Seth J. Gillihan

A meta-analytic review of prolonged exposure for posttraumatic stress disorder

Two decades of research demonstrate the efficacy of exposure therapy for posttraumatic stress disorder (PTSD). The efficacy of prolonged exposure (PE), a specific exposure therapy program for PTSD that has been disseminated throughout the world, has been established in many controlled studies using different trauma populations. However, a meta-analysis of the effectiveness of PE for PTSD has not been conducted to date. The purpose of the current paper is to estimate the overall efficacy of PE for PTSD relative to adequate controls. We included all published randomized controlled trials of PE vs. control (wait-list or psychological placebo) for the treatment of PTSD in adolescents or adults. Treatments were classified as PE if they included multiple sessions of imaginal and in vivo exposure and were based on the manualized treatment developed by Foa, Rothbaum, Riggs, and Murdock (1991). Thirteen studies with a total sample size of 675 participants met the final inclusion criteria. The primary analyses showed a large effect for PE versus control on both primary (Hedgess g=1.08) and secondary (Hedgess g=0.77) outcome measures. Analyses also revealed medium to large effect sizes for PE at follow-up, both for primary (Hedgess g=0.68) and secondary (Hedgess g=0.41) outcome measures. There was no significant difference between PE and other active treatments (CPT, EMDR, CT, and SIT). Effect sizes were not moderated by time since trauma, publication year, dose, study quality, or type of trauma. The average PE-treated patient fared better than 86% of patients in control conditions at post-treatment on PTSD measures. PE is a highly effective treatment for PTSD, resulting in substantial treatment gains that are maintained over time.

Genetic variation in serotonin transporter alters resting brain function in healthy individuals.

BACKGROUND Perfusion functional magnetic resonance imaging (fMRI) was used to investigate the effect of genetic variation of the human serotonin transporter (5-HTT) gene (5-HTTLPR, SLC6A4) on resting brain function of healthy individuals. METHODS Twenty-six healthy subjects, half homozygous for the 5-HTTLPR short allele (s/s group) and half homozygous for the long allele (l/l group), underwent perfusion functional and structural magnetic resonance imaging during a resting state. The two genotype groups had no psychiatric illness and were similar in age, gender, and personality scores. RESULTS Compared with the l/l group, the s/s group showed significantly increased resting cerebral blood flow (CBF) in the amygdala and decreased CBF in the ventromedial prefrontal cortex. The effect of functional modulation in these regions by 5-HTTLPR genotype cannot be accounted for by variations in brain anatomy, personality, or self-reported mood. CONCLUSIONS The 5-HTTLPR genotype alters resting brain function in emotion-related regions in healthy individuals, including the amygdala and ventromedial prefrontal cortex. Such alterations suggest a broad role of the 5-HTT gene in brain function that may be associated with the genetic susceptibility for mood disorders such as depression.

Ventromedial frontal lobe plays a critical role in facial emotion recognition

The ventromedial prefrontal cortex has been implicated in a variety of emotion processes. However, findings regarding the role of this region specifically in emotion recognition have been mixed. We used a sensitive facial emotion recognition task to compare the emotion recognition performance of 7 subjects with lesions confined to ventromedial prefrontal regions, 8 subjects with lesions elsewhere in prefrontal cortex, and 16 healthy control subjects. We found that emotion recognition was impaired following ventromedial, but not dorsal or lateral, prefrontal damage. This impairment appeared to be quite general, with lower overall ratings or more confusion between all six emotions examined. We also explored the relationship between emotion recognition performance and the ability of the same patients to experience transient happiness and sadness during a laboratory mood induction. We found some support for a relationship between sadness recognition and experience. Taken together, our results indicate that the ventromedial frontal lobe plays a crucial role in facial emotion recognition, and suggest that this deficit may be related to the subjective experience of emotion.

Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic Stress Lessons Learned From Prolonged Exposure Therapy for PTSD

Posttraumatic stress disorder (PTSD) poses monumental public health challenges because of its contribution to mental health, physical health, and both interpersonal and social problems. Recent military engagements in Iraq and Afghanistan and the multitude of resulting cases of PTSD have highlighted the public health significance of these conditions. There are now psychological treatments that can effectively treat most individuals with PTSD, including active duty military personnel, veterans, and civilians. We begin by reviewing the effectiveness of these treatments, with a focus on prolonged exposure (PE), a cognitive-behavioral therapy (CBT) for PTSD. Many studies conducted in independent research labs have demonstrated that PE is highly efficacious in treating PTSD across a wide range of trauma types, survivor characteristics, and cultures. Furthermore, therapists without prior CBT experience can readily learn and implement the treatment successfully. Despite the existence of highly effective treatments like PE, the majority of individuals with PTSD receive treatments of unknown efficacy. Thus, it is crucial to identify the barriers and challenges that must be addressed in order to promote the widespread dissemination of effective treatments for PTSD. In this review, we first discuss some of the major challenges, such as a professional culture that often is antagonistic to evidence-based treatments (EBTs), a lack of clinician training in EBTs, limited effectiveness of commonly used dissemination techniques, and the significant cost associated with effective dissemination models. Next, we review local, national, and international efforts to disseminate PE and similar treatments and illustrate the challenges and successes involved in promoting the adoption of EBTs in mental health systems. We then consider ways in which the barriers discussed earlier can be overcome, as well as the difficulties involved in effecting sustained organizational change in mental health systems. We also present examples of efforts to disseminate PE in developing countries and the attendant challenges when mental health systems are severely underdeveloped. Finally, we present future directions for the dissemination of EBTs for PTSD, including the use of newer technologies such as web-based therapy and telemedicine. We conclude by discussing the need for concerted action among multiple interacting systems in order to overcome existing barriers to dissemination and promote widespread access to effective treatment for PTSD. These systems include graduate training programs, government agencies, health insurers, professional organizations, healthcare delivery systems, clinical researchers, and public education systems like the media. Each of these entities can play a major role in reducing the personal suffering and public health burden associated with posttraumatic stress.

Academic Stress, Supportive Communication, and Health.

Academic stress is associated with a variety of negative health outcomes, including depression and physical illness. The current study examined the capacity of supportive communication reported as being received from friends and family to buffer the association between academic stress and health. College students completed measures of academic stress, of supportive communication received (emotional and informational), and of health status (depression and symptoms of physical illness). Results indicated that the positive association between academic stress and depression decreased as informational support increased. In addition, emotional support was negatively associated with depression across levels of academic stress. The findings are discussed with respect to reducing negative health outcomes for individuals experiencing academic stress.

Serotonin transporter genotype modulates amygdala activity during mood regulation

Recent studies have implicated the short allele of the serotonin transporter-linked polymorphic region (5-HTTLPR) in depression vulnerability, particularly in the context of stress. Several neuroimaging studies have shown that 5-HTTLPR genotype predicts amygdala reactivity to negatively valenced stimuli, suggesting a mechanism whereby the short allele confers depression risk. The current study investigated whether 5-HTTLPR genotype similarly affects neural activity during an induced sad mood and during recovery from sad mood. Participants were 15 homozygous short (S) and 15 homozygous long (L) individuals. Regional cerebral blood flow was measured with perfusion functional magnetic resonance imaging during four scanning blocks: baseline, sad mood, mood recovery and following return to baseline. Comparing mood recovery to baseline, both whole brain analyses and template-based region-of-interest analyses revealed greater amygdala activity for the S vs the L-group. There were no significant amygdala differences found during the induced sad mood. These results demonstrate the effect of the S allele on amygdala activity during intentional mood regulation and suggest that amygdala hyperactivity during recovery from a sad mood may be one mechanism by which the S allele confers depression risk.

Skill Deficit or Differential Motivation? Testing Alternative Explanations for Gender Differences in the Provision of Emotional Support

Although researchers have proposed a skill deficit account for observed gender differences in the provision of emotional support, few studies have directly tested the claim that men are less capable of providing effective support. This study advances an alternative account for gender differences in the effectiveness of supportive communication, arguing that gender differences may emerge because men and women respond differently to situational factors that influence the motivation to provide sensitive emotional support. Participants produced emotional support messages in response to scenarios varying in target gender, target responsibility for the problem, and target effort to resolve the problem, as well as in response to the problem itself (a replication factor included to increase generalizability). Women produced messages exhibiting greater emotional sensitivity than those of men across the other factors examined, providing support for the skill deficit account and failing to provide evidence of differential motivation.

Treatment of Posttraumatic Stress Disorder in U.S. Combat Veterans: A Meta-Analytic Review

Among U.S. veterans who have been exposed to combat-related trauma, significantly elevated rates of posttraumatic stress disorder (PTSD) are reported. Veterans with PTSD are treated for the disorder at Veterans Affairs (VA) hospitals through a variety of psychotherapeutic interventions. Given the significant impairment associated with PTSD, it is imperative to assess the typical treatment response associated with these interventions. 24 studies with a total sample size of 1,742 participants were quantitatively reviewed. Overall, analyses showed a medium between-groups effect size for active treatments compared to control conditions. Thus, the average VA-treated patient fared better than 66% of patients in control conditions. VA treatments incorporating exposure-based interventions showed the highest within-group effect size. Effect sizes were not moderated by treatment dose, sample size, or publication year. Findings are encouraging for treatment seekers for combat-related PTSD in VA settings.

The Child PTSD Symptom Scale: Psychometric Properties in Female Adolescent Sexual Assault Survivors

Traumatic experiences are common among youths and can lead to posttraumatic stress disorder (PTSD). In order to identify traumatized children who need PTSD treatment, instruments that can accurately and efficiently evaluate pediatric PTSD are needed. One such measure is the Child PTSD Symptom Scale (CPSS), which has been found to be a reliable and valid measure of PTSD symptom severity in school-age children exposed to natural disasters (Foa, Johnson, Feeny, & Treadwell, 2001). However, the psychometric properties of the CPSS are not known in youths who have experienced other types of trauma. The current study aims to fill this gap by examining the psychometric properties of the interview (CPSS-I) and self-report (CPSS-SR) administrations of the CPSS in a sample of 91 female youths with sexual abuse-related PTSD, a population that is targeted in many treatment studies. Scores on both the CPSS-I and CPSS-SR demonstrated good to excellent internal consistency. One-week test-retest reliability assessed for CPSS-SR scores was excellent (r=.86); interrater reliability of CPSS-I scores was also excellent (r=.87). Symptom-based diagnostic agreement between the CPSS-SR and CPSS-I was excellent at 85.5%; scores on both the CPSS-SR and CPSS-I also demonstrated good convergent validity (74.5-76.5% agreement) with the PTSD module of The Schedule of Affective Disorders and Schizophrenia for School-Age Children--Revised for DSM--IV (K-SADS; Kaufman, Birmaher, Brent, & Rao, 1997). The strong psychometric properties of the CPSS render it a valuable instrument for PTSD screening as well as for assessing symptom severity.

The Puzzle of Neuroimaging and Psychiatric Diagnosis: Technology and Nosology in an Evolving Discipline

Brain imaging provides ever more sensitive measures of structure and function relevant to human psychology and has revealed correlates for virtually every psychiatric disorder. Yet it plays no accepted role in psychiatric diagnosis beyond ruling out medical factors such as tumors or traumatic brain injuries. Why is brain imaging not used in the diagnosis of primary psychiatric disorders, such as depression, bipolar disease, schizophrenia, and attention-deficit hyperactivity disorder (ADHD)? This article addresses this question. It reviews the state of the art in psychiatric imaging, including diagnostic and other applications, and explains the nonutility of diagnostic imaging in terms of aspects of both the current state of imaging and the current nature of psychiatric nosology. The likely future path by which imaging-based diagnoses will be incorporated into psychiatry is also discussed. By reviewing one well-known attempt to use SPECT scanning in psychiatric diagnosis, the article examines a real-world practice that illustrates several related points: the appeal of the idea of image-assisted diagnosis for physicians, patients and families, despite a lack of proven effectiveness, and the mismatch between the categories and dimensions of current nosology and those suggested by imaging.