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Review
April 2017

An Integrated Neuroscience Perspective on Formulation and Treatment Planning for Posttraumatic Stress DisorderAn Educational Review

Author Affiliations
  • 1Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, Connecticut.
  • 2Department of Psychiatry, Columbia University Medical Center, New York, New York
  • 3New York State Psychiatric Institute, New York
  • 4Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 5Department of Psychiatry and Child Study Center, Yale School of Medicine, Yale University, New Haven, Connecticut
  • 6McLean Hospital, Harvard Medical School, Belmont, Massachusetts
JAMA Psychiatry. 2017;74(4):407-415. doi:10.1001/jamapsychiatry.2016.3325
Abstract

Importance  Posttraumatic stress disorder (PTSD) is a common psychiatric illness, increasingly in the public spotlight in the United States due its prevalence in the soldiers returning from combat in Iraq and Afghanistan. This educational review presents a contemporary approach for how to incorporate a modern neuroscience perspective into an integrative case formulation. The article is organized around key neuroscience “themes” most relevant for PTSD. Within each theme, the article highlights how seemingly diverse biological, psychological, and social perspectives all intersect with our current understanding of neuroscience.

Observations  Any contemporary neuroscience formulation of PTSD should include an understanding of fear conditioning, dysregulated circuits, memory reconsolidation, epigenetics, and genetic factors. Fear conditioning and other elements of basic learning theory offer a framework for understanding how traumatic events can lead to a range of behaviors associated with PTSD. A circuit dysregulation framework focuses more broadly on aberrant network connectivity, including between the prefrontal cortex and limbic structures. In the process of memory reconsolidation, it is now clear that every time a memory is reactivated it becomes momentarily labile—with implications for the genesis, maintenance, and treatment of PTSD. Epigenetic changes secondary to various experiences, especially early in life, can have long-term effects, including on the regulation of the hypothalamic-pituitary-adrenal axis, thereby affecting an individual’s ability to regulate the stress response. Genetic factors are surprisingly relevant: PTSD has been shown to be highly heritable despite being definitionally linked to specific experiences. The relevance of each of these themes to current clinical practice and its potential to transform future care are discussed.

Conclusions and Relevance  Together, these perspectives contribute to an integrative, neuroscience-informed approach to case formulation and treatment planning. This may help to bridge the gap between the traditionally distinct viewpoints of clinicians and researchers.

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