Effects of psychotherapy on brain activation during negative emotional processing in patients with posttraumatic stress disorder: a systematic review and meta-analysis.

Post-traumatic stress disorder (PTSD) is a debilitating condition which has been related to problems in emotional regulation, memory and cognitive control. Psychotherapy has a non-response rate of around 50% and understanding the neurobiological working mechanisms might help improve treatment. To integrate findings from multiple smaller studies, we performed the first meta-analysis of changes in brain activation with a specific focus on emotional processing after psychotherapy in PTSD patients. We performed a meta-analysis of brain activation changes after treatment during emotional processing for PTSD with seed-based d mapping using a pre-registered protocol (PROSPERO CRD42020211039). We analyzed twelve studies with 191 PTSD patients after screening 3700 studies. We performed systematic quality assessment both for the therapeutic interventions and neuroimaging methods. Analyses were done in the full sample and in a subset of studies that reported whole-brain results. We found decreased activation after psychotherapy in the left amygdala, (para)hippocampus, medial temporal lobe, inferior frontal gyrus, ventrolateral prefrontal cortex, right pallidum, anterior cingulate cortex, bilateral putamen, and insula. Decreased activation in the left amygdala and left ventrolateral PFC was also found in eight studies that reported whole-brain findings. Results did not survive correction for multiple comparisons. There is tentative support for decreased activation in the fear and cognitive control networks during emotional processing after psychotherapy for PTSD. Future studies would benefit from adopting a larger sample size, using designs that control for confounding variables, and investigating heterogeneity in symptom profiles and treatment response.

[The PTSD Checklist for DSM-5 (PCL-5): comparing responsivity with the Outcome Questionnaire (OQ-45) and practical utility]. / De PTSS Checklist voor DSM-5 (PCL-5) voor ROM: een vergelijking van de responsiviteit met de Outcome Questionnaire (OQ-45) en praktische bruikbaarheid.

BACKGROUND: The PTSD Checklist for the DSM-5 (PCL-5) may be a suitable addition for routine outcome monitoring (ROM) for patients with PTSD.
AIM: To determine whether the PCL-5 is worth the extra effort that administration requires from the patient.
METHOD: Pretest and retest measurement results of the PCL-5 and the OQ-45 were compared head-to-head in 464 patients from the Sinai Center of Arkin.
RESULTS: The correlations between scores on the instruments were high and analysis of variance for repeated measurements revealed no difference in responsiveness. Comparison of Cohen's d (0.49 vs. 0.43) and Delta T (5.0 vs. 4.4), indicated a slightly better responsiveness of the PCL-5 and also the proportion of recovered patients was greater according to the PCL-5 compared to the OQ-SD.
CONCLUSION: At first glance, the PCL-5 and the OQ-SD were equally sensitive to detect change during treatment. However, the PCL-5 provided more detailed information about the nature and severity of symptomatology in an individual patient and with the PCL-5 we were slightly better able to demonstrate clinical significant change than with the OQ-SD. We recommend to add the PCL-5 to ROM for patients with PTSD.

[Complex PTSD following early-childhood trauma: emotion-regulation training as addition to the PTSD guideline]. / Complexe PTSS na vroegkinderlijk trauma: emotieregulatietraining als aanvulling op de PTSS-richtlijn.

BACKGROUND: Posttraumatic stress disorder (PTSD) symptoms in individuals who have experienced repeated trauma (sexual and/or physical) in early childhood can lead to problems associated with emotion regulation, interpersonal functioning and self-image. This so-called complex PTSD is often accompanied by a comorbid personality disorder. Although ptsd is associated with structural and functional abnormalities in emotion-regulation areas in the brain, it is not known whether complex PTSD shows similar abnormalities. Experts take the view that before individuals with complex PTSD are given appropriate therapy they should receive a course of emotion-regulation therapy such as the one tested by Zlotnick e.a. (1997) in a randomised controlled trial (RCT).   AIM: To replicate Zlotnick's RCT in the Netherlands and to find out whether complex PTSD patients show specific structural and functional brain abnormalities and whether psychological recovery is linked to the 'normalisation' of these abnormalities. METHOD: In a RCT with complex PTSD patients (n = 71) who had experienced trauma in early childhood, we compared normal individual treatment with treatment supported by 'Before and beyond', which consists of emotion-regulation therapy combined with cognitive group therapy. In a subsample (n= 33) we also performed an mri (repeated, n = 9) in which individuals were required to execute an emotional memory and attention task. RESULTS: In complex PTSD, structural abnormalities in the brain seemed to be more extensive than in PTSD and brain activity in complex PTSD seemed to be strikingly different from the brain activity seen in PTSD patients who had experienced only single trauma. The results of the RCT indicate that 'Before and beyond' is a clinically meaningful treatment (with minimal drop-out) for complex PTSD patients with a variety of personality disorders. The psychological recovery of patients who received the emotion regulation and cognitive group treatment was associated with normalisation of brain function. CONCLUSION: Treatment guidelines for ptsd patients cannot be applied directly and automatically to complex PTSD because there is no scientific evidence to justify such a step. The neurobiological profile of PTSD differs from that of complex PTSD. Patients with complex PTSD seem to react favourably to emotion regulation therapy. This treatment therefore could be a useful addition to the current PTSD guideline for this specific group. There is a need for further research that focuses on complex PTSD patients.

Treatment effects on insular and anterior cingulate cortex activation during classic and emotional Stroop interference in child abuse-related complex post-traumatic stress disorder.

BACKGROUND: Functional neuroimaging studies have shown increased Stroop interference coupled with altered anterior cingulate cortex (ACC) and insula activation in post-traumatic stress disorder (PTSD). These brain areas are associated with error detection and emotional arousal. There is some evidence that treatment can normalize these activation patterns. METHOD: At baseline, we compared classic and emotional Stroop performance and blood oxygenation level-dependent responses (functional magnetic resonance imaging) of 29 child abuse-related complex PTSD patients with 22 non-trauma-exposed healthy controls. In 16 of these patients, we studied treatment effects of psycho-educational and cognitive behavioural stabilizing group treatment (experimental treatment; EXP) added to treatment as usual (TAU) versus TAU only, and correlations with clinical improvement. RESULTS: At baseline, complex PTSD patients showed a trend for increased left anterior insula and dorsal ACC activation in the classic Stroop task. Only EXP patients showed decreased dorsal ACC and left anterior insula activation after treatment. In the emotional Stroop contrasts, clinical improvement was associated with decreased dorsal ACC activation and decreased left anterior insula activation. CONCLUSIONS: We found further evidence that successful treatment in child abuse-related complex PTSD is associated with functional changes in the ACC and insula, which may be due to improved selective attention and lower emotional arousal, indicating greater cognitive control over PTSD symptoms.

[Stabilisation therapy as an answer to complex post-traumatic stress disorder. Diagnosis, treatment and research in women abused in childhood with a complex post-traumatic stress disorder]. / Stabilisatiecursus als antwoord op complexe posttraumatische stressstoornis. Diagnostiek, behandeling en onderzoek bij vroeggetraumatiseerde vrouwen met een complexe posttraumatische stressstoornis.

Complex post-traumatic stress disorder resulting from traumatic experiences in childhood includes not only the customary post-traumatic stress disorder symptoms such as intrusions, avoidance and hyperarousal, but it also includes affect-dysregulation, dissociation, problems with self-image, relationships, interpretation and somatisation. The specialist literature expresses some support for stabilisation treatment. Preliminary results of a pilot study that evaluated a stabilisation course with a psycho-educational and cognitive behavioural content indicate that a course of that kind, if linked to research, is both feasible and effective. We therefore believe that further research by means of a randomized controlled trial is warranted.