**5. Police officers under attack: Resilience implication of an fMRI study**

For the first time, in 2011, it was possible to examine the neurofunctional reciprocities of a homogeneous set of traumatized individuals through control of complex variables (free of comorbidities and medications, no need for washout, same age of traumatic memory, same traumatic event also experienced by resilient individuals) in relation to coping (Group 1), continuity (Group 2) and spontaneous resilience to trauma (Group 3) (Peres et al., 2011). After psychotherapy, Group 1 was comparable to Group 3 resilient policemen in terms of symptom scores and neural expressions related to traumatic memory retrieval. The findings underline the importance of psychotherapy for shortening the period of suffering and/or avoiding symptoms becoming chronic – since Group 2 pPTSD policemen (not subjected to psychotherapy) continued to present the same symptoms with signs of worsening, whereas all those subjected to psychotherapy presented a reduction of at least 37% in total CAPS scores.

Evidence from neuroimaging research indicates that the PFC underlies many cognitive skills (Wood et al., 2003). Current and previous findings related to mPFC deactivation report that pPTSD and PTSD patients experience difficulty in activating this area, which is related to cognitive categorization and labeling of internal states (Peres et al., 2007; Shin et al., 2006). Higher brain regions such as the mPFC fail to diminish exaggerated arousal and distress symptoms mediated via the amygdala, and this may be related to the pathological responses found in psychologically traumatized victims (Peres et al., 2008). The hypothesis that primary pathology in PTSD may be amygdala hyper-responsivity rather than deficient mPFC suggests 'bottom-up' activation of the amygdala on the mPFC (Gilboa et al., 2004). Most neuroimaging studies of PTSD show reduced mPFC activity (Peres et al., 2007; Lanius et al., 2001), and some find increased amygdala activity during threat processing (Peres et al., 2008; Shin et al., 2006).

Integrating sensory traces of memories into structured therapeutic narratives is one of the main challenges for psychotherapies applied to trauma victims (Peres et al., 2008; Shin et al.,

reinterpretation and reconstruction of emotionally charged memories may be used to good effect in exposure and cognitive restructuring therapy (Peres et al., 2007; 2011). Retrieving examples of individuals themselves being successful at other points in their lives, or highlighting other victims of psychological trauma who have managed to regain a satisfactory quality of life may ease therapeutic restructuring. Although the University of Parma monkey clearly identified with the Italian researcher's gesture, we are far from recognizing all the nuances of gestures and expressions humans derive from others and what they communicate. It is also important to remember that just as we observe and mirror the behavior of others, the same happens in relation those observing us. Our own examples of successful coping may increase awareness in our children, friends, patients, and colleagues. In this respect, Galileo Galilei left us a good example as inspiration for our "mirroring", when he said: "You cannot teach a man anything; you can only help him find it within himself." We would add that it is not a question of psychotherapists telling patients "how to do it" on an intellectual level, but rather stimulating their awareness in their ability to choose paths predictive of a better quality of life (Peres et al., 2005). We now illustrate a practical example of neuroimaging and psychotherapy integration for the benefit of

**5. Police officers under attack: Resilience implication of an fMRI study**

For the first time, in 2011, it was possible to examine the neurofunctional reciprocities of a homogeneous set of traumatized individuals through control of complex variables (free of comorbidities and medications, no need for washout, same age of traumatic memory, same traumatic event also experienced by resilient individuals) in relation to coping (Group 1), continuity (Group 2) and spontaneous resilience to trauma (Group 3) (Peres et al., 2011). After psychotherapy, Group 1 was comparable to Group 3 resilient policemen in terms of symptom scores and neural expressions related to traumatic memory retrieval. The findings underline the importance of psychotherapy for shortening the period of suffering and/or avoiding symptoms becoming chronic – since Group 2 pPTSD policemen (not subjected to psychotherapy) continued to present the same symptoms with signs of worsening, whereas all those subjected to psychotherapy presented a reduction of at least 37% in total CAPS

Evidence from neuroimaging research indicates that the PFC underlies many cognitive skills (Wood et al., 2003). Current and previous findings related to mPFC deactivation report that pPTSD and PTSD patients experience difficulty in activating this area, which is related to cognitive categorization and labeling of internal states (Peres et al., 2007; Shin et al., 2006). Higher brain regions such as the mPFC fail to diminish exaggerated arousal and distress symptoms mediated via the amygdala, and this may be related to the pathological responses found in psychologically traumatized victims (Peres et al., 2008). The hypothesis that primary pathology in PTSD may be amygdala hyper-responsivity rather than deficient mPFC suggests 'bottom-up' activation of the amygdala on the mPFC (Gilboa et al., 2004). Most neuroimaging studies of PTSD show reduced mPFC activity (Peres et al., 2007; Lanius et al., 2001), and some find increased amygdala activity during threat processing (Peres et

Integrating sensory traces of memories into structured therapeutic narratives is one of the main challenges for psychotherapies applied to trauma victims (Peres et al., 2008; Shin et al.,

traumatized patients.

scores.

al., 2008; Shin et al., 2006).

2006), and pPTSD individuals require the same level of care (Carlier et al., 1995). Neural correlations with post-psychotherapy improvement were quite marked: as CAPS and narrative Traumatic Memory Inventory (TMI) scores improved, mPFC activation increased and amygdala activation decreased. Group 1's increased mPFC activation correlated with post-psychotherapy symptom improvement, which suggests that more active cognitive mPFC processing affected the resilience of pPTSD subjects. Because the PFC plays a major role in integrating cortical functioning and mediating perception and storage of memories in the cortical system, this region may be particularly important for processing traumatic memories and the subsequent development of PTSD symptoms (McFarlane et al., 2002).

Research has pointed to the nonverbal nature of traumatic memory recall in PTSD subjects, compared to a more verbal pattern of traumatic memory recall in healthy subjects (Lanius et al., 2004). Psychotherapy may help to build narratives and resilient integrated translations of fragmented traumatic memories via mPFC, and thus weaken their sensory content while strengthening them cognitively. We found that all three groups activated the mPFC while retrieving pleasant and neutral memories in the first and second scans, which suggests preservation of the declarative memory system in pPTSD subjects for non-traumatic events (Lanius et al., 2004; Peres et al., 2008). On the basis of our results for Group 1 and 2, we would postulate that diminished mPFC activity when processing stressor information during periods of intense emotional arousal heightens the probability of the amygdala being activated. It was interesting to note that increased mPFC activity was concomitant with less amygdala activity for a traumatic memory in both the "resilient" and "pPTSD after psychotherapy" groups.

The TMI scores showed that retrieval of memory of traumatic events was emotionally and sensorially less intense for Group 1 after psychotherapy. They were able to communicate their memories in a more structured narrative, like Group 3, which showed a well-defined narrative structure and low scores for sensory modalities of traumatic memory on both TMI measures. Unlike the psychotherapy group, in the second set of symptom measurements, Group 2 did not show significantly better scores in terms of psychological improvement and the sensory modalities of traumatic memory remained similar.

Previous research on correlations between CAPS and BOLD signals show that improvements in patients' symptoms were related to higher levels of PFC activity and less amygdala activity (Peres et al., 2008; Shin et al., 2006). The higher TMI narrative scores for the traumatic memory after psychotherapy were also correlated with higher levels of mPFC activity, strengthening the evidence for involvement of this region in the psychotherapy applied. The therapeutic effects may be largely due to extinction learning (Charney et al., 2004; Phelps et al., 2004), which builds a new response hierarchy and gradually replaces the previous association with fear. The similarities between Group 1 post-psychotherapy and Group 3 in relation to neural expression and symptom scores show that resilience can be developed and psychotherapy can affect this learning process.

Emotional flexibility is a critical mechanism underlying the ability of resilient people to successfully adapt to ever-changing environments (Bonanno, 2004; Block et al., 1996 Charney et al., 2004). Resilient police officers scored high on religiosity and two indicators of resilient coping were observed: seeking spiritual support and collaborative religious coping. This cognitive reserve related to supportive feelings may have influenced their resilient processing. Fear extinction is also mediated by inhibitory control of the mPFC over amygdala-based fear processes (Phelps et al., 2004) and exposure-based treatment of PTSD is thought to facilitate extinction learning (Shin et al., 2006; Charney et al., 2004) and therefore successful coping with trauma.

PTSD, Neuroimaging and Psychotherapy: A Fruitful Encounter 415

Fig.2. Memory modality and intensity scores of traumatic memory obtained after both fMRI scans for Group 1 (red), 2 (green) and 3 (blue). Traumatic memory was affectively and sensorially less intense, and narrative scores were higher for Group 1 after psychotherapy. The sensory, affective and narrative modalities of traumatic memory remained similar for Group 2 on first and second measures. Group 3 showed a well-defined narrative structure

Several studies show greater suppression of cortisol release in PTSD individuals than in non-PTSDs (Yehuda et al., 1995 ; 1998; Grossman et al. 2003; Newport et al., 2004), supporting the hypothesis that PTSD is associated with enhanced negative feedback regulation of the hypothalamic-pituitary-adrenal (HPA) axis. Indeed, lower cortisol levels may also be a risk factor that affects peritraumatic reactivity and increases the likelihood of developing more pronounced PTSD symptoms (Yehuda et al., 1998; Delahanty et al., 2000). However, most studies have examined HPA axis alterations by comparing a sample of chronic, highly symptomatic PTSD patients with healthy controls (Yehuda et al., 1998; Grossman et al. 2003; Newport et al., 2004). Contrary to our hypothesis, the present study found that cortisol release was normal and as expected for the age group for both pPTSD and healthy police officers, which shows that non-chronic pPTSD police officers may not present an enhanced negative feedback regulation of the HPA axis, so a PTSD-risk factor

Psychotherapy appears efficacious in enabling sufferers of psychological trauma to better cope with the memories of their traumatic experience, with the reconstruction of the traumatic memories (Peres et al., 2007). Emotionally-charged memories are subjective representations of an event, often distorted and distant from the original episode, but salient in their significance to the individual (Creamer et al., 2005). Although there is a marked degree of inter individual variability in the processing of memory of life-events and basic emotions, we postulate that the re-interpretation and reconstruction of traumatic memories will be efficacious in relieving PTSD symptomatology. This process will influence the neural networks sub serving these experiences, leading to the formation of new memories that are less fragmented and available for narrative expression, an idea that is consistent with neuroimaging and clinical observations. Understanding the neural processes associated with successful response to psychotherapy may point to specific mechanisms that can be

and low scores for sensory modalities of traumatic memory on both measures.

may not be characterized if psychological assistance is provided promptly.

**6. Conclusions** 

Fig.1. Correlation between changes in BOLD and changes in total severity of posttraumatic stress disorder (Clinician-Administered PTSD Scale, or CAPS) following ECRT. The functional maps display the areas where changes in BOLD activity in medial prefrontal cortex (mPFC) and amygdala correlated with changes in total CAPS score. The scatter plots display the direction of these correlations (increase in total CAPS on the horizontal axis, extent of BOLD activity on the vertical axis).

Fig.1. Correlation between changes in BOLD and changes in total severity of posttraumatic stress disorder (Clinician-Administered PTSD Scale, or CAPS) following ECRT. The functional maps display the areas where changes in BOLD activity in medial prefrontal cortex (mPFC) and amygdala correlated with changes in total CAPS score. The scatter plots display the direction of these correlations (increase in total CAPS on the horizontal axis,

extent of BOLD activity on the vertical axis).

Fig.2. Memory modality and intensity scores of traumatic memory obtained after both fMRI scans for Group 1 (red), 2 (green) and 3 (blue). Traumatic memory was affectively and sensorially less intense, and narrative scores were higher for Group 1 after psychotherapy. The sensory, affective and narrative modalities of traumatic memory remained similar for Group 2 on first and second measures. Group 3 showed a well-defined narrative structure and low scores for sensory modalities of traumatic memory on both measures.

Several studies show greater suppression of cortisol release in PTSD individuals than in non-PTSDs (Yehuda et al., 1995 ; 1998; Grossman et al. 2003; Newport et al., 2004), supporting the hypothesis that PTSD is associated with enhanced negative feedback regulation of the hypothalamic-pituitary-adrenal (HPA) axis. Indeed, lower cortisol levels may also be a risk factor that affects peritraumatic reactivity and increases the likelihood of developing more pronounced PTSD symptoms (Yehuda et al., 1998; Delahanty et al., 2000). However, most studies have examined HPA axis alterations by comparing a sample of chronic, highly symptomatic PTSD patients with healthy controls (Yehuda et al., 1998; Grossman et al. 2003; Newport et al., 2004). Contrary to our hypothesis, the present study found that cortisol release was normal and as expected for the age group for both pPTSD and healthy police officers, which shows that non-chronic pPTSD police officers may not present an enhanced negative feedback regulation of the HPA axis, so a PTSD-risk factor may not be characterized if psychological assistance is provided promptly.
