Joana Straub

Neural Correlates of Psychotherapeutic Treatment of Post-traumatic Stress Disorder: A Systematic Literature Review

Objectives Post-traumatic stress disorder (PTSD) is a common psychiatric disease with changes in neural circuitries. Neurobiological models conceptualize the symptoms of PTSD as correlates of a dysfunctional stress reaction to traumatic events. Functional imaging studies showed an increased amygdala and a decreased prefrontal cortex response in PTSD patients. As psychotherapeutic approaches represent the gold standard for PTSD treatment, it is important to examine its underlying neurobiological correlates. Methods Studies published until August 2016 were selected through systematic literature research in the databases PubMed, PsychInfo, and Cochrane Library’s Central Register of Controlled Trials or were identified manually by searching reference lists of selected articles. Search terms were “neural correlates” OR “fMRI” OR “SPECT,” AND “therapy” AND “PTSD.” A total of 19 articles were included in the present review whereof 15 studies compared pre-to-post-therapy signal changes, six studies related pre-treatment activity to pre-to-post-symptom improvement, and four studies compared neural correlates of responders versus non-responders. The disposed therapy forms were cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing, cognitive therapy, exposure therapy, mindfulness-based intervention, brief eclectic psychotherapy, and unspecified therapy. Results Successful psychotherapy of PTSD was repeatedly shown to be accompanied by decreased activity in the amygdala and the insula as well as increased activity in the dorsal anterior cingulate cortex (dACC) and hippocampus. Elevated dACC activity prior to treatment was related to subsequent treatment success and a positive predictor for treatment response. Elevated amygdala and insula pre-treatment activities were related to treatment failure. Discussion Decreased activity in limbic brain regions and increased activity in frontal brain areas in PTSD patients after successful psychotherapeutic treatment might reflect regained top-down control over previously impaired bottom-up processes.

Convergence of children´s depression rating scale-revised scores and clinical diagnosis in rating adolescent depressive symptomatology

The Children’s Depression Rating Scale-Revised (CDRS-R) is a widely used instrument for research on depression in minors. A raw score of ≥40 has often been used as indicator of depressive symptomatology. As a validated German version of the CDRS-R has recently became available, we assessed CDRS-R raw summary scores of a video taped interview session in two different rater groups and compared them with clinical ratings of International Classification of Diseases (ICD-10) depression diagnosis as observed by a third independent group. We found that for the German version a raw score between 35 and 40 is indicative for mild depressive symptomatology as described by the ICD-10. CDRS-R scores show potential clinical applicability to deduct levels of depression.

Strong Schools against Suicidality and Self-Injury: Evaluation of a Workshop for School Staff.

Nonsuicidal self-injury (NSSI) and suicidality are common among adolescents. School staff are often the first adults to be confronted with those behaviors. However, previous studies have shown a lack of knowledge and confidence in dealing with self-harming behaviors. Objectives of this study were to evaluate a workshop on NSSI and suicidality in adolescence for teachers, school social workers and school psychologists. In total, N = 267 school staff participated in 1 of 16 two-day workshops, which were offered in different cities in southern Germany. Pre-, post- and 6-month follow-up assessments were conducted concerning attitudes, confidence in own skills, perceived knowledge, and knowledge on NSSI and suicidality. Satisfaction with the workshop was evaluated directly after the workshop; changes in handling situations involving youth with self-harm were evaluated at follow-up. Overall, participants were very satisfied with the workshop. Few negative attitudes regarding NSSI and suicidality were prevalent before and after the workshop. Large effect sizes were found for improvement in confidence, perceived knowledge, and knowledge at postassessment, which were still present at 6-month follow-up. There were significant differences between professions, with teachers seemingly benefitting the most from the workshop. At follow-up, participants reported more changes in their own behavior than having been able to implement changes on a school level. A 2-day workshop seems to be effective in changing knowledge and confidence in school staff regarding NSSI and suicidality. Workshops catered to different professions (i.e., teachers and school psychologists) might be feasible.

Suicidal behavior in German adolescents

OBJECTIVE Research in adults has identified an association between bipolar disorder and suicidal behavior. This relationship, however, has been insufficiently investigated in adolescents to date. METHODS 1,117 adolescents from 13 German schools (mean age = 14.83, SD = .63; 52.7% females) completed an extended German version of the Center for Epidemiological Studies Depression Scale (CES-D), which assesses depressive and manic symptoms during the last week, as well as the Self-Harm Behavior Questionnaire (SHBQ) for the assessment of lifetime suicidal behavior. RESULTS In the present sample 39.4% of the girls and 23.1% of the boys reported lifetime suicidal thoughts and 7.1% of the girls as well as 3.9% of the boys a lifetime history of suicide attempts. 18.7% of the adolescent sample revealed elevated symptoms of depression and 9% elevated levels of mania symptoms. Elevated sum scores of depression and mania were associated with a higher number of suicidal ideations and suicide attempts. A block-wise regression analysis revealed that sum scores of depression and mania predicted suicidal ideations best. Concerning suicide attempts, the best predictors were age as well as depression and mania sum scores. CONCLUSIONS Suicidal behavior was reported more often when adolescents demonstrate symptoms of mania as well as symptoms of depression than when they demonstrate only depressive symptoms. The presence of bipolar symptoms in adolescents should alert clinicians to the heightened possibility of suicidal behavior.

Konkordanz zwischen Selbst- und Klinikerurteil hinsichtlich depressiver Symptomatik bei Jugendlichen am Beispiel von BDI-II und CDRS-R

OBJECTIVES Preceding studies demonstrated a high agreement between self-report and clinicians assessment of depression. The concordance on the level of sum scores, subscales, and single items, however, has yet to be investigated in a psychiatric adolescent sample. Also, the influence of additional variables such as age, sex, and IQ has been insufficiently studied in adolescents. METHODS Scores on the BDI-II and CDRS-R, assessed within 1 week, were collected from 105 adolescents (mean age = 15.94 years). Analyses of correlation were done on levels of sum scores, subscales, and single items. RESULTS There was a high correlation between self-report and clinicians assessment (r = .67). At the level of subscales, items assessing somatic contents demonstrated no higher agreement than did items assessing cognitive and affective contents. The highest agreement at the symptom level was shown for the item assessing suicidal ideations. Additional variables had no significant influence on concordance. Adolescents with a high IQ and outpatient adolescents tended to overestimate their symptoms. CONCLUSIONS The overall correlation was high and did not differ from results of comparable studies of correlations. The highest congruence was shown for the item assessing suicidal ideations, which underlines the accurate assessment of suicidality by clinicians as well. In summary, questionnaires can provide information about the existence of a depressive disorder, although one diagnostic instrument should not be replaced by the other despite a high correlation.

Prevalence Rate and Course of Symptoms of Disruptive Mood Dysregulation Disorder (DMDD)

Objective According to DSM-5, Disruptive Mood Dysregulation Disorder (DMDD) is characterized by chronic temper outbursts and irritable moods. So far, little is known about its prevalence rate, course and influence on individual well-being. We assessed the prevalence rates of DMDD symptoms during adulthood and primary school age - the latter retrospectively - and studied their relationship with psychiatric disorders and socioeconomic variables. Methods A total of 2,413 subjects, aged 18-94 years, participated in this population-based, representative study based on self-reports. Results 12 (0.50 %) subjects reported elevated DMDD symptoms during adulthood, and 19 (0.79 %) reported elevated DMDD symptoms during primary school age. DMDD symptoms were associated with higher rates of depression and anxiety symptoms. Those reporting elevated DMDD symptoms during adulthood were more often single or divorced, and those reporting elevated DMDD symptoms during primary school age were more often childless and unemployed during adulthood compared to subjects without DMDD symptoms. Conclusions DMDD symptoms seem to show a chronic course and go hand in hand with elevated psychiatric symptoms and impaired socioeconomic and demographic status.

Increasing Knowledge, Skills and Confidence concerning Students’ Suicidality through a Gatekeeper Workshop for School Staff

Introduction: Around one-third of adolescents in Germany report a lifetime history of suicide ideation. School staff (e.g., teachers or school social workers) can serve as gatekeepers to identify adolescents at risk and transfer them to appropriate mental health professionals. The aim of this study was to evaluate a gatekeeper training for school staff. Methods: A total of N = 603 school social workers, school psychologists, and teachers participated in one of 33 1.5-day workshops. Knowledge, attitudes, confidence in skills, and perceived knowledge were assessed at pre and post workshops and at 6-month follow-up (FU). Behavioral changes were assessed via self-report at FU. Results: Knowledge, perceived knowledge, and confidence in own skills concerning suicidality increased significantly from pre- to post-assessment and was still significantly increased at 6-month FU. Attitudes toward suicidal adolescents were neutral to positive before the workshop and remained un-changed at FU. Overall, participants were very satisfied with the workshop. Although participants stated to be motivated to make behavioral changes at 6-month FU, they reported obstacles such as lack of resources and support from school administration. Discussion: This 1.5-day gatekeeper workshop was effective in enhancing knowledge and confidence in school staff regarding suicidality. Future workshops would benefit from ongoing supervision and inclusion of school administration in order to facilitate long-term changes on a behavioral level.

Effects of a brief cognitive behavioural therapy group intervention on baseline brain perfusion in adolescents with major depressive disorder

A number of neuroimaging studies have identified altered regional cerebral blood flow (rCBF) related to major depressive disorder (MDD) in adult samples, particularly in the lateral prefrontal, cingular and temporal regions. In contrast, neuroimaging investigations in adolescents with MDD are rare, although investigating young patients during a significant period of brain maturation might offer valuable insights into the neural mechanisms of MDD. We acquired perfusion images obtained with continuous arterial spin labelling in 21 medication-naive adolescents with MDD before and after a five-session cognitive behavioural group therapy (group CBT). A control group included medication-naive patients under treatment as usual while waiting for the psychotherapy. We found relatively increased rCBF in the right dorsolateral prefrontal cortex (DLPFC; BA 46), the right caudate nucleus and the left inferior parietal lobe (BA 40) after CBT compared with before CBT. Relatively increased rCBF in the right DLPFC postgroup CBT was confirmed by time (post vs. pre)×group (intervention/waiting list) interaction analyses. In the waiting group, relatively increased rCBF was found in the thalamus and the anterior cingulate cortex (BA 24). The relatively small number of patients included in this pilot study has to be considered. Our findings indicate that noninvasive resting perfusion scanning is suitable to identify CBT-related changes in adolescents with MDD. rCBF increase in the DLPFC following a significant reduction in MDD symptoms in adolescents might represent the core neural correlate of changes in ‘top–down’ cognitive processing, a possible correlate of improved self-regulation and cognitive control.

Hair cortisol in relation to acute and post-traumatic stress symptoms in children and adolescents

ABSTRACT Background: We report on the preliminary results of two independent studies that (1) compare the hair cortisol concentrations (HCC) of healthy controls with patients displaying post-traumatic stress symptoms (PTSS, study 1+2), (2) investigate whether pre-trauma HCC are predictive for the development of acute stress symptoms (ASS) and PTSS (study 1) and (3) determine whether HCC correlate with PTSS in a clinical sample of children (study 2). Methods: In study 1, the clinical symptoms of 35 minors were examined one (T1) and seven weeks (T2) after surgery following an accident. Hair samples were taken after the accident that reflect cortisol secretion over the past three months before the accident (healthy controls). In study 2, HCC and PTSS symptoms were cross-sectionally assessed in 22 minors who had experienced a psychological trauma. Results: The HCC of patients with PTSS were lower than the HCC of healthy controls (study 1+2). Secondary analyses showed that HCC were significantly lower in male PTSS patients than in male healthy controls, whereas the HCC in females were comparably low in both groups. Pre-trauma HCC did not predict the total ASS and PTSS scores (study 1) and HCC were not directly related to the total PTSS scores (study 2).