma–  MeetcurrentDSM-IV-TRcriteriaforPTSD

•  Exclusioncriteria–  neurologicaldisorders–  currentalcoholorsubstanceabusedisorder–  schizophreniaorotherpsychoGcdisorder–  bipolardisorder–  obsessive-compulsivedisorder–  acGvesuicidality–  Currenttreatmentwithpsychotropicsuchasbeta-blockers,moodstabilizers,

anGpsychoGcsorotheranGdepressants–  uncorrectedvisualorhearingloss–  contraindicaGonsforMRIscanning

VisualDistractor(Conflict)Task

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+

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Neuroimagingfindings:

Baseline

AnalysisandResults•  RegionsofInterest

(ROI)Mask–  Amygdala,insula,cingulategyrus,hippocampus,parahippocampalgyrus,caudate,thalamus,andprefrontalcortex

Time*Group Effect PTSD vs Control: z = 3.60, p = .001

Amygdala (12, -10, -19)

0

0.001

0.002

0.003

0.004

0.005

0.006

0.007

Mea

n C

onfli

ct A

ctiv

ity

Right Insula (+41, -05, +07)

Control PTSD PTSD vs Control: z = 3.490, p = .0005

-0.006

-0.004

-0.002

0

0.002

0.004

0.006

0.008

0.01

Mea

n C

onfli

ct A

ctiv

ity

Left Insula (-39, -08, +06)

Control PTSD

DefaultModeNetwork(DMN)

•  TheDMNisanetworkofregionsthatareacGvewhenthepersonisnotengagedinanefforaultasksuchasduringdaydreamingandmind-wandering,butitisalsoacGveinself-referenGalthinking,rememberingthepast,etc.

•  Duringgoal-orientedacGvity,theDMNisdeacGvatedandotherareasareacGvated

•  DuringefforaulcogniGveprocessing,individualswithPTSDdonotshowthisdeacGvaGon,makingitmoredifficulttofocusandconcentrateonthetaskathand.

Treatment

CogniGveProcessingTherapy(CPT)

•  DesignedforsexualassaultvicGms

•  ElicitsmemoriesoftheeventbyhavingthepaGentdescribethetraumaGceventinwriGngandthenreadtheaccount

•  UsescogniGvetherapytocorrectmaladapGvecogniGonswithemphasisonthemesof:safety,trust,power,esteem,andinGmacy

Resick & Schnicke (1992)

TreatmentOutcome

•  TreatmentResponse– Definedas>40%reducGoninCAPSscores– NolongermeeGngDSM-IV-TRcriteriaforPTSD.

PTSDTreatmentOutcome(n=23)

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40

PTSDSeverity PTSDFrequency NeuroGcism

Scores

Time1and2AssessmentScores

Time1

Time2

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40

PTSDSeverity PTSDFrequency NeuroGcism

Scores

Time1and2AssessmentScores

Time1

Time2

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PTSDSeverity PTSDFrequency NeuroGcism

Scores

Time1and2AssessmentScores

Time1

Time2

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PTSDSeverity PTSDFrequency NeuroGcism

Scores

Time1and2AssessmentScores

Time1

Time2

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10

20

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50

60

70

PTSDCAPS PTSDPDS Depression

67.51

28.123.5622.96

9.59 8.87

Pre-Treatment

Post-Treatment

Neuroimagingfindings:

TreatmentOutcome

Volume

•  Higherrightinsulavolume(R=.490,p=.028)wasassociatedwithoverallimprovementinPTSDsymptomsaLerCPT.

•  higherright(R=.617,p=.004)andleL(R=.539,p=.014)insulavolumewereassociatedwithsignificantlylargerimprovementinre-experiencingsymptoms

•  higherrighthippocampalvolume(R=.459,p=.027)associatedwithimprovementinavoidancesymptoms

FuncGonalPre-PostTreatmentDifferences

AmygdalaacGvityreducGonaLerTreatment

-0.05

0

0.05

PTSD

Pre-Treatment

Post-Treatment

InsulaacGvityreducGonaLerTreatment(CAPSchange)

-0.025

-0.02

-0.015

-0.01

-0.005

0

0.005

0.01

0.015

0.02

0.025

avg_all

pre post

-0.12

-0.1

-0.08

-0.06

-0.04

-0.02

0 avg_all

pre post

DLPFCacGvityreducGonaLerTreatment

AnteriorCingulateReducGonaLerTreatment

-0.06

-0.05

-0.04

-0.03

-0.02

-0.01

0

0.01

0.02

avg_all

pre post

Conclusions

•  ImprovementinsymptomsaLertreatmentisassociatedwithanormalizaGonofbrainacGvitythatwasdysregulatedpriortotreatment.

•  ShowsthatsuccessfulpsychotherapycanfuncGonallychangehowourbrainoperates

•  NormalizingdysfuncGonsofcogniGvecontrol,emoGonalregulaGon,anddefaultnetworksmaybeacommonbiologicalmechanismofCBTefficacyinPTSD

FutureDirecGons

•  DiffusionTensorImaging(DTI)

•  CombineGeneGc/fMRIanalyses

•  ConnecGvityAnalyses

Preliminary resting-state data indicates that CBT decreases amygdala-ACC connectivity PTSD

NeuroimagingandPTSDTreatment

•  Assessment:canbeapowerfulassessmenttoolinevaluaGngtreatmentoutcome–  brainacGvityandvolumeasaresultofsuccessfultreatmentcould

haveprofoundimplicaGonsforthedevelopmentandrefinementofpsychologicaltreatmentsforPTSD.

•  TreatmentSelecGon:canalsobeusedforpredicGngwhichpaGentsmaydobenerwithvarioustreatmentopGons.

•  PrevenGon:IdenGfythoseindividualsmostatriskfordevelopmentofPTSD

aochangShou,Ph.D.–  ZhenYang,Ph.D.–  TheodoreD.SaAerthwaiteM.D.,

M.A.–  PhilipCookPh.D.–  RussellT.Shinohara,Ph.D.