Leah Fostick

Prolonged exposure therapy for combat- and terror-related posttraumatic stress disorder: a randomized control comparison with treatment as usual

OBJECTIVE Empirically based studies have demonstrated that prolonged exposure therapy effectively reduces posttraumatic stress disorder (PTSD) symptoms in a vast range of traumas, yet reports of the efficacy of such therapies in combat- and terror-related PTSD are scarce. In this article, we examine the efficacy of prolonged exposure therapy in combat- and terror-related PTSD in comparison to treatment as usual (TAU). METHOD Between July 2002 and October 2005, 30 patients of a trauma unit within a psychiatric outpatient clinic were recruited and randomized into prolonged exposure versus TAU therapies. Patients were diagnosed with chronic PTSD (Mini-International Neuropsychiatric Interview criteria) related to combat- (n = 19) or terror-related (n = 11) trauma. Main outcome measures included symptoms of PTSD and depression, as measured by the PTSD Symptom Scale-Interview Version and the Beck Depression Inventory. RESULTS Posttraumatic stress disorder symptom severity was significantly lower in patients who received prolonged exposure therapy in comparison to patients who received TAU (F(1,24) = 35.3, P < .001). Similar results have emerged in measures of depression and state and trait anxiety. In addition, a significant change from pretreatment to follow-up was found for the prolonged exposure group (F(1,14) = 80.5, P < .0001), but not for the TAU group (F(1,10.3) = 0.6, P = .44). CONCLUSIONS Findings indicate that, similar to PTSD related to other types of trauma, prolonged exposure therapy is beneficial in the amelioration of combat- and terror-related PTSD symptoms. In addition, prolonged exposure was superior to TAU in the short- and long-term reduction of PTSD and depression symptoms. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00229372.

Effect of the diurnal rhythm and 24 h of sleep deprivation on dichotic temporal order judgment

The present study examined the impact of mild (24 h) sleep deprivation and of the circadian rhythm on auditory temporal resolution, measured by dichotic temporal order judgment (TOJ). The rationale for the present study was based on several areas of research. First, the ‘sleep‐based neuropsychological perspective’ hypothesis posits that sleep reduction initially impacts the functions associated with intact prefrontal cortical activity, e.g. language tasks. Secondly, recent studies indicate the importance of the role of auditory temporal resolution in speech comprehension. Thirdly, there is accumulating evidence of the involvement of prefrontal cortical structures in auditory temporal resolution. We hypothesized that mild to moderate sleep deprivation would affect dichotic TOJ negatively. The results showed that: (1) 24 h of sleep deprivation significantly reduced the overall level of accuracy in dichotic TOJ and increased dichotic TOJ threshold from 57.61 ms to 73.93 ms, a reduction in temporal resolution of 28.3%; (2) dichotic TOJ was subject to a small, but significant diurnal rhythm having a nadir in early to mid afternoon. As auditory temporal resolution of speech and non‐speech sounds seems to be dependent on intact functioning of the left inferior and left dorso‐lateral prefrontal cortex (PFC), these data strengthen the argument that even mild to moderate sleep deprivation can impact negatively on PFC‐dependent functions. Furthermore, based on these findings, we suggest that the deficit in auditory temporal resolution in individuals suffering from sleep loss may also affect language comprehension.

Deficits in temporal-order judgments in dyslexia: evidence from diotic stimuli differing spectrally and from dichotic stimuli differing only by perceived location.

The main debate concerning dyslexia focuses on the question of whether dyslexia is a language-specific disorder or a general nervous system dysfunction manifested in deficits of temporal processing. According to the temporal-order deficit hypothesis, dyslexia manifests difficulty in discriminating the temporal order of stimuli. Evidence has usually involved testing the ability to discriminate series of phonemes or pure tones whose components are separated by very short intervals. One of the difficulties in interpreting the data is the confound of changes in the spectrum with changes in temporal order. Two experiments are reported. In the first experiment, we verified the difficulty by adult dyslexics in judging the temporal order of two tones differing in frequency and presented diotically. The second experiment was designed to isolate temporal-order judgment (TOJ) from holistic frequency-based pattern discrimination processes. We tested temporal-order judgments with 15 ms duration tones of equal frequency presented dichotically (left-right, right-left) with ISI intervals ranging from 8 to 400 ms. Dichotic temporal threshold was significantly lower for adult normal readers than for the adult dyslexics. The results support the claim that adult dyslexics have difficulty in discriminating temporal order even when no spectral changes are involved.

Serious life events among resistant and non-resistant MDD patients

BACKGROUND Over 60% of patients with major depressive disorder (MDD) do not respond fully to therapy. Half of them eventually will not respond at all and will be referred to as treatment resistant depression (TRD) patients. Stressful life events were found to be associated with MDD and were also found to affect the course of the disease. We hypothesize that negative life events might be an independent risk factor for TRD. METHODS One hundred and seven unipolar MDD patients, all treated for at least 4 weeks, were enrolled in the study. Patients were assessed on their psychiatric and medical history, and seven categories of stressful life events. RESULTS 39.3% of participants were defined as TRD patients and 60.7% as non-TRD. TRD patients had more severe depression, more past suicide attempts, more hospitalizations, longer episodes, and received more benzodiazepines, antipsychotics, and ECT. Job loss and financial stress were more prevalent among the TRD group. Overall, the TRD patients had more negative life events than responders. LIMITATIONS This is a retrospective study. In addition, the definition of TRD was done dichotomically, therefore the association between number of stressful life events and the degree of resistance was not tested. CONCLUSIONS Job loss and financial distress were found to predict TRD. The loss of a parent and severe health conditions were not associated with TRD, suggesting that events affecting the development of MDD, do not necessarily affect the treatment outcome.

Naltrexone augmentation in OCD : A double-blind placebo-controlled cross-over study

Current treatments for Obsessive Compulsive Disorder (OCD) rely primarily on serotonergic mechanisms. However, approximately 30% of patients do not respond to serotonin reuptake inhibitors and remain chronically ill. Given the behavioral similarities between some of the compulsive behaviors in OCD and addiction, we hypothesized that the opioid antagonist naltrexone might attenuate compulsions in OCD as well. The effect of naltrexone augmentation to SRI was compared to placebo in 10 OCD outpatients who had not responded to an adequate dose of SSRI or clomipramine for at least 2 months. Participants underwent 5 weeks of treatment with naltrexone or placebo (and 1 week of tapering) in a randomized, double-blind, cross-over design. Patients were evaluated weekly using the Y-BOCS, CGI, HAM-A, and MADRS scales. A two-way repeated measures MANOVA revealed no significant effect for Y-BOCS. However, while receiving naltrexone, patients had significantly higher scores on CGI, MADRS and HAM-A as compared to placebo. The lack of significant findings on OC symptoms could be due to either ceiling effect or alternatively, due to a non-specific exacerbation on anxiety and depression but not on OC symptoms.

The economic impact of depression: Resistance or severity?

Treatment-Resistant Depression (TRD) affects 60 to 70% of patients with Major Depressive Disorder (MDD). The economic impact of depression in general, and of TRD specifically, was found to be relatively high. As the course of depression can be defined both by the severity of the disease and by the resistance to treatment, the question of the unique contribution of MDD severity vs. resistance to the economic burden of depression is being raised. One hundred and seven unipolar MDD patients, all treated for at least 4weeks, were enrolled in the study. Patients were assessed for their current MDD severity using the Hamilton Depression Rating Scale (HDRS) and past treatments, and for medical-related costs (number of blood and imaging tests, visits paid to physicians, psychiatric hospitalizations) and incapacity-related costs (number of working days lost) during the last episode. TRD and non-TRD patients were, respectively, 39.3% and 60.7% of the patients recruited for the study. TRD patients had more severe depression, and higher costs for imaging tests, physician visits, psychiatric hospitalizations, and number of working days lost. In addition, higher MDD severity was found to be associated with higher costs. Finally, when controlling for the shared variance of TRD and MDD severity, by using residual scores, TRD was associated with higher costs, but MDD severity was no longer related to costs. While both resistance and severity are associated with higher direct and indirect costs, our findings suggest that TRD may be the main factor in determining the economic burden of depression.

Risk factors for the development of posttraumatic stress disorder following combat trauma: a semiprospective study.

OBJECTIVE When positioned in a combat situation, soldiers may be subjected to extreme stress. However, only a few combat-exposed soldiers develop long-term disturbance, namely, posttraumatic stress disorder (PTSD). This study aimed to explore risk factors for developing PTSD in order to improve the psychiatric screening process of new recruits. METHOD In a semiprospective design, we compared 2,362 war veterans who developed PTSD (according to DSM-IV criteria) with an equal number of war veterans who did not develop PTSD. Controls were matched on the basis of sequential army identification numbers, that is, the soldier drafted immediately after the index PTSD veteran (usually on the same day). This method ensured similar demographic variables such as socioeconomic level and education. Data were collected from the Israeli Defense Force database and used in a comprehensive survey conducted between January 2000 and March 2001. Comparisons were made on predrafting personal factors (behavioral assessment, cognitive assessment, linguistic ability, and education) and pretrauma army characteristics (ie, rank and training). RESULTS Neither behavioral assessment nor training were found to predict PTSD. The predictive factors that were found were essentially nonspecific, such as cognitive functioning, education, rank, and position during the trauma, with little effect from training. CONCLUSIONS In an armed force that uses universal recruitment, carefully structured predrafting psychological assessment of social and individual qualifications (including motivation) failed to identify increased risk factors for PTSD. However, nonspecific factors were found to be associated with an increased risk for PTSD. This study suggests that the focus of future research on risk factors for PTSD should incorporate other domains rather than behavioral assessment alone. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00229359.

Post-traumatic stress disorder: facts and fiction

Purpose of review This review provides an update on contemporary perspectives on post-traumatic stress disorder and challenges myths about the disorder and its treatment. Post-traumatic stress disorder has recently attracted public attention because of the impact of international terrorism, although the vast majority of post-traumatic stress disorder cases actually relate to civilian events such as car accidents, rape and violent robbery. This disorder requires deeper understanding and consensus among professionals. Recent findings Advances have been made in elucidating the neurobiology of this disorder, partly by using an animal model of post-traumatic stress disorder. Recent studies have focused on memory processes and the therapeutic role played by plasticity of the hypothalamic–pituitary–adrenal axis, and how this fits (or does not fit) in with the current therapeutic interventions. Guidelines have been established by various bodies in an attempt to streamline treatment options. Summary Understanding of post-traumatic stress disorder is incomplete. Future research should attempt to determine what treatments given during the ‘window of opportunity’ – the time from exposure until post-traumatic stress disorder develops – are effective. Care should be taken not to interfere with spontaneous recovery.

Prolonged Exposure Therapy for Chronic Combat-Related PTSD: A Case Report of Five Veterans

Prolonged exposure (PE) therapy has been found efficient in reducing posttraumatic stress disorder (PTSD) symptoms mostly among rape victims, but has not been explored in combat-related PTSD. Five patients with severe chronic PTSD, unresponsive to previous treatment (medication and supportive therapy) are described. Patients were evaluated with the PTSD Symptom Scale-Interview, and Beck Depression Inventory, before and after 10-15 sessions of PE therapy. All five patients showed marked improvement with PE, with a mean decrease of 48% in PTSD Symptom Scale-Interview score and 69% in Beck Depression Inventory score. Moreover, four patients maintained treatment gains or kept improving 6-18 months after the treatment. The results suggest that PE was effective in reducing combat-related chronic PTSD symptoms.

Hemisphere asymmetry in schizophrenia as revealed through line bisection, line trisection, and letter cancellation

Individuals with schizophrenia are known to demonstrate reduced or reversed brain asymmetry. While much is known regarding anatomical brain asymmetry, little is known about how this affects the individual at the functional level. Based on the known leftward bias in normal individuals, the aim of this study was to explore whether any difference in this function would be noted in schizophrenia. This study therefore investigated the phenomenon of functional asymmetry in schizophrenia patients by means of the following tasks: line bisection, line trisection (assessing hemifield spatial neglect) and letter cancellation (assessing contralateral visuospatial exploration). Forty-five schizophrenia inpatients maintained on antipsychotic medication were evaluated. Transections were measured for accuracy, lateralization, and directional bias. In the line bisection task subjects indicated no pseudo-neglect, thus differing from a normal, leftward bias. In the line trisection there was a significant preference to perform the ambiguous instruction on the right side, with no consistent bias in accuracy. Irrespective of conditions, in the letter cancellation task there was always a significant tendency to succeed on the left third compared to the right third. Results may support findings in schizophrenia indicating decreased or altered function of the left hemisphere.