Executive Function Deficits a New Treatment Target for PTSD?

Nancy A. Melville

March 22, 2022

DENVER — Deficits in executive function are linked to with development of posttraumatic stress disorder (PTSD) symptoms and exacerbation of such symptoms over time, new research suggests.

"To our knowledge, this study is the first to show that executive function deficits maintain PTS symptoms following trauma exposure," investigators note in research presented here at the Anxiety and Depression Association of America (ADAA) Conference 2022.

The results are important in "developing precision medicine-based approaches for alleviating [posttraumatic stress] symptoms, and improving well-established PTSD treatments for those with relative deficits in executive function," study investigator Joseph R. Bardeen, PhD, an associate professor with Auburn University, Auburn, Alabama, told meeting attendees.  

The findings were also published this month in the Journal of Anxiety Disorders.

Cognitive Impairment

In earlier research, deficits in executive function were associated with an increased vulnerability for PTSD symptoms. However, less is known about the role of these deficits, which can impair higher-level cognitive ability, in sustaining PTSD symptoms.

To investigate, the authors conducted a longitudinal study that included 98 participants aged 18-65 years who had been identified via phone screening as experiencing clinically significant PTSD symptoms.

Participants completed self-report measures for PTSD symptoms, as well as measures for executive function deficits at baseline and 6-month (n = 92) and 12-month (n = 91) follow-up sessions.

A path analysis showed a significant relationship between baseline PTSD symptoms and executive function deficits at 6 months (P < .001). Baseline PTSD symptoms were associated with 12-month PTSD symptoms (P < .04).

Executive function deficits at 6 months were also associated with 12-month PTSD symptoms (P = .02).

Importantly, no associations were observed between baseline or 6-month PTSD symptoms and executive function deficits at 12 months. However, executive function deficits at 6 months drove the relationship between PTSD symptoms at baseline and at 1 year (indirect effect = .061).

"What this suggests is that executive-function deficits are a mechanism that maintains patients' symptoms over the course of 1 year," Bardeen said.

"And you don't see the reverse," he added. "You don't see that PTSD symptoms at [6 months] mediate the relationship between [baseline] and 6 month executive function deficits."

Surprising Finding

The findings suggest deficits in executive functioning have a stronger role in maintaining PTSD symptoms than these symptoms have in maintaining executive function deficits, Bardeen told Medscape Medical News.

"I had originally hypothesized a bidirectional relationship in which PTS symptoms influenced future executive function deficits and executive function deficits influenced future PTS symptoms," he said.

"So, it was a surprise that, when accounting for both variables in the same model, executive function deficits predicted future PTS symptoms, but PTS symptoms did not significantly predict future EF deficits," he added.

Bardeen noted this suggests that executive function deficits "may be a particularly important maintenance factor."  

In addition, he recommended the use of neuropsychological assessments prior to treatment to identify individuals with executive function deficits and distinguish those deficits from PTSD symptoms.

"There is certainly overlap between executive function deficits and PTS symptoms,"

Bardeen said. "For example, several of the symptoms of PTSD, such as concentration difficulties, may be indicators of executive function deficits."

He noted assessments such as the Delis Kaplan Executive Function System, and Clinician Administered PTSD Scale for DSM-5, when used as part of a larger assessment battery, can help differentiate between the executive function deficits and PTSD.

"This would take several hours to administer, but in cases in which serious cognitive impairment is suspected, a comprehensive assessment is the way to go," Bardeen said.

The standard approaches of prolonged exposure therapy and cognitive processing therapy can be effective in patients without executive function deficits, while some modifications may benefit those with these deficits, he added.

"For example, it's important to provide a more directive and structured environment in which the practitioner repeats key points frequently, uses concrete language, simplifies worksheets, and provides written summaries and reminder cards," he said.

Further Findings

In additional research presented at the meeting, Elsa Mattson, a PhD student from Case Western Reserve University, Cleveland, Ohio, and colleagues reported findings further distinguishing the role of executive function in PTSD.

In that study of 149 patients with chronic PTSD, those with low performing working memory, but not high working memory, had higher pre- as well as posttreatment PTSD symptom severity and depressive symptoms.

"Clinicians should consider that impairments in executive function may play a role in reduced treatment response, potentially impairing a client's ability to learn new information in treatment," the investigators write.

"Understanding how executive function processes change over the course of treatment, particularly in relation to processing the trauma memories, is an important next step," they add.

The first study was supported by a grant from the National Institute of Mental Health. The investigators have disclosed no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2022: Abstracts 216B and S2-048. Presented March 19, 2022.

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