steven e. bruce, ph.d. - traumatic...
TRANSCRIPT
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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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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5
10
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30
35
40
PTSDSeverity PTSDFrequency NeuroGcism
Scores
Time1and2AssessmentScores
Time1
Time2
0
5
10
15
20
25
30
35
40
PTSDSeverity PTSDFrequency NeuroGcism
Scores
Time1and2AssessmentScores
Time1
Time2
0
5
10
15
20
25
30
35
40
PTSDSeverity PTSDFrequency NeuroGcism
Scores
Time1and2AssessmentScores
Time1
Time2
0
5
10
15
20
25
30
35
40
PTSDSeverity PTSDFrequency NeuroGcism
Scores
Time1and2AssessmentScores
Time1
Time2
0
10
20
30
40
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.