Clinical trial NCT06629064: Cognitive Control Training for Extinction in PTSD
Official title: Identifying Clinically Relevant Neural Circuit Mechanisms of Cognitive Control Training for PTSD
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: NA
Conditions: Post-Traumatic Stress Disorders
Stress Disorders, Traumatic
Post Traumatic Stress Disorder
PTSD
Trauma and Stressor Related Disorders
Keywords: Trauma and Stressor Related Disorders
PTSD
cognitive training
working memory
Fear Extinction
Lead sponsor: VA Office of Research and Development
Sponsor class: FED
First posted: 2024-10-08
Enrollment: 120
Sex: ALL
Minimum age (years): 18
Maximum age (years): 65
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Two group randomized controlled trial of WMT versus a Sham training
Primary purpose: OTHER

Brief summary: The proposed study will test whether a working memory training (WMT) program improves fear extinction learning and its underlying neural circuitry in Veterans with posttraumatic stress disorder (PTSD). WMT is designed to improves the ability to maintain task-relevant information in mind. The project will further validate the relationship between working memory and fear extinction using novel computational and multivariate analyses that link to specific PTSD symptoms. If WMT can enhance fear extinction learning, then WMT may be a powerful adjunctive treatment that can enhance exposure therapy outcomes or be leveraged as a stand-alone treatment. This project supports the Department of Veteran Affairs mission of developing viable targets of treatment for Veterans with PTSD.

Detailed description: Posttraumatic stress disorder (PTSD) is prevalent, debilitating, and associated with significant levels of functional impairment in Veterans seeking care at the VA. Despite evidence that current treatments for PTSD are effective, a substantial portion of individuals maintain elevated PTSD symptoms after first line treatments. Mechanistic insight and tools that improve the neurocognitive and affective mechanisms that underlie successful clinical outcomes from evidence-based psychotherapies, like prolonged exposure, are highly needed. One of the most prominent mechanisms associated with therapeutic symptom reduction in PTSD is fear extinction. Indeed, extinction learning is a key theoretical treatment target in exposure-based therapies for PTSD. Fear extinction learning is not only an emotional process, but relies on an individual's cognitive control abilities, including working memory (WM). Under a WM framework, high WM ability offers the ability of an individual to adjudicate the competition between threat and extinction memory expression as they repeatedly encounter feared cues that are no longer threatening. Consistent with this hypothesis, previous investigations show replicable findings that variation in WM ability is associated with laboratory measures of fear extinction learning. The investigators have previously shown that psychophysiological and neural measures of fear extinction is a construct malleable to treatment. In civilian populations a brief WM training (WMT) designed to boost WM was effective in reducing anxiety during a speech exposure and was is effective in enhancing behavioral and neural markers of WM ability. These findings raise the intriguing possibility for the mechanistic link between WM and extinction, and that enhancing WM ability through WMT may also improve fear extinction learning success in Veterans with PTSD.

The current proposal aims to answer these questions. In a between-group design, Veterans diagnosed with PTSD will complete 8-sessions of working memory training (WMT) or sham-training (ST) over a four-week period. At pre- and post-training, Veterans will complete a standard fear acquisition \& extinction learning task in addition to tasks assaying WM capacity and cognitive control. The investigators will identify whether WMT modulates behavior, psychophysiological, and neural changes in extinction learning. The investigators will further test the conceptual link between WM and extinction in Veterans with PTSD by testing whether neural circuits associated with high WM capacity and extinction learning are linked. The project is expected to determine if a cognitive control training program targeting WM capacity shows the potential to enhance behavioral and neural markers of fear extinction, mechanisms that are clearly integral to current PTSD treatments. These aims support the VA mission of testing and evaluating innovative treatment targets for PTSD. Results will provide a mechanistic foundation for future clinical trials that test whether adding WMT prior to or in conjunction with exposure based psychotherapies will improve clinical outcomes and further clarify existing mechanistic and neurobiological models of PTSD and its treatment for Veterans.

Eligibility criteria: Inclusion Criteria:

* Fluent in English
* Meet current DSM-5 criteria for Posttraumatic Stress Disorder
* Are willing to attend 8 total remote sessions of working memory training over course of four weeks
* Are willing to attend MRI scans pre and post working memory training
* 4-week stability on pharmacological and psychosocial treatments

Exclusion Criteria:

* A lifetime history of psychotic disorders, lifetime history of bipolar disorder
* Past-year severe substance use and severe alcohol use disorder. Mild-to-moderate alcohol use disorder will be allowed to enhance generalizability in our sample due to the high comorbidity of alcohol use and PTSD
* History of any neurological disorder that might be associated with cognitive dysfunction (e.g., cerebrovascular accident, intracranial surgery, aneurysm, seizure disorder)
* Acute suicidality requiring immediate clinical intervention
* Moderate to severe traumatic brain injury (TBI). However, mild to moderate levels of TBI (mTBI) will be included.
* Receiving benzodiazepines or medications with anticholinergic effects that may affect fear learning measures
* Inability to safely complete fMRI session (i.e., metal in body, medical implants)

Primary outcomes:
measure: Behavioral Threat Expectancy Ratings During Extinction Performance
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: Extinction Electrodermal Activity Response
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: Extinction Blood Oxygen Level Dependent (BOLD) Response
timeFrame: Baseline, Approximately 5 or 6 weeks
Secondary outcomes:
measure: Working Memory Task Blood Oxygen Level Dependent (BOLD) Response
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: Working memory capacity change detection task
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: Affective working memory task
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: Flanker Task
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: Affective stop signal task
timeFrame: Baseline, Approximately 5 or 6 weeks
Other outcomes:
measure: PTSD Checklist for DSM-5 (PCL-5)
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: PHQ-9 (Patient Health Questionnaire-9)
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: General Anxiety Disorder 7 (GAD-7)
timeFrame: Baseline, Approximately 5 or 6 weeks
measure: Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)
timeFrame: Baseline, Approximately 5 or 6 weeks
Locations:
city: San Diego
country: United States
facility: VA San Diego Healthcare System, San Diego, CA
state: California
Study officials:
affiliation: VA San Diego Healthcare System, San Diego, CA
name: Daniel M Stout, PhD
role: PRINCIPAL_INVESTIGATOR
References: