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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: ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ 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 ◦ ◦ ◦ ◦ 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