Neuroscience Informed Prolonged Exposure Practice: Increasing Efficiency and Efficacy Through Mechanisms

Summary & key facts

This paper reviews studies about prolonged exposure therapy, a well-supported treatment for posttraumatic stress disorder. The authors summarize how PTSD changes brain networks and how prolonged exposure seems to restore connections between key areas involved in emotion and memory. They also describe several drugs and brain-stimulation methods that researchers are testing to make exposure therapy work better or keep people in treatment longer, and they point out that more research is needed to know which enhancements really help.

Key facts:

• Prolonged exposure is a proven psychological treatment for posttraumatic stress disorder that involves revisiting traumatic memories in a safe way.
• People with PTSD tend to have disrupted connections between several brain regions that handle fear, emotion regulation, and memory.
• Studies report that successful prolonged exposure is linked to stronger coordination between the ventromedial prefrontal cortex, the amygdala, and the hippocampus. These three areas help calm fear and store memories.
• After prolonged exposure, some people show increased connections in the dorsolateral prefrontal cortex, a brain area tied to controlling emotions in stressful situations.
• How a person’s brain regions are connected before treatment can sometimes predict how well they will respond to exposure therapy.
• Researchers have tested several ways to boost exposure therapy, including common antidepressant drugs called serotonin reuptake inhibitors, the drugs D-cycloserine, allopregnanolone, propranolol, the hormone oxytocin, the drug MDMA, and brain stimulation called repetitive transcranial magnetic stimulation.
• Because changes in brain connectivity seem important for how exposure therapy works, the authors suggest that repetitive transcranial magnetic stimulation is a sensible option for more research as an add-on to exposure therapy.
• The review summarizes existing studies but does not prove that any particular enhancement will definitely help every person, and the authors call for more research to test safety and real-world benefits.

Abstract

Prolonged exposure (PE) is an empirically supported efficacious treatment for posttraumatic stress disorder (PTSD). In this focused review, we briefly review the neurobiological networks in PTSD relevant to PE, discuss the theoretical basis of PE, review the neurobiological mechanisms underlying the effectiveness of PE and identify the enhancements that can be applied to increase treatment response and retention. Based on the reviewed studies, it is clear that PTSD results in disrupted network of interconnected regions, and PE has been shown to increase the connectivity within and between these regions. Successful extinction recall in PE is related to increased functional coherence between the ventromedial prefrontal cortex (vmPFC), amygdala and the hippocampus. Increased connectivity within the dorsolateral PFC (dlPFC) following PE is associated with more effective downregulation of emotional responses in stressful situations. Pre-existing neural connectivity also in some cases predicts response to exposure treatment. We consider various enhancements that have been used with PE, including serotonin reuptake inhibitors (SSRIs), D-cycloserine (DCS), allopregnanolone (ALLO) and propranolol, repetitive transcranial magnetic stimulation (rTMS), oxytocin and MDMA. Given that neural connectivity appears to be crucial in mechanisms of action of PE, rTMS is a logical target for further research as an enhancement of PE. Additionally, exploring the effectiveness and mechanisms of action of oxytocin and MDMA in conjunction with PE may lead to improvement in treatment engagement and retention.

Topics

Memory and Neural Mechanisms Neuroendocrine regulation and behavior Stress Responses and Cortisol

Categories

Behavioral Neuroscience Life Sciences Neuroscience

Tags

Amygdala Anxiety Biology Cognition Exposure therapy Extinction (optical mineralogy) MDMA Neuroscience Oxytocin Paleontology Prefrontal cortex Psychiatry Psychology Stimulation Transcranial magnetic stimulation Ventromedial prefrontal cortex

Substances

MDMA

Conditions & symptoms

Anxiety PTSD Anxiety or worry Feeling disconnected from others Poor sleep Sadness or low mood