PTSD and the brain: What clinicians need to know Namik Kirlić, MA Elana Newman, PhD Underexplored Territories in Trauma Education: Charting Frontiers for Clinicians and Researchers The University of Tulsa December 10 th, 2014
Learning Objectives Describe the neurocircuitry of posttraumatic stress disorder (PTSD) Explain two clinical implications of neuroimaging findings in PTSD Name one research area of future importance
What is fmri? Nuclear magnetic resonance Image biological tissue Hydrogen BOLD signal Correlate of brain activity
dlpfc REGULATION (COGNITIVE) dmpfc, dacc EVALUATION / MEANING vmpfc, sgacc, racc Hippocampus INTEGRATION / REGULATION (CONTEXTUAL) CONTEXT Threat INPUT CS-US Insula Amygdala REGISTRATION / EXPRESSION (PHASIC) BNST EXPRESSION (SUSTAINED) AUTONOMIC REGULATION Hypothalamus / PAG Davis et al., 2010; Etkin, 2010; Hartley & Phelps, 2010 SYMPATHETIC / ENDOCRINE RESPONSES
Amygdala amygdala responsitivity Childhood Trauma Questionnaire Dannlowski et al., 2011; Hayes et al., 2012; Hughes & Shin, 2011
Hippocampus Mixed findings during fear extinction during encoding/ learning Hughes & Shin, 2011; Milad et al., 2009; Villarreal et al.., 2002
Insula insula responsitivity Hopper et al., 2007; Hughes & Shin, 2011; Simmons et al., 2008
Prefrontal cortex vmpfc activity Hayes et al., 2012; Hughes & Shin, 2011; Milad et al., 2009
dlpfc REGULATION (COGNITIVE) dmpfc EVALUATION / MEANING vmpfc INTEGRATION / REGULATION (CONTEXTUAL) Hippocampus CONTEXT Threat INPUT CS-US Insula AUTONOMIC REGULATION Amygdala REGISTRATION / EXPRESSION Hypothalamus / PAG SYMPATHETIC / ENDOCRINE RESPONSES
Neurocircuitry of PTSD: implications Traditional model Emotional Hyperactive Regulatory Hypoactive PTSD Triple network model Salience (conflict monitoring, autonomic regulation, reward processing Hyperactive Executive (working memory, attentional processes) Hypoactive Default (cognitive flexibility) Hypoactive Etkin & Wager, 2007; Patel et al., 2012
Implications for your practice Psychoeducation Intervention strategies exposure cognitive restructuring emotion regulation Client: Why am I constantly angry, looking over my shoulder, and hitting the dirt every time there was a loud bang? Therapist: There is a logical explanation. A structure within the brain s limbic system, the amygdala, is hyperactive in individuals with PTSD, thereby inappropriately and repeatedly overreacting to prepare the body to fight or flee. By engaging in cognitivebehavioral therapy, other brain areas with a regulatory effect on the amygdala may become more active, thereby helping you adjust to a more appropriate arousal level.
Treatment findings & further implications Psychological interventions modify brain function Reversal of structural and functional abnormalities (i.e., normalization) Compensatory changes in areas not altered before therapy Limited PTSD treatment results Pharmacotherapy: hippocampus volume Psychotherapy: amygdala activity mpfc, hippocampus activity Use neuroimaging to predict Risk Prognosis Response to treatment Understand resilience and recovery Linden, 2011; Thomas et al., 2014
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References 1. Dannlowski, U., Stuhrmann, A., Beutelmann, V., Zwanzger, P., Lenzen, T., Grotegerd, D., &... Kugel, H. (2012). Limbic scars: long-term consequences of childhood maltreatment revealed by functional and structural magnetic resonance imaging. Biological Psychiatry, 71(4), 286-293. doi:10.1016/j.biopsych.2011.10.021 2. Davis, M., Walker, D. L., Miles, L., & Grillon, C.. (2010). Phasic vs sustained fear in in rats and humans: role of the extended amygdala in fear vs anxiety. Neuropsychopharmacology, 35(105-125). 3. Etkin, A. (2010). Functional neuroanatomy of anxiety: a neural circuit perspective. Current Topics In Behavioral Neurosciences, 2251-277. 4. Etkin, A., & Wager, T. D. (2007). Functional neuroimaging of anxiety: a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. The American Journal Of Psychiatry, 164(10), 1476-1488. 5. Hartley, Catherine A., & Phelps, Elizabeth A. (2010). Changing fear: The neurocircuitry of emotion regulation. Neuropsychopharmacology, 35(1), 136-146. doi: 10.1038/npp.2009.121 6. Hayes, J. P., Hayes, S. M., & Mikedis, A. M. (2012). Quantitative meta-analysis of neural activity in posttraumatic stress disorder. Biology Of Mood & Anxiety Disorders, 2(1), 9. doi:10.1186/2045-5380-2-9 7. Hopper, J. W., Frewen, P. A., van der Kolk, B. A., & Lanius, R. A. (2007). Neural correlates of reexperiencing, avoidance, and dissociation in PTSD: symptom dimensions and emotion dysregulation in responses to script-driven trauma imagery. Journal Of Traumatic Stress, 20(5), 713-725. 8. Hughes, K. C., & Shin, L. M. (2011). Functional neuroimaging studies of post-traumatic stress disorder. Expert Review Of Neurotherapeutics, 11(2), 275-285. doi:10.1586/ern.10.198 9. Linden, D. J. (2012). The challenges and promise of neuroimaging in psychiatry. Neuron, 73(1), 8-22. doi:10.1016/j.neuron. 2011.12.014 10. Milad, M. R., Pitman, R. K., Ellis, C. B., Gold, A. L., Shin, L. M., Lasko, N. B., &... Rauch, S. L. (2009). Neurobiological basis of failure to recall extinction memory in posttraumatic stress disorder. Biological Psychiatry, 66(12), 1075-1082. doi:10.1016/j.biopsych. 2009.06.026 11. Patel, R., Spreng, R. N., Shin, L. M., & Girard, T. A. (2012). Neurocircuitry models of posttraumatic stress disorder and beyond: a meta-analysis of functional neuroimaging studies. Neuroscience And Biobehavioral Reviews, 36(9), 2130-2142. doi:10.1016/ j.neubiorev.2012.06.003 12. Simmons, A. N., Paulus, M. P., Thorp, S. R., Matthews, S. C., Norman, S. B., & Stein, M. B. (2008). Functional activation and neural networks in women with posttraumatic stress disorder related to intimate partner violence. Biological Psychiatry, 64(8), 681-690. doi: 10.1016/j.biopsych.2008.05.027 13. Thomaes, K., Dorrepaal, E., Draijer, N., Jansma, E. P., Veltman, D. J., & van Balkom, A. J. (2014). Can pharmacological and psychological treatment change brain structure and function in PTSD? A systematic review. Journal Of Psychiatric Research, 501-15. doi:10.1016/j.jpsychires.2013.11.002 14. Villarreal, G., Hamilton, D. A., Petropoulos, H., Driscoll, I., Rowland, L. M., Griego, J. A., &... Brooks, W. M. (2002). Reduced hippocampal volume and total white matter volume in posttraumatic stress disorder. Biological Psychiatry, 52(2), 119-125.