Transcript Handout

Neural Correlates of
Symptom Reduction
During TF-CBT
JOSH CISLER, PHD
BRAIN IMAGING RESEARCH CENTER
PSYCHIATRIC RESEARCH INSTITUTE
UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES
Overview
Discuss a recent collaborative study between AR BEST and BIRC to understand treatment
response to TF-CBT
◦ Participants were local Arkansan adolescent girls with PTSD related to assault
◦ Many of the participants were even referred to us by AR BEST clinicians
Purpose of the study
What the study involved
Results and some preliminary conclusions
What is TF-CBT?
Trauma-focused cognitive behavioral therapy – structured psychological therapy targeting the
following domains:
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Psychoeducation and Parenting
Relaxation
Affect Modulation
Cognitive Coping Skills
Trauma Narrative / Cognitive Processing
In vivo exposure
Conjoint parent-child sessions
Enhancing future safety
Typically delivered in 12-16 sessions
Strong evidence base for traumatized children with PTSD, anxiety, depression, or externalizing
behaviors related to trauma exposure
Purpose of the Study
TF-CBT is our gold-standard treatment for youth with traumatic stress-related symptoms
Nonetheless, 100% symptom reduction does not always occur
On average, children after TF-CBT
still demonstrated significant PTSD
symptoms
From Cohen et al. 2011 – randomized
controlled trial of TF-CBT in a
community setting
Purpose of the Study
TF-CBT is our gold-standard treatment for youth with traumatic stress-related symptoms
Nonetheless, 100% symptom reduction does not always occur
Our overall goal is to understand how to improve the consistency of response to TF-CBT
◦ 1) Can we identify pre-treatment markers of who will response best?
◦ 2) can we identify the mechanisms through which TF-CBT works so that we can learn how to enhance
it?
Study Overview
Recruited adolescent girls, aged 11-17, with PTSD related to physical or sexual assault
Provided 12 sessions of manualized TF-CBT
◦ Thanks to Drs. Karin Vanderzee, Joy Pemberton, and Ben Sigel!!!!
◦ Followed standard PRACTICE modules
Assessed clinical symptoms before and after treatment
Assessed brain function before and after treatment
◦ Functional magnetic resonance imaging (fMRI)
◦ Measure brain activity while the adolescent performs a cognitive task
Enrollment Flow
Assessed for eligibility
(n = 53)
Excluded (n = 14)
Not meeting inclusion criteria
(n = 4)
Refused to participate
(n = 4)
Other reasons (n = 6)
Consented (n = 39)
Enrolled and Began TF-CBT
(n = 34)
Ineligible for
enrollment following
assessments
(n = 5)
(No current PTSD)
Withdrew before
skills portion
complete (n = 4)
Completed skills portion
but withdrew prior to full
completion (n = 5)
Completed all TF-CBT
modules (n = 25)
Emotion Processing Task
Fearful expression
Neutral expression
Cognitive re-appraisal task
Participant gets an instruction:
‘notice your feeling’
or
‘think positive’
Then they see either a
negative image or a
neutral image
Participant gets an instruction:
‘notice your feeling’
or
‘think positive’
“the building wasn’t safe
so they are taking it down
to build a safer one”
Variable
Mean/frequenc
y (SD)
Age
13.87 (1.77)
Verbal IQ
95.26 (15.00)
Ethnicity
39% Caucasian
52% African
American
9% Biracial
0% Hispanic
Total number of types 5.65 (3.98)
of assaults
Direct Physical Assault 96%
Sexual Assault
87%
Witnessed Violence 91%
Psychotropic
SSRI - 39%
Medication
Antipsychotic –
17%
SARI – 4%
Alpha blocker –
4%
Pre-Treatment
Current PTSD
100%
# comorbid diagnoses 2.74 (2.22)
Current Anxiety Disorder 65%
Current Depressive
Disorder
Current Bipolar Disorder
Current Alcohol Use (past
year)
Current Substance Use
(past year)
Current Conduct/ODD
UCLA PTSD Index
SMFQ
PostTreatment
35%
1.00 (1.62)
17%
52%
13%
4%
8%
0%
4%
12%
17%
26%
36.04 (17.87)
21%
18.30 (16.62)
12.22 (8.25)
4.61 (6.55)
Who is likely to be a good responder to
TF-CBT?
Can we identify markers that let us predict who will and will not have good responses to TF-CBT?
Who is likely to be a good responder to
TF-CBT?
Can we identify markers that let us predict who will and will not have good responses to TF-CBT?
◦ Using data from the emotion processing task
◦ Does pre-treatment brain activity to emotional images predict symptom reduction?
Who is likely to be a good responder to
TF-CBT?
Adolescent girls who differentiate danger from safety signals seem to be more likely to respond
better to TF-CBT
What are the mechanisms of TF-CBT?
Through what intermediate mechanisms does TF-CBT produce symptom change?
Penicillin
Fever reduction
Infection reduction
Penicillin
Fever reduction
TF-CBT
PTSD symptom reduction
??????
TF-CBT
PTSD symptom reduction
Emotion
Regulation
TF-CBT
PTSD symptom reduction
What are the mechanisms of TF-CBT?
TF-CBT may improve the adolescent’s ability to regulate emotions, which results in PTSD
symptom reductions
Better emotion regulation may be due to specific brain changes:
◦ Suppression of amygdala-insula functional connectivity
◦ Heightened amygdala-dACC functional connectivity appears to be detrimental
Overall Discussion
There is significant variability in PTSD symptom reduction during TF-CBT
◦ Partly related to initial symptom severity
◦ Partly related to how well the adolescent initially discriminates danger from safety
◦ Partly related to how well TF-CBT helps the child learn to regulate emotions
◦ Which is partly related to specific changes in brain function during emotion regulation
Overall Discussion
There is significant variability in PTSD symptom reduction during TF-CBT
◦ Partly related to initial symptom severity
◦ Partly related to how well the adolescent initially discriminates danger from safety
◦ Partly related to how well TF-CBT helps the child learn to regulate emotions
◦ Which is partly related to specific changes in brain function during emotion regulation
Limitations
Small sample (N=25)
Only girls
Only 12 sessions
◦ Allows comparability across adolescents, but real-world TF-CBT can be more flexible
Long-term follow-up?
We are recruiting for more research
studies!!!
Further investigations of how early life trauma changes brain function and increases risk for
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Drug use disorders
PTSD
Risk for revictimization
Problems with intimacy and trust
We recruiting for more research
studies!!!
Adolescent girls
age 11-17
With or without histories of physical or sexual assault
With or without histories of drug use
No internal metal (no braces)
Adolescent and caregiver earn monetary compensation
Contact Jennifer Payne: 501-526-8497