fMRI可預期對認知行為治療的反應


  【24drs.com】新研究顯示,基本的腦部活動研究可以預期接受認知行為治療(CBT)之受家暴婦女的創傷後壓力異常(PTSD)治療反應。
  
  受虐婦女認知創傷治療(CTT-BW)前後分別進行功能性磁振造影(fMRI),研究者發現,腦部活動的某些基本模式可以預測較佳的治療反應;特別的是,研究顯示,開始時前扣帶反應越多且後腦島反應越少可用來預測治療反應。
  
  第一作者Robin Aupperle博士在聖地牙哥的加州大學和退伍軍人事務醫學中心蒐集了研究資料,後來轉任到堪薩斯市的密蘇里大學,她表示,如果我們可以發現針對這些區域的技術,用於促進CBT和後續治療,將頗為重要。
  
  該研究發表於美國焦慮異常協會(ADAA)第32屆年會。
  
  Aupperle博士表示,某些研究顯示,家暴受害者的CBT治療反應率只有50%,表示還有改善空間。既然我們發展的這些行為治療目前只對某些人有用,我們該如何進展而使它們的效益提升?
  
  Aupperle博士表示,促進CBT的研究在該會議中相當突出,但是很少有研究探討併用fMRI和CBT。
  
  她指出,治療前的PTSD影像檢查顯示杏仁核和腦島區域、以及前額區域的神經迴路失能。 所以,當發生PTSD時,無法啟動前額區域適當地抑制杏仁核和腦島反應。
  
  少數探討fMRI對於CBT治療反應的研究顯示,與開始時相比,治療後杏仁核反應降低、前扣帶反應增加。
  
  不過,有關影像預測治療反應的所知有限。目前的研究聚焦在涵蓋預期處理的特定神經機轉,因為預期反應堪稱我們對焦慮的理解中樞,在迴避行為中扮演重要角色。
  
  研究開始時,14名受家暴併有PTSD的婦女進行了fMRI,然後接受10-15週的CTT-BW治療,接著再做一次fMRI;對正向和負向情緒影像進行預期處理時測量其腦部活性。
  
  依據臨床醫師PTSD量表(CAPS)測量治療反應,發現平均分數顯著降低— 從開始時的66分降到治療後的16分(P < .001) — 且反應大部份可維持到追蹤3個月時。
  
  她指出,fMRI顯示,治療增加了前扣帶與後扣帶反應,減少了前腦島反應,確認了我們的假設。
  
  因為只有2名婦女顯示對治療的反應低於50%,fMRI預測無法確定有反應或者無反應,因此,研究者欲探討反應程度的預測因子。他們指出,背側前扣帶與後扣帶在開始時的活性越大,可預期治療後的CAPS分數越好。
  
  Aupperle博士表示,在開始時,預期處理過程時啟動越多這些區域,治療反應越佳。這些研究發現幫助聚焦到PTSD特定的神經目標,強調影像檢查對監測和預測治療反應的重要性。
  
  重點在於如何應用這個知識進行後續介入,如果我們知道腦中的某些區域在反應上有困難或異常,我們可以想出針對這些的方法嗎?之後,我們或許可以使用fMRI或其他技術,檢測看哪種方式可以進行更大型的臨床試驗?
  
  費城賓州大學心理系臨床訓練副主任Melissa Hunt博士受邀發表評論時表示,在某些方面,這篇研究「相當令人失望」。該研究認為已經有許多傷害造成,反映在腦部型態和腦部功能,預期對治療反應較差。
  
  不過,治療反應的影像資料是令人欣慰的。這篇研究聚焦在PTSD,強迫症(OCD)的許多早期影像資料認為,OCD的有效曝露療法實際使腦部功能正常化。所以,我們或許可以更樂觀一點,透過有效治療,可使這些恢復正常。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6794&x_classno=0&x_chkdelpoint=Y
  

fMRI May Predict Response to Cognitive Behavioral Therapy

By Kate Johnson
Medscape Medical News

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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