A recent study, Beyond extinction: erasing human fear responses and preventing the return of fear, is making a lot of headlines.
I will go through the study in a moment. But first I want to make an observation from my clinical experience.
A number of persons that I treated for anxiety disorders were on propanolol. Some used it for cardiac health, some took it to help with their anxiety problems. Their anxiety disorders ranged from uncomplicated phobias to severe, chronic PTSD stemming from service in the Viet Nam war.
For better or worse, I cannot confirm the results claimed in the new study. I did not, then or in retrospect now, find that the exposure trials or treatment in general went any smoother or quicker for the persons on propanolol. Nor did I find that the medication extinquished the fear associated with memories of the war.
Admittedly, my sample size is not as statistically significant as the one in the study. My treatment approach did not incorporate the fact, one way or another, that the patient was on propanolol. In fact, for all intents and purposes, I ignored whether or not they were on that medication.
But I think I would have noticed something if propanolol had such beneficial effects. At least I would recall those patients as being easy cases. In fact, two of them are among the most memorable for the tenacity and duration of their symptoms.
With that caveat, let me summarize the recent research.
When we bring a memory to consciousness, there is the potential to change parts of that memory and the emotions assoicated with it. This, itself, is not a new concept. It goes back to at least Freud. The process of recalling and changing aspects of a memory is termed "reconsolidation" in this and other studies.
The authors "repeatedly showed healthy volunteers pictures of spiders, one image of which was followed by an electrical shock." (Aren’t you glad you did not volunteer for that study?)
The volunteers learned to associate the image of the spider with fear. The degree of fear was measured by the "startle response" exhibited by the subjects.
Afterwards, some of the volunteers received propanolol and others got a placebo. They were then tested for how much of a startle response was elicited by the the image of the spider.
The authors found that for persons given the propanolol "the conditioned fear response was not only reduced but even eliminated…"
In contrast, those who got the placebo, their "startle response remained significant."
Simply put, after receiving propanolol, “The people did not forget seeing the photograph of the spider,” Kindt says. ”But the fear associated with the image was erased."
How does that work in the brain? The authors suggest that "(i)t may be hypothesized that beta-adrenergic blockade during reconsolidation may selectively disrupt the protein synthesis of the amygdalar fear memory, resulting in deconsolidation of the fear memory trace while leaving the declarative memory in the hippocampus untouched."
Furthermore, “Beta-blockers wouldn’t stop reconsolidation of only frightening memories, the researchers say. ‘It’s likely that any emotional memory, happy or sad, recalled after taking the drug would be dulled,’ Kindt speculates.”
On the clinical side, these findings would suggest using propanolol in conjunction with procedures like Breur’s abreaction, Freud’s cathartic method, some Gestalt therapy procedures, NLP’s dissociating and reframing, venting, exposure and other methods.
The question remains about how to square this study’s findings with my clinical experience. Here are a few guesses. It may be that there was something peculiar to the patients I treated that made them resistant to the benefits of propanolol. That, I suppose, is possible but I do not think it is likely. Alternatively, it may be that propanolol is useful in treating newly acquired fears or phobias. Or it may have a prophylactic benefit for people soon to be exposed to a trauma (think of a firefighter going to his/her first apartment building fire, a sniper fresh from boot camp about to be deployed to an Afghan hilltop).
In the end, I agree with the Guardian’s conclusion: "we don’t know whether the results would apply outside of this artificial situation. We need to see good-quality studies among people who have suffered a genuinely painful or upsetting event, to see whether this type of treatment can help them in a meaningful way."
And then there are some ethics questions to be addressed.
Kerri Smith hints at this by recalling the movie “Eternal Sunshine of the Spotless Mind.” Do we use drugs to extinguish affective memories of unhappy relationships?
If propanolol is effective in negating or dulling the emotional aspect of an event, what impact would that have on the decision-making of, say, a sniper determining whether or not to take a shot if the pathway to the target was through the body of a civilian? Would it embolden persons considering a heroic act? What would it do for persons about to commit a violent crime?
This study, for me, raises as many questions as it answers.