Skip to main content
Brain and Behavior logoLink to Brain and Behavior
. 2020 Aug 28;10(11):e01807. doi: 10.1002/brb3.1807

Stellate ganglion block treats posttraumatic stress: An example of precision mental health

James H Lynch 1,
PMCID: PMC7667325  PMID: 32856430

The U.S. Precision Medicine Initiative (PMI), launched in 2015, is a nationwide initiative to move away from “one‐size‐fits‐all” medicine and instead to tailor treatment strategies to a patient's unique characteristics (HealthIT.gov). The long‐term goals of this effort focus on bringing precision medicine to all areas of health on a large scale (U.S. National Library of Medicine, 2020). Psychiatry is exceptionally complex compared to many other medical fields where precision diagnostics rely on quantified laboratory values, imaging findings, cytology, etc. Psychopathology is primarily diagnosed by an expert clinician's judgment applying criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) (American Psychiatric Association, 2013). Over recent years, some have questioned the utility of such psychiatric taxonomy in present day clinical treatment (Dalgleish, Black, Johnston, & Bevan, 2020). These diagnostic aspects complicate the goal of achieving precision medicine for mental illness. Moving forward, reframing mental illness as disorders of brain functioning may facilitate these discussions (Fernandes et al., 2017). Many will associate the term “precision medicine” in psychiatry with current efforts to discover genetic variables and biotypes for mental illness. I offer an alternate use of the term here. A procedure called stellate ganglion block used for posttraumatic stress symptoms provides us with a contemporary example of delivering “precision mental health” now without waiting for future research to provide a more complete understanding of the pathophysiology of mental disorders (DeRubeis, 2019).

1. DEFINING THE PROBLEM

Using DSM‐5 criteria, there are over 636,000 possible combinations of symptoms that qualify for the diagnosis of posttraumatic stress disorder (PTSD). For comparison, major depressive disorder has 227 possible combinations, and panic disorder has 23,442 combinations (Galatzer‐Levy & Bryant, 2013). It is challenging to study such a heterogeneous condition and draw logical conclusions about which treatments are effective for the vast array of symptom combinations. This may explain why it is difficult to determine which PTSD treatments are superior. It may also explain why many current standard PTSD therapies demonstrate somewhat disappointing results and weak effect sizes when evaluated in large clinical trials (Lewis, Roberts, Andrew, Starling, & Bisson, 2020; Watts et al., 2013). While scientifically sound and widely accepted, using aggregate outcomes such as change in mean Clinician‐Administered PTSD Scale (CAPS) to determine if a treatment is superior to placebo provides an incomplete answer to the question of “What works for whom?” particularly when applied to the patient sitting in front of you with one of 636,000 posttraumatic symptom combinations (DeRubeis, 2019).

Worth mentioning are the countless undiagnosed individuals in need of mental health care who fall short of DSM‐5 criteria for PTSD despite suffering from significant posttraumatic symptoms (Kotov, Krueger, & Watson, 2018). Based on DSM‐5, there are over 100,000 combinations of PTSD symptoms that do not meet full diagnostic criteria despite having one or more symptoms in all categories (Galatzer‐Levy & Bryant, 2013). This implies that there are many patients who may benefit from therapies that target the symptoms of PTSD rather than purely treating the diagnosis.

In line with the goals of the Precision Medicine Initiative, some initial gains have been made in the field of genomics, but we may be years away from their practical application in mental health (Stein & Smoller, 2018). It is certainly likely that someday we will personalize treatment for all patients with mental disorders based on a complex analysis of “biotypes” (Stanford Medicine Department of Psychiatry and Behavioral Sciences). In the meantime, the science exists today to improve our approach to a disorder that affects over 10 million Americans with PTSD by applying more precise diagnostics and neuroscience‐informed treatment (American Psychiatric Association, 2020). The goal is the same—to more precisely target our patients’ distinct symptomatology.

2. THE UNDERLYING BRAIN CIRCUITRY MALFUNCTION

While not completely elucidated presently, several maladaptive biologic processes likely contribute to different posttraumatic symptoms. Some PTSD symptoms are caused by a stimulated sympathetic nervous system including hyperarousal symptoms such as irritability, angry outbursts, and heightened startle reflex. The physical symptoms which accompany reexperiencing traumatic events including racing heart, sweating, and increased body tone are sympathetically driven. This psychological overlap with the neuroendocrine system should be understood and exploited to focus therapies for PTSD which target hyperarousal when present.

For many trauma victims, hyperarousal is a predominant PTSD feature. This cluster of symptoms has been attributed to a type of “dysfunctional sympathetic tone” describing a process where somatic response to stimuli is inappropriately amplified (Mulvaney et al., 2014). Many of these physical symptoms of PTSD serve as barriers to effective psychotherapy. Previous research has identified several predictors of poor PTSD treatment trajectories such as comorbid depression and substance abuse. Exaggerated hyperarousal is also an independent predictor of nonresponse to treatment (Averill, Averill, Fan, & Abdallah, 2020). Despite large decreases in clinician‐rated symptoms, nearly half of patients completing cognitive behavioral therapy (CBT) for PTSD still manifest clinically significant insomnia, anger, and irritability (Zayfert & DeViva, 2004). PTSD patients with high levels of hyperarousal at the onset of therapy may require additional treatment (Stein, Dickstein, Schuster, Litz, & Resick, 2012).

Hyperarousal symptoms can be specifically addressed in a variety of ways (e.g., meditation) (Crawford, Talkovsky, Bormann, & Lang, 2019). Some treatments targeting an overstimulated sympathetic nervous system may have undesirable side effects. This is particularly true with some pharmacologic agents (e.g., benzodiazepines) and can contribute to noncompliance and dropout (Guina, Rossetter, DeRhodes, Nahhas, & Welton, 2015). Given the known difficulty treating hyperarousal in PTSD, clinicians should strongly consider precision treatment plans tailored to the individual patient.

3. INTEGRATING BRAIN SCIENCE WITH TECHNOLOGY

Advanced neuroimaging techniques such as functional magnetic resonance imaging (fMRI) have identified several neuronal circuits relevant to the pathophysiology of PTSD. Prominent findings in PTSD include (a) hyperactivation of the amygdala and dorsal anterior cingulate cortex (dACC), (b) hypoactivation of the ventromedial prefrontal cortex, and (c) atrophy of the hippocampus (Kamiya & Abe, 2020). A network‐based neurobiologic model defines a central autonomic network composed of three interconnected subnetworks located in different regions of the brain—the salience, central executive, and default mode networks. The core structures of the salience network are the amygdala, insula, and dACC, which are associated with hyperarousal and found to be hyperactive on fMRI in PTSD patients (Menon, 2011).

The interconnections between these specific regions of the brain's central autonomic network are complex. However, the cervical sympathetic trunk which runs deep in the neck has been described as an “anatomic funnel through which all sympathetic fibers must flow on their way to the head, neck, and thorax” (Moore, 1954). The stellate ganglion, located along the cervical sympathetic trunk at the level of C7‐T1, provides a connection to the hypothalamus and central nucleus of the amygdala as well as the insular cortex (Westerhaus & Loewy, 2001). This neural circuit connecting the brain to the body provides a precise anatomic target to address the physical symptoms of hyperarousal.

4. NEUROSCIENCE‐INFORMED TREATMENT

For over one hundred years, a simple, safe procedure called stellate ganglion block (SGB) has been used successfully to treat a variety of sympathetically modulated pathologies ranging from chronic regional pain syndrome (CRPS) to postherpetic neuralgia (Imani, Hemati, Rahimzadeh, Kazemi, & Hejazian, 2016; Moore, 1954; Moore & Bridenbaugh, 1956; Summers & Nevin, 2017). Stellate ganglion block is an injection of local anesthetic in the neck to temporarily block the cervical sympathetic trunk which controls the body's fight‐or‐flight response. This outpatient procedure, performed under ultrasound or fluoroscopic guidance, takes less than thirty minutes and is immediately effective. SGB is not a silver bullet; however, it has been used successfully for over ten years in conjunction with trauma‐focused psychotherapy to treat posttraumatic stress symptoms with a success rate of approximately 70%–80% (Lipov & Ritchie, 2015; Navaie et al., 2014). Due to its safety, effect size (symptoms scores reduced by 50%), and rapid onset of relief, SGB has gained wide acceptance in several locations including select US military hospitals where it has been available. In this time, SGB has been used effectively to help heal thousands of military service members suffering from symptoms associated with PTSD. A small sample of these cases is documented in the literature primarily in level 3 studies, yet if the collective results are considered in entirety, they show great consistency in SGB effects. There are 14 original studies published since 1990 in the peer‐reviewed medical literature documenting SGB’s successful treatment of PTSD symptoms (Alino, Kosatka, McLean, & Hirsch, 2013; Alkire et al., 2014; Alkire et al., 2015; Hanling et al., 2016; Lebovits, Yarmush, & Lefkowitz, 1990; Lipov, Joshi, Lipov, Sanders, & Siroko, 2008; Lipov et al., 2012, 2013; Lynch et al., 2016; McLean, 2015; Mulvaney et al., 2014; Mulvaney, Lynch, de Leeuw, Schroeder, & Kane, 2015; Mulvaney, McLean, & De Leeuw, 2010; Rae Olmsted et al., 2020). In November 2019, a large multicenter, randomized clinical trial demonstrated twice the effect of SGB over a sham procedure (Rae Olmsted et al., 2020).

Stellate ganglion block can be applied in terms of precision mental health for posttraumatic stress, not as a standalone treatment, but rather as an adjunct with a precise purpose to complement trauma‐focused psychotherapy. Patients treated with SGB report that many of their symptoms are improved, but particularly affected are hyperarousal symptoms such as irritability, angry outbursts, difficulty concentrating, and trouble falling or staying asleep (Lynch et al., 2016). For many of our patients, these dramatic improvements are life‐changing and enhance long‐term compliance with their psychotherapy. SGB improves more than just hyperarousal symptoms. While a decrease in intrusive memories, thoughts, and dreams has also been seen following this procedure, the most consistent improvement patients report following SGB is dramatic relief from undesired fight‐or‐flight reactions. (Lynch et al., 2016).

5. FUTURE DIRECTIONS

There are several unknowns regarding how to optimize SGB treatment for posttraumatic stress symptoms. For instance, when during therapy is SGB most effective? Targeting multiple levels of the cervical sympathetic trunk as well as the effects of right‐ versus left‐sided SGB have yet to be fully investigated. One possibility may include utilizing preprocedure fMRI to acquire laterality in amygdala hyperactivity in order to determine whether right‐ or left‐sided SGB is more appropriate. Preliminary work in this area shows promise (Kim, Park, Chung, & Kang, 2016). Future work should also attempt to determine the specific mechanism of action for SGB. Previous research has proposed a biologic mechanism related to brain norepinephrine levels (Lipov, Candido, & Ritchie, 2017; Lipov, Joshi, Sanders, & Slavin, 2009). While the precise mechanism of action for SGB is currently unclear, the evidence is convincing enough now to consider stellate ganglion block as an adjunct to trauma‐based psychotherapy for any patient exhibiting symptoms of increased hyperarousal.

6. CONCLUSION

Precision mental health treatments for posttraumatic stress disorder should (a) focus more on specific symptoms than a heterogenous diagnosis, (b) integrate emerging neuroscience with traditional models of mental illness, and (c) direct multidisciplinary, personalized therapies for individuals based on interventions that address their symptoms. Given these goals along with the presently expanding neurobiologic model of posttraumatic stress disorder, we can implement precision mental health now for potentially millions of patients by offering stellate ganglion block as part of their individualized treatment plan.

CONFLICT OF INTEREST

The author has no conflicts of interests or has declared any such conflicts.

ACKNOWLEDGMENTS

I would like to thank Dr. Gary Means, Dr. Peter Muench, and Dr. John Okiishi for their critical review of this manuscript. I would also like to thank Dr. Leanne Williams and the Stanford Center for Precision Mental Health & Wellness for inspiring some of the content of this manuscript.

Lynch JH. Stellate ganglion block treats posttraumatic stress: An example of precision mental health. Brain Behav. 2020;10:e01807 10.1002/brb3.1807

The peer review history for this article is available at https://publons.com/publon/10.1111/brb3.1807

This work has not been published previously and is not currently under consideration elsewhere. This work is original and the author's own, and that no copyright has been breached by the inclusion of any content drawn from another source. The author approves of the publication.

The opinions and assertions expressed herein are those of the author and do not necessarily reflect the official policy or position of the United States Army or the Department of Defense.

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

REFERENCES

  1. Alino, J. , Kosatka, D. , McLean, B. , & Hirsch, K. (2013). Efficacy of stellate ganglion block in the treatment of anxiety symptoms from combat‐related post‐traumatic stress disorder: A case series. Military Medicine, 178(4), e473–e476. 10.7205/MILMED-D-12-00386 [DOI] [PubMed] [Google Scholar]
  2. Alkire, M. T. , Hollifield, M. , Khoshsar, R. , Nguyen, L. , Alley, S. R. , Courtney, C. G. , & Reist, C. (2014). Prolonged relief of chronic extreme PTSD and depression symptoms in veterans following a stellate ganglion block. American Society of Anesthesiology. [Google Scholar]
  3. Alkire, M. T. , Hollifield, M. , Khoshsar, R. , Nguyen, L. , Alley, S. R. , & Reist, C. (2015, October). Neuroimaging suggests that stellate ganglion block improves post‐traumatic stress disorder (PTSD) through an amygdala mediated mechanism. In American Society of Anesthesiology annual meeting. [Google Scholar]
  4. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (DSM‐5®), Arlington, VA: American Psychiatric Pub. [Google Scholar]
  5. American Psychiatric Association (2020). Posttraumatic stress disorder (PTSD). Retrieved from https://www.psychiatry.org/patients‐families/ptsd/what‐is‐ptsd [Google Scholar]
  6. Averill, C. L. , Averill, L. A. , Fan, S. , & Abdallah, C. G. (2020). Of forests and trees: bridging the gap between neurobiology and behavior in posttraumatic stress disorder. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 5(2), 135–137. 10.1016/j.bpsc.2019.12.010 [DOI] [PubMed] [Google Scholar]
  7. Crawford, J. N. , Talkovsky, A. M. , Bormann, J. E. , & Lang, A. J. (2019). Targeting hyperarousal: Mantram Repetition Program for PTSD in US veterans. European Journal of Psychotraumatology, 10(1), 1665768 10.1080/20008198.2019.1665768 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Dalgleish, T. , Black, M. , Johnston, D. , & Bevan, A. (2020). Transdiagnostic approaches to mental health problems: Current status and future directions. Journal of Consulting and Clinical Psychology, 88(3), 179–195. 10.1037/ccp0000482 [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. DeRubeis, R. J. (2019). The history, current status, and possible future of precision mental health. Behaviour Research and Therapy, 123, 103506 10.1016/j.brat.2019.103506 [DOI] [PubMed] [Google Scholar]
  10. Fernandes, B. S. , Williams, L. M. , Steiner, J. , Leboyer, M. , Carvalho, A. F. , & Berk, M. (2017). The new field of ‘precision psychiatry’. BMC Medicine, 15(1), 80 10.1186/s12916-017-0849-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Galatzer‐Levy, I. R. , & Bryant, R. A. (2013). 636,120 ways to have posttraumatic stress disorder. Perspectives on Psychological Science, 8(6), 651–662. 10.1177/1745691613504115 [DOI] [PubMed] [Google Scholar]
  12. Guina, J. , Rossetter, S. R. , DeRhodes, B. J. , Nahhas, R. W. , & Welton, R. S. (2015). Benzodiazepines for PTSD: A systematic review and meta‐analysis. Journal of Psychiatric Practice®, 21(4), 281–303. 10.1097/PRA.0000000000000091 [DOI] [PubMed] [Google Scholar]
  13. Hanling, S. R. , Hickey, A. , Lesnik, I. , Hackworth, R. J. , Stedje‐Larsen, E. , Drastal, C. A. , & McLay, R. N. (2016). Stellate ganglion block for the treatment of posttraumatic stress disorder: A randomized, double‐blind, controlled trial. Regional Anesthesia & Pain Medicine, 41(4), 494–500. 10.1097/AAP.0000000000000402 [DOI] [PubMed] [Google Scholar]
  14. HealthIT.gov . Precision Medicine. Retrieved from https://www.healthit.gov/topic/scientific‐initiatives/precision‐medicine [Google Scholar]
  15. Imani, F. , Hemati, K. , Rahimzadeh, P. , Kazemi, M. R. , & Hejazian, K. (2016). Effectiveness of stellate ganglion block under fuoroscopy or ultrasound guidance in upper extremity CRPS. Journal of Clinical and Diagnostic Research: JCDR, 10(1), UC09. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Kamiya, K. , & Abe, O. (2020). Imaging of Posttraumatic Stress Disorder. Neuroimaging Clinics, 30(1), 115–123. 10.1016/j.nic.2019.09.010 [DOI] [PubMed] [Google Scholar]
  17. Kim, D. Y. , Park, C. A. , Chung, R. K. , & Kang, C. K. (2016). Effect of stellate ganglion block on the cerebral cortex: A functional magnetic resonance imaging study. Applied Magnetic Resonance, 47(1), 101–109. 10.1007/s00723-015-0735-7 [DOI] [Google Scholar]
  18. Kotov, R. , Krueger, R. F. , & Watson, D. (2018). A paradigm shift in psychiatric classification: The Hierarchical Taxonomy Of Psychopathology (HiTOP). World Psychiatry, 17(1), 24 10.1002/wps.20478 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Lebovits, A. H. , Yarmush, J. , & Lefkowitz, M. (1990). Reflex sympathetic dystrophy and posttraumatic stress disorder. Multidisciplinary evaluation and treatment. Clinical Journal of Pain, 6(2), 153–157. 10.1097/00002508-199006000-00015 [DOI] [PubMed] [Google Scholar]
  20. Lewis, C. , Roberts, N. P. , Andrew, M. , Starling, E. , & Bisson, J. I. (2020). Psychological therapies for post‐traumatic stress disorder in adults: Systematic review and meta‐analysis. European Journal of Psychotraumatology, 11(1), 1729633 10.1080/20008198.2020.1729633 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Lipov, E. G. , Candido, K. , & Ritchie, E. C. (2017). Possible reversal of PTSD‐related DNA methylation by sympathetic blockade. Journal of Molecular Neuroscience, 62(1), 67–72. 10.1007/s12031-017-0911-3 [DOI] [PubMed] [Google Scholar]
  22. Lipov, E. G. , Joshi, J. R. , Lipov, S. , Sanders, S. E. , & Siroko, M. K. (2008). Cervical sympathetic blockade in a patient with post‐traumatic stress disorder: A case report. Annals of Clinical Psychiatry, 20(4), 227–228. 10.1080/10401230802435518 [DOI] [PubMed] [Google Scholar]
  23. Lipov, E. G. , Joshi, J. R. , Sanders, S. , & Slavin, K. V. (2009). A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Medical Hypotheses, 72(6), 657–661. 10.1016/j.mehy.2009.01.009 [DOI] [PubMed] [Google Scholar]
  24. Lipov, E. G. , Navaie, M. , Brown, P. R. , Hickey, A. H. , Stedje‐Larsen, E. T. , & McLay, R. N. (2013). Stellate ganglion block improves refractory post‐traumatic stress disorder and associated memory dysfunction: A case report and systematic literature review. Military Medicine, 178(2), e260–e264. 10.7205/MILMED-D-12-00290 [DOI] [PubMed] [Google Scholar]
  25. Lipov, E. G. , Navaie, M. , Stedje‐Larsen, E. T. , Burkhardt, K. , Smith, J. C. , Sharghi, L. H. , & Hickey, A. H. (2012). A novel application of stellate ganglion block: Preliminary observations for the treatment of post‐traumatic stress disorder. Military Medicine, 177(2), 125–127. 10.7205/MILMED-D-11-00328 [DOI] [PubMed] [Google Scholar]
  26. Lipov, E. , & Ritchie, E. C. (2015). A review of the use of stellate ganglion block in the treatment of PTSD. Current Psychiatry Reports, 17(8), 63 10.1007/s11920-015-0599-4 [DOI] [PubMed] [Google Scholar]
  27. Lynch, J. H. , Mulvaney, S. W. , Kim, E. H. , de Leeuw, J. B. , Schroeder, M. J. , & Kane, S. F. (2016). Effect of stellate ganglion block on specific symptom clusters for treatment of post‐traumatic stress disorder. Military Medicine, 181(9), 1135–1141. 10.7205/MILMED-D-15-00518 [DOI] [PubMed] [Google Scholar]
  28. McLean, B. (2015). Safety and patient acceptability of stellate ganglion blockade as a treatment adjunct for combat‐related post‐traumatic stress disorder: A quality assurance initiative. Cureus, 7(9), 1–9. 10.7759/cureus.320 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Menon, V. (2011). Large‐scale brain networks and psychopathology: A unifying triple network model. Trends in Cognitive Sciences, 15(10), 483–506. 10.1016/j.tics.2011.08.003 [DOI] [PubMed] [Google Scholar]
  30. Moore, D. C. (1954). Stellate ganglion block: Techniques, indications, uses. Thomas. [Google Scholar]
  31. Moore, D. C. , & Bridenbaugh, L. D. (1956). The anterior approach to the stellate ganglion: Use without a serious complication in two thousand blocks. Journal of the American Medical Association, 160(3), 158–162. 10.1001/jama.1956.02960380006003 [DOI] [PubMed] [Google Scholar]
  32. Mulvaney, S. W. , Lynch, J. H. , de Leeuw, J. , Schroeder, M. , & Kane, S. (2015). Neurocognitive performance is not degraded after stellate ganglion block treatment for post‐traumatic stress disorder: A case series. Military Medicine, 180(5), e601–e604. 10.7205/MILMED-D-14-00504 [DOI] [PubMed] [Google Scholar]
  33. Mulvaney, S. W. , Lynch, J. H. , Hickey, M. J. , Rahman‐Rawlins, T. , Schroeder, M. , Kane, S. , & Lipov, E. (2014). Stellate ganglion block used to treat symptoms associated with combat‐related post‐traumatic stress disorder: A case series of 166 patients. Military Medicine, 179(10), 1133–1140. 10.7205/MILMED-D-14-00151 [DOI] [PubMed] [Google Scholar]
  34. Mulvaney, S. W. , McLean, B. , & De Leeuw, J. (2010). The use of stellate ganglion block in the treatment of panic/anxiety symptoms with combat‐related post‐traumatic stress disorder; preliminary results of long‐term follow‐up: A case series. Pain Practice, 10(4), 359–365. 10.1111/j.1533-2500.2010.00373.x [DOI] [PubMed] [Google Scholar]
  35. Navaie, M. , Keefe, M. S. , Hickey, A. H. , Mclay, R. N. , Ritchie, E. C. , & Abdi, S. (2014). Use of stellate ganglion block for refractory post‐traumatic stress disorder: A review of published cases. Journal of Anesthesia & Clinical Research, 5(403), 2 10.4172/2155-6148.1000403 [DOI] [Google Scholar]
  36. Rae Olmsted, K. L. , Bartoszek, M. , Mulvaney, S. , McLean, B. , Turabi, A. , Young, R. , … Walters, B. B. (2020). Effect of stellate ganglion block treatment on posttraumatic stress disorder symptoms: A randomized clinical trial. JAMA Psychiatry, 77(2), 130–138. 10.1001/jamapsychiatry.2019.3474 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Stanford Medicine Department of Psychiatry and Behavioral Sciences (2019). Precision mental health and wellness. Retrieved from https://med.stanford.edu/psychiatry/special‐initiatives/pmhw.html [Google Scholar]
  38. Stein, M. B. , & Smoller, J. W. (2018). Precision psychiatry—will genomic medicine lead the way? JAMA Psychiatry, 75(7), 663–664. 10.1001/jamapsychiatry.2018.0375 [DOI] [PubMed] [Google Scholar]
  39. Stein, N. R. , Dickstein, B. D. , Schuster, J. , Litz, B. T. , & Resick, P. A. (2012). Trajectories of response to treatment for posttraumatic stress disorder. Behavior Therapy, 43(4), 790–800. 10.1016/j.beth.2012.04.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Summers, M. R. , & Nevin, R. L. (2017). Stellate ganglion block in the treatment of post‐traumatic stress disorder: A review of historical and recent literature. Pain Practice, 17(4), 546–553. 10.1111/papr.12503 [DOI] [PubMed] [Google Scholar]
  41. U.S. National Library of Medicine (2020). What is the Precision Medicine Initiative? Retrieved from https://ghr.nlm.nih.gov/primer/precisionmedicine/initiative [Google Scholar]
  42. Watts, B. V. , Schnurr, P. P. , Mayo, L. , Young‐Xu, Y. , Weeks, W. B. , & Friedman, M. J. (2013). Meta‐analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74(6), e541–e550. 10.4088/JCP.12r08225 [DOI] [PubMed] [Google Scholar]
  43. Westerhaus, M. J. , & Loewy, A. D. (2001). Central representation of the sympathetic nervous system in the cerebral cortex. Brain Research, 903(1–2), 117–127. 10.1016/S0006-8993(01)02453-2 [DOI] [PubMed] [Google Scholar]
  44. Zayfert, C. , & DeViva, J. C. (2004). Residual insomnia following cognitive behavioral therapy for PTSD. Journal of Traumatic Stress: Official Publication of the International Society for Traumatic Stress Studies, 17(1), 69–73. 10.1023/B:JOTS.0000014679.31799.e7 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.


Articles from Brain and Behavior are provided here courtesy of Wiley

RESOURCES