Kate Johnson

April 18, 2012

April 18, 2012 (Arlington, Virginia) — Baseline brain activation studies may predict treatment response in women undergoing cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD) related to domestic violence, new research shows.

Using functional magnetic resonance imaging (fMRI) before and after cognitive trauma therapy for battered women (CTT-BW), researchers found that certain baseline patterns of brain activation predicted better response to treatment.

Specifically, the study showed that greater baseline anterior cingulate and less baseline posterior insula response to anticipation predicted treatment response.

"If we can find techniques to target these areas specifically to enhance CBT and future treatments, that is important," said lead investigator Robin Aupperle, PhD, who collected the data at the Veterans Affairs Medical Center and the University of California, both in San Diego, before moving to her current position at the University of Missouri in Kansas City.

The study was presented here at the Anxiety Disorders Association of America (ADAA) 32nd Annual Conference.

Room for Improvement

Some studies show only a 50% response rate to CBT therapies in the domestic violence population, so "there is room for improvement," said Dr. Aupperle.

"Given that we have developed these great behavioral treatments that are only currently effective for certain individuals, how do we push that forward...to actually enhance their effectiveness further?"

Work aimed at enhancing CBT was featured prominently at the meeting, but very few studies have explored the combination of fMRI with CBT, said Dr. Aupperle.

Pretreatment PTSD imaging studies have shown dysfunctional neurocircuitry involving the amygdala and insula regions as well as prefrontal regions, she noted.

"So the idea is that perhaps with PTSD, you're seeing an inability to recruit the prefrontal regions to appropriately inhibit the amygdala and insula responses."

The few studies exploring fMRI response to CBT treatment demonstrate decreased amygdala response and increased anterior cingulate response with treatment compared with baseline, she said.

However, very little is known about imaging predictors of treatment response.

The current study focused on the specific neural mechanisms involved in anticipatory processing because "anticipation lies at the center of our understanding of anxiety" and plays an important role in avoidance behavior, she said.

Fourteen women with domestic violence–related PTSD underwent fMRI at baseline and then again after a 10- to15-week CTT-BW treatment. Brain activation was measured during anticipatory processing of positive and negative emotional images.

The Clinician-Administered PTSD Scale (CAPS) was used to measure response to treatment and showed a significant decrease in mean scores — from 66 at baseline to 16 posttreatment (P < .001) — a response that was largely maintained at the 3-month follow-up, she said.

Hypothesis Confirmed

fMRI showed that treatment increased anterior cingulate and posterior cingulate responsivity and decreased anterior insular responsivity, "confirming our hypothesis," she said.

Because only 2 women showed less than a 50% response to treatment, fMRI predictors could not be identified for response vs no response, so instead, the researchers examined predictors of level of response.

They noted that greater baseline activation within the dorsal anterior cingulate and the posterior cingulate predicted better posttreatment CAPS score.

"The more they recruited these regions during anticipation at baseline, the better they responded to treatment," said Dr. Aupperle.

The findings help narrow the focus on specific neural targets in PTSD and underscore the role of imaging in both monitoring and predicting treatment response, she said.

"What will be important is using this knowledge for future interventions. If we know there are certain areas of the brain that are responding differently or abnormally...can we think of ways to specifically target those? And then could we perhaps use fMRI or other techniques to test those out to see which ones might have the potential to go forward with larger clinical trials?"

"Discouraging" Findings?

Asked to comment on the presentation for Medscape Medical News, Melissa Hunt, PhD, associate director of clinical training at the University of Pennsylvania's Department of Psychology, in Philadelphia, said that in some ways, the research was "rather discouraging."

"What it suggests is that a lot of damage has already been done, that it's reflected in brain morphology and brain function, and that it predicts poor response to treatment," she said.

However, the imaging documentation of treatment response was reassuring, she said.

"This [research] was focused on PTSD. There's a lot of early imaging data in OCD [obsessive compulsive disorder] that suggests that effective exposure therapy for OCD actually normalizes brain function. So that makes me a little more optimistic that perhaps we can, through effective therapy, actually normalize some of these things."

Dr. Aupperle and Dr. Hunt have disclosed no relevant financial relationships.

Anxiety Disorders Association of America (ADAA) 32nd Annual Conference. Session 316R, presented April 13, 2012.


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