Showing posts with label hippocampus. Show all posts
Showing posts with label hippocampus. Show all posts

Anxiety My Old Friend - Will I Let It Kill Me?

Anxiety and stress are not the same thing.

Stress is a physiological experience in the face of a change in the internal or external system. It has its plusses and minuses. A little bit of stress over something you can do something about [I need to make that doctor's appointment] provides motivation to get it done and satisfaction (a nice hit of dopamine) once you do it.

via GIPHY

On the other hand, chronic stress that cannot be resolved [I never knew when he would explode] exhausts every resource the body has to maintain homeostasis/balance. And that's not good.

Anxiety describes the negative thoughts and feelings that accompany stress.

via GIPHY

It's not the only feeling that could accompany stress. When faced with changes like a new job, a challenging ski slope, or a date with the person of your dreams, you might also feel excitement.

via GIPHY

Or maybe not. "Good" change and "bad" change are labels we apply from our own perspective. As far as the body goes, they don't really figure in. The physiological response is the same.

Consider a winding mountain road in a snowstorm. Some people default to excitement. [That would be Colorado-raised me.] Some people default to anxiety. [That would be my California-born wife.] The people who can't help but default to it have an anxiety disorder. These are my people.

Anxiety Defined

Anxiety is the intense, excessive, persistent worry, fear, or dread about everyday situations, present, future, and imagined future. It's a normal enough experience. It becomes a disorder when "intense" tilts over into "excessive" to the point of interfering with daily activities.

Insert side comment here: People who have a mental illness, whether social anxiety disorder, depression, or schizophrenia, are not a different kind of people. Almost every symptom of a mental illness is a "normal" experience - shared by people who do not have a mental illness. These experiences do not need to be diagnosed or treated, until they pile up and become so intrusive that they become unmanageable, until they interfere with daily activities.

The physical manifestations of anxiety include fast heart rate, heavy breathing, sweating, and fatigue. How do we get from a thought to a heart rate? The brain - that's how.

Anxiety in the brain


Anxiety involves an interaction of three different parts of the brain in particular.

It begins when the amygdala senses a threat. The job of the amygdala is to leap into action at the sign of a threat. The amygdala initiates a sequence that releases adrenaline and cortisol to gear the body up to address the threat. As with the body's response to other stress, these hormones cause the faster heart rate and heavy breathing. Blood flow increases to the limbs to prepare it for action, and away from the digestive system - when your life is in danger, lunch can wait.

The prefrontal cortex, the "thinking" part of the brain, provides information and interpretation that mitigate or support the threat. [That's a garter snake, not a rattler. It's harmless.]

The anterior cingulate cortex sorts through the sense of threat and the additional information to find patterns and determine whether the current situation is a big deal or not. It tells the amygdala whether to calm down or GET MORE EXCITED!

The difference between anxiety and anxiety disorder

When there is a threat, the amygdala goes into action. When the threat goes away, what is supposed to happen is that the amygdala and all its downstream partners stand down. The body returns to its pre-threat state.

When the threat is chronic or, even worse, unpredictable, then these systems do not stand down. They just keep pumping out that cortisol.

In the brain, the amygdala increases in size.

Under constant assault from cortisol, the hippocampus (memory and emotion) and prefrontal cortex shrink. The hippocampus gets stuck on negative memories and emotions. [I call this the little time machine inside my brain. It plays the worst of my past on an unending loop.]

The connection between the amygdala and the prefrontal cortex that could moderate the fear goes down.

In other words, the brain changes. It changes in a way that reinforces the the problematic pattern, raising the risk for depression and dementia. Yuk!

Everybody gets anxious is not a helpful thing to say to a person with Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, Post-Traumatic Stress Disorder, or Social Anxiety Disorder. These are real things. They have tipped past the experiences of everybody. And a warm bath or deep breathing do not fix them.

Healing the problematic pattern may take many forms: distancing from the chronic stressors, medication, a variety of modalities in psychotherapy, even therapy dogs.

At ProzacMonologues.com I like to focus on what is happening inside the brain, to help me remember that my issues are not mere thoughts. They are experienced in my body. Here's an article with much more detail about the sympathetic and parasympathetic nerve systems and how they function.

A physical therapist friend, encouraging me to take a leave of absence to deal with my tattered brain, once told me, It's just like a broken bone. It takes time to heal.

I do wish it healed as easily as that broken foot is healing. But these issues do respond to treatment. If your anxiety interferes with your life, you don't have to suffer alone!


photo by author
Red Green Show meme from imgur on Pinterest

Getting My Brain Back -- I'm Still Excited by BDNF

Learning has been fundamental to my mental health recovery. It started with this blog itself. I wanted to know What the hell happened to my brain?!!! So I read the research and used ProzacMonologues.com to keep track of my notes.

For a while I added piano to my recovery regimen. Not for music therapy, but for brain development. Okay, I didn't keep at it. I can sort of play Desperado. But it did get me a few more miles down the road.

Lately I am learning a new language. Five minutes a day of Irish on Duolingo -- I don't expect to be fluent any time this decade. I don't need to be fluent. For those five minutes a day, I am building my brain.

Which is always a good thing.

I did a search in my blog for BDNF. And found something I wrote in 2011, right after I wrote that review of Ellen Frank's Treating Bipolar Disorder. Now you, kind reader, have no idea the struggle it took back then to write these paragraphs. I am proud of it both for the accomplishment and for the content itself. I present it to you again:

Getting My Brain Back -- In Praise of BDNF


Six Ways to Heal the Holes in Your Head


Do you ever feel like you have holes in your head? Actually, you do. Ventricles are the spaces between the grey matter (brain cells) and white matter (wiring that connects the brain cells) in your brain. Depressive episodes, manic episodes, and psychosis all burn up brain tissue, leading to bigger ventricles. (Image: Effects of Western diet on the brain. See companion image, Effects of Mediterranean diet below.)

This loss of brain cells hits the hippocampus (in charge of memory and emotion regulation) particularly hard. In the early years after my last mental health crisis, I talked about my “Swiss cheese brain.” At my worst, I lost bills, I lost words, I lost everything my wife said to me on the way out the door in the morning. She took to writing down what I said I would do before she got home, never more than two items.

I lost the list.

Holiday Shopping for Your Diagnosed Someone

Black Friday, the traditional start of the Christmas, Hanukkah and Kwanzaa shopping season has left us in the dust. Are you still wondering what to get for your neuro-diverse friend or relation? Here is Prozac Monologues' attempt ever to be helpful to my dear readers.  As my therapist said, Virgo -- your destiny is service.  Get used to it.  (I once had a therapist who said stuff like that.) The following is a holiday shopping list to guide neuro-typicals who want to please their loved ones.

This is a repost from ten years ago. So the pricetags have probably changed. But the links have been checked.

Crazy Meds can be your one stop shopping for Straight Jacket T-shirts, when you're crazy enough to let your medication do the talking, with a range of messages for any diagnosis, medication or level of in your face. The lettering is made by arranging real medication capsules for that homemade, from the heart touch. If you are shopping for me, medium size, long-sleeved, and black, of course.  My favorite message: Bat Shit Crazy.  In three years nobody ever took the hint, so I finally bought it myself.  If you are shopping for me, today I'll go with Mentally Interesting.  I'm still into black, and still refusing antipsychotics, so still a medium.

The following gift suggestions are targeted to differential diagnoses.

Bipolar and Mitochondria

Misfirings and mis-timings of a number of systems affecting: hormones, neurotransmitters, and immune system cycles that go off-kilter; glitches in communication between brain cells and within brain cells; and wonky wiring among the networks that connect the thinking, feeling, and evaluating parts of the brain -- that's bipolar disorder in a nutshell.  Okay, a very full nutshell.  Last week I explored one example of hormone cycles gone off-kilter, cortisol.

This week, we go inside cells to discuss my favorite little critters, mitochondria.  I first learned about mitochondria from Madeleine L'Engle, from the second of her Wrinkle in Time series, A Wind in the Door.  Charles Wallace is sick, dying, because of a problem inside his cells.  His mitochondria are not doing their job.

Mitochondria are organisms (technically, organelles) that crawled inside the cells of animals back when animals were being formed out of the ooze.  It is a beautiful relationship.  We are their hosts and meal ticket; they are the power plants that convert food into energy.  If they don't work well, neither do we.  Since the brain uses bucket loads of energy, a problem with energy production has serious consequences for anything the brain is supposed to do.

What Do Mitochondria Do?

The Brain on Tetris

What happened to that hour?  That other hour?  The one after that?  Where did they go?

My son's best friend from childhood, whom I haven't seen in ten years, sent me a message with this link to a BBC story, The Psychology of Tetris.  When he saw it, did he remember that I used to ask my son to hide the Gameboy?

Project Implicit and the State of One's Soul

Remember, Dumbledore said to Harry, It is our choices that show what we truly are.

Project Implicit

So did you do the homework?  Did you try any of the Implicit Association Tests?  Do you still want to read my blog?

This is how they describe what they are doing:

Project Implicit represents a collaborative research effort between researchers at Harvard University, the University of Virginia, and University of Washington. While the particular purposes of each study vary considerably, most studies available at Project Implicit examine thoughts and feelings that exist either outside of conscious awareness or outside of conscious control. The primary goals of Project Implicit are to provide a safe, secure, and well-designed virtual environment to investigate psychological issues and, at the same time, provide visitors and participants with an experience that is both educational and engaging.

The variety of topics include attitudes toward age, race, disability, ethnicity, mental illness and others.  The tests are constructed to bypass thought, commitment, decision.  They dive deeper into what is known as the lizard brain, the part that evolved before reason, and that simply reacts, by setting one to tasks that have to be accomplished faster than the thinking part of the brain thinks.

Project Implicit is well aware that we may not like what we find in the lizard brain. I don't care for what I find in mine.  But it is important information, for two reasons.

Dopamine - Can't Live Without It

Dopamine -- It's what gets the lab rat turn to left at the T, race down the hallway, make a flying leap at an 18" wall, snag the ledge with its little claws, and struggle over to fall to the other side and win those four food pellets.  If you artificially deplete the lab rat's dopamine, it will turn right at the T and settle for the two pellets lying on the floor.

Dopamine -- It's what got you out of bed this morning and to work on time.  Or if your dopamine levels are depleted, you pulled the covers over your head, while your spouse pleaded with you to go back to your therapist.

Dopamine -- It's what got you out of the house early to redeem that two-for-one mocha coupon at your favorite coffee shop on your way to work, and as long as you were there, might as well order that banana chocolate chip muffin.  Bananas are good for you, right?  Or if you just never got into the habit of that particular coffee shop, and it's not on the way to work, and you really like the French Roast you have at home anyway, then your dopamine never got you fired up, and the coupon went to waste.

Habit and the Stages of Change


I have been writing for several weeks now about this mass of electrical activity inside our brains, dendrites and nerve endings, meeting at synapses, passing their spark from one neuron to the next, creating -- what?  A wink, a whisper, a sensation, the next big brainstorm.

Most of these connections could be called, in the widest sense, habits.  By habits, I mean that pathways get used over and over, form patterns, become familiar, channel us to certain outcomes.  Most bypass the cortex, requiring no decision.  Like breathing, smelling, salivating at the cinnamon.
 
Most of the remainder are still automatic.  But with effort, they can be brought to consciousness where the cortex could interfere, and a decision made.  Like blinking.  Or picking up the cookie.

What if you don't want to pick up the cookie?  Okay, you really do want to pick up the cookie.  What if you want to not pick up the cookie anyway? 

How Do You Change A Habit?


You're gonna take more than one step.

Last week, I put some numbers out there, the Wahls diet.  Nine cups a day of vegetables and fruits.  I broke it down for you: 3 cups leafy greens, 3 cups cruciferous veggies, 3 cups intensely colored.

This food plan helped Dr. Terry Wahls reverse her secondary progressive MS and get up out of her wheelchair.  It could help you reduce your symptoms of heart disease, lung disease, asthma, hypertension, depression, obesity, bipolar disorder, diabetes, Alzheimer's or Parkinson's.

If you have, or are tending toward any of these chronic diseases, you have already heard your doctor/mother/spouse tell you that you need to improve your diet.  Dr. Wahl's book, Minding My Mitochondria tells you just how much and why. 

Nine cups a day of vegetables and fruits:

3 cups leafy greens
3 cups cruciferous veggies
3 cups intensely colored

Stages Of Change 

So there is your canyon.  Here are the steps, more than one.  Several, in fact.  The steps are known as the Stages of Change.



The Stages of Change model appears all over the place lately.  This article from the journal American Family Physician uses the Stages to help physicians help their patients, something more effective than Just do it.  A Youtube search yields results for addiction recovery counselors, life coach trainers, weight loss clinics.


Different sites number the stages differently.  Some say Precontemplation is Stage 0.  Some give Relapse its own number.  Some add Transcendence, whatever that is -- said the priest who gets cynical when quasi-religious language gets used for the purposes of self-improvement.  Whatever we are supposed to transcend, evidently it is not our desire to improve ourselves. -- But I digress.


I like this site, which is the source of the graphic above, even if the author does use that word Transcendence that made me twitchy there for a minute before I got back on track.  It works through the stages from the perspective of the person who is making the change, not the person who wants somebody else to change. 


Crossing Canyons/Building Bridges In My Brain 


Dr. Wahls calls it a diet.  I don't diet.  Who wants to DIE-t?   Each chocolate chip cookie left on the plate represents a little death.  A diet is a temporary interruption.  When it ends, you go back to your life.  But there is nothing temporary about the nutritional needs of my mitochondria, without whom there would be no life.


I'm into changing my brain.  In that mass of electrical wiring, some potentially healthy pathways are blocked by the detritus of dead dendrites.  Other destructive pathways are carved into canyons of well-worn automatic responses. 


Changing my brain will take time.  It is taking decades.  It will take at least another blogpost. 


And The Word Became Flesh 


Question: What do the Stages of Change have to do with Prozac Monologues? 


Answer: Words.  The Stages of Change use language to shape the brain.


Language is one kind of pathway from neuron to neuron.  It connects electrical impulses from the autonomic systems, the olfactory nerve, the amygdala, through the hippocampus (memory and emotion) and the anterior cingulate cortex (pattern seeking) and into the frontal cortex (conscious thought).

Language is how all this electrical activity gets turned into meaning.  It is where the brain and the mind become one. 

The Stages of Change include a process of changing our patterned thinking about food.  And thinking is how we move from one stage to the next. 

Dr. Wahls' writes about synergy, how exercise and diet work together to heal her myelin and reduce the symptoms of her MS.  I'm thinking the same process works for changing habits, particularly food habits.  Each new behavior reinforces the preceding thought that moved you to the new stage.  That repeated behavior patterns the thought that will move you to the next stage. 

Meanwhile, what you are eating while you are trying to make any change matters.  Your mitochondria need the right materials to build the dendrites that form the new pathways.  Like lunch for the road crew.

So don't try to skip stages.  And don't skip broccoli.

One of these days I will write my own food autobiography, my trip through these stages.

photo of Women Working at a Bell Telephone Switchboard from the National Archives and Records Administration and in the public domain
photos of Hatherton Canal in Staffordshire by Roger Kidd, Coal Creek Falls by Walter Siegmund, Glen Canyon by Sascha BrückJeff Kubina used under the Creative Commons Attribution-Share Alike 3.0 Unported license.
Stages of Change graphic was created by Todd Atkins, who placed it in the public domain

Getting My Brain Back -- In Praise of BDNF


Here is the star of Getting My Brain Back, the Neuron. I've got lots of neurons. So do you. They are our friends and we need to take care of them, so they take care of us. BDNF, brain-derived neurotrophic factor will help us do that. How BDNF is giving me my brain back is our story for the day.  But first...

Preface

Did you notice? I wrote a book report in April. If you are a regular reader, I guess that is obvious. Let me try again.

I read a book. Not just the one by Agatha Christie. Maybe you still don't get it. Never mind. Here is the story.

Introducing Neuron, The Brain Cell

 

Cognitive Deficits -- on the way to Getting My Brain Back

The speaker at our monthly NAMI meeting was tall, mid-60's, military bearing, a former ER doc who did a couple tours of duty in Iraq.  You know the type.  Only, a little less of that ER doc -- I'll call it self-assurance.

He showed us slides of the work he used to do, the before shots (which we really did not want to see) and the after shots of young people, kids he patched together at the medic stations.  He told us about the sticky dark trail running from the helicopter pad to the table, and what made it sticky dark.

His passion for his work lit the room.  We listened to stories of kids for whom he had after shots.  There weren't always after shots.

He told us about TBI's, traumatic brain injuries and PTSD and how war does damage to brains.

He was taking a break after two tours of duty, back in an ER state-side when he had the stroke.

Now it became a different story.

Stroke -- The Brain Is Part Of The Body

They told him it would be a long recovery.  Two months later, he was astounded at how long it was taking.  They told him again, it would be a long recovery.  Six months later, the frustration overwhelmed him.  His body was back, the use of his limbs, his balance, more or less.  But his brain wasn't.  And the rehab people said, This is good.  Rehab has begun.

See, we know a stroke is a physical event, something that happens inside the body.  But still we have trouble thinking of the brain as the body.  We have trouble thinking of the functions of the brain, like thinking, as physical functions.  The injured body has to rehabilitate.  We know that.  Doesn't the brain just come along for the ride?

But thinking is done by a body, the part of the body called the brain.  Thinking is a physical process, electrical charges tracing a pathway from one cell to the next, within an organ of the body called the brain.  And when the brain is injured, it has trouble performing its physical functions, like thinking.

Cognitive Deficits

This emergency medicine doctor with battle front experience can't work anymore.  He used the phrase cognitive deficits.

To illustrate, he told us about the work of an emergency room doctor.  When somebody comes into ER with a potential heart attack, there is a protocol.  There are 17 steps to this protocol.  [It might be 23 -- I wasn't taking notes.]  He told us the first step.  Check.  Then he told us the second.  The second step requires a certain mathematical calculation.  He told us what needs to be calculated, the ratio between two measurements.  [I didn't write them down.]  He knows how to do the calculation.  He can do it in 18 minutes.  The whole process is still in there, inside his brain.

The thing is, this entire 17 step protocol has to be done in 93 seconds.

So he can't work as an ER doc anymore.  His job is to do rehab for his cognitive deficits.  In rehab he is learning how to connect all the bits that are still in there.  His brain is finding new pathways around damaged areas to turn all those bits into coherent and accessible thoughts.

And I thought -- That's it!  That's my swiss cheese brain!

My Swiss Cheese Brain

I am told, now that I have lost half of my cognitive functioning, I am still smarter than 80% of the people in the room.  Well okay, between 10 and 11:30 on alternate Wednesday mornings.

All the bits are in there.  If only I could connect the dots.  I wander inside this brain like the hallways of Hogwarts, wondering what's behind those locked doors, getting caught on moving staircases that take me to places I shouldn't be, sitting cross-legged on the floor in front of the Room of Requirement, desperately requiring entrance, but not a clue how to get in.

Sometimes all the bits taunt me.  They light up like little Christmas tree lights, blink off and on.  But if I grab one, the whole chain goes out.  Other times, all of a sudden, it's back, my brain.  I can get it to take me exactly where I want to go.

You don't notice.  You don't see the day spent on a paragraph, the week that is lost when the wall will not yield.  It hurts to write.  But I don't know who else to be, if not a writer.

Brain Damage

I have been writing about this stuff for years now.  Listening to somebody recovering from stroke, it finally hit me, brain damage.  I have brain damage.  The source is not the same.  A stroke kills brain cells through oxygen deprivation.  Trauma kills brain cells through chemistry, a surge of catecholamines, depression of thyroid function and hypoxia... an outpouring of other neurotransmitters, neuropeptides, and hormones... heightened catecholamine endorphin secretion with eventual depletion... the secretion of corticotrophin releasing hormone (CRH), adrenocorticotrophic hormone (ACTH) and cortisol... always more cortisol...

All of which really screws your hippocampus, seat of memory.  Here is the source of my cognitive deficits.  They say that, unlike cancer or a broken bone, there is no picture of depression.  Actually, that is not true.  MRI's show that anxiety and mood disorders damage and shrink the hippocampus.  They do have the pictures.  It is real.  It is brain damage.



Traumatic Brain Injuries, Post Traumatic Stress Disorder and severe depression all do the same brain damage.  They look the same.  By that, I mean the same MRI's.  They act the same.  By that I mean the same dysfunctions.  And, what do you know, they respond to the same treatments.  [I wrote about this in more detail back on March 28, 2010, one of my most frequently viewed posts.]

You can rehabilitate brains damaged by TBI's, PTSD and depression, just as you can rehabilitate brains damaged by stroke.  Just like stroke, some damage is reversible, some is not.  And just like stroke, expect it to take a long time.

A Long Recovery

A friend who has been my mentor through this life transition of mine told me, Yes, your brain will come back.  Give it five years.

So then my brain did its half-full/half-empty thing.

Five years -- that takes the pressure off.  I can give myself a break, and give myself time.  I can have hope.  Maybe my brain will be brilliant like my friend's brain again.

Five years -- my career really is over.  I will be too old to go back.  There is no reclaiming what I lost.  The presenter will never work in the ER again, and I will never be Diocesan Ministry Developer again.

Both.

I do tend to focus on the half empty part.

But my brain stretches out to as healthy as I can imagine, if only for a moment --

So I will do something else, instead.

to be continued...

photo of army doctor during training in Baghdad in public domain, (not the speaker referred to in this post)
flair by facebook
reproduction of hippocampus from Gray's Anatomy in public domain
fresco of The Visitation from the 14th century, Museo Matris Domini in Bergamo Italy

Cognitive Behavioral Therapy -- Mindfulness

Last Week's Cognitive Therapy Technique -- Distraction

 I can't stop thinking about... [some traumatizing thought.]

So think about something else instead.

Distraction is a basic Cognitive Therapy tool.  Personally, I think it's stupid on the face of it.  The point is, I can't stop thinking about what I am already thinking about.  I am stuck on this horror movie, and somebody stole the channel changer.

Except I can change the channel.  You can, too.  You can think about something else instead.

That diagnosable gingerbread house of mine worked just fine.  It changed my channel.  How weird is that?

Here's the deal.  I think it worked is because, just like that other channel, it was all-consuming.  I had to pay exquisite attention to those cans supporting those fragile walls, whether the walls would meet, whether the pretzels would break... 

Mindfulness -- Another Cognitive Therapy Technique

 There was no room for a wandering mind on this construction site.  Gingerbread was my own personal Yoda, sitting on my shoulder, hitting me over the head any time my mind was not on where I was.  Like when I knocked over that nearly new bottle of single malt scotch holding up the back wall.  Balvenie, to be precise.

Matthew A. Killingsworth and Daniel T. Gilbert of Harvard University recently published a study on wandering minds and happiness.  The short version: a wandering mind is an unhappy mind.

“Mind-wandering is an excellent predictor of people’s happiness,” Killingsworth says. “In fact, how often our minds leave the present and where they tend to go is a better predictor of our happiness than the activities in which we are engaged.”

The researchers estimated that only 4.6 percent of a person’s happiness in a given moment was attributable to the specific activity he or she was doing, whereas a person’s mind-wandering status accounted for about 10.8 percent of his or her happiness.

The unhappy news: people spend 46.9% of their waking hours thinking about something other than what they’re doing.  That would be the average.  Me -- here and now is my worst subject in all the world.  This has something to do with a hippocampus the size of a poppy seed.  And yet so often it has that channel changer in a death grip.

Mindfulness is the non-judgmental observation of the ongoing stream of internal experiences as they arise.  Mindfulness acknowledges the hippocampus.  It just doesn't let it run the show.

Other parts of my brain deserve their say, as well.  My traumas are not here and now.  In any given moment, the odds are overwhelming that I am perfectly safe -- an objective fact.

There are other objective facts, including that I was not always safe.  But that was then, this is now.  Remember, remember.  Keep a tight grip on this fact -- this is now.  This is when I need to focus on whether the roof meets the side wall or if there is a gap.

My misery comes from two things, then and the fear that then is next, with no room for now in between.  Like the Jewish joke, without guilt and dread, who am I?

But the odds of an unsafe event in the future are not overwhelming -- they are as miniscule as my poppy seed sized hippocampus.  My frontal cortex is perfectly able to calculate the odds.

Here and now is pretty cool.  This exact moment is a gift.  And many good things are possible in it.

By the way, that prototype served its purpose.  It taught me a lot, including the fact that it was not possible to replicate it in the one week I had onsite.



I did have a Plan B.  And not chained to my past aspirations, I decided to go to Plan B before, not after the meltdown.


I like this channel a lot better.


gingerbread photos by Helen Keefe
Harold Lloyd from Safety Last in public domain

PTSD: Prevention -- Sort Of


Readers will know that I am firmly in the camp that calls for  the "trauma" in Post-Traumatic Stress Disorder to include more than war and rape.  Nevertheless, as I write this third in my PTSD series on Memorial Day weekend, I write with love, honor and respect for my parishioners, friends and family members who have served this nation in combat.  As it happens, all of my people have come home.  But none of them ever really.

Now know this.  It frames the whole conversation about research into prevention of Post Traumatic Stress Syndrome.  All the efforts currently being studied and tried for prevention are about preventing PTSD in those who have already experienced trauma.  (That's called "secondary prevention.")  They are not about preventing the trauma in the first place.  Read it again and remember that point.  I shall return to it.

[If you want to skip the research, you can scroll down from here to the **** where I take up my conclusions.] 

A number of medications are being tried post-trauma (the "morning-after" pill) to interrupt stress mechanisms and to impede the particular memory consolidation that leads to PTSD.  If memories of the trauma, including sights, sounds, smells, sensations are not associated with the conditioned fear response, then triggers will not elicit symptoms and PTSD will be prevented.

One strategy is to damp down the activity of the adrenal gland.  Propranolol is a prime candidate for this use.  It is used now to treat hypertension and anxiety disorders, because it reduces the fight or flight mechanism, the release of catecholamine from the adrenal gland and speeding up of the heart rate, among other things.  Propranolol interferes with the memory of emotional events, because the mental image is not "consolidated" with the bodily experience of adrenaline.

Studies of propranolol have been conducted on trauma victims.  Usually it is administered in the emergency room, within a few hours of the trauma, and then continuing over the course of several days.  The results are mixed.  In some studies, those who received the medication experience fewer PTSD symptoms one or two months later.  A NIMH study in 2007 did not replicate these results.

Another approach is to address the damage done farther downstream, by changing the balance of neurotransmitters.  Neurotransmitters sit in the space between brain cells (called synapse) and help messages move along from one to the other.  Serotonin (of Prozac fame) carries the messages and is the best known by the general public, but there are several others, as well.

Glutamate is a neurotransmitter that speeds up the action between brain cells.  There is a lot of glutamate in the hippocampus, where it helps develop long-term memory.  GABA slows down the passage of messages, which gives it a tranquilizing effect on glutamate.

The balance of these two affects the health of neurons.  Persons with PTSD have more glutamate and less GABA on board than those without PTSD.  The Defense Department is currently funding a study to discover whether an intervention to redress the balance might make communication between brain cells less efficient -- again, interfering with the consolidation of long term memory.

Another option is an earlier and more aggressive use of serotonin.  Serotonin supports brain-derived neurotrophic factor (BDNF).  So it indirectly helps the brain repair itself, reversing shrinkage in the hippocampus.

The neurotransmitter Neuropeptide Y (NPY) inhibits the release of stress hormones norepinephrine and corticotropin releasing factor.  There is some evidence that enhancing the production of NPY might reduce the problems caused by stress overload.  But there are no such medications available yet.

Then there are the opiates, such as morphine.  It would be unethical to conduct the typical research using morphine, i.e., giving the medication to one group and placebo to another.  This January, the New England Journal of Medicine reported an "observational study" of morphine use in the battlefield.  The medical records of 696 injured military personnel were examined after treatment.  Those with moderate or severe traumatic brain injuries were excluded from the study, because severe brain damage protects against PTSD.  How's that for irony.

The study concluded that morphine does provide some protection against PTSD.  Among the patients in whom PTSD developed, 61% received morphine; among those in whom PTSD did not develop, 76% received morphine.  The odds of this difference occurring by coincidence are less than one in a thousand (odds ratio, 0.47; P<0.001 in statistics-speak.)  Severity or mechanism of injury, age and amputation -- none of these factors made a significant difference in the findings.

It is speculated that morphine has this protective effect because severe pain increases the trauma of the injury, and hence of the memory.  I wonder if it might prove more effective in nonmilitary use, among those whose brains are not being primed for PTSD every single day.

Okay, the limitation of any of these medications is that they are directed at single event traumas, rape, injury, one time devastating experience.  The brains of soldiers and abused children are injured and prepared for PTSD daily.  What are we going to do, sprinkle propanolol into the cornflakes of everybody deployed in a battle zone, make it part of school lunches?

There are also more creative, nonpharmocological approaches being explored.  Louisiana State University Health Sciences Center is going to study hyperbaric oxygen treatment for those with traumatic brain injuries. TBI has been called the signature wound of the wars in Iraq and Afghanistan. A RAND Corporation study released in April estimates that about 320,000 service members may have experienced a traumatic brain injury during deployment. 

In hyperbaric oxygen treatment, burn and carbon monoxide victims are placed in a pressure chamber to increase oxygen in the blood stream, and hence in the brain.  Think of deep breathing to relieve your anxiety attacks.  LSUHSC will compare TBI victims who receive or don't receive this treatment, in hopes of discovering a new approach to help this subset of injured soldiers.

Like the medications, hyperbaric oxygen treatment (if it works) will be given to those with one time traumas, not so useful for continuing trauma.  Here is another approach that might work on a daily prophylactic basis.  Tetris!

An admittedly small study conducted at the University of Oxford examined whether "visiospatial cognitive stimulation" could provide a vaccine against flashbacks.  It was based on the capacity of the brain to process just so much stimulus at one time.  If that capacity is used up by the intrusion of non-traumatic images, then perhaps the traumatic ones would be encoded in memory less deeply. 

So they showed the Trauma Film, a twelve minute piece that is known to produce flashbacks.  After thirty minutes, ten subjects played Tetris, and ten sat quietly.  Tetris was chosen because it is known to intrude upon image-based memory (people see images of the game at a later time after playing).

In fact, these intrusive memories are why I stopped playing it.  It was additively soothing, but I kept seeing the Tetris shapes around me in everyday objects.  Like, the silhouette of a head and shoulders became that L-shaped piece.  At one point I asked my young son to hide his game-boy, so I couldn't find it!  Now I play other games that intrude on image-based memory.

I digress.  Anyway, in the following week, the Tetris-playing group had fewer flashbacks to the Trauma Film than the others.

Now this is an application that could be used in the battlefront.  I understand that soldiers often play computer games when they return to base, though usually they are war games.  Tetris or maybe some other matching three type game could push the day's images out of their brains.

***********

Okay now, I have spent months gathering these studies of secondary prevention of PTSD, and struggling with two issues regarding the vast numbers of new sufferers of PTSD who are created every day in Iraq and Afghanistan.

The first is a dilemma.  After we have put our young people in harm's way, after they have been injured in the service of their country, surely they need -- and deserve -- the best medical care we can give them.  And better.  Surely we need to do more research for better medications and better treatments.

What troubles me is that the medications and treatments are designed to obscure from them the horror of their experiences.  While we treat them, we are creating more effective soldiers, soldiers who can do more and more terrible things, because we have undone part of their most human response to these terrible things.  And we are creating in ourselves denial about what war is.  The healthy human being would go crazy.

And we can't do this so selectively as we would like.  When we interfere with the consolidation of traumatic long term memories, we also interfere with all long term memories.  Which, ironically, is what PTSD does.  Part of how the brain protects itself from horror is to go numb to all feeling.

And yet, their suffering is real and urgent.  How can we not relieve their pain by any means possible?

See what I mean?

My second issue is this.  All the medications and treatments I have described are secondary prevention. -- I said at the beginning that I would return to this point.

What is primary prevention?  It's what we do with lung cancer.  We don't invent treatments that intervene between inhaled carcinogens and the lungs.  We conduct public campaigns against smoking.  We don't make the liver more efficient in processing poison.  We prohibit the use of lead-based paint.  We don't prevent Froot Loops and the sugar in even salad dressing from overwhelming the pancreas and kidneys.  We educate about high fructose corn syrup and our epidemic of diabetes and obesity.  -- Okay, there's a little hypocrisy in that last one, when we compare the money spent on health education to the subsidies given to produce high fructose corn syrup.

What about primary prevention of PTSD?

When is the Surgeon General of the United States of America, Vice Admiral Regina M. Benjamin going to stand up and tell us the truth -- that war is a health hazard?

The frontal cortex of the human brain, the part that comprehends the consequences of actions, is not fully developed until age 25.  When are recruiters going to be banned from high schools and college campuses and malls?  Or federal funding refused to schools that permit ROTC programs?  When are those ads for the Marines going to be banned from the Super Bowl and other sporting events?  When are parents going to teach their children, Just say no?

Defense Secretary Robert Gates said recently that leaving aside “the sacred obligation we have to America’s wounded warriors, health care costs are eating the Defense Department alive.”  Imagine how much money we could save is we stopped putting them in harm's way.

Before automated warning systems were developed, coal miners used to take canaries with them into the mine.  When the canary died, the miners knew the air was poisonous.  It was time to get out of the mine.

So here is the last thing I am going to say about PTSD for a while:

We gotta lot of dead canaries.  When will we get out of the mine?


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.

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