Friday, May 28, 2010

PTSD: The State of Treatment

This is the second part of a series on Post Traumatic Brain Syndrome.  Let me recap last week and expand on what we know about the neurobiological mechanisms (how the brain works) of PTSD, and then discuss treatment strategies.

When something stressful happens, the brain prepares the body for action.  The hypothalamus, pituitary gland, amygdala, locus ceruleus and opioid system all release hormones to speed up respiration, raise blood pressure, reduce sensitivity to pain, all useful conditions for the proverbial fight or flight.

Under normal stressors, as soon as these hormones are released, feedback systems go into operation.  The hypothalamus tells everybody else that their job is done and they can back off.

These hormones, especially cortisol, damage brain structures, notably the hippocampus, whose job is to regulate emotion and to perform the "that was then, this is now" function.  I named it that, and am very proud of it.  My own brain has almost no "that was then, this is now" function.  Pretty much zip.

The healthy brain has its own repair system, brain-derived neurotrophic factor (BDNF).  I know it's a mouthful, but it plays a big role in brain health.  So bear with me.  BDNF rebuilds the damaged brain cells in the hippocampus.  You see, the healthy brain is not a stable state.  It changes all the time to respond to new conditions.  Then it rebalances.  And all is well.

When a brain experiences repeated, constant and/or extreme stress, the feedback system can become overwhelmed and stop functioning.  The adrenal glands continue to release cortisol after the danger has passed, further damaging the hippocampus and also depleting endorphins (pain reducers).  BDNF has too much work to do, gets depleted and its source damaged.  Under these conditions the brain has difficulty recovering from the damage.  The depletion of BDNF, by the way, is now considered by many to be the issue in depression, replacing the simple "not enough serotonin" theory.

The gold standard treatment for PTSD is a combination of antidepressants, anti-anxiety medications, and Cognitive Behavioral Therapy (along with all the other self-care strategies, exercise, sleep, mindfulness, healthy diet, abstaining from street drugs and alcohol...)

Antidepressants are helpful because the neurobiological mechanisms of PTSD are pretty much the same as the neurobiological mechanisms of depression.  While the problem is not about the quantity of serotonin per se, increasing serotonin does seem to help the brain generate more BDNF.  BDNF then repairs the brain over time.  That is why, even though antidepressants quickly increase the serotonin on board, it still takes several weeks for the person to feel better.  BDNF needs time to do its job.  Scientists are now looking for more direct ways to increase BDNF, which may have fewer side effects than the medications that work indirectly to increase serotonin.  We can only hope.

Anti-anxiety medications are used to interrupt that stress cycle that is not righting itself on its own, to reduce the production of these hormones and prevent the damage they cause.

Cognitive Behavioral Therapy (CBT) is a general term for a variety of therapies that focus on thoughts and behaviors.  One version is called Rational Emotive Therapy.  Aaron Beck called his style Cognitive Therapy, operating on the theory that thoughts give rise to emotions, not the other way round.  Change the thought, the interpretation of facts, and you change the feeling.  In Cognitive Therapy, the therapist asks the client to examine the facts supporting the client's negative conclusion which led to the negative emotion.  If sufficient evidence does not support the conclusion (that the world is a dangerous place and everybody is out to get me, for example), then the thought can be corrected.  Over time, with practice and homework, the client learns to ask him/herself the therapist's questions, and eventually to eliminate the automatic negative thoughts (ANTs) that have created so many automatic negative feelings.

The underlying theory, that thought gives rise to emotion, seems to me, at the very least, misleading.  In the hierarchy of the brain, the amygdala (reptilian brain) is the first responder, the fastest to go into action.  The amygdala signals the hippocampus (mammalian brain), the source of emotion.  The frontal cortex (homo sapien brain), the origin of thought, is the last on the scene.  According to both the evolutionary and the physiological time line, emotion gives rise to thought.

Nevertheless, CBT works, because the brain can be trained to interrupt out of control anxiety reactions, sometimes so automatically that the mind doesn't realize it happened.  Last July, my Mother Amygdala, Have Mercy Upon Us post reported a study that compared the brains of women who had been depressed and recovered with those who had never been depressed.  When exposed to a stressor, fMRIs showed that the amygdalas of the formerly depressed women became activated.  For those who had never been depressed, their amygdalas were quiet.  Instead, the action was in the prefrontal cortex, the part of the brain that makes judgments.  Both groups reported the same thoughts and feelings, even though their brains were functioning differently

So the brain can learn to change its feelings with new thoughts, with one very important caveat -- the inappropriately active amygdala continues to do its damage, albeit less.  It can be brought under control once thought intervenes.  People who do CBT do relapse.  They spend more time between relapses than those who are treated with medication alone.  And that is a very good thing.  But they relapse.

On May 16, 2010 USA Today reported that the Army had 10,222 mental health hospitalizations last year, accounting for almost 19% of all Army hospitalizations.  Recently Defense Secretary Robert Gates said that "health care costs are eating the Defense Department alive."  In this environment, the exploration of potential treatments for PTSD has found a sense of urgency.

A variety of newer techniques are related to CBT.  The essential idea is that the brain has established a direct track from the traumatic memory to the disturbing emotion, but that another track can be laid with less emotion and less distress attached to it.

In Eye Movement Desensitization and Reprocessing therapy (EMDR), the therapist waves a finger in front of the client's following eyes, while the client recounts the traumatic event.  This is supposed to desensitize the memory.  The brain can process just so much at one time.  The waving finger distracts the client from the troubling emotions.  So a less emotion-laden memory of the traumatic event is recorded.  EMDR got a lot of press for a while.  Unfortunately, those who do research have not been able to replicate the anecdotal claims of relief.  Which is a shame, because if you could get relief by watching a moving finger, wouldn't you try it?  Similar techniques substitute tapping or counting for the finger.

The therapeutic value of Neuro-Linguistic Programming seems more obvious.  [The websites I found by googling NLP were nearly incomprehensible.  PTSD for Dummies does a better job to explain it -- my source for a number of these therapies, and very useful for a general audience view of the bigger picture.]  The sequence from triggers/to memories/to emotions is true of positive events, as well as traumatic ones.  For example, the smell of suntan lotion (trigger) makes me think of summer (memory) and feel calm (emotion.)  NLP  turns this phenomenon to the good, training your mind to go some place other than the trauma place when confronted by triggers.

Here is an example, the NLP method called "anchoring."  I have a set of intrusive memories of a particular person and place, triggered by very common experiences, not PTSD level traumas, but hurtful anyway.  So I have decided to experiment with anchoring.  It occurred to me today that when I was with this person in this place, I was almost always wearing red shoes.  (I have this thing about red shoes, and many, many pleasant associations with red shoes, from my earliest memories.)  So today whenever these hurtful memories intrude, I am focusing on my red shoes, whichever pair that comes immediately to mind.  We'll see how it goes.  So far so good.

These techniques (the nay-sayers might call them gimmicks) are multiplying.  De-sensitization, distraction from emotion, and substitution of a different... well, a different something are common themes, making them offspring or cousins of Cognitive Behavioral Therapy.  Some may have value for some people, though they are not standing up to research.

And then there is good old-fashioned psychotherapy, talking it out, exploring your "issues" and relationships.  Let's not count it out just because it's so hard to come up with a research protocol to test it.  It hasn't been shown to be as effective as CBT, but works well when combined with it.

Maybe the value is not in any of these techniques so much as in the relationship with the therapist doing it.  Ah, the dread "placebo effect," healing that your own body accomplishes because you believe in the healer.  The placebo effect provides 75% of the therapeutic value of antidepressants.  So why quibble about it in non-pharmacological treatments?  The point is, if what works is in the relationship, then get into a therapeutic relationship, already! -- Of whatever stripe makes sense to you.

Last, but not least (at least in practice) are street drugs and alcohol.  These have been tested over and over through the centuries by self-medicating sufferers.  They don't work.  There is no placebo effect.  They just do not work.

Next week: Prevention.

Saturday, May 22, 2010

PTSD and the DSM: Science and Politics -- Again

Several weeks of what I call "swiss cheese brain" interrupted my series on PTSD.  Now with a couple posts in reserve and a two week cushion, I am trying again.  To get us back on the same page, here is a (tweaked) reprint of March 28, a history of the issue in the Diagnostic Statistical Manual and current context, to be followed by PTSD: The State of Treatment, and then PTSD: Hope for Prevention.

With the ongoing war in Iraq, Post Traumatic Stress Disorder -- PTSD is much in the news nowadays.  We can expect that to continue.

Nancy Andreasen, author of The Broken Brain, traces the social history of this mental illness in a 2004 American Journal of Psychiatry article.  The features of what we call PTSD have long been noted in the annuls of warfare.  More recently, in World War I it was called shell shock, and those who had it were shot for cowardice in the face of the enemy.  In World War II it was recognized as a mental illness and called battle fatigue.  Afflicted soldiers were removed from the front and given counseling designed to return them to battle within the week -- though there is one infamous story about General Troglodyte Patton who, while touring a hospital, cursed and slapped one such soldier for his "cowardice."

The DSM I, from the post-WWII era, recognized battle fatigue as Gross Stress Disorder.  It was removed from the DSM II in the early 1960s , when U.S. society was not regularly confronted with this cost of war.

Andreasen had the task of addressing Gross Distress Disorder again in the 1980s for DSM III, when veterans' groups wanted its return as Post-Vietnam Syndrome.  Given her experience with burn victims, Andreasen pressed for a more inclusive description of the illness.  Post Traumatic Stress Disorder entered the new edition, described as a stress reaction to a catastrophic stressor that is outside the range of usual human experience.

In both DSM III and IV, and now in the draft DSM V, the first criterion for PTSD is not a symptom, but an event.  The DSM IV widened the application to include events that are not necessarily out of range of usual human experience:  The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. In addition, The person's response involved intense fear, helplessness, or horror.  This criterion has been applied to a wider assortment of events, the traumas of rape, child abuse, auto accidents, earthquakes and even witnessing events not experienced directly.  David Conroy argues that being suicidal fits the description, and that those who have been suicidal may develop PTSD, as well.  The literature on suicidality, depression and PTSD notes that these three sometimes co-concur, but I have found no one else who considers that the threat of death may come from ones own self, a threat from which we cannot escape.

The DSM V tightens the criteria, though some would say not enough.  The traumatizing event now is described this way: The person was exposed to the following event(s): death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation.  It also identifies specific means of exposure to the event, and eliminates others.

Andreasen expresses a conservative approach, Giving the same diagnosis to death camp survivors and someone who has been in a motor vehicle accident diminishes the magnitude of the stressor and the significance of PTSD.  Sally Satel, also a psychiatrist and a Fellow at the American Enterprise Institute puts it more provocatively, "We've dumbed down PTSD."  There is a false assumption, she added, that ''if something bad happens, people are damaged unless they talk about it.''

Perhaps the confusion about what we now call PTSD arises from the focus on the traumatic event.  The world has long known that war messes with soldiers' minds.  Other traumas are more individual and not so easily observed by the general public.  So similarities are obscured.  Common sense says that a death camp and an auto accident are of a different magnitude of trauma.  However, the differences become less obvious when viewed from the perspective of symptoms.  Each edition of the DSM has struggled with the differences and similarities, and each lurched from one direction to another.

This focus on some precipitating event runs counter to diagnostic criteria for other mental illnesses, where the symptoms are given priority.  In some illnesses, such as depression, it is widely accepted that experiences and environment play a role in causation.  Past attempts to diagnose depression by its source (reactive, meaning in response to an event, or endogenous, meaning arising from biological sources) have been abandoned as unhelpful, since biological processes are part of any depression.

People with similar circumstances do not necessarily develop the same illness.  And most people who experience even a significant trauma do not develop PTSD, or they have symptoms that are easily resolved.  So why do some experience intrusive memories, feel numb and avoid triggers for years after the original event?

As it happens, the same therapies, antidepressants, anti-anxiety medications and cognitive behavioral therapy are used to treat both depression and PTSD, suggesting that these illnesses may be similar in other ways.

In fact, the brain science supports the comparison.  Stress plays a significant role in both.  Neuroscientists are studying three biochemical changes in the brain that occur under severe stress and persevere past the stress.
  • The locus ceruleus (marked in pink to the right) becomes over-active and releases too much of hormones called catecholamines, used to respond to an emergency, even when there is no emergency.
  • Pathways that connect the hypothalamus, pituitary gland and amygdala (HPA axis) fail to regulate another hormone used in crisis, called corticotropin-releasing factor (CRF).  (The hippocampus is green in the graphic, the amygdala blue and the pituitary gland yellow. -- Yes, I did have fun with the airbrush in my paint program!)
  • The opioid system of the brain also becomes overactive, releasing  endorphins, which cause a higher tolerance for pain, accounting for the numbed feelings of PTSD, and which eventually become depleted, causing loss of interest, one of depression's core symptoms.
In addition, each of these systems feeds into the others.

These hormones are necessary to help the body deal with potential pain and danger.  Under smaller stress, feedback systems tell the brain to back off when the danger has passed.  However, an intense enough stressor changes these underlying brain functions.  It destroys the feedback systems and dis-regulates processes that otherwise right themselves and return the brain to a stable state when the stress has passed.

But what is intense enough?  It depends on the individual.  Those who perceive they have some control over the traumatic event are at less risk.  For example, a fire fighter has more resources and so more control than somebody else caught in a burning building.  The fire fighter would be at less risk for PTSD.

Adults who were abused, or who faced many extreme stresses in their early lives, are at greater risk for developing PTSD following later trauma than others who do not have the same history.  The brain science demonstrates that their brains have been primed, by damage to these critical areas of the brain.

Another finding reveals the original insight behind calling it shell shock.  Explosions send out waves of energy that can cause concussions, traumatic brain injuries or TBIs.  These physical injuries create the same neurological stresses as what are thought of as psychological stresses.  Even minor TBIs, in which there is only short or no loss of consciousness, set up the brain conditions for developing PTSD.  TBIs also result from blows to the head, as in an assault, flying debris or a motor vehicle accident.

These findings explain why individuals vary by the trauma threshold that can cause the brain changes and consequent symptoms, and why an event that most are able to shake off is devastating to a smaller portion of the population.  Just as "reactive depression" became an obsolete notion, perhaps it is time to stop defining the exact nature of the trauma behind PTSD and focus instead on the neuroscience. 

In fact, a Walter Reed Army Institute study of 2,525 U.S. Army infantry soldiers discovered that minor TBIs are more likely to result in PTSD than severe TBIs with loss of consciousness for ten or more hours.  The theory is that PTSD comes from recording memories in a malfunctioning hippocampus.  Those who go in and out of consciousness, or remain conscious but are dazed, have more memories to be recorded, hence more memories to become intrusive at a later date.

At stake are billions of dollars, as diagnosis has increased exponentially, as the illness is asserted in personal injury lawsuits, as Viet Nam vets present themselves for treatment of "reactivated" PTSD, and as the war in Iraq produces more soldiers with more problems.

The scope of the problem from the Iraqi war is enormous.  From the Washington Post report of the Walter Reed study: Head and neck injuries have been reported in one quarter of troops evacuated from [Iraq and Afghanistan.]  The proportion of soldiers with concussion may be as high as 18 percent... Almost 44 percent of soldiers reporting an injury involving loss of consciousness met the criteria for PTSD versus only 27.3 percent of those reporting an injury involving altered mental status, 16.2 percent of those with other injuries and 9.1 percent of those with no injury.  A 2008 RAND Corporation study put the incidence of PTSD in soldiers who have served in Iraq at 13.8%.  Other studies claim much higher numbers.  [On May 14, 2010 USA Today released a Pentagon study announcing that hospitalizations for mental illness now exceed hospitalizations for other injuries, and involve much, much longer stays.]

Debate continues about how inclusive or restrictive the criteria for diagnosis should be, with the proposed DSM V drifting toward the more restrictive criteria, where the economics of PTSD converge with the politics.  Repeating Andreasen from above, Giving the same diagnosis to death camp survivors and someone who has been in a motor vehicle accident diminishes the magnitude of the stressor and the significance of PTSD.

There is, of course, another way to honor those whose mental illness is the result of war, in line with Andreasen's original insight.  Instead of their own diagnosis, we might give them a Purple Heart.

Next up: Treatment.

U.S. Army Soldiers attached to 3rd Squadron,
2nd Cavalry Regiment patrol and search for weapons
or Improvised Explosive Devices (IED) during a clearing mission
photo in public domain

Thursday, May 13, 2010

NAMI Walks for the Mind of America

Saturday, May 8 -- It was COLD!!! and windy.  No upright displays this year.  But there were the usual belly dancers, musicians, dogs, fabulous bagels, cream cheese, fruit, granola bars, cookies...

And volunteers -- serving food, registering walkers, taking photos, cheering us on.  The clown making toy balloons!

And the walkers.  And the strollers.  And the dogs.

Speaking of which:
Here she is, in a rare moment walking the designated path.  Mazie had never been to City Park before.  So many new smells!  So many new trees!  So much marking to do!

After we walked a mile, the short loop, Mazie's back leg began to falter -- the one that has done twice the work of the other two for the last thirteen years.  What with all the zig-zagging between trees, it's likely she did do 5K, and it was just her people who gave out.

Meanwhile, she cooperated magnificently, wearing her own shirt.  As soon as she returned to the start, she got into her therapy dog mode, sitting stock still while little girls with various levels of petting skills mobbed her, countless adults pondered her, and one woman who lives in a group home asked to be photographed with her. -- If her staff person is reading this, we are waiting for your email, so we can send the photo!

There were the requisite speeches from the requisite politicians.  Thank you, Dave Loebsack for doing your part to get mental health parity, more or less, into the health care bill.  Please support the President's interpretation that case management and reimbursement rates for psychiatrists have to match other forms of health care.  -- That issue has cost me thousands, because my care providers won't contract with my stingy health insurance company.

But I had to listen to speeches only from a distance.  They had serious competition.  The Old Capitol City Roller Girls were giving a demonstration in the parking lot.  No, it is not the chaos and brawling that I remember from childhood tv.  It probably wasn't then.  There are rules.  There is a point.  There are fabulous outfits!

This video is a bit long.  But it gives you the idea:

Anyway, as always, a fabulous day.  NAMI Johnson County raised $65,983.99 by walk day, 88% of its goal on the way to $75,000.  Did I mention that it was COLD?!

And Team Prozac Monologues, dressed in layers, but still proudly sporting our t-shirts, has raised $2395 of our $3500 goal so far.

Yes, there still is time to help us reach our goal!  In fact, for a limited time you, too, can receive one of our t-shirts.  They are cotton tagless t's, navy blue, with logos front and back.

The front is a shameless bid to win the t-shirt contest.

while the back says:

-- a shameless bit of self promotion!

Just make a donation of $30 or more or MORE by clicking the link up top on the right.  Then send your size and your address to:  I'll make one up custom for for you!  This offer expires June 25!  So do it today!  Thanks!!

On a more sober note,  Gay and Ciha Funeral and Cremation Service was one of the main sponsors, and got a promo on the official walk t-shirt, while Lensing Funeral & Cremation Service sponsored a kilometer.  Their support reminds me that mental illness is potentially fatal, just like heart disease and breast cancer.  They might sponsor those walks, too.

As a priest I occasionally worked with those who provide funeral services.  I respect these people immensely, as do most clergy I know.  They do things for the bereaved that communities used to do, communities that don't much exist anymore.  Hospice has re-created a way for friends and family to talk with and support one another in the sorrow of many forms of death.  But funeral homes are the ones who step up to the plate for survivors of suicide.  They offer resources and support groups to friends and family.  I appreciate the work that they do.  And I appreciate their support of NAMI, in its work to stomp out the stigma of mental illness.

With them, with you, one step at a time, we shall overcome.

Oh yes, and it was COLD!!?!