Acquisition, extinction, and return of fear in veterans in intensive outpatient prolonged exposure therapy: A fear-potentiated startle study

• Type of Material: Article
• Authors: Jessica Maples-Keller, Emory University; Laura Watkins, Emory University; Karin Nylocks, Emory University; Charlotte Yasinski, Emory University; Callan Coghlan, Emory University; Kathryn Black, Emory University; Tanja Jovanovic, Emory University; Sheila Rauch, Emory University; Barbara Rothbaum, Emory University; Seth Norrholm, Emory University
• Language: English
• Date: 2022-05-25
• Publisher: PERGAMON-ELSEVIER SCIENCE LTD
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2022 Elsevier Ltd. All rights reserved.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1016/j.brat.2022.104124
• Title of Journal or Parent Work: BEHAVIOUR RESEARCH AND THERAPY
• Volume: 154
• Start Page: 104124
• End Page: 104124
• Grant/Funding Information: This work is supported by Building Interdisciplinary Research Careers in Women’s Health of the National Institutes of Health (JMK; Award Nos. K12HD085850, UL1TR002378), The authors acknowledge, with gratitude, critical support from Wounded Warrior Project (B.O.R.), who supports the Emory Healthcare Veterans Program and serves as a partner in the Warrior Care Network, dedicated to filling gaps in mental health care for the invisible wounds of war in service members, veterans, and military families, and to the Robert McCormick Foundation. We thank Manessa Riser for her assistance in the preparation of this work.
• Keywords: Extinction; Exposure therapy; Psychophysiology; POSTTRAUMATIC-STRESS-DISORDER; PTSD; ANXIETY; INTERVIEW; Psychology, Clinical; Social Sciences; RECALL; Fear; Startle; Psychology

Abstract

Prolonged exposure (PE) therapy is a first-line treatment for posttraumatic stress disorder (PTSD) and involves repeated presentation of trauma-related cues without aversive outcomes. A primary learning mechanism of PE is fear extinction (new learning that a dangerous cue is now safe) and its retention (maintaining this new learning over time). Extant research suggests extinction is impaired in PTSD patients. In this study, we employed an established fear-potentiated startle-based paradigm to examine fear acquisition, extinction learning and retention before and after completion of intensive outpatient treatment. First, PTSD patients undergoing PE (n = 55) were compared to trauma-exposed patients without PTSD (n = 57). We identified excessive fear in PTSD patients during acquisition and extinction before treatment compared to non-PTSD patients. At post-treatment, we examined the return of fear after extinction in PTSD patients showing high or low treatment response to PE (≥50% change in PTSD symptom severity vs. < 50%). High PE responders maintained fear extinction learning whereas low PE responders showed significant return of fear at post-treatment. These results replicate and extend previous findings of impaired extinction in PTSD and provide support for the proposed theoretical link between fear extinction and PE response.