Tag Archives: Post traumatic stress disorder

Controversy About PTSD

Bob Herbert, in today’s NY Times, writes: “I couldn’t have been less surprised to read last week that an American G.I. had been charged with gunning down five of his fellow service members in Iraq.”

He goes on to say that “Recent attempts by the military to deal with some of the most egregious aspects of its deployment policies have amounted to much too little, much too late. The RAND study found that approximately 300,000 men and women who had served in Iraq and Afghanistan were already suffering from P.T.S.D. or major depression. That’s nearly one in every five returning veterans.”

His conclusion is that “We’re brutally and cold-bloodedly sacrificing the psychological well-being of these men and women, which should be a scandal.”

That is a scathing review of the current treatment of America’s service personnel.

On the other hand, Scientific American ran a lengthy article, Soldiers’ Stress: What Doctors Get Wrong about PTSD. The ‘key concept’ of this author’s position is that “The syndrome of post-traumatic stress disorder (PTSD) is under fire because its defining criteria are too broad, leading to rampant overdiagnosis.”

The author, David Dobbs, writes in his blog, Neuron Culture that:
“We are likely overdiagnosing PTSD in veterans by some 300 to 400%….the arcane disability system at the VA so discourages recovery that those receiving VA treatment — which is roughly similar to treatments that cure 2/3 of civilian patients — show no treatment effect at all. They’re no more likely to get better than are vets with PTSD not getting treatment.”

If the system is so broken and resistant, then one would assume that persons or groups, for their own benefit, maintain the current system instead of adopting a better alternative.

I suppose that it is possible that some in the VA benefit from the current model and would resist change to whatever might be a more effective model.

However, Dobbs finds that the country as a whole is invested in maintaining what he calls an “arcane disability system.”

Dobbs asserts that “war… might not be as scarring as we like to think it is….American culture seems to have a deep investment in the the picture of war as irredeemably toxic, and in its experience as incurably damaging.”

The structure of Dobbs argument runs similar to (but not as far as) Thomas Szasz or those in the anti-psychiatry movement. According to Wikipedia, Szasz finds that “people with mental illness have a “fake disease,” and these “scientific categories” are in fact used for power controls. Schizophrenia is “the sacred symbol of psychiatry” and, according to Szasz, is not really an illness. To be a true disease, the entity must somehow be capable of being approached, measured, or tested in scientific fashion.”

Hence there is a lot of emphasis on refining the criteria for PTSD and being able to objectively identify and measure the disorder in the brain. As Dobbs writes: “To make the diagnosis of PTSD more rigorous, some have suggested that blood chemistry, brain imaging or other tests might be able to detect physiological signatures of the disorder.”

And there is some progress being made in that arena. For instance, Medical News Today reported on recent research using functional magnetic resonance imaging scans (fMRI) that “found marked differences between the two groups in an area of the brain governing the sense of self. When the soldiers were shown the combat photos, this area, found in the medial prefrontal cortex, lit up remarkably in the PTSD group, but very little in the non-PTSD group.”

To give him his due, Dobbs does not find PTSD to be a “fake” disease. He concludes his blog entry with: “PTSD exists. Where it exists we must treat it. But our cultural obsession with PTSD has magnified, replicated, and finally perhaps become the thing itself — a prolonged failure to contextualize and accept our own collective aggression. It may be our own postwar neurosis.”

We have now gone from Herbert’s moral outrage at the lack of proper care and concern for veterans to Dobbs’ view that PTSD cases are 300-400% overly diagnosed and then for a quick stroll through metapsychiatric and cultural analysis.

Let’s return to the subject that is of real interest here: those who suffer from the psychological distress called PTSD.

The Canadian Journal of Psychiatry published a piece by Brunet, Akerib and Birmes titled: “Don’t Throw Out the Baby With the Bath Water” in 2007. The authors argue that:
“If we consider the evolution in the field of trauma research, there are at least 2 major tendencies: on the one hand, the criteria for diagnosing PTSD have become stricter, while, on the other hand, our ability to detect and correctly assess trauma exposure and PTSD has improved, thereby leading to the identification of new, previously undiagnosed cases. The net result of these 2 tendencies is a remarkably stable rate of PTSD in the epidemiologic surveys of the last decade.”

There are, then, real persons with PTSD, whether due to rape in the US or witnessing battle in Afghanistan, suffering from real emotional pain and cognitive limitations. We should get to the heart of the matter and figure out the best means of treating the illness and the best way to finance that treatment. Let’s not get side-tracked by fMRI results and whether or not America has a guilty conscience and so has made war out to be a scarring experience.

As Brunet, Akerib and Birmes write:
“the public debate and increased awareness about the hidden human and financial costs of traumatogenic events such as warfare, rape, and child abuse—to name just a few—must continue for the good of society.”

Anxiety, PTSD and Propanolol

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.

No One Knowingly Errs

In the very first post on this blog, I wrote: "Actions based on anxiety are often regrettable."

That may be true, but someone experiencing intense anxiety or a panic attack feels under great pressure to do something, anything to relieve the anxiety and improve their situation.

Nevertheless, actions born from anxiety often have poor or unintended outcomes.

Those negative outcomes reinforce one’s feeling of being out of control, or of being inept, flawed. There is no sense of having a certain mastery or competence in the situation. In turn, those thoughts and emotions fuel further anxiety. There is now "objective" proof that the situation is overwhelming and threatening. The anxiety and panic is now grounded in hard evidence. This is the same situation I wrote about in "Anxiety, Self-Esteem and Self-Soothing."

Some recent studies shed a bit more light on this self-fulfilling prophecy.

The Rockefeller University posted "Stress disrupts human thinking, but the brain can bounce back" on January 27, 2009. In sum, they found that:

  • "A new neuroimaging study on stressed-out students suggests that male humans…don’t do their most agile thinking under stress."
  • "[stressed persons] had a harder time shifting their attention from one task to another than other healthy young men who were not under the gun."
  • In research on rats, the workers found further biological basis for poor performance under stress:
    "repeated stress on rats shriveled nerve cells of the medial prefrontal cortex, and that a shrunken prefrontal cortex is linked to slower performance on attention-shifting tasks."
  • However, there is good news as well. Within a month after the stress ends, the brain bounces back to its normal state and attention and performance returns to a person’s baseline level.

These findings are generally verified in another recent study: "Driving Under the Influence (of Stress): Regional Effects of 9/11 Attacks on Driving." "The authors found that there was an increase in the rate of traffic fatalities in the three months following the 9/11 attacks, but only in the Northeast, the region closest to the terrorist attack…" Further, there was "a 100 percentage point increase in the rate of drug- and alcohol-related fatal traffic accidents in the Northeast."

The authors theorize that "being close to the location of a traumatic event, such as the 9/11 attacks, may increase psychological stress, which may, in turn, impair one’s driving ability and thus lead to an increase in fatal traffic accidents."

Being under stress, whether from an upcoming test or a nearby terrorist attack, impairs a person’s ability to think, plan, perform. The consequences of choosing a course of action under stress and anxiety (for example, is it a good idea to drink alcohol if I know that I will have to drive later), can be severe. Doing poorly on a test or getting into a car crash can provide the illusory conclusions that I am not smart or I am a really bad person. With those beliefs, one is even more likely to become unduly anxious and underperform in the future.

But again notice the silver lining in the second study-traffic fatalities declined again three months after the stress of the 9/11 attack.

However, the effects of long-term stress or life-threatening events may not be so quickly reversed.

A study from the University of Wisconsin, published in the January 26, 2009 Proceedings of the National Academy of Sciences, looked at the immune systems of children who had lived in orphanages in Romania, Russia or China and were later adopted by American families. They found that, even after ten years of life in "stable, affluent, loving environments…their immune systems are compromised as well. In fact, they look just like the [more recently] physically abused kids."

"’Even though these children’s environments have changed, physiologically they’re still responding to stress. That can affect their learning and their behavior, and having a compromised immune system is going to affect these children’s health,’ says senior author Seth Pollak, a professor of psychology and pediatrics at UW-Madison."

Imagine, if you will, how easy then it would be for those children to form negative opinions about themselves and their abilities. They are ill more frequently than the children around them, have more difficulty making correct judgements. Their behaviors are not as well controlled as their peers’. They have more difficulty learning and in school. All this despite the apparent advantage of now living in "stable, affluent, loving environments." Who else to blame but themselves?

Let’s look at the sheerly biological side of this matter. In 2006, the Department of Neuroscience, Mount Sinai School of Medicine studied rats exposed to 21 days of restraint stress. [Readers interested in the effects of restraint stress on animals, in simpler language, are recommended to read Restraint and Handling of Wild and Domestic Animals By Murray E. Fowler] Mount Sinai’s study found significant impairment of the medial prefrontal cortex. "[N]early one-third of all axospinous synapses on apical dendrites of pyramidal neurons in medial PFC are lost following repeated stress…Dendritic atrophy and spine loss may be important cellular features of stress-related psychiatric disorders where the PFC is functionally impaired."

That’s a dense packet of jargon. Let’s break down those last two sentences a bit.

Click here for a look at the medial prefrontal cortex.

Now, why is the medial pre-frontal cortex important?

Here’s what Wikipedia says about that area of the brain:

"The most typical psychological term for functions carried out by the pre-frontal cortex area is executive function. Executive function relates to abilities to differentiate among conflicting thoughts, determine good and bad, better and best, same and different, future consequences of current activities, working toward a defined goal, prediction of outcomes, expectation based on actions, and social ‘control’ (the ability to suppress urges that, if not suppressed, could lead to socially-unacceptable outcomes)."

So the pre-frontal cortex assists in judgement, planning, decision-making (e.g., should I drink if I am going to have to drive home).

The dendrites bring information into the cells of the medial pre-frontal cortex. A loss of "nearly one-third" of these information carriers would have significant and negative impact on the ability to make judgements, plans, etc.

This same area of the brain has been implicated in Post-Traumatic Stress Disorder. In "Amygdala, Medial Prefrontal Cortex, and Hippocampal Function in PTSD", the authors find that the "medial prefrontal cortex appears to be volumetrically smaller and is hyporesponsive during [PTSD] symptomatic states and the performance of emotional cognitive tasks in PTSD. Medial prefrontal cortex responsivity is inversely associated with PTSD symptom severity."

So, in both PTSD and situations of significant, chronic stress, there is long-term impairment of the medial prefrontal cortex. In turn, the afflicted person’s executive functioning (judgement, planning, decision-making, etc.) is worsened for lengthy periods of time.

It appears that shorter periods of lower grade stresses (e.g., an upcoming important test) produce briefer periods of poor executive functioning and less extensive impairment of the medial prefrontal cortex.

These studies can be used to make another point. We have seen that a stressed person has impaired executive functioning that stems at least in part from damage to the medial prefrontal cortex. Consequently, a stressed person will be cognitively, emotionally and behaviorally functioning at a lower level than their best capabilities. Therefore, these persons should be especially cautious before making and carrying out plans (even one as simple as whether or not to drive to a keg party). Equally important, their choices and behaviors have to be viewed in the context of being stressed and having a damaged prefrontal cortex.

With this knowledge in hand, a stressed, anxious or panic-stricken person can revise their opinions of themselves in a more objective fashion.

We would not judge how good a runner one was if the judgement was based on a 100 yard dash done when the person had the flu. All that can tell us is how they perform when significantly ill and impaired.

Forming your self-image and self-esteem on the evidence of beliefs, judgements and actions while stressed or suffering its after-effects is equally absurd.

Unfortunately, many people with anxiety, panic and other psychiatric disorders do exactly that. The net result is to generate further stress because of the internal self-criticisms and anxiety about their ability to function in the world. That, in turn, yields more impairment of the prefrontal cortex and consequently worsening executive functioning. A person’s self-image and self-esteem will then be in a graveyard spiral.

I will return to these studies and their implications in a later post about anxiety and self-image. For now I will leave you to ponder Socrates’ claim that "No one knowingly errs." Especially as it might apply to persons who are anxious, panicky, stressed and make invalid assumptions, poor judgements and mistakes in their actions.

Follow-up on PTSD and The Pentagon

I’d like to subtitle this post “Waiting for Martians,” for reasons that I hope will become clear as we go along.

The Army Times yesterday posted an article about the Pentagon’s decision to withhold the Purple Heart from soldiers who are inflicted with Post-Traumatic Stress Disorder.

The article notes that about 20% of the soldiers in Iraq meet the criteria for PTSD.  The article cites Department of Veterans Affairs findings that nearly 76,000 soldiers were given a provisional diagnosis of Post-Traumatic Stress Disorder between 2003 and 2007.  Obviously, this is a prevalent problem for our soldiers.

The article repeats the Pentagon’s reasons for disqualifying PTSD as an injury meriting the Purple Heart.

To further explain the Pentagon’s decision, the article quotes Charles Figley, professor of disaster mental health at Tulane University.  Figley is quoted as saying “There’s no blood test…no neurological map that clearly identifies” PTSD.

That’s true enough. But Figley goes on to say that PTSD is:

“an anxiety disorder, and all anxiety disorders are extraordinarily subjective. They’re difficult to treat through medication for precisely that reason.” However, “ongoing research could someday lead to a blood test…for the disorder…Figley said.”

Now I must admit that I am lost in this tangled trail of thought.  Let’s pull out the highlights of this argument.

“There’s no blood test…”
“All anxiety disorders are extraordinarily subjective…”
Anxiety disorders are “difficult to treat” because they are “extraordinarily subjective.”
Some day there may be a blood test to diagnose PTSD and anxiety disorder.
And a Pentagon spokesperson added “predictable and quantifiable physiologic injuries associated with specific psychological injuries is less robust now than it may be in the future”

I take this to mean that PTSD is difficult to diagnose by standardized tests like a blood screening or a CAT scan or an MRI.

That point is granted. Like the disorders Major Depression, Schizophrenia, Bipolar and many more, diagnosis is made largely by evaluation of a patient’s reports of their symptoms and levels of functioning. There are no lab tests to confirm the diagnosis of these conditions.

But here comes the point where I become confused. “Anxiety disorders are extraordinarily subjective” which makes them “difficult to treat.”  But someday there may be blood tests to verify the diagnosis.  And at some point in the future we may be able to specify the physical injury behind the disorder.

Only three interpretations of these statements come to me.

I am going to assume this first possible interpretation is not what they meant. They could be saying that since there is no external lab test to confirm the diagnosis, then there is no way to tell if the soldier is lying about his/her injury.  The Purple Heart could then be mistakenly awarded to persons malingering and conjuring up the illness.  So, 20% of the returning soldiers from the current wars could be faking the illness and not deserving of the Purple Heart.

I also assume that this second possible interpretation is false.  They could be saying that since there is no objective lab test for PTSD, then it may not be a real “illness” at all.  That would also imply that nearly all psychiatric disorders are not true illnesses or disorders.

The last intepretation that I can come up with is that unless there is proof of physical injury (in this case damage to the organ of the brain), then the assumption is that there is no injury.

So, for a soldier suffering from PTSD, there would have to be physical, independently verifiable proof of physical injury.

Allow me to make an aside for a moment.  One of the most intelligent persons I have ever met is a neurologist.  Several years ago, he allowed me to follow him around on his morning hospital rounds for a year or so as a volunteer.  I was and remain fascinated by the brain and neurology and he was kind enough to share his time and knowledge.  One day I asked him a fairly detailed question about the neurological pathways and neurotransmitters involved in a particular task and the set of related emotions.  His candid answer to me was: “Mike, we are going to have to wait for Martians to land and have them explain the brain to us in that kind of detail.  So far, we humans haven’t been smart enough.”

Back to the point at hand: objective physical trauma to verify the diagnosis of PTSD.  PTSD is not traumatic brain injury, it is not a closed head injury, it is not a lesion in the frontal or any other lobe.  It is not something that you can identify in a brain scan, picture or even by autopsy. Post-traumatic stress disorder is a psychiatric disorder whose specific mechanisms are unknown to us at this time. Never mind figuring out a way to distinguish those mechanisms in a fashion that would be suitable for a blood test. Like it or not, there is no way to send off a blood sample or a biopsy specimen and confirm the diagnosis.

That certainly does not imply that the psychiatric disorders are not true illnesses.  It does say that we simply do not have a complete understanding of the brain at this point in time.

May I suggest that if Professor Charles Figley and the Pentagon are, in earnest, waiting for the “neurological map that clearly identifies (PTSD)”, then perhaps they are waiting for the martians to land as well.

In the meantime, it seems cruel to me to deny the Purple Heart to soldiers who are suffering from PTSD as a result of their service to their country.

Why deprive them of such recognition simply because our science has not advanced sufficiently to provide absolute diagnostic confirmation?

Of PTSD, Purple Hearts and the Pentagon’s Shame

It seems clear that one of the goals of warfare is to render your opponent’s warriors incapable of fighting. If that’s not one of the goals, then why would you try to kill their soldiers? Therefore, inflicting enough psychological damage to keep them off the battlefield would logically seem to be a weapon of choice.

PSYOPS (psychological operations), according to Wikipedia, have “been used by military institutions throughout history.”

I am not declaring that PsyOps either does or does not calculate the quantity or quality of injuries and death inflicted on the enemy to maximize post-traumatic stress disorder casualties. I have no way of knowing if that is covered by their mission. Although there must have been some reason that the initial assault in the current war with Iraq was called Shock and Awe. Wikipedia’s entry for Shock and Awe reads, in part, as follows: “the use of overwhelming power, dominant battlefield awareness, dominant maneuvers, and spectacular displays of force to paralyze an adversary’s perception of the battlefield and destroy its will to fight (emphasis mine).”

Here is a link to psywarrior.com’s links to sites devoted to psychological operations and warfare. I present that as a reminder that psychological operations and the resultant damage inflicted on soldiers and civilians is a well-known and long-standing art of warfare (if such practices can be called an art).

What has this to do with anxiety? Let’s recall that post-traumatic stress disorder falls under the anxiety disorder classification.

In that vein, the Pentagon has determined that soldiers returning from battle with post-traumatic stress disorder do not qualify for Purple Hearts. Their reasoning, as reported by the Army Times, is that PTSD does not meet the criteria of a Purple Heart:

“The Purple Heart recognizes those individuals wounded to a degree that requires treatment by a medical officer, in action with the enemy or as the result of enemy action where the intended effect of a specific enemy action is to kill or injure the service member.”

If one side launches a fiercely violent and brutal assault, at least part of the casualities will be soldiers who have witnessed their fellow service personnel and friends die, get injured or maimed in ways that are highly likely to traumatize the witnesses. Any armed force, whether aggressor or victim, who failed to take that into their calculations would be foolish indeed.

In its wisdom the Pentagon, again according to the Army Times, goes further to say that “PTSD is an anxiety disorder caused by witnessing or experiencing a traumatic event.” It is not “a wound intentionally caused by the enemy from an outside force or agent…”

What possible line of reasoning could they be using? It would seem that they are ignoring their own PsyOps division.

So much for logic, reason and parity between “physical” and “mental” injury and illness.

And shame on the Pentagon.