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New PTSD program answers need for comprehensive treatment

July 02, 2009

Jul 02, 2009 (DEFENSE DEPARTMENT DOCUMENTS AND PUBLICATIONS/ContentWorks via COMTEX) — 7/1/2009 – LANDSTUHL REGIONAL MEDICAL CENTER, Germany (AFNS) — Symptoms of combat stress and post-traumatic stress disorder for wounded warriors include continual nightmares, avoidance behaviors, denial, grief, anger and fear.

Some servicemembers battling these and other symptoms, can be treated successfully as an outpatient while assuming their normal duties, but for others; however, returning to work and becoming their old selves again were challenges recognized by several mental health professionals across the European theater.

“We were looking at how we can best meet the needs of our clientele, and we were identifying that a lot of the Soldiers needed more than once a week outpatient, individual therapy and probably needed more than once or twice a week group therapy,” said Joseph Pehm, the chief of Medical Social Work at Landstuhl Regional Medical Center.

The solution came in the creation of an intensive eight-week therapeutic Post-Traumatic Stress Disorder Day Treatment Program called “evolution” that began in March 2009 at LRMC. During the eight-hour days, patients enrolled in the program participate in multiple disciplines and interests, including art therapy, yoga and meditation classes, substance abuse groups, anger and grief management, tobacco cessation, pain management and multiple PTSD evidence-based practice protocols.

“I am a great believer in the kitchen sink, meaning I throw everything, including the kitchen sink, and something will stick,” said Dr. Daphne Brown, chief of the Division of Behavioral Health at LRMC. “And so we’ve come with all the evidence-based treatment for PTSD that we know about. We’ve taken everything that we can think of that will be of use in redirecting symptoms for these folks and put it into an eight-week program.”

Doctor Brown, Mr. Pehm and Sharon Stewart, a Red Cross volunteer who holds a Ph.D. in psychology, said the program is designed from research into the effects of traumatic experience and mirrors successful PTSD programs at Walter Reed Army Medical Center and the Department of Veterans Affairs, as well as programs run by psychologists in the U.S.

“We are building on the groundbreaking work that some of our peers and colleagues have done and just expanding it out,” Doctor Brown said.

During treatment, patients begin the day with a community meeting where they discuss how well they feel and any additional issues or concerns since their last meeting. The remainder of the day depends on the curriculum scheduled for that week.

The first few weeks focus on learning basic coping skills such as how to reduce anxiety and fight fear, as well as yoga and meditation for relaxation. Eye Movement Desensitization and Reprocessing, an evidence-based practice for treating PTSD, is also conducted during the early phases of the treatment program.

“The concept behind EMDR is that, essentially, memories become fixed in one part of our brain and they maintain their power and control over our emotions as long as they are fixed there,” Doctor Brown said. “And if we can activate a different part of the brain while we’re experiencing that memory, we can help to remove some of that emotional valence from it. So we use physiological maneuvers to activate both sides of the brain.”

The goal at the beginning of the PTSD program is to provide patients with a number of tools they can use to help them calm down when feeling overwhelmed, especially before more intense therapy begins in the latter weeks. Cognitive processing therapy is used throughout the program. EMDR and prolonged exposure therapy are also available on an individual basis at the Soldier’s request. All three techniques are research-based treatments.

When life-changing events occur, Doctor Brown said perceptions about the world may change. For example, before Soldiers experience combat trauma they may think the world is safe. Following combat, a Soldier’s perceptions may change; a majority of the world may now seem unsafe. Cognitive processing therapy attempts to readdress experiences and reshift a Soldier’s perceptions.

Prolonged exposure therapy is behaviorally based and addresses a Soldier’s fears, which are seen as reflex reactions to a stimulus. To decondition the reactions, a patient is continually exposed to the stimulus by retelling the story repeatedly, minus the negative outcome. Doctor Brown compared it to riding a roller coaster over and over again to overcome a fear of roller coasters.

“So they’re getting EMDR, they’re getting cognitive processing therapy, they’re getting individual therapy, they’re getting group therapy, they’re getting education, anger management, self-esteem, relationship issues, grief and loss, yoga, meditation exercise, skill building — a little bit of everything across the board,” Doctor Brown said. “Not everything’s going to resonate with everyone who comes through, but something’s going to resonate for everyone who comes through.”

In addition to the overall core curriculum, Doctor Brown and her staff have programs such as pain management, relationship enrichment and tobacco cessation to help individualize treatment.

“The core of the group and individual education is consistent for everyone,” Doctor Brown said. “But we recognize that every patient is different, and we have to tailor make it to give an individualized treatment plan. We don’t keep people in pain management if they’re not in pain. We don’t give them tobacco cessation if they’re not smoking. So we do try and tailor as much of it as we can.”

Spirituality, relationship enrichment and gender-specific issues are also areas of focus.

“The program is holistic,” Mr. Pehm said. “It looks at people from different spheres, not just the medical model because everything is impacted when someone has combat stress or PTSD; not just the individual Soldier, but everybody who comes in contact with them.”

The intensity, length and “kitchen sink” qualities are not the only aspects that make this program unique, Doctor Brown said. It is a joint military and civilian effort accomplished entirely by volunteers. The staff is as diverse as the therapy options, and includes chaplains, social workers, Red Cross volunteers, psychiatrists, a nurse practitioner, enlisted psychiatric technicians, and graduate students. Brown said having a sundry of personnel keeps the program fresh and the staff excited.

“The patients get perspectives from people from a number of different backgrounds,” Doctor Brown said.

Thus far, the staff outnumbers the program’s participants.

“By design we started out small, and we were able to establish a really good working relationship with the local Warrior Transition Unit people … It’s been a wonderful working relationship with them,” Mr. Pehm said.

Evolution is currently on it second eight-week course, with five patients enrolled. The first class had four. The goal is to keep the class size small in order to benefit from the program’s intensity. Thinking small also helps keep the impact large by successfully returning Soldiers to their units, while also expanding access outside the WTUs. However, Mr. Pehm said they would like to expand the program to include patients from throughout the European Command.

“Ideally, we’d like to max it at about 10 because it is so intensive,” Doctor Brown said. “These are folks we hope to remediate and return to the Army to be functional members again. Also, if they go back to their communities and their providers or spouses see the changes that have come about, that will increase the willingness or desire of more people to be here.”

Though few have completed this young program, signs of success have already started to surface.

“With the last group, the shift from ‘I have to be here’ to ‘I’m so glad I came’ was really phenomenal,” Mr. Pehm said.

“One of them said that he didn’t think he was getting anything out of the program,” Doctor Brown said. “It was about week six until he saw himself react differently to a situation that came up, and watched himself do it differently using skills that he didn’t know he learned. He went, ‘Wow, maybe I am getting something out of this.'”

It is too early, and the numbers are too small, to generalize the early trends, but self-completed PTSD checklists showed a significant decrease in reported symptoms for three of the four patients in the first cohort. Additionally, anxiety and depression symptom measures decreased.

“The whole idea is that we know all the changes aren’t going to take place here,” Doctor Brown said. “But we hope we give them enough learning to send them in a different direction. My hope is that we can build a program to provide valid, effective treatment to folks who have put themselves in harm’s way at the request of their country, and help them live happier and better lives.”

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Filed under: Other Mental Health, trauma, , , ,

Professor helps train mental-health workers in Iraq

July 04, 2009

Victims of traumatic events sometimes get so hung up thinking about what happened to them that they can’t let go of their torment.

Rigid, “black-and-white kinds of thoughts” play over and over in their minds and keep them from moving forward in life, says University of Richmond researcher Kristen P. Lindgren.

“Those kinds of thoughts can keep people stuck in their lives,” she said.

A licensed clinical psychologist, Lindgren has studied a technique called cognitive processing therapy that helps people escape those thoughts.

She worked at the Department of Veterans Affairs hospital in Seattle with veterans of wars from Vietnam to Iraq. They suffer from post-traumatic stress disorder and depression, and Lindgren says the therapy was so helpful that the VA plans to use it as a treatment model nationally.

And now, it might also help victims of torture in Iraq.

Lindgren, an assistant professor of psychology at UR for the past year, recently spent eight intensive days training mental-health workers in the Kurdish region of Iraq.

Their goal is to help victims of the violence waged against the people of Kurdistan during the 1980s and 1990s.

It was the most attentive class she has ever had, Lindgren said. The workers, primarily physician assistants at community clinics who have limited opportunities for advanced training, were eager to learn new techniques.

“I’ve never had a group of students who were so focused and literally writing down every word,” she said.

Lindgren describes herself as “very much the junior partner” on the pilot project organized by Johns Hopkins University. The team included Johns Hopkins researchers Paul Bolton and Judith K. Bass, as well as Debra Kaysen, Lindgren’s mentor when she did postdoctoral studies at the University of Washington.

Lindgren hopes that if the mental-health workers find that the technique helps their patients, she can return to Iraq within the year to expand the training.

The therapy technique encourages people to identify thoughts that are stuck in their minds and to challenge that way of thinking, she said.

The patients learn to come up with thoughts that are more flexible but believable.

“It’s not about thinking with rosecolored glasses,” she said.

Lindgren is optimistic the treatment will help the Kurds. In Iraq, the technique had to be adapted to account for cultural differences. Self-esteem, for example, didn’t translate very well. “The closest we could get was respect,” Lindgren said.

They also had to account for illiteracy because the technique involves written homework for patients.

If the therapy with those adaptations proves successful in Iraq, that should help answer lingering questions about its worth back home, she said. Because the technique is research-based and developed in university settings, some still question how well the therapy works in the real world, she said.

“If this is not the real world, I don’t know what is in terms of getting outside the ivory tower.”

——

Contact Karin Kapsidelis at (804) 649-6119 or kkapsidelis@timesdispatch.com. To see more of the Richmond Times-Dispatch, or to subscribe to the newspaper, go to http://www.timesdispatch.com. Copyright (c) 2009, Richmond Times-Dispatch, Va. Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Filed under: Other Mental Health, trauma, , , , ,

Rising unemployment will lead to a rise in suicide rates

Rising unemployment will lead to a rise in suicide rates across Europe unless preventative action is taken, a study says

The stress triggered by job losses could see suicides rise across Europe if governments fail to take preventative action, a new study claims.

Researchers at the London School of Hygiene and Tropical Medicine in London and the University of Oxford examined economic downturns over the past 30 years and concluded that when unemployment rose by 3%, there was a corresponding increase of 4.5% in the number of suicides among people under 65.

In the study published today in medical journal the Lancet, the authors conclude that people who lose their jobs during a recession are at greater risk of suicide – and that for the least well-educated, the risks are even higher.

However, governments can help by providing social security safety nets, and programmes to help people cope with redundancy and get back to work.

Researcher David Stuckler said that while the study found differences between how countries classified and measured suicide, it was possible to look at how governments could reduce the likelihood of suicide during an economic crisis.

“Governments might be able to protect their populations specifically by budgeting for measures that keep people employed. This is a complex issue but we can see what has happened and hopefully use this to work out what to do about it.”

Joe Ferns, deputy director of the Samaritans, welcomed the report. “People who are unemployed are two to three times more likely to die by suicide than people who have jobs, because unemployment can lead to anxiety, depression, lowered self-esteem and feelings of hopelessness – all of which increase the likelihood that someone will think that life is not worth living,” he said.

Dr David Gunnell, a professor of epidemiology at the university of Bristol, cautioned against over-simplifying the link with unemployment. “Suicides are the tip of a much larger iceberg of emotional distress caused by job loss and economic hardship. It is important to appreciate that the causes of suicide are complex and most people who lose their jobs do not end their lives.”

Filed under: Suicide, , , ,

Black & Minority Ethnic Groups: Concern over mental health training in public sector

Educating police and teachers on early signs of mental illness could be catastrophic for black and minority groups, say critics

A mental health group has criticised a report recommending police, teachers and other public sector workers should be trained to spot early signs of mental illness, saying it could marginalise those of black and minority ethnic backgrounds.

Black Mental Health UK (BMHUK) has accused the report’s authors, which includes a group of prominent mental health charities, the Royal College of Psychiatrists and the Association of Directors of Children’s Services, of ignoring black and minority ethnic (BME) communities’ views on the possible fallout of their proposal.

The group claims that, if implemented, the recommendation could increase the chances of people from black and minority ethnic backgrounds being misdiagnosed by amateurs with no professional mental health credentials and lead to further stigmatisation. People from black African-Caribbean backgrounds are more likely to enter the mental health system through the criminal justice system than any other group, and campaigners are worried that encouraging police officers to try to “spot” signs of mental distress could exacerbate the problem.

“There are grave concerns over the suggestion that the police or teachers should be trained in spotting signs of mental ill health,” said Matilda MacAttram, of BMHUK. “Currently black men are six times more likely to be stopped and searched than their white counterparts, as such it is unwise to suggest that the police should be responsible for spotting signs of mental ill health. It could lead to catastrophic results.”

The Future Vision Coalition, the umbrella group behind the report, risks losing credibility if potentially negative fallout of such a policy is not fully assessed, claimed MacAttram. The “labelling” or stigmatising of young people is a particular area of concern. “There is a real danger that cultural norms could be misconstrued, which could have disastrous consequences for a child’s educational career,” she added.

Steve Shrubb, the coalition’s chair, insisted that, far from being damaging to people from BME backgrounds, the proposed training would directly benefit marginalised and “diverse” groups. He said the number of organisations involved with the coalition had doubled since it first started and that many of these represented the views “of a range of vulnerable” groups.

“What we are saying is that mental health awareness training should be included in induction programmes for public sector workers.” he said. “People who work in public services often come into contact with people with mental health difficulties, and we are saying that helping them to identify how to direct someone to the assistance they need is very worthwhile.”

The police and teachers are “a special case”, Shrubb suggested, and should be provided with extra mental health training. “This is not about creating amateur psychiatrists. In our report we talk about how we can improve services for lots of vulnerable groups and BME [individuals] are one of those groups,” he said.

The aim, Shrubb said, was to improve services from local authority housing departments to jobcentre plus, as well as from teachers and the police. The views of BME groups had been put forward in discussions, he added.

As well as mental health awareness training, the report – A Future for Mental Health – makes a number of recommendations including the appointment of a “champion” for mental health issues in government at Cabinet level, and the widening of access to “talking therapies” beyond working age adults to children and older people.

Angela Greatley, chief executive of coalition member the Sainsbury Centre for Mental Health, said too little was being done to promote good mental health in schools, workplaces and communities and that the 10-year agenda laid out in today’s report would contribute to “better life chances” for a wider range of people.

According to MacAttram, the views of BME campaigners were not adequately canvassed before the report. “This could have done with input from black groups who could speak out on behalf of those who will be directly affected by these suggestions,” she said.

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A new scheme trains adults in ‘first aid’ for young people who turn to them in a time of crisis

Emotional rescue

Lucy is explaining why she didn’t go to school today. “I just couldn’t get up. I wasn’t being lazy. I just felt as if every bit of me has been filled with weighted blocks of sadness.” She is at a point of crisis and has singled you out to tell about her mounting depression. What do you do?

This scenario is one of a number of filmed true accounts of young people’s struggles with emotional distress, their sadness, fear, shame and anger – which are a key ingredient in a training scheme being pioneered in Southampton. The idea is to make sure young people get support from the first person they confide in about their troubles.

In most cases, such people will not have specialist medical knowledge. Those who have taken the first Emotional First Aid (EFA) training have included teachers and teaching assistants, youth workers and student support officers.

“The course’s aim is not to create experts in adolescent mental health but to help people recognise that they have an invaluable role in assisting young people in need,” explains family therapist Dave Smith, one of EFA’s designers. “Sometimes their involvement will be enough, getting the young person back on track, but even if more specialist services have to be mobilised, then there’s a part for an EFA-trained adult to play in supporting the young person through the process.”

This is an aspect of the training that Paul Jetten particularly appreciates as an outreach worker with the national charity Fairbridge in Solent, his focus being young people whose lives are often already seriously troubled. “I have already seen the EFA training come good in my work with a teenager with anger-management problems. I was honest and explained that I didn’t have all the answers, but I was happy to work together with her trying to get them. She has really responded.”

Barbara Inkson, children and adolescent mental health manager for Southampton’s city primary care trust, says: “EFA needs to be seen in the context of a broader policy of trying to ‘roll-back’ help for young people so that they get the early interventions they often need to stop their problems developing into severe kinds of illness.”

The trust has championed a multi-agency scheme offering young people a short burst of specialist counselling – often all they need to turn their lives around. For seasoned campaigners such as Dr Andrew McCulloch, head of the Mental Health Foundation, the scheme is an exemplary means of alleviating some of the “referrals congestion” that besets most children and adolescent mental health services nationwide. Young people are saved the agony of long waits for appointments – crucial time lost, during which their mental health often deteriorates.

McCulloch is also impressed by EFA: “It is essential to help young people before they get stuck, and equipping those adults that young people might turn to first for help is a sensible step.”

His use of the word “stuck” is significant. “Among the most important lessons we teach,” says Stuart Gemmel, strategic lead for primary mental health in the town and one of the creators of the approach, “is that young people’s behaviour, however distressing, is often their solution to their problems. We also emphasise the notion of ‘stuckness’ – the fact that self-harm, not eating or drug-taking may offer temporary relief, and there is a danger that they come to dominate a young person’s life.”

For Linda Tanner, the special education needs co-ordinator at St George Catholic voluntary aided college in Southampton, this aspect of the EFA training has already borne fruit. “Thanks to that simple word ‘stuck’, I have been able to move a huge distance with a young boy who is very withdrawn,” she says. “The concept seemed to click with him and he started to open up to me. I don’t think I would have had the confidence to address this with him had I not had the EFA experience.”

Gemmel says there is a responsibility for institutions, too, to offer staff the kind of support workers in health services receive in the form of proper “supervision” – the chance to discuss their case load. “Without the proper structures in place, there’s a real danger people can be left exposed when it comes to the kinds of powerful two-way transference that can go on in any human interaction, but particularly so in a counselling situation.”

The EFA training devotes one of its six two-and-a-half hour sessions to addressing the importance of the adults looking after themselves.

“Among our next moves,” says Gemmel, “is to provide the EFA training to new audiences such as carers or those working with certain minorities.”

NHS Innovations South East is working to develop EFA into a national brand. Karen Underwood, a spokeswoman for the organisation, says a recent posting advertising the next round of EFA training brought 300 applicants in just a few hours: “We don’t see that level of enthusiasm for something new in the NHS every day.”

Filed under: Other Mental Health, , , , ,

Stressed Men More Likely To Gamble And Takes Risks

Stressed Men More Likely To Gamble And Takes Risks

ScienceDaily (July 1, 2009) — Stressed out, dude? Don’t go to Vegas.

New research, to be published July 1 in the journal PLoS One, shows that men under stress may be more likely to take risks, correlating to such real-life behavior as gambling, smoking, unsafe sex and illegal drug use.

In contrast, stressed women moderate their behavior and may be less likely to make risky choices, the study found.

“Evolutionarily speaking, it’s perhaps more beneficial for men to be aggressive in stressful, high-arousal situations when risk and reward are involved,” said Nichole Lighthall of the University of Southern California Davis School of Gerontology and lead author of the paper. “Applied to financial risk taking, it’s akin to competition for territory or other valuable resources.”

The researchers asked participants to play a game called the Balloon Analogue Risk Task in which inflating a balloon earns money (five cents per pump). Participants were told that they could cash out their earnings by clicking a “Collect $$$” button at any point in the game.

However, the balloon would explode if it was inflated beyond its randomly determined breakpoint. All winnings for exploded balloons would be lost.

“One valuable aspect of the [balloon task] is its predictive validity for real-world impulsivity,” Lighthall explained. “Some risk taking was necessary to make gains, but excessive risk was associated with diminishing returns. If you always clicked and never cashed out, you would lose every time.”

The balloon task has been previously used to assess tolerance for risky behavior among inner-city adolescents and substance abusers, among others.

“Obviously, there are situations in the real world where risky behavior would not be beneficial,” Lighthall said. “Sometimes being conservative, thoughtful and taking it slow are good things.”

In the control group, men and women displayed statistically similar levels of risk taking, inflating the balloon about 40 times on average.

However, women in the stressed group only inflated the balloon an average of 32 times – more than 30 percent less often than their stressed male counterparts, who inflated the balloon an average of 48 times.

“Men seem to enter more risky financial situations than women, which was part of the impetus for our study,” Lighthall said. “But only in the stressed condition did we see any statistical differences in risky behavior between men and women.”

Stressful experiences have been shown to stimulate the release of cortisol, commonly known as the “stress hormone.” Participants randomly assigned to the stress group held a hand in ice-cold water, which raised cortisol levels, particularly among female participants. No participants were using hormone birth control.

According to Lighthall, future research might use neuroimaging to explore how the brain processes stress or examine whether psychological stress, such as anticipating giving a speech, would yield similar results as the physical stress manipulation used in this study.

Mara Mather, director of the Emotion and Cognition Lab at USC and associate professor of psychology and gerontology at the USC Davis School of Gerontology, and Marissa Gorlick, also of the USC Davis School of Gerontology, were co-authors of the study.
Adapted from materials provided by University of Southern California, via EurekAlert!, a service of AAAS.

Filed under: Other Mental Health, Violence, , , ,

Where Fear Is Stored In The Brain

ScienceDaily (July 8, 2009) — Fear is a powerful emotion, and neuroscientists have for the first time located the neurons responsible for fear conditioning in the mammalian brain. Fear conditioning is a form of Pavlovian, or associative, learning and is considered to be a model system for understanding human phobias, post-traumatic stress disorder and other anxiety disorders.

Using an imaging technique that enabled them to trace the process of neural activation in the brains of rats, University of Washington researchers have pinpointed the basolateral nucleus in the region of the brain called the of amygdala as the place where fear conditioning is encoded.

Neuroscientists previously suspected that both the amygdala and another brain region, the dorsal hippocampus, were where cues get associated when fear memories are formed. But the new work indicates that the role of the hippocampus is to process and transmit information about conditioned stimuli to the amygdala, said Ilene Bernstein, corresponding author of the new study and a UW professor of psychology.

The study is being published on July 6, in PLoS One, a journal of the Public Library of Science.

Associative conditioning is a basic form of learning across the animal kingdom and is regularly used in studying how brain circuits can change as a result of experience. In earlier research, UW neuroscientists looked at taste aversion, another associative learning behavior, and found that neurons critical to how people and animals learn from experience are located in the amygdala.

The new work was designed to look for where information about conditioned and unconditioned stimuli converges in the brain as fear memories are formed. The researchers used four groups of rats and placed individual rodents inside of a chamber for 30 minutes. Three of the groups had never seen the chamber before.

When control rats were placed in the chamber, they explored it, became less active and some fell asleep. A delayed shock group also explored the chamber, became less active and after 26 minutes received an electric shock through the floor of the chamber. The third group was acclimated to the chamber by a series of 10 prior visits and then went through the same procedure as the delayed shock rats. The final group was shocked immediately upon being introduced inside the chamber.

The following day the rats were individually returned to the chamber and the researchers observed them for freezing behavior. Freezing, or not moving, is the most common behavioral measure of fear in rodents. The only rats that exhibited robust freezing were those that received the delayed shock in a chamber which was unfamiliar to them.

“We didn’t know if we could delay the shock for 26 minutes and get a fear reaction after just one trial. I thought it would be impossible to do this with fear conditioning,” said Bernstein. “This allowed us to ask where information converged in the brain.”

To do this, the researchers repeated the procedure, but then killed the rats. They then took slices of the brains and used Arc catfish, an imaging technique, which allowed them to follow the pattern of neural activation in the animals.

Only the delayed shock group displayed evidence of converging activation from the conditioned stimulus (the chamber) and the unconditioned stimulus (the shock). The experiment showed that animals can acquire a long-term fear when a novel context is paired with a shock 26 minutes later, but not when a familiar context is matched with a shock.

“Fear learning and taste aversion learning are both examples of associative learning in which two experiences occur together. Often they are learned very rapidly because they are critical to survival, such as avoiding dangerous places or toxic foods,” said Bernstein.

“People have phobias that often are set off by cues from something bad that happened to them, such as being scared by a snake or being in a dark alley. So they develop an anxiety disorder,” she said.

“By understanding the process of fear conditioning we might learn how to treat anxiety by making the conditioning weaker or to go away. It is also a tool for learning about these brain cells and the underlying mechanism of fear conditioning.”

Co-authors of the study, all at the UW, are Sabiha Barot, who just completed her doctoral studies; Ain Chung, a doctoral student; and Jeansok Kim, an associate professor of psychology.

Journal reference:

1. Sabiha K. Barot, Ain Chung, Jeansok J. Kim, Ilene L. Bernstein. Functional Imaging of Stimulus Convergence in Amygdalar Neurons during Pavlovian Fear Conditioning. PLoS ONE, 2009; 4 (7): e6156 DOI: 10.1371/journal.pone.0006156

Adapted from materials provided by University of Washington.

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