Göran Högberg

Gray matter density in limbic and paralimbic cortices is associated with trauma load and EMDR outcome in PTSD patients

There is converging evidence of gray matter (GM) structural alterations in different limbic structures in Post-Traumatic Stress Disorder (PTSD) patients. The aim of this study was to evaluate GM density in PTSD in relation to trauma load, and to assess the GM differences between responders (R) and non-responders (NR) to EMDR therapy. Magnetic Resonance Imaging (MRI) scans of 21 subjects exposed to occupational trauma, who developed PTSD (S), and of 22 who did not (NS), were compared by means of an optimized Voxel-Based Morphometry (VBM) analysis as implemented in SPM. Within S, further comparisons were made between 10 R and 5 NR. A regression analysis between GM density and the Traumatic Antecedents Questionnaire (TAQ) was also performed on all 43 subjects. Results showed a significantly lower GM density in S as compared to NS in the left posterior cingulate and the left posterior parahippocampal gyrus. Moreover, NR showed a significantly lower GM density as compared to R in bilateral posterior cingulate, as well as anterior insula, anterior parahippocampal gyrus and amygdala in the right hemisphere. Regression analysis showed that GM density negatively correlated with trauma load in bilateral posterior cingulate, left anterior insula, and right anterior parahippocampal gyrus. In conclusion, a GM lower density in limbic and paralimbic cortices were found to be associated with PTSD diagnosis, trauma load, and EMDR treatment outcome, suggesting a view of PTSD characterized by memory and dissociative disturbances.

On treatment with eye movement desensitization and reprocessing of chronic post-traumatic stress disorder in public transportation workers – A randomized controlled trial

Previous studies on post-traumatic stress disorder (PTSD) investigated a variety of treatments and included mostly patients victims of sexual and combat assault. This study aimed to determine the short-term efficacy of eye movement desensitization and reprocessing (EMDR) in occupation-based PTSD. Employees of the public transportation system in Stockholm, who had been experiencing a person-under-train accident or had been assaulted at work were recruited. Subjects with trauma exposure since more than 3 months but less than 6 years were included. Twenty-four subjects who fulfilled the DSM-IV criteria for PTSD were randomized to either EMDR therapy (n=13) or waiting list (WL, n=11). They were assessed pre-treatment and shortly after completion of treatment or WL period. The pre-defined primary outcome variable was full PTSD diagnosis. Secondary outcome variables were the results of various psychometric scales. Twelve participants began and completed five sessions of EMDR and nine completed the WL. After therapy, eight subjects in the EMDR group (67%) and one (11%) in WL did not fulfil the criteria for PTSD diagnosis (difference, P=0.02). Among the secondary outcome variables, there were significant differences post-treatment between the groups EMDR/WL in Global Assessment of Function (GAF) score and Hamilton Depression (HAM-D) score. This study indicates that EMDR has a short-term effect on PTSD in public transportation workers exposed to occupational traumatic events. Such intensive and brief therapy might be further validated in larger samples of exposed workers with longer periods of follow-up.

Regional cerebral blood flow during auditory recall in 47 subjects exposed to assaultive and non-assaultive trauma and developing or not posttraumatic stress disorder

ObjectivePsychological trauma leads to posttraumatic stress disorder (PTSD) in susceptible subjects. The aim of this study was to investigate the differences in regional cerebral blood flow (rCBF) between two groups of subjects exposed to different types of traumatic stressor either developing or not developing PTSD.MethodsTwenty subjects developing (S) and 27 not developing (NS) PTSD after being exposed to either earlier person–under–the–train accident (NA) or being assaulted in the underground environment (A) were included in the study. 99mTc–HMPAO SPECT was performed and the uptake in 29 regions of the brain (VOIs), bilaterally, was assessed. rCBF distribution was compared, using analysis of variance (ANOVA), between groups (S/NS) and type (A/NA) during a situation involving an auditory evoked re–experiencing of the traumatic event. Discriminant analysis was applied to test the concordance between clinical diagnosis and SPECT findings.ResultsIn the general analyses significant differences were found between groups and types and there was a significant hemisphere × type interaction. S showed higher CBF than NS and so did A as compared to NA, particularly in the right hemisphere. Discriminant analysis correctly classified 66% of cases (p < 0001) in testing S/NS and 72% (p < 0001) in testing NA/A.ConclusionsUnder recall of their traumatic experience we found higher relative CBF distribution values in S as compared to NS. CBF was higher in the right hemisphere and particularly in assaulted subjects. These findings underscore the role upon trauma recall of both the right hemisphere and the nature of the stressing event.

Volumetrics of the caudate nucleus: Reliability and validity of a new manual tracing protocol

Our aim was to develop a reliable and valid manual segmentation protocol for tracing the caudate nucleus in MRI for volumetric and, potentially, shape analysis of the caudate. Using the protocol, two inter- and intra-rater reliability studies were conducted using five different raters on two different image analysis platforms (ANALYZE, Mayo Biomedical Imaging Resource, Rochester MN, USA, and HERMES, Nuclear Diagnostics AB, Stockholm, Sweden). Reference images for the detailed protocol are described. Two studies were performed. In study 1, the intra-rater class correlation ICC(1,1) for an experienced rater (JCLL) using this protocol for caudate nucleus volumes was evaluated by repeating right and left caudate measurements on 10 scans (20 comparisons) and was 0.972. The inter-rater class correlation ICC(1,k) with OL was 0.922 on 5 scans (10 comparisons) and with BL was 0.960 on 5 scans (10 comparisons). In study 2, VT obtained an intra-rater class correlation of 0.9 on 5 scans (involving 10 comparisons, e.g. right and left caudate). The inter-rater class correlation ICC(1,k) was 0.988 on 5 scans (again involving 10 comparisons) with EM. We therefore developed a novel, reliable and reference image-based, method of outlining the caudate nucleus on axial MRI scans, usable in two different image analysis laboratories, across two different sets number of tracers reliably, and across software platforms. This method is therefore potentially usable for any image analysis package capable of displaying and measuring outlined voxels from MRI brain scans.

Gray matter volume alterations related to trait dissociation in PTSD and traumatized controls

This study used voxel‐based morphometry (VBM) to investigate brain structural alterations related to trait dissociation and its relationship with post‐traumatic stress disorder (PTSD).

Caudate volumes in public transportation workers exposed to trauma in the Stockholm train system

The caudate nucleus is a structure implicated in the neural circuitry of psychological responses to trauma. This study aimed to quantify the volume of the caudate in persons exposed to trauma. Thirty-six subjects under 65 were recruited from transport workers in Stockholm who reported having been unintentionally responsible for a person-under-the-train accident or among employees having experienced an assault in their work (1999-2001) between 3 months and 6 years before MRI scanning. In those exposed to the trauma, a DSM-IV diagnosis of post-traumatic stress disorder (PTSD) was made by an independent psychiatrist, with subjects being classified as PTSD or no PTSD. MRI data were analyzed blindly to all clinical information by an experienced rater using a standardized manual tracing protocol to quantify the volume of the caudate. Within-group comparisons of PTSD (n=19) and no PTSD (n=17) found the right caudate nucleus to be significantly (9%) larger than the left: a right hemisphere baseline asymmetry. A multivariate analysis of covariance (MANCOVA) was conducted to assess the volume of the caudate nucleus (right and left) in relation to the diagnosis of no PTSD (n=17) or PTSD (n=19). After adjustment for the covariates (age, sex, intracranial volume, years since trauma, and number of trauma episodes), there was a significant difference in raw right caudate nucleus volume between subjects with PTSD compared with those without PTSD. Volume of the left caudate nucleus was not significantly different between the PTSD and no PTSD groups. The right caudate volume in the PTSD group was 9% greater compared with the no PTSD group. There is a larger right hemisphere volume of the caudate within those exposed to trauma with active PTSD compared with those without PTSD, superimposed upon a baseline caudate asymmetry.

Screening for depressed mood in an adolescent psychiatric context by brief self-assessment scales - testing psychometric validity of WHO-5 and BDI-6 indices by latent trait analyses

BackgroundMajor depressive disorder is prevalent in the adolescent psychiatric clinical setting and often comorbid with other primary psychiatric diagnoses such as ADHD or social anxiety disorder. Systematic manual-based diagnostic procedures are recommended to identify such comorbidity but they are time-consuming and often not fully implemented in clinical practice. Screening for depressive symptoms in the child psychiatric context using brief, user-friendly and easily managed self-assessment scales may be of clinical value and utility. The aim of the study is to test the psychometric validity of two such scales, which may be used in a two-step screening procedure, the WHO-Five Well-being Index (WHO-5) and the six-item version of Beck’s Depression Inventory (BDI-6).Method66 adolescent psychiatric patients with a clinical diagnosis of major depressive disorder (MDD), 60 girls and 6 boys, aged 14–18 years, mean age 16.8 years, completed the WHO-5 scale as well as the BDI-6. Statistical validity was tested by Mokken and Rasch analyses.ResultsThe correlation between WHO-5 and BDI-6 was −0.49 (p=0.0001). Mokken analyses showed a coefficient of homogeneity for the WHO-5 of 0.52 and for the BDI-6 of 0.46. Rasch analysis also accepted unidimensionality when testing males versus females (p > 0.05).ConclusionsThe WHO-5 is psychometrically valid in an adolescent psychiatric context including both genders to assess the wellness dimension and applicable as a first step in screening for MDD. The BDI-6 may be recommended as a second step in the screening procedure, since it is statistically valid and has the ability to unidimensionally capture the severity of depressed mood.

Neurobiology of Sleep Disturbances in PTSD Patients and Traumatized Controls: MRI and SPECT Findings

Objective Sleep disturbances such as insomnia and nightmares are core components of post-traumatic stress disorder (PTSD), yet their neurobiological relationship is still largely unknown. We investigated brain alterations related to sleep disturbances in PTSD patients and controls by using both structural and functional neuroimaging techniques. Method Thirty-nine subjects either developing (n = 21) or not developing (n = 18) PTSD underwent magnetic resonance imaging and a symptom-provocation protocol followed by the injection of 99mTc-hexamethylpropyleneamineoxime. Subjects were also tested with diagnostic and self-rating scales on the basis of which a Sleep Disturbances Score (SDS; i.e., amount of insomnia/nightmares) was computed. Results Correlations between SDS and gray matter volume (GMV)/regional cerebral blood flow (rCBF) were computed in the whole sample and separately in the PTSD and control groups. In the whole sample, higher sleep disturbances were associated with significantly reduced GMV in amygdala, hippocampus, anterior cingulate, and insula; increased rCBF in midbrain, precuneus, and insula; and decreased rCBF in anterior cingulate. This pattern was substantially confirmed in the PTSD group, but not in controls. Conclusion Sleep disturbances are associated with GMV loss in anterior limbic/paralimbic, PTSD-sensitive structures and with functional alterations in regions implicated in rapid eye movement-sleep control, supporting the existence of a link between PTSD and sleep disturbance.

Affective psychotherapy in post-traumatic reactions guided by affective neuroscience: memory reconsolidation and play

This paper reviews the affective neuroscience dealing with the effects of traumatic events. We give an overview of the normal fear reactions, the pathological fear reaction, and the character of emotional episodic memories. We find that both emotions and emotional memories are a tripartite unit of sensory information, autonomic reaction, and motor impulse (the PRM complex). We propose that emotions and movements are part and parcel of the same complex. This is our main finding from the review of affective neuroscience, and from here we focus on psychotherapy with post-trauma reactions. The finding of the process of memory reconsolidation opens up a new treatment approach: affective psychotherapy focused on reconsolidation. The meaning of reconsolidation is that an emotional memory, when retrieved and being active, will rest in a labile form, amenable to change, for a brief period of time, until it reconsolidates in the memory. This leads us to the conclusion that emotions, affects, must be evoked during the treatment session and that positive emotion must come first, because safety must be part of the new memories. In the proposed protocol of affective psychotherapy based on reconsolidation the emotional episodic memory is relived in a safe and positive setting, focused in turn on the sensory experience, the autonomic reaction, and the motor impulse. Then it is followed by a fantasy of a different positive version of the same event. All in all treatment should provide a series of new memories without fear related to the original event. With the focus on the motor program, and the actions, there is a natural link to art therapy and to the mode of play, which can rehearse and fantasize new positive actions.

Correlates of EMDR Therapy in Functional and Structural Neuroimaging: A Critical Summary of Recent Findings

Neuroimaging investigations of the effects of psychotherapies treating posttraumatic stress disorder (PTSD), including eye movement desensitization and reprocessing (EMDR), have reported findings consistent with modifications in cerebral blood flow (CBF; single photon emission computed tomography [SPECT]), in neuronal volume and density (magnetic resonance imaging [MRI]), and more recently in brain electric signal (electroencephalography [EEG]). Additionally in the recent past, EMDR-related neurobiological changes were monitored by EEG during therapy itself and showed a shift of the maximal activation from emotional limbic to cortical cognitive brain regions. This was the first time in which neurobiological changes occurring during any psychotherapy session have been reported, making EMDR the first psychotherapy with a proven neurobiological effect. The purpose of this article was to review the results of functional and structural changes taking place at PTSD treatment and presented during the period of 1999–2012 by various research groups. The reported pathophysiological changes are presented by neuropsychological technique and implemented methodology and critically analyzed.