RESUMEN
The goal of this retrospective cohort study was to determine whether stressors related to military service, determined by a diagnosis of chronic post-traumatic stress disorder (cPTSD) or receiving a Purple Heart (PH), are associated with an increased risk of vascular risk factors and disease, which are of great concern for veterans, who constitute a significant portion of the aging US population. The Veterans Integrated Service Network (VISN) 16 administrative database was searched for individuals 65 years or older between October 1, 1997 to September 30, 1999 who either received a PH but did not have cPTSD (PH+/cPTSD-; n = 1499), had cPTSD without a PH (PH-/cPTSD+; n = 3593), had neither (PH-/cPTSD-; n = 5010), or had both (PH+/cPTSD+; n = 153). In comparison to the control group (PH-/cPTSD-), the PH+/cPTSD- group had increased odds ratios for incidence and prevalence of diabetes mellitus, hypertension, and hyperlipidemia. The PH-/cPTSD+ group had increased odds ratios for prevalence of diabetes mellitus and for the incidence and prevalence of hyperlipidemia. The PH-/cPTSD+ and PH+/cPTSD- groups were associated with ischemic heart disease and cerebrovascular disease, but not independently of the other risk factors. The PH+/cPTSD+ group was associated only with an increase in the incidence and prevalence of hyperlipidemia, though this group's much smaller sample size may limit the reliability of this finding. We conclude that certain physical and psychological stressors related to military service are associated with a greater incidence of several vascular risk factors in veterans aged 65 years or older, which in turn are associated with greater rates of ischemic heart disease and cerebrovascular disease.
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Trastornos Cerebrovasculares/epidemiología , Isquemia Miocárdica/epidemiología , Trastornos por Estrés Postraumático/psicología , Veteranos/psicología , Factores de Edad , Anciano , Anciano de 80 o más Años , Trastornos Cerebrovasculares/psicología , Humanos , Incidencia , Masculino , Isquemia Miocárdica/psicología , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Trastornos por Estrés Postraumático/diagnóstico , Trastornos por Estrés Postraumático/epidemiología , Estados Unidos/epidemiología , Heridas y Lesiones/epidemiologíaRESUMEN
Physiological assessment of posttraumatic stress disorder (PTSD) presents an additional avenue for evaluating the severity of PTSD symptoms. We investigated whether the presence of a high number of uncommon symptoms attenuated the relation between self-reported PTSD symptoms and heart rate variability (HRV). Participants were 115 veterans from Operation Iraqi Freedom and Operation Enduring Freedom with or without PTSD. Symptom over-report was assessed using the Miller Forensic Assessment of Symptoms Test (M-FAST). Participants completed the Clinician-Administered PTSD Scale and M-FAST and underwent physiological assessment to determine HRV. These data were then entered into a hierarchical linear regression equation to test the moderating effect of over-reporting on the relation between PTSD symptom severity and HRV. The result of this analysis failed to demonstrate a significant moderating effect of over-reporting on the PTSD and HRV relation. HRV was a significant predictor of PTSD symptom severity, and this relation did not differ across levels of over-reporting. These findings did not support the hypothesis that over-reporting would attenuate the relation between PTSD and HRV. Clinical and research implications and directions for future investigation are discussed.
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Sistema Nervioso Autónomo/fisiopatología , Trastornos de Combate/fisiopatología , Frecuencia Cardíaca/fisiología , Trastornos por Estrés Postraumático/fisiopatología , Veteranos , Campaña Afgana 2001- , Arkansas , Femenino , Humanos , Guerra de Irak 2003-2011 , Masculino , Persona de Mediana Edad , Psicometría , Índice de Severidad de la EnfermedadRESUMEN
A valid sham control is important for determining the efficacy and effectiveness of repetitive transcranial magnetic stimulation (rTMS) as an experimental and clinical tool. Given the manner in which rTMS is applied, separately or in combination with self-regulatory approaches, and its intended impact on brain states, a valid sham control of this type may well serve as a meaningful control for biofeedback studies, where efforts to develop a credible control have often been less than ideal. This study examined the effectiveness of focal electrical stimulation of the frontalis muscle as a sham technique for blinding participants to high-frequency rTMS over the dorso-lateral prefrontal cortex (DLPFC) at durations, intensities, and schedules of stimulation similar to many clinical applications. In this within-subjects single blind design, 19 participants made guesses immediately after receiving 54 counterbalanced rTMS sessions (sham, 10 Hz, 20 Hz); 7 (13 %) of the guesses were made for sham, 31 (57 %) were made for 10 Hz, and 16 (30 %) were made for 20 Hz. Participants correctly guessed the sham condition 6 % (CI 1, 32 %) of the time, which is less than the odds of chance (i.e., of guessing at random, 33 %); correctly guessed the 10 Hz condition 66 % (CI 43, 84 %) of the time, which was greater than chance; and correctly guessed the 20 Hz condition 41 % (CI 21, 65 %) of the time, which was no different than chance. Focal electrical stimulation therefore can be an effective sham control for high-frequency rTMS of the DLPFC, as well as for active biofeedback interventions. Participants were unaware that electrical stimulation was, in fact, sham rTMS.
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Biorretroalimentación Psicológica/métodos , Estimulación Eléctrica , Estimulación Magnética Transcraneal/métodos , Adulto , Grupos Control , Interpretación Estadística de Datos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Corteza Prefrontal/fisiología , Proyectos de Investigación , Método Simple Ciego , Adulto JovenRESUMEN
Importance: To date, no psychopharmacologic treatment has been found to be uniformly effective in veterans with posttraumatic stress disorder (PTSD); novel targets and approaches are needed to treat this disabling disorder. Objective: To examine whether treatment with the glucocorticoid receptor antagonist mifepristone yields a signal for clinical efficacy in male veterans with PTSD. Design, Setting, and Participants: This phase 2a, double-blind, parallel-group randomized clinical trial was conducted from November 19, 2012 (accrual started), through November 16, 2016 (final follow-up), within the US Department of Veterans Affairs. Participants were male veterans with chronic PTSD and a screening Clinician-Administered PTSD Scale score of 50 or higher. A total of 181 veterans consented to participation. Statistical analysis was conducted between August 2014 and May 2017. Interventions: Participants were randomized in a 1:1 ratio to mifepristone (600 mg) or matched placebo taken orally for 7 days. Main Outcomes and Measures: The clinical outcome was whether a veteran achieved a clinical response status (a reduction of ≥30% of total Clinician-Administered PTSD Scale score from baseline) at 4- and 12-week follow-up. On the basis of a binary statistical selection rule, a difference in the proportion of treatment vs control group responders of 15% would be a clinically relevant difference. Self-report measures of PTSD and associated symptoms were also obtained. Neuroendocrine outcomes and plasma levels of mifepristone were measured. Safety was assessed throughout the study. The primary analysis was based on a multiple imputation technique to address missing outcome data; thus, some participant numbers may not appear as whole numbers. Results: A total of 81 veterans were enrolled and randomized. Excluding 1 participant randomized in error, 80 were included in the modified intention-to-treat analysis (41 randomized to mifepristone and 39 to placebo). The mean (SD) age was 43.1 (13.7) years. A total of 15.6 (38.1%) in the mifepristone group and 12.1 (31.1%) in the placebo group were clinical responders at 4 weeks in the analysis using the multiple imputation technique. The group difference in the proportion of clinical responders (7.0%) was less than the predefined margin of 15% indicating signal for clinical efficacy. In an exploratory analysis, the difference in response to mifepristone vs placebo in the subgroup with no lifetime history of traumatic brain injury (TBI) (7.0 [50.0%] vs 3.0 [27.3%]; difference, 22.7%) exceeded the efficacy margin at 4 weeks and was sustained at 12 weeks. In contrast, in veterans with PTSD and lifetime TBI, the response rate to mifepristone was lower than placebo at 12 weeks (7.4 [27.4%] vs 13.5 [48.3%]; difference, -20.9%). Conclusions and Relevance: This study did not detect a signal for efficacy for mifepristone at 600 mg/d for 1 week in male veterans with chronic PTSD. Thus, this study does not support a phase 3 trial in this population. Future studies of mifepristone for the treatment of PTSD may be of interest in those without a history of TBI or in samples with a low base rate of lifetime head trauma. Trial Registration: ClinicalTrials.gov Identifier: NCT01946685.
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Lesiones Traumáticas del Encéfalo , Trastornos por Estrés Postraumático , Veteranos , Estados Unidos , Humanos , Masculino , Adulto , Femenino , Mifepristona/efectos adversos , Trastornos por Estrés Postraumático/tratamiento farmacológico , Ceguera , GalopamiloRESUMEN
Using the event-related potential P3a component as a marker, the authors tested the efficacy of repetitive transcranial magnetic stimulation (rTMS) for reducing hyperarousability to specific threat stimuli in one Vietnam veteran with chronic posttraumatic stress disorder (PTSD), who exhibited an exaggerated P3a response to combat-related pictures. Twenty minutes of 1-Hz rTMS to the right prefrontal area effected a reduction in the P3a amplitude, whereas similar rTMS to the left prefrontal area did not. In addition to providing evidence for the effectiveness of right frontal rTMS for an exaggerated response to trauma-related stimuli, this study provides electrophysiological corroboration of subjective reports of PTSD symptoms.
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Trastornos de Combate/fisiopatología , Trastornos de Combate/terapia , Potenciales Relacionados con Evento P300/fisiología , Lóbulo Frontal/fisiología , Memoria/fisiología , Estimulación Magnética Transcraneal/métodos , Trastornos de Combate/psicología , Humanos , Masculino , Persona de Mediana Edad , Estimulación Luminosa/métodosRESUMEN
This systematic review analyzed data from studies examining memory and cognitive function in subjects with posttraumatic stress disorder (PTSD), compared with subjects exposed to trauma (but without PTSD). Based on analysis of 21 articles published in English from 1968 to 2009, the conclusion is that individuals with PTSD, particularly veterans, show signs of cognitive impairment when tested with neuropsychological instruments, more so than individuals exposed to trauma who do not have PTSD.
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Trastornos del Conocimiento/psicología , Cognición , Trastornos por Estrés Postraumático/psicología , Heridas y Lesiones/psicología , Animales , Cognición/fisiología , Trastornos del Conocimiento/etiología , Humanos , Pruebas Neuropsicológicas , Trastornos por Estrés Postraumático/complicaciones , Veteranos/psicología , Heridas y Lesiones/complicacionesRESUMEN
Introduction: There is a long history of pre-deployment PTSD prevention efforts in the military and effective pre-deployment strategies to prevent post-deployment PTSD are still needed. Materials and Methods: This randomized controlled trial included three arms: heart rate variability biofeedback (HRVB), cognitive bias modification for interpretation (CBM-I), and control. The hypothesis was that pre-deployment resilience training would result in lower post-deployment PTSD symptoms compared with control. Army National Guard soldiers (n = 342) were enrolled in the Warriors Achieving Resilience (WAR) study and analyzed. The outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at pre-deployment, 3- and 12-month post-deployment. Due to the repeated measures for each participant and cluster randomization at the company level, generalized linear mixed models were used for the analysis. This study was approved by the Army Human Research Protection Office, Central Arkansas Veterans Healthcare System Institutional Review Board (IRB), and Southeast Louisiana Veterans Health Care System IRB. Results: Overall, there was no significant intervention effect. However, there were significant intervention effects for subgroups of soldiers. For example, at 3-months post-deployment, the HRVB arm had significantly lower PCL scores than the control arm for soldiers with no previous combat zone exposure who were age 30 and older and for soldiers with previous combat zone exposure who were 45 and older (unadjusted effect size -0.97 and -1.03, respectively). A significant difference between the CBM-I and control arms was found for soldiers without previous combat zone exposure between ages 23 and 42 (unadjusted effect size -0.41). Similarly, at 12-months post-deployment, the HRVB arm had significantly lower PCL scores in older soldiers. Conclusion: Pre-deployment resilience training was acceptable and feasible and resulted in lower post-deployment PTSD symptom scores in subgroups of older soldiers compared with controls. Strengths of the study included cluster randomization at the company level, use of iPod device to deliver the resilience intervention throughout the deployment cycle, and minimal disruption of pre-deployment training by using self-paced resilience training. Weaknesses included self-report app use, study personnel not able to contact soldiers during deployment, and in general a low level of PTSD symptom severity throughout the study. In future studies, it would important for the study team and/or military personnel implementing the resilience training to be in frequent contact with participants to ensure proper use of the resilience training apps.
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Terapia Cognitivo-Conductual/normas , Retroalimentación , Frecuencia Cardíaca , Trastornos por Estrés Postraumático/prevención & control , Veteranos/psicología , Adaptación Psicológica , Adolescente , Adulto , Arkansas , Terapia Cognitivo-Conductual/métodos , Femenino , Humanos , Louisiana , Masculino , Persona de Mediana Edad , Personal Militar/psicología , Personal Militar/estadística & datos numéricos , Monitoreo Fisiológico/métodos , Factores de Riesgo , Trastornos por Estrés Postraumático/psicología , Veteranos/estadística & datos numéricos , Guerra/psicologíaRESUMEN
The authors aim to delineate cognitive dysfunction associated with posttraumatic stress disorder (PTSD) by evaluating a well-defined cohort of former World War II prisoners of war (POWs) with documented trauma and minimal comorbidities. The authors studied a cross-sectional assessment of neuropsychological performance in former POWs with PTSD, PTSD with other psychiatric comorbidities, and those with no PTSD or psychiatric diagnoses. Participants who developed PTSD had average IQ, while those who did not develop PTSD after similar traumatic experiences had higher IQs than average (approximately 116). Those with PTSD performed significantly less well in tests of selective frontal lobe functions and psychomotor speed. In addition, PTSD patients with co-occurring psychiatric conditions experienced impairment in recognition memory for faces. Higher IQ appears to protect individuals who undergo a traumatic experience from developing long-term PTSD, while cognitive dysfunctions appear to develop with or subsequent to PTSD. These distinctions were supported by the negative and positive correlations of these cognitive dysfunctions with quantitative markers of trauma, respectively. There is a suggestion that some cognitive decrements occur in PTSD patients only when they have comorbid psychiatric diagnoses.
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Trastornos del Conocimiento/etiología , Prisioneros/psicología , Trastornos por Estrés Postraumático/complicaciones , Segunda Guerra Mundial , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Trastornos del Conocimiento/psicología , Evaluación de la Discapacidad , Humanos , Acontecimientos que Cambian la Vida , Masculino , Escala del Estado Mental , Pruebas Neuropsicológicas , Estudios Retrospectivos , Trastornos por Estrés Postraumático/psicología , Veteranos/psicologíaRESUMEN
OBJECTIVES/HYPOTHESIS: Low-frequency repetitive transcranial magnetic stimulation (rTMS) has been shown to alleviate tinnitus perception, presumably by inhibiting cortical activity associated with tinnitus. We conducted a pilot study to assess effectiveness of neuronavigated rTMS and its effects on attentional deficits and cortical asymmetry in four patients with chronic tinnitus using objective and subjective measures and employing an optimization technique refined in our laboratory. STUDY DESIGN: Randomized, placebo-controlled (sham stimulation) crossover study. METHODS: Patients received 5 consecutive days of active, low-frequency rTMS or sham treatment (using a 45-degree coil-tilt method) before crossing over. Subjective tinnitus was assessed at baseline, after each treatment, and 4 weeks later. Positron emission tomography/computed tomography (PET/CT) scans were obtained at baseline and immediately after active treatment to examine change in cortical asymmetry. Attentional vigilance was assessed at baseline and after each treatment using a simple reaction time test. RESULTS: All patients had a response to active (but not sham) rTMS, as indicated by their best tinnitus ratings; however, tinnitus returned in all patients by 4 weeks after active treatment. All patients had reduced cortical activity visualized on PET immediately after active rTMS. Mean reaction time improved (P < .05) after active but not sham rTMS. CONCLUSIONS: rTMS is a promising treatment modality that can transiently diminish tinnitus in some individuals, but further trials are needed to determine the optimal techniques required to achieve a lasting response. It is unclear whether the improved reaction times were caused by tinnitus reduction or a general effect of rTMS. PET/CT scans immediately after treatment suggest that improvement may be related to reduction of cortical asymmetry associated with tinnitus.
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Acúfeno/terapia , Estimulación Magnética Transcraneal/métodos , Adulto , Nivel de Alerta/fisiología , Atención/fisiología , Estudios Cruzados , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Tomografía de Emisión de Positrones , Desempeño Psicomotor/fisiología , Acúfeno/diagnóstico , Acúfeno/fisiopatología , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVES/HYPOTHESIS: Correlate subjective improvements in tinnitus severity with restoration of cortical symmetry and sustained attention after neuronavigated low-frequency, repetitive transcranial magnetic stimulation (rTMS). STUDY DESIGN: Case study. METHODS: Positron emission tomography and computed tomography imaging (PET-CT) guided rTMS was performed on a 43-year-old white male with more than a 30 year history of bilateral tinnitus. rTMS was administered to the area of increased cortical activation visualized on PET-CT at a rate of 1 Hz for 30 minutes (1,800 pulses/session) for each of 5 consecutive days, with optimization applied on day 5 using single pulses of TMS to temporarily alter tinnitus perception. Subjective tinnitus severity was rated before and after rTMS using the tinnitus severity index with analogue scale. Attention and vigilance were assessed before and after therapy using the psychomotor vigilance task (PVT), a simple reaction time test that is sensitive to thalamocortical contributions to sustained attention. Posttherapy PET-CT was used to evaluate any change in asymmetric cortical activation. RESULTS: The most marked reduction in tinnitus severity occurred after rTMS optimization; this persisted up to 4 weeks after rTMS. PVT testing showed the patient exhibited a statistically significant improvement in mean slowest 10% reaction times after rTMS (P = .004). PET-CT imaging 2 days after the cessation of rTMS showed no changes in cortical blood flow or metabolic asymmetries. CONCLUSIONS: Low-frequency rTMS applied to the primary auditory cortex can reduce tinnitus severity, with rTMS optimization yielding the most favorable results. Beneficial changes occurring in the patient's slowest reaction times suggest that attentional deficits associated with tinnitus may also respond to low-frequency rTMS.
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Acúfeno/terapia , Estimulación Magnética Transcraneal/métodos , Adulto , Nivel de Alerta/fisiología , Atención/fisiología , Corteza Auditiva/irrigación sanguínea , Corteza Auditiva/metabolismo , Corteza Auditiva/fisiopatología , Fluorodesoxiglucosa F18 , Estudios de Seguimiento , Humanos , Masculino , Tomografía de Emisión de Positrones , Desempeño Psicomotor/fisiología , Radiofármacos , Tiempo de Reacción/fisiología , Tálamo/fisiopatología , Terapia Asistida por Computador , Factores de Tiempo , Acúfeno/clasificación , Acúfeno/fisiopatología , Tomografía Computarizada por Rayos XRESUMEN
Heart rate variability is a physiological measure associated with autonomic nervous system activity. This study hypothesized that lower pre-deployment HRV would be associated with higher post-deployment post-traumatic stress disorder (PTSD) symptoms. Three-hundred-forty-three Army National Guard soldiers enrolled in the Warriors Achieving Resilience (WAR) study were analyzed. The primary outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at baseline, 3- and 12-month post-deployment. Heart rate variability predictor variables included: high frequency power (HF) and standard deviation of the normal cardiac inter-beat interval (SDNN). Generalized linear mixed models revealed that the pre-deployment PCL*ln(HF) interaction term was significant (p<0.0001). Pre-deployment SDNN was not a significant predictor of post-deployment PCL. Covariates included age, pre-deployment PCL, race/ethnicity, marital status, tobacco use, childhood abuse, pre-deployment traumatic brain injury, and previous combat zone deployment. Pre-deployment heart rate variability predicts post-deployment PTSD symptoms in the context of higher pre-deployment PCL scores.
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Trastornos de Combate/psicología , Frecuencia Cardíaca/fisiología , Personal Militar/psicología , Trastornos por Estrés Postraumático/fisiopatología , Adulto , Sistema Nervioso Autónomo/fisiopatología , Trastornos de Combate/complicaciones , Femenino , Humanos , Guerra de Irak 2003-2011 , Modelos Lineales , Estudios Longitudinales , Masculino , Valor Predictivo de las Pruebas , Estados Unidos , Adulto JovenRESUMEN
Biased appraisal is central to cognitive theories of posttraumatic stress, but little research has examined the potentially distinct meanings of the term. The ongoing process of appraising social information and the beliefs that emerge as products of that process can be distinguished conceptually. This study sought to examine whether these 2 meanings are empirically distinct as well, and if so, to begin exploring potential relations between these appraisal constructs and posttraumatic stress symptoms. Soldiers (N = 424) preparing for deployment to Iraq or Afghanistan were administered measures of each construct. Results of confirmatory factor analysis suggest that the appraisal process and the products of that process (i.e., beliefs) are indeed distinct. Structural equation models are consistent with cognitive bias and social information processing literatures, which posit that a biased appraisal process may contribute to the development of dysfunctional beliefs and posttraumatic stress symptoms following trauma. The potential utility of distinctly conceptualizing and measuring the appraisal process in both clinical and research settings is discussed.
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Juicio , Modelos Psicológicos , Trastornos por Estrés Postraumático/psicología , Adolescente , Adulto , Campaña Afgana 2001- , Cognición , Análisis Factorial , Femenino , Humanos , Guerra de Irak 2003-2011 , Masculino , Persona de Mediana Edad , Personal Militar/psicología , Modelos Estadísticos , Pronóstico , Trastornos por Estrés Postraumático/diagnóstico , Adulto JovenRESUMEN
IMPORTANCE: Posttraumatic stress disorder (PTSD) is prevalent, persistent, and disabling. Although psychotherapy and pharmacotherapy have proven efficacious in randomized clinical trials, geographic barriers impede rural veterans from engaging in these evidence-based treatments. OBJECTIVE: To test a telemedicine-based collaborative care model designed to improve engagement in evidence-based treatment of PTSD. DESIGN, SETTING, AND PARTICIPANTS: The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial design with intention-to-treat analyses. Outpatients were recruited from 11 Department of Veterans Affairs (VA) community-based outpatient clinics serving predominantly rural veterans. Inclusion required meeting diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale. Exclusion criteria included receiving PTSD treatment at a VA medical center or a current diagnosis of schizophrenia, bipolar disorder, or substance dependence. Two hundred sixty-five veterans were enrolled from November 23, 2009, through September 28, 2011, randomized to usual care (UC) or the TOP intervention, and followed up for 12 months. INTERVENTIONS: Off-site PTSD care teams located at VA medical centers supported on-site community-based outpatient clinic providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, telepsychologists, and telepsychiatrists. Nurses conducted care management activities. Pharmacists reviewed medication histories. Psychologists delivered cognitive processing therapy via interactive video. Psychiatrists supervised the team and conducted interactive video psychiatric consultations. MAIN OUTCOMES AND MEASURES: The primary outcome was PTSD severity as measured by the Posttraumatic Diagnostic Scale. Process-of-care outcomes included medication prescribing and regimen adherence and initiation of and adherence to cognitive processing therapy. RESULTS: During the 12-month follow-up period, 73 of the 133 patients randomized to TOP (54.9%) received cognitive processing therapy compared with 16 of 132 randomized to UC (12.1%) (odds ratio, 18.08 [95% CI, 7.96-41.06]; P < .001). Patients in the TOP arm had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 29.1) compared with those in the UC arm (from 33.5 to 32.1) at 6 months (ß = -3.81; P = .002). Patients in the TOP arm also had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 30.1) compared with those in the UC arm (from 33.5 to 31.7) at 12 months (ß = -2.49; P=.04). There were no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens were not significant. Attendance at 8 or more sessions of cognitive processing therapy significantly predicted improvement in Posttraumatic Diagnostic Scale scores (ß = -3.86 [95% CI, -7.19 to -0.54]; P = .02) and fully mediated the intervention effect at 12 months. CONCLUSIONS AND RELEVANCE: Telemedicine-based collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00821678.
Asunto(s)
Terapia Cognitivo-Conductual/métodos , Grupo de Atención al Paciente , Trastornos por Estrés Postraumático , Telemedicina , Veteranos/psicología , Adulto , Instituciones de Atención Ambulatoria/estadística & datos numéricos , Centros Comunitarios de Salud/estadística & datos numéricos , Femenino , Humanos , Comunicación Interdisciplinaria , Masculino , Persona de Mediana Edad , Escalas de Valoración Psiquiátrica , Psicotrópicos/uso terapéutico , Población Rural , Trastornos por Estrés Postraumático/diagnóstico , Trastornos por Estrés Postraumático/psicología , Trastornos por Estrés Postraumático/terapia , Telemedicina/métodos , Telemedicina/organización & administración , Resultado del Tratamiento , Comunicación por VideoconferenciaRESUMEN
Repetitive transcranial magnetic stimulation (rTMS) holds promise as a probe into the pathophysiology and possible treatment of neuropsychiatric disorders. To explore its regional effects, we combined rTMS with positron emission tomography (PET). Fourteen healthy volunteers participated in a baseline 18-fluorodeoxyglucose (FDG) PET scan. During a second FDG infusion on the same day, seven subjects received 30 min of 1 Hz rTMS at 80% of motor threshold to left prefrontal cortex, and seven other subjects received sham rTMS under identical conditions. Global and normalized regional cerebral glucose metabolic rates (rCMRglu) from the active and sham conditions were compared to baseline and then to each other. Sham, but not active 1 Hz rTMS, was associated with significantly increased global CMRglu. Compared to baseline, active rTMS induced normalized decreases in rCMRglu in right prefrontal cortex, bilateral anterior cingulate, basal ganglia (L>R), hypothalamus, midbrain, and cerebellum. Increases in rCMRglu were seen in bilateral posterior temporal and occipital cortices. Sham rTMS compared to baseline resulted in isolated normalized decreases in rCMRglu in left dorsal anterior cingulate and left basal ganglia, and increases in posterior association and occiptal regions. Differences between the 1 Hz active versus sham changes from baseline revealed that active rTMS induced relative decrements in rCMRglu in the left superior frontal gyrus and increases in the cuneus (L>R). One Hertz rTMS at 80% motor threshold over the left prefrontal cortex in healthy subjects compared to sham rTMS in another group (each compared to baseline) induced an area of decreased normalized left prefrontal rCMRglu not directly under the stimulation site, as well as increases in occipital cortex. While these results are in the predicted direction, further studies using other designs and higher intensities and frequencies of rTMS are indicated to better describe the local and distant changes induced by rTMS.
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Fenómenos Electromagnéticos/instrumentación , Lateralidad Funcional/fisiología , Glucosa/metabolismo , Periodicidad , Corteza Prefrontal/metabolismo , Tomografía Computarizada de Emisión , Adulto , Encéfalo/metabolismo , Femenino , Fluorodesoxiglucosa F18/farmacocinética , Humanos , Masculino , Radiofármacos , CráneoRESUMEN
The current study investigated in a sample of Operation Enduring and Iraqi Freedom (OEF/OIF) veterans how a symptom overreporting response style might influence the association between PTSD diagnostic status and color-naming response latency for trauma-related stimuli during the Modified Stroop Task (i.e., the Modified Stroop Task effect, MST effect). It was hypothesized that, if an overreporting response style reflected feigning or exaggerating PTSD symptoms, an attenuated MST effect would be expected in overreporters with PTSD as compared with PTSD-diagnosed veterans without an overreporting style. If, however, overreporting stemmed from high levels of distress, the MST effect might be greater in overreporters compared with those with a neutral response style. The results showed that veterans with PTSD and an overreporting response style demonstrated an augmented MST effect in comparison with those with a more neutral style of response. Overreporters also reported greater levels of psychopathology, including markedly elevated reports of dissociative experiences. We suggest that dissociation-prone overreporters may misattribute emotional distress to combat experiences leading to the enhanced MST effect. Other possible explanations for these results are also discussed.
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Atención/fisiología , Tiempo de Reacción/fisiología , Trastornos por Estrés Postraumático/diagnóstico , Veteranos/psicología , Adulto , Campaña Afgana 2001- , Femenino , Humanos , Guerra de Irak 2003-2011 , Masculino , Simulación de Enfermedad/diagnóstico , Simulación de Enfermedad/psicología , Persona de Mediana Edad , Trastornos por Estrés Postraumático/psicología , Test de StroopRESUMEN
Repetitive transcranial magnetic stimulation (rTMS) is a new frontier in the examination of addictive behaviors and perhaps the development of new interventions. This study examined differences in recruitment, eligibility, and retention among smokers and nonsmokers in an rTMS study. We modeled participant eligibility and study completion among eligible participants accounting for demographic differences between smokers and nonsmokers. Nonsmokers were more likely than smokers to remain eligible for the study after the in-person screen (84.2% versus 57.4%; OR 4.0 CI: 1.0, 15.4, p=0.05) and to complete the study (87.5% versus 59.3%; OR=43.9 CI: 2.8, 687.2, p=0.007). The preliminary findings suggest that careful screening for drugs of abuse and brain abnormalities among smokers prior to administering rTMS is warranted. More research is needed concerning the prevalence of brain abnormalities in smokers. Smokers might need to be informed about a higher risk of incidental MRI findings.
RESUMEN
Implementation of evidence-based treatments (EBT) is necessary to address posttraumatic stress disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) military service personnel. Because virtual reality (VR) offers a promising tool for delivery of one type of EBT--exposure therapy--this study explored veterans' perceptions of VR as an assessment tool and treatment adjunct. We conducted semi-structured interviews with 14 OEF/OIF veterans being treated for PTSD after viewing two 3 minute VR scenarios as part of a larger research study. Veterans reported a capacity for immersion in VR in both combat and civilian environments, characterized by self-reported physiological reactivity, thoughts/behaviors similar to those experienced in Iraq, and triggered memories. Although participants were generally positive about VR, they expressed concerns about the possibility of negative reactions after viewing VR. Findings are discussed in the context of further development of VR aided interventions in veteran healthcare systems.
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Actitud Frente a la Salud , Trastornos de Combate/terapia , Terapia Implosiva , Trastornos por Estrés Postraumático/terapia , Interfaz Usuario-Computador , Veteranos/psicología , Adulto , Trastornos de Combate/diagnóstico , Trastornos de Combate/psicología , Simulación por Computador , Femenino , Humanos , Masculino , Percepción , Trastornos por Estrés Postraumático/diagnóstico , Trastornos por Estrés Postraumático/psicologíaRESUMEN
Cigarette smokers and substance users discount the value of delayed outcomes more steeply than non-users. Higher discounting rates are associated with relapse and poorer treatment outcomes. The left dorsolateral prefontal cortex (DLPFC) exerts an inhibitory influence on impulsive or seductive choices. Greater activity in the prefrontal cortex is associated with lower discounting rates. We hypothesized that increasing activity in the left DLPFC with high frequency repetitive transcranial magnetic stimulation (HF rTMS) would decrease delay discounting and decrease impulsive decision-making in a gambling task as well as decrease cigarette consumption, similar to other studies. In this single-blind, within-subjects design, smokers with no intention to quit (n = 47) and nonsmokers (n = 19) underwent three counterbalanced sessions of HF rTMS (20 Hz, 10 Hz, sham) delivered over the left DLPFC. Tasks were administered at baseline and after each stimulation session. Stimulation decreased discounting of monetary gains (F([3,250]) = 4.46, p < .01), but increased discounting of monetary losses (F([3,246]) = 4.30, p < .01), producing a reflection effect, normally absent in delay discounting. Stimulation had no effect on cigarette consumption. These findings provide new insights into cognitive processes involved with decision-making and cigarette consumption and suggest that like all medications for substance dependence, HF rTMS is likely to be most effective when paired with cognitive-behavioral interventions.
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Cognición/fisiología , Toma de Decisiones/fisiología , Fumar/epidemiología , Estimulación Magnética Transcraneal/métodos , Adulto , Conducta de Elección/fisiología , Femenino , Juego de Azar/psicología , Humanos , Conducta Impulsiva/psicología , Masculino , Persona de Mediana Edad , Corteza Prefrontal/metabolismo , Recompensa , Método Simple Ciego , Fumar/psicología , Factores de Tiempo , Adulto JovenRESUMEN
OBJECTIVES/HYPOTHESIS: The objective was to determine whether low-frequency repetitive transcranial magnetic stimulation (rTMS) improves tinnitus by decreasing neural activity in auditory processing regions of the temporal cortex and the utility of positron emission tomography (PET) for targeting treatment. STUDY DESIGN: Randomized, sham-controlled crossover. METHODS: Patients received a five-day course of active and sham 1-Hz rTMS (1800 pulses at 110% of motor threshold) to the temporal cortex, with a week separating active and sham treatment. Visual analogue ratings of tinnitus loudness (VARL) were assessed at baseline and the end of each treatment week; regional brain blood flow (rBBF) and glucose metabolism (via PET) were measured before and after treatment in regions of interest (ROI) beneath the stimulating coil and control sites. RESULTS: The VARL for both ears significantly decreased after active but not sham treatment. Responders comprised 43% of patients, experiencing at least a 33% drop in tinnitus loudness. The site most consistently associated with a positive response was the secondary auditory cortex (Brodmann Area 22) in either hemisphere. PET asymmetries were variable across patients and not always accessible to rTMS. Whereas PET activity decreased significantly beneath the stimulating coil following active treatment, similar changes occurred at control sites and after sham stimulation. Change in tinnitus perception did not correlate significantly with change in PET activity at the treatment site ROI. CONCLUSIONS: Active TMS led to a significant reduction in tinnitus loudness, but PET scans failed to support the hypothesis that low-frequency rTMS improves tinnitus by reducing cortical activation at the stimulation site, questioning the utility of PET for targeting rTMS.
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Glucemia/metabolismo , Tomografía de Emisión de Positrones , Flujo Sanguíneo Regional/fisiología , Lóbulo Temporal/diagnóstico por imagen , Lóbulo Temporal/fisiopatología , Acúfeno/diagnóstico por imagen , Acúfeno/terapia , Estimulación Magnética Transcraneal , Adulto , Anciano , Estudios Cruzados , Femenino , Fluorodesoxiglucosa F18 , Humanos , Masculino , Persona de Mediana Edad , Dimensión del DolorRESUMEN
OBJECTIVE: Implementation of evidence-based, innovative treatments is necessary to address posttraumatic stress disorder (PTSD) and related mental health problems of Operation Enduring Freedom and Operation Iraqi Freedom (OEF-OIF) military service personnel. The purpose of this study was to characterize mental health clinicians' perceptions of virtual reality as an assessment tool or adjunct to exposure therapy. METHODS: Focus groups were conducted with 18 prescribing and nonprescribing mental health clinicians within the Veterans Health Administration. Group discussion was digitally recorded, downloaded into Ethnograph software, and coded to arrive at primary, secondary, and tertiary themes. RESULTS: Most frequently mentioned barriers pertained to aspects of virtual reality, followed by veteran characteristics. Organizational barriers were more relevant when implementing virtual reality as a treatment adjunct. CONCLUSIONS: Although the study demonstrated that use of virtual reality as a therapy was feasible and acceptable to clinicians, successful implementation of the technology as an assessment and treatment tool will depend on consideration of the facilitators and barriers that were identified.