2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Treatment Recommendations for Post-Traumatic Stress Disorder: Lessons from Neuroimaging

This paper reviews current treatment recommendations for post-traumatic stress disorder (PTSD). We focus in particular on therapeutic interventions and how neuroimaging studies have informed treatment options.

PTSD can develop after exposure to potentially traumatic events such as assault, combat, disasters, and accidents. While approximately half the U.S. population will experience at least one potentially traumatic event in their lives, PTSD prevalence for American adults is estimated at 6.8 percent across the lifetime (Kessler et al., 2005a), and 3.5 percent over the past year (Kessler et al., 2005b).

Rates are much higher in certain populations such as combat veterans and refugees, with trauma exposure among veterans linked to alarmingly high suicide rates. In 2014, an average of 20 veterans died by suicide each day, accounting for 18 percent of all deaths by suicide in the U.S., despite only accounting for 8.5 percent of the population (U.S. Dept. of Veterans Affairs, 2016).

Individuals with PTSD may experience distressing memories of the event, heightened startle reactions, avoidance of certain situations, and sleep and concentration difficulties that can impair daily functioning. In light of the pervasive effects of trauma, further research is needed to help improve available treatment options.

Last year, the American Psychological Association released empirically-derived treatment guidelines for PTSD (APA, 2017), which strongly recommended the use of cognitive behavioral therapy (CBT) for PTSD; in particular, cognitive processing therapy (CPT), cognitive therapy (CT), and prolonged exposure (PE).

Cognitive therapy focuses on modifying and replacing maladaptive thoughts, beliefs and expectations. CPT and PE involve processing trauma memories by going over, or exposing, the trauma narrative to enhance the individual’s ability to tolerate, rather than avoid, trauma memories.

Dysfunctional cognitions are often identified through this process as targets for intervention. These treatments outperformed waitlist and treatment-as-usual in various randomized controlled trials of military-related PTSD (Steenkamp, 2015), with 49 – 70 percent of participants receiving CPT or PE experiencing clinically meaningful symptom improvement. However, approximately two-thirds of these individuals retained their diagnosis of PTSD even after treatment. It is possible that improvements would have been greater in civilian populations, given that combat veterans typically experience multiple traumas following deployments.

Current evidence indicates that that treatment for PTSD can be significantly improved by psychotherapeutic approaches alone. Regarding pharmacotherapy, the APA guidelines state that selective serotonin reuptake inhibitors (SSRIs) may be used. However, the U.S. Department of Veterans Affairs cautions that medications do not treat the underlying cause of PTSD symptomatology (U.S. Veteran’s Affairs, 2018) and therefore, psychotherapeutic interventions should be offered as first line treatment.

Neuroimaging studies provide one important avenue for improving PTSD interventions. To date, these studies suggest that psychological trauma leads to dysregulation of fear processing circuitry in the brain, as well as changes in brain structure (Erickson et al., 2014; Pagani and Cavallo, 2014). Clinicians may need training to understand, and be able to deliver, validated treatments that prevent or reverse these alterations in brain function.

Neuroimaging research on PTSD has mostly focused on circuits that are thought to be important for fear learning and extinction, including the ventromedial prefrontal cortex (PFC), which has an inhibitory influence on the amygdala, a brain structure associated with emotional control in the fear processing network. Taken together, these areas are important in fear learning and extinction, as well as the hippocampus which is important in declarative memory (Erickson et al., 2014).

Importantly, neuroimaging studies have shown that successful exposure-based cognitive behavioral therapy can impact the neurophysiology of PTSD (Felmingham et al, 2007). In other words, successful CBT treatment not only can reduce PTSD symptoms, but also may improve the brain’s ability to regulate fear processing as evidenced by changes in neural fear processing networks. It is critical to understand that successfully treating PTSD using psychotherapeutic approaches can clearly impact the physiology in the brain that underlies PTSD symptoms. To our knowledge, there is no such similar evidence supporting neural change with medication (SSRI) treatment in PTSD patients.

Furthermore, other neuroimaging studies have shown a relationship between an individual’s successful response to exposure-based CBT and frontal brain circuitry responsible for fear processing (Falconer et al., 2008; Bryant et al., 2008).

While these studies provide encouraging evidence for trauma-focused therapy, not all individuals who may benefit from treatment are able to access it. Barriers to treatment include the unavailability of appropriate services, high costs, and lack of transportation to access services.

Moreover, one of the largest obstacles to treatment is the stigma surrounding mental health issues. This may be particularly true for certain populations such as military veterans. Innovative research is attempting to overcome this challenge by exploring other avenues for the collection of trauma-related data. For instance, one study found that service members disclose their PTSD symptoms more fully when they anonymously answer Post-Deployment Health Assessment (PDHA) questionnaires, compared to the official PHDA administered by the military which is tied to their identity (Lucas et al., 2017). This study also examined the use of automated virtual reality humans that interview people about their symptoms and found that active-duty service members reported more symptoms to a virtual human interviewer, compared to an anonymized PDHA.

In summary, while promising and somewhat effective treatments for PTSD do exist, these interventions may benefit from ongoing innovations made possible by advances in neuroimaging and technology- supported approaches to managing PTSD.

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