Dr. Roger Pitman a Professor of Psychiatry at Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA delivered a lecture entitled, “Stress, Anxiety, and Trauma.” Because of the breadth of this topic, Dr. Pitman focused on his group’s research into biological aspects of posttraumatic stress disorder (PTSD). He noted that although PTSD is still largely regarded as a psychological phenomenon, ultimately the impact of an environmental event, such as a psychological trauma, must be understood at organic, cellular, and molecular levels. Dr. Pitman reviewed research in the psychophysiology laboratory beginning in the 1980’s indicating that trauma victims diagnosed with PTSD showed larger heart rate, skin conductance, and facial electromyogram responses during personal, script-driven imagery of their traumatic events. When the script-driven imagery method was taken into the positron emission tomography (PET) scanner, results indicated that PTSD subjects also showed greater concurrent activation of amygdalocentric anterior plimbic brain areas thought to underlie emotional experience. However, one brain region, the ventromedial prefrontal cortex (vmPFC), showed pdoxically reduced activation in PTSD subjects during traumatic imagery. Further work with functional magnetic resonance imaging (fMRI) revealed an inverse association between vmPFC and amygdala activation, suggesting that vmPFC activation acts to inhibit amygdala and thereby confers resilience.
Pitman also presented results of a 15-year ongoing study of identical twins discordant for combat exposure in Vietnam, which has addressed the origin of biological abnormalities in PTSD. If his combat-unexposed co-twin shares an abnormality in a PTSD veteran, it is unlikely to have been acquired as a result of combat trauma but rather likely represents a familial vulnerability factor. If it is not shared, it is likely to have been acquired. This research has suggested that greater heart rate response to loud (startling) tones, lower electroencephalographic P300 event-related potential (ERP) response, increased P2 intensity dependence, lower vmPFC volume according to voxel-based morphometry, and impaired retention of extinction of a de novo conditioned fear response are acquired PTSD biomarkers, whereas more neurological soft signs (suggestive of subtle central nervous system impairment), diminished volume of the hippocampus, and both hypermetabolism and hyperreactivity of dorsal anterior cingulate cortex (a brain region found to promote the fear response) are familial vulnerability factors for PTSD.
Dr. Mohammed R Milad from the Department of Psychiatry at the Department of Psychiatry and Massachusetts General Hospital presented a talk entitled “Neurobiology of learning not to fear: implications to PTSD and beyond”. In his presentation, Dr. Milad presented data on the neural correlates of fear extinction using a translational and multi-modal approach. After a brief definition and description of the classical fear conditioning pdigms used to study fear extinction, Dr. Milad presented data describing the basic mechanisms of how fear extinction learning is formed and stored with a network of brain regions including the ventromedial prefrontal cortex (vmPFC), the amygdala and the hippocampus. Dr. Milad presented data regarding the apparently apposing effects of two prefrontal regions on fear expression: the activation of the dorsal anterior cingulate cortex (dACC) seems to enhance the expression of conditioned fear, and the vmPFC seems to quell the expression of fear. The function of these brain regions within the context of fear learning and extinction seems to be impaired in patients diagnosed with PTSD, and that such functional impairment seem to be associated with exaggerated fear expression in PTSD patients.
In the second part of his talk, Dr. Milad described the potential role of gonadal hormones, such as estrogen, on fear extinction and how these hormones may contribute to sex differences in fear learning and extinction and may also contribute to the differences in the epidemiology of PTSD between men and women. In brief, Dr. Milad presented data showing that an increased estrogen level in both female rats and in women is associated with enhanced consolidation of extinction memory. The elevated levels of estrogen seem to interact with the functional activation of the fear extinction network, specifically, the higher the estrogen levels, the more activation the vmPFC exhibits during extinction recall in women. The importance of assessing hormonal status in women during treatment for PTSD and other anxiety disorders was highlighted in the presentation.
Dr. Gregory Quirk from the University of Puerto Rico presented a talk entitled “Neurobiological Basis of Conditioned Fear and Extinction” in which he talked about the neural mechanism of fear conditioning, using rats as a model organism. Fear conditioning has become a popular model of emotional learning, in which neurons in the amygdala, hippocampus, and prefrontal cortex acquire information about stimuli (such as tones) that predict danger (such as shocks). Disruption of such circuits leads to excessive fear seen in anxiety disorders such as PTSD and OCD. Quirk showed that expression of fear in the amygdala is under bidirectional control by the prelimbic and infralimbic subdivisions of prefrontal cortex. Modulation of activity in these circuits can increase fear either by facilitating expression or by impairing extinction of fear. In addition to modulating fear (such as freezing), these areas also modulate avoidance behaviors, in which rats escape a shock by moving to a safe place. Deep brain stimulation (DBS) of the ventral striatum has been shown to help some patients suffering from OCD, and Quirk showed rodent data suggesting that DSB may act by augmenting plasticity in extinction circuits located in amygdala and prefrontal areas. In collaboration with Dr. Haber, Quirk is characterizing the striatal-cortical circuits by which DBS enhances extinction of fear.
Topic 3: Anxiety and depression: perspective from the region.
Dr. Abdul-Monaf Al-Jadiry, Professor and chair of Psychiatry, Department of Medicine, Medical Faculty, The University of Jordan, Amman, Jordan gave a presentation entitled, "Prevalence of Anxiety and Mood Disorders and the link to Trauma: An Iraqi Perspective". The presentation initiated with a general conclusion, based on literature review, about the impact of trauma on mental health in general, and the prevalence of anxiety and mood disorders in particular. Dr Al-Jadiry presented data from Iraqi Mental Health Survey (IMHS) to demonstrate the link between the two. IMHS is the first nationwide mental health epidemiological survey in Iraq and the second in the Middle East after Lebanon. The IMHS was undertaken in the years 2006-207, amidst circumstances of extreme instability and minimal security following the second gulf war. IMHS used World Mental Health Survey (WMHS) methodology and diagnostic instrument to provide data on the prevalence of mental health disorders, their impact and treatment, and their relationship to violence in the population. Trained interviewers used the “Composite International Diagnostic Interview (CIDI), Version 3” as a diagnostic tool for the assessment of mental disorders. The IMHS for the first time provides evidence-based data about the prevalence of mental health problems and mental health of Iraqi people. The survey provides an initial indicator of lifetime prevalence, and 12 months and 30 days prevalence rates alongside the experience of trauma. The importance of the Iraqi example springs from the fact that the state of Iraqis has been unique, as they have suffered more than any other people from decades of war trauma, sanctions and violence, which are still going on.
The IMHS demonstrated that 11.58% of population suffered from any anxiety disorder, including stress disorder, lifetime, and 7.82% from any affective disorder lifetime, with a significant difference between women and men, age groups, and several other socio-demographic variables. Moreover, the overall lifetime exposure to traumatic events, according to the survey was 60.02%. In the lifetime prevalence rate of these disorders cases had significant higher exposure to trauma. The most striking finding of the survey is the very high exposure of the population to various types of trauma and the relative low prevalence rates of anxiety and mood disorders though in line with prevalence rates reported in Lebanon and Afghanistan. Dr. Al-Jadiry attributed this discrepancy to the biological nature of people vulnerability for anxiety and mood disorders in addition to inherent protective sociocultural characteristics of Iraqis; these include: development of resilience, high community support, rituals to canalize distress and bereavement in a socially acceptable manner, and viewing losses as divine states. Moreover, the effect of stigma of mental illness is to make some patients hide their symptoms. Dr Al–Jadiry concluded, despite massive exposure to traumatic events, the prevalence of anxiety and mood disorders amongst Iraqis is relatively lower than expected, though in accordance with the literature from post conflict zones.
Dr. Walid Sarhan a consultant Psychiatrist from Amman Jordan gave a talk entitled “Cognitive behavioral therapy of Islamic religious OCD”. The talk started by brief background of Islamic religion with emphases on how its comprehensive application to people’s daily lives and its rules to be followed in praying, washing, cleaning may relate to OCD symptoms expressed in some of the patients in the region. In managing those patients, Dr. Sarhan discussed how therapists may need to be aware of the compatibility of the cognitive behavioral therapy with the Islamic religion. The clinical experience of dealing with cleaning, abolition, praying, divorce and doubts in beliefs were discussed in light of the literature, while at the same time addressing the common clinical challenges presented by Arab Muslim patients suffering from OCD. Dr. Sarhan discussed how religious individuals with authority to declare legal rulings or decrees (Fatwa) on some aspects of the Islamic religion may also influence patient’s symptoms. The clinician’s knowledge of some of these rulings or “fatwas” may be necessary to understanding how some aspects of the OCD symptoms (especially those related to cleansing) came to exist.
In obsessions related to one’s faith, Dr. Sarhan suggested that clinician’s knowledge of the Islamic religion might be used as an additional tool to help aid the treatment; a clinician could make use of the teachings of the prophet to his followers as the key element in cognitive therapy.
Dr. Radwan A. BaniMustafa from the University of Jordan Medical School & Hospital gave a talk entitled “Depression in Primary patients with chronic medical diseases” he described a study which included a group of 407 primary care patients with chronic medical diseases. These patients were seen in the primary care clinics in Jordan University hospital in 2011. Prevalence of depression in this sample was 45.5%. Depression was significantly associated with young age, low level of education, chronic headache and chronic musculoskeletal diseases. In addition, it was associated but not significantly so with having more than three medical problems, chronic cardiopulmonary disorders, chronic Skin and thyroid disorders, female sex and single status.