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.

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.

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: wmgoodfe@yahoo.com.  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!!?!

NAMI Walks -- We All Win

This is my second year for the NAMI Walk Johnson County, Iowa.  It's how people across the United States raise money for the National Alliance on Mental Illness, an organization whose mission is support, education and advocacy with and on behalf of people with mental illness and their families.

National Alliance On Mental Illness

I became passionate about NAMI when I learned about its origins.  Once upon a time, not so long ago, the holy writ on schizophrenia was that it was caused by overprotective mothers and disinterested fathers.  Wow.  In 1979, a bunch of these mothers started to push back.  They organized and demanded better research, better treatments, better treatment.  Would there ever be any progress in the world if it weren't for uppity women?  A new documentary, When Medicine Got It Wrong tells the story, coming soon to a PBS station near you.

NAMI has grown into a national program, built on local chapters.  It fights stigma.  It advocates for funding of services, research and rights.  It provides information about mental illnesses and medications.  It offers a variety of educational programs and services.

Peer To Peer

Prozac Monologue followers read with some regularity what I have learned from NAMI's Peer to Peer program.  In Peer to Peer, those who have a mental illness and are in recovery help others learn about recovery, living to the fullest while managing a mental illness.  I drove (my wife drove -- my meds won't let me drive anymore) 120 miles round trip every week for nine Iowa winter nights so that I could attend this program.  It was worth every mile.

Make A Difference

So here's the deal.  Every year NAMI raises money through local Walks.  My local chapter will walk on May 8th, rain or shine.  Last year was my maiden voyage into NAMIWalks.  I went with some trepidation, wondering just how bleak and weird a walk for mental illness could be.  Instead, I discovered a registration process that reminded me of summer camp, belly dancers leading the warm up, pep talks from the Hawkeye football team, a balloon arch, kids, dogs, food, t-shirts and more t-shirts, displays that kept falling over in the breeze, and chalk drawings along the trail made by the Girl Scouts.  It was a party!

I did not do a shabby job raising funds my first time out.  I knew I would do well, because I know my friends.  This year I decided to co-chair a team called, wouldn't you know, Team Prozac Monologues!  And right there, on the name, is where you can go to support my team.  Giving online is safe, easy, fast and tax deductible.

Team Prozac Monologues is about halfway to our goal so far.  Any amount you can give is important.

And as Hoops and Yoyo say,

National Blog Post Recyling Day -- I Am Not SAD

"In order to do my part for Earth Day, I am participating in a new national celebration in conjunction with Earth Day called “National Blog Post Recycling Day.” Other than the sentences you are reading now, I will be posting no “new” content on my blog today. Grab your lap top, your smart phone or your iPad, sit under a tree and enjoy some digital recycling."

From April 12, 2009 -- I Am Not SAD

What month has the highest rate of suicides in the northern hemisphere? What about the lowest? You will find the answer at the end of this post.

Calling All Mood Charts

A comment on yesterday's post inspired this quicky.  Based on a my narrow experience, I have a rigidly held opinion on the topic of mood charts.  Well, like a lot of things.

But I have a readership that might have a broader experience.  And while I am not above blathering away on my own opinions, I do have the wit to listen and learn from others, even to ask.  So...

What are YOUR experiences with mood charts?  (Mental health professionals can answer based on your clients' experiences, if you are sure they aren't bullshitting you.)

What kind of charts have you used?  Are you still using one?  Why or why not?

What have you learned by using a mood chart?  Or not?

Make liberal use of the comment section below.  When I get to that post, maybe I will have a slightly larger experience base from which to draw!

Thanks --