Tuvia Peri

Psychophysiologic assessment of aversive conditioning in posttraumatic stress disorder.

BACKGROUND The objective of this study was to evaluate the acquisition, generalization, and extinction of conditioned physiologic responses to aversive stimuli in posttraumatic stress disorder (PTSD). METHODS Thirty-six PTSD patients, 20 individuals with past trauma and no current PTSD, and 30 mentally healthy individuals without exposure to major trauma underwent a differential aversive conditioning experiment. Bursts of 105 dB white noise were used as unconditioned stimuli (UCSs), and 35x24 mm slides of different colors served as either CS+ (paired) or CS- (unpaired) stimuli. Heart rate (HR) and nondominant palm skin conductance (SC) were measured at rest and between 1 and 4 sec following each CS presentation. RESULTS The PTSD group showed higher levels of resting SC and resting HR, larger SC responses to the initial presentation of unpaired CSs, larger HR responses following paired CS+ stimuli, larger SC responses to unpaired CS- during acquisition and extinction, and larger SC and HR responses to CS+ during extinction. The group differences in responses to CS+ during extinction remained statistically significant after controlling for age, resting physiologic levels, and initial responsivity. CONCLUSIONS PTSD is associated with elevated autonomic responses to both innocuous and aversive stimuli, with larger responses to unpaired cues and with reduced extinction of conditioned responses.

Physiologic responses to loud tones in israeli veterans of the 1973 yom kippur war

Eyeblink and autonomic components of the acoustic startle response were evaluated in a community sample of Israeli veterans of the Yom Kippur war. Individuals were solicited by mail and telephone to participate in the study; they were not seeking treatment or compensation. Nineteen Israeli veterans with current posttraumatic stress disorder (PTSD) and 74 veterans without PTSD were exposed to 15 consecutive 95-dB, 500-msec, 1000-Hz tones with 0-msec rise and fall times, while orbicularis oculi electromyogram, skin conductance, and heart rate responses were measured. Individuals with PTSD produced larger averaged heart rate responses, and a slower decline in skin conductance responses, across the 15 tone presentations compared to non-PTSD subjects. There was no group difference in the magnitude of the averaged electromyogram response. Results of this study replicate previous findings of increased autonomic responses to loud tone stimuli in this disorder.

Gender differences in responses to traumatic events: A prospective study

Gender differences in psychological responses to motor vehicle accidents were examined as part of a large-scale prospective study of PTSD. Participants were recruited from an emergency room (n = 275) and interviewed 1 week, 1 month, and 4 months later. No gender differences were seen in the prevalence or recovery from PTSD, or in symptom levels at 1- and 4 months. Women had a higher prevalence of lifetime- and postaccident generalized anxiety disorder. Gender differences were found regarding the type, but not the total number, of potentially traumatic events previously experienced. These results suggest that gender differences in responses to traumatic events are not explained by exposure as such, but rather may result from gender-specific attributes of the event.

Effectiveness of Deep Transcranial Magnetic Stimulation Combined with a Brief Exposure Procedure in Post-Traumatic Stress Disorder – A Pilot Study

BACKGROUND Post-traumatic stress disorder (PTSD) is a debilitating anxiety disorder induced by traumatic experiences. To date, psychotherapy and drug treatment achieve only partial success, indicating need for further development of treatment strategies. Recent research has found that impaired acquired fear extinction capability serves as an important factor at the pathogenesis of the disorder. Medial prefrontal cortex (mPFC) hypo-activity has been implicated in this extinction impairment, providing insight as to why some trauma exposed individuals will develop PTSD. OBJECTIVE To test whether fear extinction can be facilitated and therapeutic effect achieved by repeated mPFC deep transcranial magnetic stimulation (DTMS) of PTSD patients resistant to standard treatment. METHODS In a double-blind study, 30 PTSD patients were enrolled and randomly assigned into 3 treatment groups: A) DTMS after brief exposure to the traumatic event with the script-driven imagery procedure; B) DTMS after brief exposure to a non-traumatic event; C) sham stimulation after brief exposure to the traumatic event. RESULTS Significant improvement was demonstrated in the intrusive component of the CAPS scale in patients administered DTMS after exposure to the traumatic event script, while patients in the control groups showed no significant improvement. Similar trend was demonstrated in the Total-CAPS score as in the other rating scales. A significant reduction in the HR response to the traumatic script was evident in group A, further supporting the above results. CONCLUSIONS Combining brief script-driven exposure with DTMS can induce therapeutic effects in PTSD patients. A wide multi-center study is suggested to substantiate these findings. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00517400.

Auditory startle responses in help-seeking trauma survivors.

Studies of the acoustic startle reflex in post-traumatic stress disorder (PTSD) yielded controversial results, whilst PTSD patients consistently report exaggerated startle. Addressing methodological difficulties of previous studies, the authors investigated the eyeblink, skin conductance and heart rate responses to 15 consecutive 95-dB, 500-ms, 1000-Hz sudden tones in 58 consecutive referrals of unmedicated help-seeking trauma survivors (30 with PTSD and 28 without PTSD). PTSD patients had higher average eyeblink and skin conductance responses to the tones. Differences between reports of exaggerated startle in PTSD and negative experimental findings may be explained by specific experimental conditions, such as reduced environmental input, and by concurrent use of medication.

The Efficacy of Amitriptyline and Acetaminophen in the Management of Acute Low Back Pain

Thirty-nine patients with acute low back pain were treated with amitriptyline (150 mg/d) or acetaminophen (2,000 mg/d) in a controlled double-blind design for 5 weeks. Both groups revealed mild depression, normal coping, and increased anxiety at the beginning, with significant improvement in anxiety state and pain at the end of treatment. A repeated measures analysis of variance demonstrated that amitriptyline was more effective than acetaminophen in reducing pain intensity from the second week of treatment. Age and depression were the only significant pretreatment predictors of posttreatment pain. The study evaluates the significance of these findings.

Alprazolam reduces response to loud tones in panic disorder but not in posttraumatic stress disorder

BACKGROUND Posttraumatic stress disorder (PTSD) and panic disorder (PD) share several clinical features, and theory postulates that phasic arousal is similarly dysregulated in both. The modulation of phasic arousal can be probed by measuring the effect of pharmacologic agents on auditory startle. METHODS Eyeblink electromyogram, heart rate, and skin conductance (SC) responses to 15 consecutive presentations of 1000-Hz, 95-dB, zero rise-time pure tones were measured, before and during treatment with alprazolam, in 9 PTSD and 9 PD patients. Concurrent anxiety was assessed by the Hamilton Anxiety Rating Scale. RESULTS The groups did not differ in initial psychometric and physiological measures. Significant decrease in anxiety was observed in both groups during treatment. A decrease in response probability and a decrease in the SC responses were observed in PD, but not in PTSD. CONCLUSIONS The results may reflect a difference in the modulation of phasic arousal between the disorders. They may also express an impaired between-session habituation or contextual sensitization in PTSD.

Narrative reconstruction therapy for prolonged grief disorder—rationale and case study

Background Prolonged grief disorder (PGD) is a potentially disabling condition affecting approximately 10% of bereaved people. It has been suggested that the impaired integration of the loss memory, as expressed in recurrent memories of the loss and disorganization of memory, is involved in the development of PGD. Narrative reconstruction (NR), originally designed for the treatment of posttraumatic stress disorder (PTSD) in an integrative therapy module, and consisting of exposure to the loss memory, detailed written reconstruction of the loss memory narrative and an elaboration of the personal significance of that memory for the bereaved, has been shown to be effective in the treatment of intrusion symptoms. Objective In light of findings that cognitive behavior therapy (CBT), including cognitive restructuring and exposure, is effective in the treatment of PGD, we suggest the implementation of a somewhat novel therapy module, NR, for the treatment of intrusive phenomena in bereaved patients. Method The rationale for the implementation of NR for PGD and a case study of the treatment of a woman suffering from PGD after the death of her father are presented. Therapy took place in a university outpatient training clinic. Results Evaluations conducted before and after treatment and at a 3-month follow-up demonstrated the effectiveness of NR in reducing symptoms of PGD and depression. The analysis of spontaneous narratives recorded before and after treatment showed an increased organization of the narratives. Conclusions This case report demonstrates an adaptation of NR for the treatment of PGD. The results provide preliminary support for the effectiveness of NR for PGD. The significance of the study and its limitations are discussed. Highlights of the article Prolonged grief disorder (PGD) affects approximately ten percent of bereaved people. Narrative Reconstruction (NR), an integrative therapy module originally used for PTSD patients, was adapted for PGD. NR consists of exposure to the loss memory, detailed written reconstruction of the loss and an elaboration its significance and meaning for the bereaved. NR was demonstrated in a case study. It was well tolerated and effective in the treatment of PGD.

Auditory startle response during exposure to war stress

This report describes the immediate effect of war stress on physiological measures of the auditory startle responses (ASRs). Ten healthy Israeli subjects were examined 4 months before the Gulf war, during a missile alert on the first day of the war, and 8 months after the war. The magnitude and rate of habituation of orbicularis oculi electromyogram (EMG), heart rate (HR), and skin conductance (SC) responses to 15 consecutive presentations of 95-dB, 0-rise time, 1,000-Hz pure tones were recorded on each occasion, along with self-reports of anxiety. The groups anxiety scores were significantly higher during the war. ASRs, in contrast, remained stable across exposure conditions. However, a decrease in SC habituation was observed in few individuals during the war, and may illustrate a distinctive vulnerability to stress. The results are discussed in light of recent findings of abnormal startle response in posttraumatic stress disorder (PTSD).

Embodied simulation in exposure-based therapies for posttraumatic stress disorder - a possible integration of cognitive behavioral theories, neuroscience, and psychoanalysis

Exposure to the trauma memory is the common denominator of most evidence-based interventions for posttraumatic stress disorder (PTSD). Although exposure-based therapies aim to change associative learning networks and negative cognitions related to the trauma memory, emotional interactions between patient and therapist have not been thoroughly considered in past evaluations of exposure-based therapy. This work focuses on recent discoveries of the mirror-neuron system and the theory of embodied simulation (ES). These conceptualizations may add a new perspective to our understanding of change processes in exposure-based treatments for PTSD patients. It is proposed that during exposure to trauma memories, emotional responses of the patient are transferred to the therapist through ES and then mirrored back to the patient in a modulated way. This process helps to alleviate the patients sense of loneliness and enhances his or her ability to exert control over painful, trauma-related emotional responses. ES processes may enhance the integration of clinical insights originating in psychoanalytic theories—such as holding, containment, projective identification, and emotional attunement—with cognitive behavioral theories of learning processes in the alleviation of painful emotional responses aroused by trauma memories. These processes are demonstrated through a clinical vignette from an exposure-based therapy with a trauma survivor. Possible clinical implications for the importance of face-to-face relationships during exposure-based therapy are discussed.