Assistant Professor Jesse Cougle

In addition, women who reported more “re-experiencing” symptoms, such as nightmares and flashbacks, at the initial assessment were more likely to suffer from persistent PTSD symptoms two years after the study began.

“What makes our findings unique is the recovery component,” Cougle said. “Most studies of this kind have looked at risk and resiliency or the factors that determine who develops PTSD and who doesn’t. We studied factors that influence recovery, or lack thereof, in a sample with PTSD.”

“What we found,interestingly, is that more than half of the women in our sample — 58 percent — recovered within two years,” Cougle said.

Most people will experience at least one potentially traumatic event during their lifetimes that could result in PTSD. Knowing the factors that predict chronic PTSD will help to identify people who are most in need of assistance and treatment after suffering a traumatic event.

Cougle also found that about half of the women who recovered from PTSD during the study did so without any sort of professional treatment.

“Some women have a natural capacity to recover from PTSD,” Cougle said. “They won’t require treatment to get better.”

Cougle’s research, “Factors Associated with Chronicity in Post-Traumatic Stress Disorder: A Prospective Analysis of a National Sample of Women,” has been published in the journal Psychological Trauma: Theory, Research, Practice and Policy. He conducted the study with Medical University of South Carolina psychiatry professors Heidi Resnick and Dean G. Kilpatrick.

In addition to re-experiencing symptoms, a PTSD diagnosis includes avoidance and numbing, such as efforts to avoid thoughts, feelings or conversations associated with the trauma; efforts to avoid activities, places or people that arouse recollections of the trauma; an inability to recall an important aspect of the trauma; and feelings of emotional detachment. Additional symptoms include hyperarousal, such as difficulty concentrating; difficulty falling or staying asleep; irritability; and hypervigilance.

Material adapted from Florida State University.

The high rate of PTSD helps to explain why some patients have persistent fears of recurrent SAH — even after being reassured that their risk of suffering another brain hemorrhage is low. “PTSD treatment could alleviate fears of SAH recurrence and promote better outcome,” according to the new study, led by Adam J. Noble, Ph.D., of King’s College London.

Posttraumatic Stress Disorder Linked to Persistent Fears of Recurrent SAH
The researchers studied the relationship between fear of recurrence and PTSD in SAH survivors. Subarachnoid hemorrhage is a type of stroke in which there is bleeding into the brain, most commonly caused by a ruptured aneurysm. For some SAH survivors, recovery is hampered by fear that they will suffer another SAH. Although they’re at higher risk than the general population, the absolute risk is low—between one and three percent.

However, some patients have persistent fear of recurrent SAH, despite reassurance. These fears can become a disabling problem, causing patients to limit their activities and putting a strain on family relationships.

In the study, 142 patients underwent a standard assessment of PTSD symptoms at up to 18 months after surviving an SAH. About one-third of patients met criteria for a diagnosis of PTSD, based on symptoms such as intrusive thoughts, avoidant behaviors, and hyperalertness that interfere with daily functioning. First described in combat veterans, PTSD can develop after exposure to many different kinds of traumatic events.

The patients with PTSD were more fearful of recurrent SAH and more pessimistic about their likelihood of having another brain hemorrhage. Over 30 percent rated themselves “extremely fearful” of a further SAH. They were also more fearful of other life-threatening diseases unrelated to SAH, such as lung cancer or a heart attack.

Patients with PTSD and high levels of fear were less likely to find their current treatment helpful—including reassurance from health professionals that they were unlikely to suffer another brain hemorrhage. Rather than reflecting lack of knowledge, their fears appear to have a psychological origin — “and therefore [are] not easily modifiable through provision of information and reassurance,” Dr. Noble and coauthors write.

The researchers suggest that enhanced treatment targeting the underlying PTSD could be helpful for patients with persistent fears of recurrent SAH. Psychological therapies for PTSD are effective for most patients, reducing negative thoughts and interference with daily functioning. “Offering patients with PTSD an established treatment for it may reduce fear and improve outcome,” Dr. Noble and colleagues conclude.

Material adapted from Wolters Kluwer Health: Lippincott Williams & Wilkins.

“Chronic PTSD is tenacious and disabling. Short-term interventions without prior assessment or diagnosis have failed to prevent PTSD,” the authors write as background information in the study. “Preventing posttraumatic stress disorder (PTSD) is a pressing public health need.”

Researchers conducted a study to compare early and delayed exposure-based, cognitive and pharmacological interventions for preventing PTSD. Study participants were selected from consecutively admitted survivors of traumatic events at Hadassah Hospital in Jerusalem, through a telephone-based interview a mean (average) 9.61 days after the traumatic event occurred. Patients identified as having symptoms of acute stress disorder during the telephone interview were referred for clinical assessment, and those who met PTSD symptom criteria during assessment were invited to receive treatment.

The authors randomly assigned consenting patients to one of four intervention groups: prolonged exposure (PE), cognitive therapy (CT), a double-blind comparison of treatment with a selective serotonin reuptake inhibitor (SSRI) vs. placebo, or a waiting list (WL) control group. The study design allowed participants to decline treatment options they did not desire, and to be randomly assigned to one of the remaining treatment groups. Participants in the WL group who met PTSD criteria at the five-month follow-up received PE at that time, to compare the effects of a delayed intervention on PTSD symptoms. Prolonged exposure included psychoeducation, training in breathing control, prolonged imaginal exposure to traumatic memories and in vivo exposure to avoided situations. Cognitive therapy included identifying and challenging negative automatic thoughts and modifying underlying cognitive schemas. Participants in each of these groups received 12 weekly 1.5-hour sessions administered by clinical psychologists with prior PTSD treatment experience. PTSD prevalence was determined using the Clinician-Administered PTSD Scale (CAPS).

Following randomization, 63 participants started PE, 40 started CT, 93 were placed on the waiting list, and 46 were in the SSRI and placebo subgroups (23 in each group). At the five-month follow-up, the prevalence of PTSD in the PE and CT groups (21.4 percent and 18.2 percent, respectively) were significantly less than in the WL, SSRI and placebo groups (58.2 percent, 61.9 percent and 55.6 percent, respectively). The analysis showed significant group differences in CAPS and mean (average) PTSD Symptom Scale-Self Report scores at five months, showing fewer PTSD symptoms in the PE and CT groups compared with the WL, SSRI and placebo groups. At the five-month follow-up, 57 WL participants had PTSD and were eligible for delayed PE and 41 started treatment at that time.

At the nine-month follow-up, the prevalence of PTSD in the PE, CT, and WL groups were 21.2 percent, 22.8 percent, and 22.9 percent, respectively while rates for the SSRI and placebo subgroups (42.1 percent and 47.1 percent, respectively) remained higher. Analysis also showed significant group differences in CAPS and mean PTSD Symptom Scale-Self Report scores at nine months, showing fewer PTSD symptoms in the PE, CT and WL groups compared with the SSRI and placebo groups. Participants with partial PTSD before treatment onset did similarly well with and without treatment.

“The results of our study show that there are significant and similar preventive effects of PE and CT,” the authors conclude. “Our finding suggests that delaying the intervention does not increase the risk of chronic PTSD. Thus, a delayed intervention is an acceptable option when early clinical interventions cannot be provided (e.g., during wars, disasters, or continuous hostilities).”

Material adapted from JAMA.

Reference
Arch Gen Psychiatry. Published online October 3, 2011. doi:10.1001/archgenpsychiatry.2011.127.

“Effective disaster mental health planning and response depend on accurate information about the numbers of people who will need distinct types of services,” the authors write in background information in the article. “In large-scale disasters such as the September 11, 2001 attacks affecting large populations, estimated proportions may translate into tens and hundreds of thousands of people needing services.” The authors note, “Yet even though the 9/11 attacks constituted an undeniable trauma, the occurrence of a traumatic event is not sufficient for the diagnosis of PTSD; a qualifying exposure to the traumatic event is also necessary for consideration of this diagnosis.” The authors add that “exposure cannot be assumed; it must be determined on a case-by-case basis.”

This study by Carol S. North, M.D., M.P.E., from the VA North Texas Health Care System and the University of Texas Southwestern Medical Center, Dallas, and colleagues examined disaster trauma exposure and its relationship to PTSD in a sample of 379 employees of eight New York City organizations (176 from WTC tower companies and 203 from organizations not in the towers) with a range of exposures, including some who were evacuated from the WTC towers and others who were nearby.

“This study uniquely combined assessment of PTSD according to full DSM-IV-TR criteria with detailed data about geographical proximity and specific experiences of the 9/11 WTC attacks for determination of qualifying trauma exposure,” the authors write. Study participants provided information approximately three years after the 9/11 attacks and a follow-up assessment was conducted at approximately six years post-disaster. The participants were interviewed with the Diagnostic Interview Schedule/Disaster Supplement and symptoms assessed by the DSM-IV-TR qualifying 9/11 trauma exposures: “physical endangerment (by planes striking the towers and collapse of the towers, fleeing the falling towers and debris, physical injury in the attacks); witnessing injury to others either during the attacks of during the aftermath at the Ground Zero site during the recovery operation (e.g., people falling from the towers, people with severe injuries, dead bodies and body parts); and through exposures of close associates (i.e., immediate family members/friends).” Also factored in was the study participant’s geographical proximity by a calculation of the nearest reported location to the towers during the attacks.

“In summary, 169 (45 percent of the sample) had a DSM-IV-TR qualifying exposure: of these, 102 were physically exposed to danger in the attacks, another 41 not physically endangered were exposed through directly witnessing the attacks of the Ground Zero aftermath, and another 26 were exposed only through the exposure of a close associate,” the authors report. “The direct exposure zone was largely concentrated within a radius of 0.1 mile and completely contained within .75 mile of the towers.”

“The post disaster prevalence rate of PTSD in the first three years was 35 percent of those in the towers or nearby who were directly exposed to physical danger in the attacks, a finding that is remarkably consistent with the 34 percent PTSD incidence identified among directly exposed survivors of the Oklahoma City bomb blast in the first six months using the same assessment tool,” the authors note. “These findings collectively suggest that among highly exposed survivors of severe terrorist incidents, one-third may be expected to develop PTSD.”

In conclusion the authors write: “Reflecting on a decade of mental health research on the 9/11 attacks, it is clear that the complexities of exposure in estimation of PTSD present a substantial challenge to researchers to provide accurate information to guide disaster mental health planning. A substantial proportion of people in the current study who were directly exposed to physical danger or exposed through close associates developed PTSD. This PTSD was relatively persistent. Among those outside of a small geographic distance from the towers without known qualifying exposures – who cannot by definition be diagnosed with PTSD – a small proportion, representing potentially large numbers of people in extended populations, may develop similar symptoms.”

“The importance of examining trauma exposures with precision is relevant for populations with other types of trauma, such as combat veterans who deserve similar careful consideration of trauma exposures in relations to PTSD.”

Material adapted from JAMA.

Reference
Disaster Med Public Health Preparedness. 2011; 5: (doi:10.1001/dmp.2011.50)

In background information in the article, the authors write: “The terrorist attack on the World Trade Center (WTC) on September 11, 2001 (9/11) killed 2,974 residents and workers in lower Manhattan, including 343 rescue workers (341 firefighters and 2 paramedics) from the Fire Department of the City of New York (FDNY). After the towers collapsed, rescue/recovery workers endured hazardous and chaotic working conditions for up to ten months. Since 9/11, post-traumatic stress disorder (PTSD) has been of major interest, as it is arguably one of the most prevalent and debilitating consequences of terrorism-related incidents.” The authors note that previous studies have estimated the prevalence of probable PTSD to be anywhere from 11 percent to nearly 20 percent.

In this study, Jackie Soo, M.P.H., from the Montefiore Medical Center, New York, and colleagues analyzed data from 11,006 firefighters who completed 40,672 questionnaires during the nine years since 9/11 (through 2010). A formal Medical Monitoring Program (FDNY-WTC-MMP) has been in place for all FDNY rescue/recovery workers that includes monitoring visits scheduled every 18-months of physical examinations and self-administered questionnaires that collect information on exposure to the WTC site, physical and mental health symptoms. The researchers used the FDNY-WTC-MMP Exposure Intensity Index and divided the firefighters into groups based on initial arrival times at the World Trade Center. “Arrival Group 1” included those who arrived during the morning of 9/11; those who arrived during the afternoon of 9/11 were “arrival group 2”; those who arrived on day 2 were in “arrival group 3”; and those who arrived at any time between days 3 through 14 were in “arrival group 4.” The main outcome measure was current symptoms indicative of probable PTSD, as of September 11, 2010. The researchers also looked at PTSD risk factors, including change in alcohol intake, change in exercise and smoking status.

“Nine years after the WTC attacks, in the longest longitudinal study to date, we found that about 7 percent of the WTC-exposed firefighters met the criteria for current probable PTSD, a decrease from the almost 10 percent prevalence in the first year post-9/11,” the authors report. They note that by comparison, the current national statistic for 12-month prevalence of PTSD in the U.S. male population is 1.8 percent. “Arrival group was significantly associated with delayed onset of probable PTSD, with individuals in arrival group 1 more likely to experience delayed onset of probable PTSD compared with individuals in arrival groups 3 and 4.”

“We found that nine years after 9/11, PTSD continues to be a significant concern in the WTC-exposed FDNY population. Factors associated with the persistence or onset of PTSD symptoms include early arrival at the WTC site, decreases in exercise, increases in alcohol intake, and concurrent symptoms of respiratory or gastroesophageal illness. PTSD may thus persist, or may arise, not solely due to the intensity of the event experienced, but also due to physical injuries or illnesses sustained during the event, as well as changes in health behaviors after the event. A full comprehensive treatment approach that addresses the physical, behavioral, and mental health consequences of WTC exposure is of critical importance,” the authors conclude.

Material adapted from JAMA.

Reference
Disaster Med Public Health Preparedness. 2011;4: (doi:10.1001/dmp.2011.48)

The findings are reported in the September 2011 issue of Elsevier’s Cortex.

Dr. Ervin Poljac from the International University of Sarajevo and the University of Leuven together with Dr. Barbara Montagne from the Radboud University Nijmegen Medical Centre and Prof. Edward de Haan from the University of Amsterdam, investigated emotional processing in a group of war veterans with symptoms developed after prolonged exposure to combat-related traumatic events. PTSD is already known to be associated with difficulties in experiencing, identifying, and describing emotions, the new study however specifically examined the participants’ ability to recognize particular emotional facial expressions. Participants were shown short video clips of emotional faces representing one of the six basic emotions (happiness, anger, fear, surprise, disgust and sadness). Compared to healthy subjects, the participants with PTSD were less able to recognize two emotions in particular: fear and sadness.

This is the first study to show impairment in the processing of specific emotions in PTSD. Results could be helpful not only in providing further insights into this disorder, but also in the development of new ways of assessing PTSD and the development of more detailed prognostic models. At the same time these results can betaken into account when designing therapeutic interventions.

Material adapted from Elsevier.

Reference
“Reduced recognition of fear and sadness in post-traumatic stress disorder” by Ervin Poljac, Barbara Montagne, Edward H.F. de Haan and appears in Cortex, Volume 47, Issue 8 (September 2011), published by Elsevier in Italy.

Posttraumatic stress disorder is among the most common and disabling psychiatric disorders among military personnel serving in combat. Antidepressants are the predominant pharmacotherapy for PTSD, and within the U.S. Department of Veterans Affairs (VA), 89 percent of veterans diagnosed with PTSD and treated with pharmacotherapy are prescribed serotonin reuptake inhibitors (SRIs), according to background information in the article.

“However, SRIs appear to be less effective in men than in women and less effective in chronic PTSD than in acute PTSD. Thus, it may not be surprising that an SRI study in veterans produced negative results. Second-generation antipsychotics (SGAs) are commonly used medications for SRI-resistant PTSD symptoms, despite limited evidence supporting this practice,” the authors write.

John H. Krystal, M.D., of the VA Connecticut Healthcare System, West Haven, Conn., and colleagues evaluated whether risperidone (a second-generation antipsychotic often used for the treatment of schizophrenia and bipolar disorder), when added to an ongoing pharmacotherapy regimen would be more effective than placebo for reducing chronic military-related PTSD symptoms among veterans whose symptoms did not respond to at least 2 adequate SRI treatments. The study consisted of a 6-month, randomized, placebo-controlled multicenter trial conducted between February 2007 and February 2010 at 23 Veterans Administration outpatient medical centers. Of the 367 patients screened, 296 were diagnosed with military-related PTSD and had ongoing symptoms despite at least 2 adequate SRI treatments, and 247 contributed to analysis of the primary outcome measure. Patients received risperidone (up to 4 mg once daily) or placebo and other psychosocial mental health therapies. Symptoms of PTSD, depression, anxiety and other health outcomes were gauged via various scales and surveys.

After analysis of the data, the researchers found no statistically significant difference between risperidone and placebo in reducing measures of PTSD symptoms after 6 months of treatment. In addition, risperidone was not statistically superior to placebo on any of the other outcomes, including improvement on measures of quality of life, depression, anxiety, or paranoia/psychosis.

Overall, the rate of adverse events during treatment was low but appeared related to dosing of risperidone.

“In summary, risperidone, the second most widely prescribed second-generation antipsychotic within VA for PTSD and the best data-supported adjunctive pharmacotherapy for PTSD, did not reduce overall PTSD severity, produce global improvement, or increase quality of life in patients with chronic SRI-resistant military-related PTSD symptoms. Overall, the data do not provide strong support for the current widespread prescription of risperidone to patients with chronic SRI-resistant military-related PTSD symptoms, and these findings should stimulate careful review of the benefits of these medications in patients with chronic PTSD,” the authors conclude.

Editorial: Interventions for War-Related Posttraumatic Stress Disorder

In an accompanying editorial [2] on treating military-related PTSD, Charles W. Hoge, M.D., of the Walter Reed Army Medical Center, Silver Spring, Md., writes that “significant improvements in population care for war veterans will require innovative approaches to increase treatment reach.”

“Attention to the occupational context, combat physiology, and mental and physical comorbidities is essential. Validating and implementing collaborative care models based in primary care should be a high priority. Matching evidence-based components of therapy to patient preferences and reinforcing narrative processes and social connections through peer-to-peer programs are encouraged. Family members, who have their own unique perspectives, are essential participants in the veteran’s healing process and also need their own support. Research is required to better understand the perceptions war veterans have concerning mental health care, acceptability of care, willingness to continue with treatment, and ways to communicate with veterans that validate their experiences as warriors.”

Material adapted from American Medical Association (AMA).

References
[1] JAMA. 2011;306[5]:493-502.
[2] JAMA. 2011;306[5]:549-551.

“Throughout the war and thereafter, the Northern Ugandan communities have been confronted with large numbers of formerly abducted children, adolescents, and young adults returning after their rescue, flight, or release. The successful reintegration of these former child soldiers continues to be a major challenge,” according to background information in the article. “Despite high rates of impairment, there have been no randomized controlled trials examining the feasibility and efficacy of mental health interventions for former child soldiers.”

Verena Ertl, Ph.D., of Bielefeld University, Bielefeld, Germany, and colleagues conducted a randomized controlled trial to test the feasibility and effectiveness of narrative exposure therapy for the treatment of former child soldiers with posttraumatic stress disorder (PTSD). Narrative exposure therapy is a short-term, trauma-focused treatment developed for use in low-resource countries affected by crises and conflict. During narrative exposure therapy the participant constructs a detailed chronological account of his or her own biography in cooperation with a therapist to reconstruct fragmented memories of traumatic events and to achieve habituation.

The trial included 85 former child soldiers with PTSD from a population-based survey of 1,113 Northern Ugandans ages 12 to 25 years. The study was conducted in camps for internally displaced persons between November 2007 and October 2009. Participants were randomized to 1 of 3 groups: narrative exposure therapy (n = 29), an academic catch-up program with elements of supportive counseling (n = 28), or a waiting list (n = 28). Symptoms of PTSD, depression, and related impairment were assessed using various analytic tools before treatment and at 3 months, 6 months, and 12 months postintervention. Treatments were carried out in 8 sessions by trained local lay therapists, directly in the communities.

The researchers found that PTSD symptom severity was significantly more improved in the narrative exposure therapy group than in the academic catch-up and waiting-list groups. In one measure of clinically significant change, 20 of 25 participants (80 percent) in the narrative exposure therapy group were found to have improved with regard to PTSD severity. “In the academic catch-up and waiting-list conditions, 11 of 23 (47.8 percent) and 14 of 28 (50 percent), respectively, showed clinically relevant improvement. Subgroup comparisons revealed that improvement was significantly greater in the narrative exposure therapy group vs. the academic catch-up group and the narrative exposure therapy vs. the waiting-list groups,” the authors write. At 12 months, 68 percent of the narrative exposure therapy participants, 52.2 percent of the academic catch-up participants, and 53.6 percent of the waiting-list participants no longer fulfilled criteria for PTSD.

Also, a larger within-treatment effect size was seen in the narrative exposure therapy group, with a 51.6 percent reduction in the PTSD symptom score from pretreatment assessment to 12-month follow-up compared with the academic catch-up group (30.9 percent symptom severity reduction) and the waiting-list group (30.4 percent symptom severity reduction).

“Moreover, results indicated that there were additional positive effects of treatment on associated problems not primarily targeted, such as depression, suicidal ideation, feelings of guilt, and important indicators of readjustment such as stigmatization and functioning,” the researchers add.

The authors note that the findings of this study indicate that narrative exposure therapy can be applied successfully by community-based lay therapists without a mental health or medical background.

Material adapted from JAMA.

Reference
JAMA. 2011;306[5]:503-512.

“Depression and PTSD exert a significant, independent, and persistent effect on general health, work status, somatic symptoms, adjustment to illness, and function after injury,” the authors wrote, also emphasizing that even minor injuries can lead to traumatic stress responses. The findings allow healthcare providers to identify patients at highest risk for developing these disorders and to target appropriate resources to this vulnerable group.

This screening tool – reportedly one of the first of its kind for adults in the U.S. – could have a great impact on the judicious allocation of costly mental health resources.

Using an eight-question survey, all injured patients can be rapidly assessed for risk in the hospital. Healthcare providers can then provide patients classed as high-risk for developing depression or PTSD with information about symptoms to look for and advise them to contact their primary care provider should symptoms surface. This intervention can facilitate early diagnosis of these disabling disorders.

The study reported nearly 100 percent accuracy in negative results. Only five percent of injured patients who tested negative for risk of depression on the screening survey developed depression and no patients who tested negative for PTSD risk developed PTSD. At the same time, not all patients who screen positive will develop these disorders. The researchers do not suggest that all patients who screen positive receive mental health services, but rather that this finding prompt systematic provision of information and additional follow-up.

The authors caution that while the findings of this initial study are most promising, they need to be replicated in an independent sample.

The other authors involved in the study were: Josef Ruzek, PhD; Theimann Ackerson, MSSW; Douglas J. Wiebe, PhD; Flaura Winston, MD, PhD; Nancy Kassam-Adams, PhD.

Material adapted from University of Pennsylvania School of Nursing .

In this paper, lead author B. Lee Peterlin and colleagues review the epidemiology of PTSD and migraine, underscoring the established sex differences. While individually both migraine and PTSD are more common in women than men, a recent study by Peterlin and colleagues — the only study to date to look at sex differences in the PTSD-migraine association — suggests that men with migraines had up to a four-fold greater odds of PTSD than females who experience migraine headaches. This finding suggests that sex hormones play an important role in the PTSD-migraine association.

The age of the traumatic life event resulting in PTSD may also be an important factor for the sex differences in the PTSD-migraine association. When a traumatic life event occurs before 13 years of age, the risk of depression is greater than the risk of PTSD; however, when the traumatic life event occurs after 12 years of age, the risk of PTSD is greater. Although the migraine population has a documented high prevalence of abuse, the peak age of vulnerability for childhood sexual abuse, is under 13 years of age. In contrast, transportation accidents and combat (two of the most common traumatic events reported by migraineurs with PTSD in one study) may be more commonly experienced by those older than 12 years of age. It is therefore possible that in the migraine population, sex differences in the type and age of traumatization contributes to the sex differences in the risk of PTSD.

Studies have also shown that the presence of PTSD in those with migraine is associated with greater headache-related disability than in migraine sufferers without PTSD. Dr. Peterlin explains, “The current data indicate that behavioral PTSD treatment alone can positively influence chronic pain conditions and disability. Therefore, physicians should consider screening migraine sufferers for PTSD, and men in particular. Further, in those migraineurs with PTSD, behavioral therapy should be considered, alone or in combination with pharmacological treatment.” The authors suggest that further research investigating the sex differences in the association between PTSD and migraine is necessary to validate the sex differences found in their study, as well as to determine suitable treatment options in those migraineurs suffering with PTSD.

A second related article published this month in Headache also reviews sex and gender differences in those with headache. Todd Smitherman, PhD, from the University of Mississippi and Thomas Ward, MD, of the Dartmouth Medical School in New Hampshire, reviewed extant medical literature to examine the psychosocial factors of gender and social role expectations, and coping strategies as they relate to sex and gender differences in headache pain.

A distinction was made in this paper between sex — the biologically-based indicators of male or female; and gender — “the traits and behaviors characteristic of and appropriate to members of each sexual category” (Unger, 1976) given that pain-related differences between men and women established in the medical literature cannot be reduced solely to biological determinants.

The authors suggest that women’s pain experiences, multiple role responsibilities, and coping strategies likely influence the sex and gender differences in pain perception and response. “Gender-based differences are not strictly biological and important psychosocial issues are involved with headache pain as well,” Dr. Smitherman concluded. “Further research of the impact of sex and gender on psychosocial variables may help clinicians tailor treatment plans that reduce pain and disability for headache patients.”

Material adapted from Wiley-Blackwell.

References
“Post-Traumatic Stress Disorder and Migraine: Epidemiology, Sex Differences, and Potential Mechanisms.” B. Lee Peterlin, Satnam S. Nijjar, Gretchen E. Tietjen. Headache; Published Online: May 17, 2011 (DOI: 10.1111/j.1526-4610.2011.01907.x). http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2011.01907.x/abstract.

“Psychosocial Factors of Relevance to Sex and Gender Studies in Headache.” Todd A. Smitherman and Thomas N. Ward. Headache; Published Online: June 1, 2011 (DOI: 10.1111/j.1526-4610.2011.01919.x).http://doi.wiley.com/10.1111/j.1526-4610.2011.01919.x.

“Sex Matters: Evaluating Sex and Gender in Migraine and Headache Research.” B. Lee Peterlin, Saurabh Gupta,Thomas N. Ward and E. Anne MacGregor. Headache; Published Online: June 1, 2011 (DOI: 10.1111/j.1526-4610.2011.01900.x). http://doi.wiley.com/10.1111/j.1526-4610.2011.01900.x.

“Sex-Related Differences in Epidemiological and Clinic-Based Headache Studies.” E. Anne MacGregor, Jason D. Rosenberg and Tobias Kurth. Headache; Published Online: June 1, 2011 (DOI: 10.1111/j.1526-4610.2011.01904.x). http://doi.wiley.com/10.1111/j.1526-4610.2011.01904.x.

“Childhood Abuse and Migraine: Epidemiology, Sex Differences, and Potential Mechanisms.” Gretchen E. Tietjen and B. Lee Peterlin. Headache; Published Online: June 1, 2011 (DOI: 10.1111/j.1526-4610.2011.01906.x). http://doi.wiley.com/10.1111/j.1526-4610.2011.01906.x.

“Migraine Genes and the Relation to Gender.” Reinald Shyti, Boukje de Vries and Arn van den Maagdenberg. Headache; Published Online: June 1, 2011 (DOI: 10.1111/j.1526-4610.2011.01913.x). http://doi.wiley.com/10.1111/j.1526-4610.2011.01913.x.

“Sex-Related Differences in Animal Models of Migraine Headache.” Hayrunnisa Bolay, Nancy E. J. Berman and Didem Akcali. Headache; Published Online: June 1, 2011 (DOI: 10.1111/j.1526-4610.2011.01903.x). http://doi.wiley.com/10.1111/j.1526-4610.2011.01903.x.

“Mechanisms of Pain Modulation by Sex Hormones in Migraine.” Saurabh Gupta, Kenneth E. McCarson, K.M.A. Welch and Nancy E.J. Berman. Headache; Published Online: June 1, 2011 (DOI: 10.1111/j.1526-4610.2011.01908.x). http://doi.wiley.com/10.1111/j.1526-4610.2011.01908.x.

After studying information from 193 married male Army soldiers who returned from military deployment within the past year, investigators found that more frequent spousal communication through “delayed” communication such as letters, care packages, and emails was linked with lower PTSD symptoms after deployment, but only in soldiers with higher levels of marital satisfaction. For soldiers with lower marital satisfaction, frequent communication was linked with more PTSD symptoms.

“We think this means that when soldiers are maritally dissatisfied, communication with their wives during deployment may be less positive and doesn’t provide soldiers with social support that can help protect against PTSD symptoms,” said co-author Ben Loew, University of Denver.

Interestingly, the benefits of communication against PTSD symptoms in happily married soldiers did not hold for “interactive” communication, such as phone calls and instant messaging.

“We think that letters, which happened less often overall compared to phone calls, had stronger effects,” said Loew. “When you receive letters, they can be read again and again, and when you write them, it can be therapeutic.”

According to Loew, this study highlights the importance of knowing how soldiers communicate with their spouses during deployment, and how this communication could be protective or not for a soldier’s mental health and marriage.

Loew and his colleagues plan to conduct more comprehensive research that could help military decision-makers as well as Army couples themselves as they think about optimal communication during deployment.

Material adapted from Wiley-Blackwell.

Veterans of the Iraq/Afghanistan wars showed a 50 percent reduction in their symptoms of post-traumatic stress disorder (PTSD) after just eight weeks of practicing the stress-reducing Transcendental Meditation technique, according to a pilot study published in the June 2011 issue of Military Medicine.

The study evaluated five veterans, ages 25- to 40-years-old, who had served in Iraq, Afghanistan or both from 10 months to two years involving moderate or heavy moderate combat.

The study found that Transcendental Meditation produced significant reductions in stress and depression, and marked improvements in relationships and overall quality of life. Furthermore, the authors reported that the technique was easy to perform and was well accepted by the veterans.

By the fourth week of practicing TM, OEF/OIF veterans with PTSD experienced dramatic reductions in PTSD symptoms according to the Clinically-Administered PTSD Scale (the gold standard of PTSD testing). They also reported decreased depression and improved quality of life—showing a greater ability to return to their lives after the war. These findings replicated an earlier study examining TM as a treatment for Vietnam veterans with PTSD. (Credit: Roth Media)

The Clinician Administered PTSD Scale (CAPS) was the primary measure for assessing the effectiveness of TM practice on PTSD symptoms. CAPS is considered by the Department of Veterans Affairs as the “gold standard” for PTSD assessment and diagnosis for both military Veteran and civilian trauma survivors.

The paper’s senior researcher, Norman Rosenthal, M.D., is clinical professor of psychiatry at Georgetown University Medical School and director of research at Capital Clinical Research Associates in Rockville, Maryland. Dr. Rosenthal was the first to describe seasonal affective disorder (SAD) and pioneered the use of light therapy as a treatment.

An Interview with Researchers Drs. Norman Rosenthal and Sarina Grosswald

Researchers Drs. Norman Rosenthal and Sarina Grosswald discuss the reduction of PTSD symptoms in veterans practicing Transcendental Meditation. Credit - David Lynch Foundation

“Even though the number of veterans in this study was small, the results were very impressive,” Rosenthal said. “These young men were in extreme distress as a direct result of trauma suffered during combat, and the simple and effortless Transcendental Meditation technique literally transformed their lives.”

The findings were similar to those from a randomized controlled study of Vietnam veterans conducted by researchers at the University of Colorado School of Medicine. In that study, published in the Journal of Counseling and Development in 1985, after three months of twice-daily TM practice, the veterans had fewer symptoms than those receiving conventional psychotherapy of the day. In fact, most of the TM-treated subjects required no further treatment.

“Even though the combat experiences of OEF/OIF veterans and Vietnam veterans are quite different, the fact that our study corroborates the results of the previous study tells us that this technique has the potential to be an effective tool against PTSD and combat stress, regardless of combat situation,” explained Sarina Grosswald, EdD, co-researcher on the study.

Rosenthal hypothesizes that Transcendental Meditation helps people with PTSD because regular practice produces long-term changes in sympathetic nervous system activity, as evidenced by decreased blood pressure, and lower reactivity to stress. “Transcendental Meditation quiets down the nervous system, and slows down the ‘fight-or-flight’ response,” he said. People with PTSD show overactive fight-or-flight responses, making them excellent candidates for Transcendental Meditation.

Rosenthal points out that there is an urgent need to find effective and cost-effective treatments for veterans with combat-related PTSD. “The condition is common, affecting an estimated one in seven deployed soldiers and Marines, most of whom do not get adequate treatment. So far, only one treatment — simulation exposure to battleground scenes — has been deemed effective, but it requires specialized software and hardware, trained personnel and is labor intensive.

“Based on our study and previous findings, I believe Transcendental Meditation certainly warrants further study for combat-related PTSD,” says Rosenthal.

Material adapted from Roth Media.

Reference / Abstract
Rosenthal, J., et al. (2011). Effects of Transcendental Meditation in Veterans of Operation Enduring Freedom and Operation Iraqi Freedom With Posttraumatic Stress Disorder: A Pilot Study. Military Medicine

Their findings are published online in the June issue of Springer’s Journal of Clinical Psychology in Medical Settings, specially dedicated to contemporary psychological advances as they apply to soldiers and their families [2].

The stressful experiences that characterize the Operation Iraqi Freedom/Operation Enduring Freedom war fighting environments have produced significant numbers of returning military personnel at risk of developing PTSD. At the same time, virtual reality (VR) has stepped into clinical practice as a result of technological advances that have made it feasible and cost-effective to run VR systems on a personal computer.

What Rizzo and team’s work shows is that VR is able to deliver exposure therapy – the number one therapy recommended for PTSD – by immersing returning soldiers in simulations of trauma-relevant environments. The emotional intensity of the scenes can be precisely controlled by the clinician in collaboration with the patients’ wishes. VR allows multi-sensory and context-relevant cues that evoke the trauma without exclusively relying on the patient to actively remember and imagine actual experiences (as is required in traditional exposure approaches).

Rizzo and team review their immersive virtual reality exposure therapy (VRET) system for combat-related PTSD. Their application consists of a series of virtual scenarios, based on accounts by returning soldiers of what it is like out there in a war environment.

Their clinical results to date are encouraging. One test in particular found that 80 percent of those who completed treatment with this system showed clinically meaningful reductions in PTSD, anxiety, and depressive symptoms. In addition, anecdotal evidence from patient reports suggests improvements in their everyday lives for at least three months after treatment.

The researchers are also exploring other applications for their system, including stress resilience training (i.e., to teach soldiers coping strategies prior to deployment to better prepare them for the types of emotional challenges they are likely to encounter in the combat environment). Another area of interest for the system is the identification of those soldiers who are ready to get back into the field versus those who need further treatment or more time between deployments.

According to the authors, this new approach to psychotherapy has widespread ramifications: “The current generation of young military personnel, having grown up with digital gaming technology, may actually be more attracted to and comfortable with participation in virtual reality exposure therapy. The need for treatments to address the mental health needs of our military personnel, alongside the virtual revolution that has taken place, has led to a state of affairs which stands to transform the vision of future clinical practice and research.”

Material adapted from Springer Science+Business Media.

References
1. Rizzo A et al (2011). Virtual reality goes to war: a brief review of the future of military behavioral healthcare. Journal of Clinical Psychology in Medical Settings; DOI 10.1007/s10880-011-9247-2. Available at http://www.springerlink.com/content/03533254r5q65p86/

2. Special issue, June 2011 “Strengthening Our Soldiers (SOS) and Their Families: Contemporary Psychological Advances Applied to Wartime Problems.”

“The relationship between preinjury psychiatric status and postinjury PTSD is not well understood because studies have used retrospective methods,” write the authors. “The primary objective of our study was to prospectively assess the relationship of self-reported preinjury psychiatric status and injury severity with PTSD among those deployed in support of the conflicts in Iraq and Afghanistan.” They study also sought to ascertain other demographic, military, and deployment-related factors that exacerbate post-deployment PTSD.

Donald A. Sandweiss, M.D., M.P.H., from Naval Health Research Center, and colleagues, studied U.S. service members who participated in the Millennium Cohort Study, a program created in 2001 to examine the health status of military members before, during and after deployment. A total of 22,630 individuals completed a baseline questionnaire (which includes the PTSD Checklist–Civilian Version) before deploying and one or more follow-up questionnaires during or after their service.

Information regarding deployment-related injuries was retrieved from the Joint Theater Trauma Registry (JTTR), a registry maintained by the U.S. Army Institute of Surgical Research, and the Navy–Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database (CTR EMED). The study cohort included participants from all branches of the U.S. armed forces, including the Reserves and the National Guard.

At baseline, 739 participants (3.3 percent) had at least one psychiatric disorder, defined as PTSD, depression, panic syndrome, or another anxiety syndrome. Of the overall group, 183 individuals (0.8 percent) sustained a physical injury during deployment. Follow-up questionnaires showed that 1,840 participants (8.1 percent of the 22,630 subjects in the study population) had PTSD symptoms after deployment.

Participants who showed signs of PTSD at baseline had nearly five times the odds of developing the disorder after deployment. Similarly, among those who experienced other mental health issues were at baseline, the odds of post-deployment PTSD symptoms was 2.5 times more likely. Further, the study found each three-unit increase in Injury Severity Score (as assigned by the JTTR or CTR EMED) was associated with a 16.1 percent greater odds of having post-deployment PTSD symptoms.

The authors note that baseline psychiatric status was a stronger predictor than injury severity.

The authors suggest that such screening might help to better protect service members during their time in the field. Checking pre-deployment mental health, they conclude, “might be useful to identify a combination of characteristics of deployed military personnel that could predict those most vulnerable or, conversely, those most resilient to post-deployment PTSD, thereby providing an opportunity for the development of pre-deployment interventions that may mitigate post-deployment mental health morbidity.”

Material adapted from JAMA.

Reference
Arch Gen Psychiatry. 2011;68[5]:496-504.

In a study published in the March, 2011 issue of Brain, Behavior, and Immunity, the authors took blood samples from 49 men (24 with PTSD and 25 controls) and 18 women (10 with PTSD and 8 controls). They then used gene microarray technology to determine which genes were activated in the subjects’ monocytes, which are immune cells that regularly cross the barrier between the bloodstream and the brain, and thus give a broad picture of immune reaction in both the body and brain.

“We were looking for evidence of inflammation caused by immune activation,” explained lead author Thomas Neylan, MD, director of the PTSD program at SFVAMC and a professor in residence of psychiatry at UCSF. “We know that people with PTSD have higher rates of cardiovascular disease and arthritis, which are diseases associated chronic inflammation. We also hoped that seeing which genes were expressed in PTSD might show us potential therapeutic approaches that we hadn’t thought of.”

The researchers found no evidence of increased immune activation among the men with PTSD compared to those without PTSD. In contrast, the women with PTSD showed significant evidence of immune activation compared to women without PTSD.

“Previous gene microarray studies on PTSD grouped men and women together, which gave inconclusive results,” said senior investigator Lynn Pulliam, MS, PhD, chief of microbiology at SFVAMC and professor of laboratory medicine and medicine at UCSF.

“This is the first time that it’s been shown that men and women respond differently to PTSD on a very basic biological level.” Neylan characterized the finding as “unexpected.”

The researchers do not know why there seems to be such a marked difference between men and women, said Neylan. However, in a study published in the January, 2011 issue (posted in April, 2011) of the journal Disease Markers, they analyzed data collected from the same subjects to explore one possible explanation: gender differences in cell signaling pathways.

“We know that gene expression patterns are determined by hormones and proteins that are circulating in the body, and we know that some of those hormones and proteins are produced in response to signals from the brain or central nervous system,” explained lead author Aoife O’Donovan, PhD, a researcher in psychiatry at SFVAMC and UCSF. “These signaling pathways are used by the brain and central nervous system to communicate with the immune system and tell immune cells what to do.”

The researchers used sophisticated bioinformatics software to look at three different signaling pathways associated with inflammation: NF-kappa B, glucocorticoid receptor (GR), and CREB/ATF.

In the NF-kappa B and GR pathways in both men and women with PTSD, they found evidence of signaling that could promote inflammation.

In the CREB/ATF pathway, however, they found what O’Donovan called “totally contrasting” effects: men with PTSD had increased signaling, which in turn could possibly lead to less inflammation, while women with PTSD had decreased signaling, which could lead to more inflammation.

“This particular pathway might be a clue to the gender difference in monocyte gene expression in PTSD,” said Pulliam.

“It’s still very early,” cautioned O’Donovan, “but these bioinformatics results are telling us something about how PTSD could increase the risk for autoimmune disorders like arthritis as well as cardiovascular disease, cancer, and other diseases of aging. They also point us in the direction of some potential treatment targets, telling us where future investigative energy might be well spent.”

Neylan emphasized that because of the small sample size, particularly among the women, the results of the two studies are suggestive rather than conclusive. “The next step is to look at larger groups of men and women, and we are working on that,” he said.

Co-authors of the Brain, Behavior, and Immunity study are Bing Sun, MD, PhD, and Hans Rempel, PhD, of SFVAMC; Jessica Ross, MD, MS, of SFVAMC and UCSF; and Maryann Lenoci, MA, of SFVAMC.

Co-authors of the Disease Markers study are Bing Sun, MD, PhD; Steve Cole, PhD, of UCLA; Hans Rempel, PhD; and Maryann Lenoci, MA.

Both studies were supported by grants from the Department of Defense and the Department of Veterans Affairs Sierra Pacific Mental Illness Research & Education Clinical Center. Some of the funds were administered by the Northern California Institute for Research and Education.

Material adapted from University of California – San Francisco.

Telomeres are DNA-protein complexes that cap the ends of chromosomes and protect them from damage and mutations. Short telomere length is associated with an increased risk of cancer, cardiovascular disease, and autoimmune and neurodegenerative diseases, as well as early death.

For the study, the authors collected DNA samples from 43 adults with PTSD and 47 matched participants without PTSD. Initial analysis showed that on average, the subjects with PTSD had shorter telomere length than those without.

“This was striking to us, because the subjects were relatively young with an average age of 30 and in good physical health,” said lead author Aoife O’Donovan, PhD, a researcher in psychiatry at SFVAMC and UCSF. “Telomere length was significantly shorter than we might expect in such a group.”

The authors then looked at incidence of severe childhood trauma, including neglect, family violence, physical abuse, and sexual abuse. They found that, among the subjects with PTSD, the more childhood trauma a subject had experienced, the higher the risk of shorter telomere length. “People who had multiple categories of childhood traumas had the shortest telomere length,” said O’Donovan.

In contrast, subjects with PTSD but without childhood trauma had telomere length equal to those of the matched healthy subjects.

The results are intriguing for a number of reasons, observed principal investigator Thomas Neylan, MD, director of the PTSD program at SFVAMC and a professor in residence of psychiatry at UCSF. “For one thing, this gives us a potential mechanism for why people with PTSD tend to have a greater disease burden and more problems with aging,” said Neylan. “It might be because of their telomere biology.”

In addition, he speculated, “we might be seeing the cumulative effect of PTSD on telomere length – in other words, the subjects with shorter telomere length may have PTSD dating from their childhood traumas, in addition to PTSD acquired in adulthood.”

According to O’Donovan, however, the major drawback of the study was that, because the subjects without PTSD did not in general have high levels of exposure to childhood traumas, the authors were “unable to tease apart the relative contributions of childhood trauma and adult PTSD to shorter telomere length.”

To investigate that question, they plan to conduct a study looking at telomere length in subjects with and without childhood trauma and with and without PTSD in adulthood.

“A major question is whether we can actually have an effect on telomere biology by treating PTSD,” said Neylan. “If we successfully treat PTSD, can we slow the rate of telomere shortening, and thereby decrease or at least postpone the risk for some diseases of aging?”

Co-authors of the paper are Elissa Epel, PhD, Jue Lin, PhD, and Owen Wolkowitz, MD, of UCSF; Beth Cohen, MD, and Shira Maguen, PhD, of SFVAMC and UCSF; Thomas Metzler, MS, and Maryann Lenoci, MA, of the Northern California Institute for Research and Education; and Elizabeth Blackburn, PhD, Morris Hertztein Professor of Biology and Physiology at UCSF, who received the 2009 Nobel Prize in Physiology or Medicine for co-discovering telomerase, the enzyme that replenishes the telomere, and for her studies on telomeres themselves.

Material adapted from University of California – San Francisco.

That could change depending on the results of a $3.5 million study led by University of Central Florida Professor Deborah Beidel and funded by the U.S. Army Medical Research and Materiel Command’s Military Operational Medicine Research Program. Individual behavioral treatment, using virtual reality to enhance the experience, will be used along with small group therapy sessions to help participants diagnosed with PTSD eliminate their fear, manage their depression and anger, and reconnect with family and friends.

Dr. Beidel and her team are blending virtual reality, smells and therapy to help soldiers. (Credit - Courtesy of UCF)

About 150 military personnel who have fought in Afghanistan or Iraq and have post-traumatic stress disorder will participate. Seventy-five participants will receive treatment at the University of Central Florida. The other seventy-five participants will be recruited from the Charleston, S.C., area and will be treated at the Medical University of South Carolina.

Servicemen and women returning from Iraq or Afghanistan often say smells that remind them of war or the countries where they fought can trigger memories or flashbacks of combat trauma – just as the sound of fireworks produced the same symptoms in Vietnam War veterans, said Beidel, a clinical psychologist who will lead the research in Orlando.

Over five weeks, the individual behavior therapy sessions using virtual reality will gradually expose participants to the sights, sounds, and smells of trauma that they experienced in Afghanistan and Iraq. Those smells will include garbage, which is often found where they patrol.

Smells are an integral part of the new therapy aimed at helping people suffering from post traumatic stress syndrome. (Credit - Jason Greene, UCF)

“We hope a more complete treatment will help veterans readjust to their lives in the United States and connect better with their family and friends,” said Beidel, who has several family members who have served in the military. “People who go to war sacrifice so much for all of us. This is a small way that I can give back to the warriors who defend our country.”

The second component of the study will involve 12 weeks of therapy in small groups. For some soldiers, the small-group sessions will be modeled after the typical PTSD therapy sessions offered by the Department of Veterans Affairs. During those sessions, participants discuss their experiences and learn how their peers are dealing with the same issues.

The new study will compare that approach with a comprehensive therapy program that will focus on three issues that returning soldiers often face: how to cope with depression, how to deal with anger and how to reconnect with family, friends and co-workers.

A virtual reality, including smells, is created for people in the study, in hopes of helping them overcome their fears. (Credit - Jason Greene, UCF)

Beidel has extensive experience working with virtual reality and helping veterans. Her research program to treat combat-related PTSD in servicemen and women began in the mid-1990s when she was at the Medical University of South Carolina. More recently, while at the Penn State College of Medicine, she treated Vietnam War veterans suffering from PTSD.

In addition to Beidel, the research team includes Professor Christopher Frueh of the University of Hawaii at Hilo and Professor Thomas Uhde, chair of the Medical University of South Carolina’s Department of Psychiatry & Behavioral Sciences. Several graduate students at the three institutions also will assist with the study.

Additional Resource
Veterans of any military branch, as well as National Guard and Reserve members, who have served in Iraq or Afghanistan are eligible. For more information on UCF’s portion of the study, go to http://anxietyclinic.cos.ucf.edu or call 407-823-1668.

Material adapted from University of Central Florida.

The study titledAssociation of FKBP5, COMT and CHRNA5 Polymorphisms among Outpatients at Risk for Posttraumatic Stress Disorder, finds that individuals with a certain set of “at risk” genes were at seven times higher risk for PTSD than those without the genes.

“We found that individuals with these ‘at risk’ genes were more likely to develop PTSD, especially when associated with a higher exposure to traumatic events or greater exposure to childhood adversity,” said Dr. Boscarino. “They say what doesn’t kill you makes only you stronger, but what we’ve found is that the opposite may actually be the case if you have the PTSD risk genes.”

Boscarino adds that genetic screening individuals for these genetic factors in the future may lead to better post-trauma treatments and genetic counseling related to career options in the military or in the civil services, such as police work or firefighting.

In a related study, Development and Validation of a New PTSD Prediction Tool for Use in Clinical Practice, Dr. Boscarino and his team developed a PTSD prediction tool that can be used in clinical practice after traumatic event exposures. After collecting information from more than 2,300 adults following the September 11 terrorist attack on the World Trade Center, Boscarino’s team examined various clinical factors including stressor exposures, psychosocial resources, functional status, depression, suicidal thoughts, PTSD symptoms, and demographics to evaluate different PTSD prediction models.

The team then developed a simple 10-item prediction tool that included core PTSD symptoms, depression symptoms, personal physician status, sleep disturbance, and trauma history. Findings show the tool is highly successful in predicting PTSD following traumatic exposures in different clinical populations, including a sample of chronic pain outpatients and a sample of Level-I trauma patients discharged from Geisinger Clinic.

“Until now there’s been no easy-to-use tool to help clinicians rapidly identify PTSD in patients in routine practice or after a traumatic event,” said Boscarino. “We now have a 10-step process that can accurately and quickly identify PTSD cases from non-cases and facilitate the most appropriate therapy.”

Material adapted from Geisinger Health System.

Early MRI studies suggested that the volume of the hippocampus was reduced in some people with chronic PTSD. This observation was interpreted as suggesting that stress produced atrophy within the hippocampus, consistent with a body of research conducted in animals. Supporting this hypothesis, it appears that the same region of the hippocampus that is most-sensitive to stress effects in animals, the CA3 region, may show the greatest volume reductions in people with PTSD.

More recently, the non-traumatized identical twins of people with PTSD were shown to have smaller hippocampal volumes, suggesting that a small hippocampus might be a risk factor for PTSD. This hypothesis relates to the role that the hippocampus plays in drawing inferences about one’s environmental context, such as evaluating the safety of the environment. The hippocampus also provides some inhibitory control of hypothalamic centers that control the levels of the stress hormone cortisol.

Now, a new study has found that larger hippocampal volume is associated with recovery of PTSD. Brigitte Apfel and colleagues used structural magnetic resonance imaging to study hippocampal volume in Gulf War veterans who recovered from PTSD in comparison to veterans with chronic PTSD and to control participants who never had PTSD. They found that recovered veterans had, on average, larger hippocampal volumes than those with chronic PTSD and similar volumes compared to the control participants.

“These results need to be interpreted with caution because we did not measure brain changes over time. However, the finding suggests that hippocampal damage in PTSD is reversible once the symptoms remit,” explained Dr. Apfel. “If our finding can be confirmed, it might suggest that treatment of PTSD could be viewed as brain restoration rather than primarily a way to ease symptoms.”

Does this finding help to resolve the conundrum of whether the hippocampus is a target of stress or a contributor to stress response?

This finding would appear to support the hypothesis that a small hippocampus is a risk factor for the persistence of PTSD because people with larger hippocampi seemed better able to recover. This finding may be consistent with the observation that some gene variants associated with emotional resilience in response to stress are also associated with larger hippocampal volume. Alternatively, it is possible that smaller hippocampi reflect early life stress or other environmental factors that compromise resilience in adulthood.

A major remaining question is whether treatment-related increases in hippocampal volume mediate aspects of the therapeutic responses to PTSD treatments. A prior study reported that six months of antidepressant treatment increased hippocampal volume in people with PTSD.

“It may be time to view hippocampal volume as both a modulator of stress resilience and as a target for the negative impact of stress and the positive effects of treatments,” commented Dr. John Krystal, Editor of Biological Psychiatry. “This more complex view might explain how the negative effects of stress “feed forward” to worsen outcomes in the face of subsequent stressors, while treatments would similarly cumulatively promote resilience.”

Material adapted from Elsevier.

Reference / Abstract
The article is “Hippocampal Volume Differences in Gulf War Veterans with Current Versus Lifetime Posttraumatic Stress Disorder Symptoms” by Brigitte A. Apfel, Jessica Ross, Jennifer Hlavin, Dieter J. Meyerhoff, Thomas J. Metzler, Charles R. Marmar, Michael W. Weiner, Norbert Schuff, and Thomas C. Neylan. Apfel, Ross, Metzler, and Neylan are affiliated with Mental Health Service, Veterans Affairs Medical Center, San Francisco, California. Apfel, Ross, and Neylan are also with the Department of Psychiatry, University of California, San Francisco, California. Hlavin, Meyerhoff, Weiner, and Schuff are affiliated with the Center for Imaging of Neurodegenerative Diseases, Veterans Affairs Medical Center, San Francisco, California. Meyerhoff, Weiner, and Schuff are also with the Department of Radiology and Biomedical Imaging, University of California, San Francisco, California. Marmar is from the Department of Psychiatry, New York University, New York, New York. The article appears in Biological Psychiatry, Volume 69, Number 6 (March 15, 2011), published by Elsevier.

Initially, he did not report any traumatic events in a clinical interview about traumatic and major life events and did not rate any traumatic events on the Posttraumatic Diagnostic Scale. A structured diagnostic interview (SCID) revealed no psychiatric disorders, including no former or current posttraumatic stress disorder or other anxiety disorders. The Anxiety Sensitivity Index did not indicate a higher individual disposition towards fear-related sensations. He had no family history of anxiety disorders. Physical examination and laboratory workup showed no peculiarities. A urinary drug screen was negative.

The investigtors used a mixture of 35% CO2 and 65% oxygen. Vital capacity was evaluated by a respirometer connected to a face mask. He was informed that he would be inhaling a gas mixture of CO2 and oxygen, and that he might experience anxiety. He inhaled a single breath of > 80% of vital capacity. Before and after the inhalation, he completed the Acute Panic Inventory, the Panic Symptom Scale, and the Acute Dissociation Inventory.

He indicated very low levels of anxiety and dissociation before the inhalation, but a strong anxiety, panic, and prodissociative reaction to CO2. Surprisingly, he felt as if he was near-drowning and reported life-like flashbacks and intrusions with visual and auditory modalities involved. He also experienced massive fear of suffocation and death. He fulfilled criteria for a panic attack in the Panic Symptom Scale. Anxiety and intrusions persisted for over 3 minutes.

These symptoms turned about to be related to a respective traumatic event at the age of 10 years, which he had not thought about for years. This case advises that a history of traumatic events, particularly suffocative events like near-drowning, could lead to panic and posttraumatic flashbacks in a subject without any former or current posttraumatic stress disorder symptoms or anxiety symptoms.

This case emphasizes that the biological underpinnings of flashbacks might be similar to panic attacks and that CO2 -induced panic could reactivate traumatic events.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference / Abstract
Muhtz, C.; Daneshi, J.; Braun, M.; & Kellner, M. Carbon-Dioxide-Induced Flashback in a Healthy Man with a History of Near-Drowning. Psychother Psychosom 2011;80:55-56.

“To our knowledge, this is the first study to ask actual patients with PTSD about their health preferences,” said lead author Jason Doctor, associate professor of Pharmaceutical Economics and Policy at the USC School of Pharmacy. “These findings identify targets for treatment that may improve quality of life among people with PTSD.”

The researchers interviewed 184 persons seeking treatment for PTSD at two treatment sites in different regions of the United States. The researchers found that of four major symptoms associated with PTSD not all were associated with a patient’s immediate quality of life even though those who sought treatment for PTSD expressed significant overall declines in mental health.

Distressing recollections of a traumatic event and avoidance of certain activities and thoughts – both commonly thought to be dysfunctional behaviors – had little correlation to a patient’s reported sense of well-being, according to the study.

However, symptoms tied to heightened arousal, such as trouble sleeping, irritability, and vigilance, were associated with lower quality of life among patients with PTSD. Anxiety and depression were also associated with lower quality of life.

“We conjecture that although avoidance is an important aspect of PTSD, its effect on quality of life may be limited because it is a coping strategy. Avoidance may be a dysfunction that improves, in the short term, subjective well-being,” explained Doctor, who is on the research faculty of the Schaeffer Center for Health Policy and Economics at USC.

PTSD presents such troubling symptoms that participants with PTSD were willing to accept a treatment with up to an average of 13 percent chance of immediate death in order to achieve total relief of PTSD symptoms.

Lori Zoellner of the University of Washington, Seattle, and Norah Feeny of Case Western Reserve University were co-authors of the study.

The research was funded by the National Institute of Mental Health.

Material adapted from University of Southern California.

Reference
Doctor et. al, “Predictors of Health-Related Quality-of-Life Utilities Among Persons With Posttraumatic Stress Disorder.” Psychiatric Services: March 2011.

During the treatment the soldier repeatedly revisits the memory, and through the use of their imagination, they safely access emotions related to the original traumatic experience. Revisiting the memory while safely emotionally engaged reduces anxiety and allows the engagement process to be comfortably repeated.

Lead author Dr. Greg Reger, “We know that lengthy military deployments in stressful environments with exposure to multiple, potentially traumatic events can lead to the desire to emotionally ‘unplug.’ By using multi-sensory virtual reality that can be customized in real time, the provider can help activate the memory with relevant sights, sounds, vibrations, even scents that resemble aspects of the event that is haunting them.”

A clinical trial with Vietnam veterans and World Trade Center survivors has shown that virtual exposure therapy is an innovative and effective form of treatment. The current research extends those findings to the population of military service members returning from deployments to Iraq or Afghanistan with PTSD.

Dr. Reger went on to state that, “It is possible that virtual reality exposure therapy would provide a more appealing treatment option to a young, technologically savvy generation of service members and veterans. In addition, it is possible that a treatment option like virtual reality exposure would be viewed by some service members as less stigmatizing than traditional treatment approaches. If accurate, virtual reality exposure therapy might provide us with the opportunity to treat service members and veterans who may not otherwise seek help.”

Material adapted from Wiley-Blackwell.

Reference / Abstract
Greg Reger, et. al. Effectiveness of Virtual Reality Exposure Therapy for Active Duty Soldiers in a Military Mental Health Clinic. Journal of Traumatic Stress; Published Online: February 3, 2011 (DOI: 10.1002/jts.20574)

These results will be published in the scientific journal Molecular Psychiatry.

Between 2008 and 2010 the researchers studied a group of 36 soldiers. Before and after taking part in the mission, the soldiers’ brain activity was measured and compared with the brain activity of a control group of equal size who stayed at home. Unique to this study is that it is the first to use a control group. This control group, which stayed behind in the barracks in the Netherlands, had received similar combat training.

First study with control group
‘Thanks to the design of our study, for the first time we can now conclude that the effects on the brain really are due to experiences in combat. The soldiers taking part in the ISAF mission in Afghanistan had their brains scanned twice. They also filled out questionnaires about their experiences during combat.

The soldiers did not develop posttraumatic stress disorders (PTSD), but their experiences did have an effect on the neural circuits in the brain that regulate vigilance and that are also involved in controlling emotion. This effect persisted for at least two months after the soldiers returned home,’ says Guido van Wingen of the Donders Institute for Brain, Cognition and Behaviour at Radboud University Nijmegen, first author of the study.

Military mental health study
This research is part of a long-term project in collaboration with the Military Mental Health Research Centre and the Rudolf Magnus Institute of Neuroscience in Utrecht. Activity in the amygdala and insula, the fear and vigilance centres in the brain, increases in all soldiers on mission. But the changes in the emotional control centre in the frontal lobe depend strongly on how they perceived threatening events during the mission. The researchers are now working on a follow-up study to see how long the changes in soldiers’ heads remain, and whether or not those that perceived high levels of stress are also at higher risk of developing symptoms of posttraumatic stress.

Material adapted from Radboud University Nijmegen.

Download / Reference
Wingen, GA, Geuze, E, Vermetten, E., & Fernandez, G. Perceived threat predicts the neural sequelae of combat stress. Molecular Psychiatry, January 19, 2011. doi:10.1038/mp.2010.132

The study was conducted in conjunction with the New York City Department of Health and Mental Hygiene and the federal Agency for Toxic Substances Disease Registry (ATSDR).

While past studies have examined PTSD prevalence among rescue and recovery workers, Lower Manhattan residents, other downtown building occupants, and passersby, this is the first study to focus specifically on people who were inside the towers when they were struck. The full study findings are currently online in the American Journal of Epidemiology.

PTSD is a psychiatric disorder that occurs after experiencing or witnessing events that threaten death or serious injury and that involves intense feelings of fear, helplessness, or horror and is the third most common anxiety disorder in the United States.

The researchers report that characteristics of direct exposure to the terrorist attacks were predictors of PTSD:

• a key component was initiating late evacuation
• being on a high floor in the towers,
• being caught in the dust cloud that resulted from the tower collapses,
• personally witnessing horror,
• sustaining an injury, and
• working for an employer that sustained fatalities also increased risk.

Each addition of an experience of a direct exposure resulted in a two-fold increase in the risk of PTSD.

The vast majority, 91% of survivors above the impact zone in 2 WTC, reported that they began evacuation after the first plane hit 1 WTC. Overall, 60.8% were caught in the dust cloud from the tower collapses. Ninety-four percent witnessed horror and 32% sustained an injury that ranged from a concussion to a sprain or strain. The overwhelming majority of survivors reported that the WTC was their usual place of work (95.8%).

The researchers found that women and minorities in particular were at an increased risk of PTSD, although the strongest demographic risk factor for PTSD in the study was low income. Survivors with incomes less than $25,000 per year were eight times more likely to have PTSD than those earning more than $100,000 per year.

The study was based on interviews with 3,271 English-speaking, civilian survivors who are enrolled in the WTC Health Registry, the largest post-disaster public health registry in U.S. history, tracking the health of more than 71,000 people directly exposed to the WTC disaster. Eligibility criteria for this particular study included a minimum age of 18 years, physical presence in either Tower 1 or 2 between the first plane impact and subsequent tower collapses, and no participation in WTC rescue/recovery activities.

In terms of other demographic characteristics of this cohort of survivors, 58.5% were men and 68.2% were white. However, the risk of PTSD was highest among Hispanics and African Americans. Sixty-seven percent of the survivors were college graduates and 60% had an annual household income greater than $75,000. Sixty-seven percent worked for an employer that sustained fatalities on 9/11.

Because this study targeted those with the greatest direct exposure, the burden of posttraumatic stress was higher for these survivors than that documented in previous 9/11 studies, and the number of cases of posttraumatic stress observed was directly related to the number of direct exposures reported.

“PTSD risk was greater among survivors who experienced serious life threat as defined by location in the towers, time of evacuation initiation, or dust cloud exposures,” said Dr. Laura DiGrande, DrPH, MPH, Columbia’s Mailman School of Public Health doctoral degree recipient for this research and first author of the study. “As one would expect, individuals who were exposed to several of the most troubling and life threatening events during the disaster were at the greatest risk of PTSD.” Only 145 or four percent of survivors had no symptoms of PTSD.

“As the long-term effects of the WTC disaster emerge the results from this study suggest that some survivors of the WTC disaster will continue to report psychological symptoms years after their exposure to the events of 9/11. The implication of this finding is that the impact of terrorism on survivors, particularly those in low socioeconomic positions, could be substantial, as PTSD is known to be co-morbid with other disorders and harmful behaviors that affect daily functioning, wellness, and relationships,” noted Dr. Sandro Galea, MD, chair of the Department of Epidemiology at Columbia’s Mailman School of Public Health and study senior author.

“As disaster literature moves toward understanding long-term risks in the general population, this study reminds us that the relation between direct exposures and PTSD is clear and suggests potential avenues for planning policy to reduce the burden of terrorism-related psychopathology,” noted Dr. Robert Brackbill, PhD, MPH, the Registry’s founding principal investigator and study coauthor.

As the 10-year anniversary of the World Trade Center disaster approaches, Columbia researchers and the WTC Health Registry are continuing to ascertain even longer term implications.

Material adapted from Columbia University’s Mailman School of Public Health.

Reference / Abstract
Laura DiGrande, Yuval Neria, Robert M. Brackbill, Paul Pulliam, and Sandro Galea. Long-term Posttraumatic Stress Symptoms Among 3,271 Civilian Survivors of the September 11, 2001, Terrorist Attacks on the World Trade Center. Am. J. Epidemiol. first published online December 29, 2010

The study investigates how the emotion of fear depends on an almond-shaped brain region called the amygdala. The patient in the case study has a rare condition that destroyed her amygdala. UI researchers observed the patient’s response to frightening stimuli such as a haunted house, snakes, spiders, and horror films, and asked her about traumatic experiences in her past – including situations that had endangered her life. They found that without a functioning amygdala, the patient is unable to experience fear.

Studies in the past 50 years have shown the amygdala to play a central role in generating fear reactions in animals from rats to monkeys. This study confirms for the first time that the amygdala is also required for triggering a state of fear in humans. Previous studies with this patient confirmed she cannot recognize fear in facial expressions, but it was unknown until this study if she had the ability to experience fear herself.

Daniel Tranel, Ph.D., UI professor of neurology and psychology and senior study author, said the discovery could lead to new interventions for PTSD and related anxiety disorders. PTSD affects more than 7.7 million Americans, according to the National Institute of Mental Health, and a 2008 analysis by the Rand Corporation predicted that 300,000 soldiers returning from combat in the Middle East would experience PTSD.

“This finding points us to a specific brain area that might underlie PTSD,” said Tranel, director of the UI’s Interdisciplinary Graduate Program in Neuroscience. “Psychotherapy and medications are the current treatment options for PTSD and could be refined and further developed with the aim of targeting the amygdala.”

Justin Feinstein, lead study author and a UI doctoral student studying clinical neuropsychology, says the findings suggest that methods of safely and non-invasively dampening amygdala activity may help people with PTSD.

“This past year, I’ve been treating veterans returning home from Iraq and Afghanistan who suffer from PTSD. Their lives are marred by fear, and they are oftentimes unable to even leave their home due to the ever-present feeling of danger,” Feinstein said. “In striking contrast, the patient in this study is immune to these states of fear and shows no symptoms of post-traumatic stress. The horrors of life are unable to penetrate her emotional core. In essence, traumatic events leave no emotional imprint on her brain.”

In examining the role of the amygdala, Feinstein observed and recorded the patient’s responses during exposure to snakes and spiders (two of the most commonly feared animals) during a visit to one of the world’s scariest haunted houses, and while watching a series of horror films. Feinstein also measured the patient’s experience of fear with a large number of standardized questionnaires that probed different aspects of fear, ranging from the fear of death to the fear of public speaking. Additionally, over a three-month period, the patient carried a computerized emotion diary that randomly asked her to rate her current fear level throughout the day.

Across all of the scenarios, the patient failed to experience fear. Moreover, in everyday life, she has encountered numerous traumatic events that have threatened her very existence, yet, by her report have caused no fear.

“Taken together, these findings suggest that the human amygdala is a pivotal area of the brain for triggering a state of fear,” Feinstein said. “While the patient is able to experience other emotions, such as happiness and sadness, she is unable to feel fear. This suggests that the brain is organized in such a way that a specific brain region – the amygdala – is specialized for processing a specific emotion – fear.”

For Feinstein and Tranel, the most surprising finding of the study was the patient’s behavior when exposed to snakes and spiders. For many years, the patient told the researchers that she hates snakes and spiders and tries to avoid them, yet she immediately started touching them at a pet store, stating that she was overcome with curiosity.

Antonio Damasio, professor of neuroscience at the University of Southern California and a longtime collaborator of Tranel, helped interpret the findings. The researchers say that the results suggest that our fear behavior is often times controlled at a very instinctual, unconscious level.

“Without our amygdala, the alarm in our brain that pushes us to avoid danger is missing,” Feinstein said. “The patient approaches the very things she should be avoiding, yet, strikingly, appears to be totally aware of the fact that she should be avoiding these things. It is quite remarkable that she is still alive.”

Material adapted from University of Iowa – Health Science.

The relevancy of an individual’s subjective experience in determining what constitutes a traumatic event has been a source of debate among PTSD specialists for years. The study concludes that both objective and subjective factors are relevant and that current PTSD criteria are missing several reactions that many trauma survivors experience.

The study’s authors conducted a comprehensive literature review of the research on peritraumatic experiences and the types of reactions that trauma survivors often demonstrate. They found that individuals adapt to extreme experiences in a highly complex and coordinated manner.

“A person’s response is multifaceted and may include appraisals and other thoughts, a variety of felt emotions and behaviors. It’s not enough to rely on the objective qualities of an experience to determine whether it should be considered traumatic or not,” said co-author Brian P. Marx, PhD, an associate professor of psychiatry at Boston University School of Medicine and psychologist at the VA National Center for PTSD. “Trauma should be defined as the interaction between the individual and his or her environment and all parts of an individual’s response should be considered.”

PTSD is believed to be the result of exposure to trauma, so understanding what defines a traumatic experience is critical. Current criteria for PTSD in the Diagnostic and Statistical Manual include few distinct subjective emotions. The authors suggest that researchers investigate and add more appropriate examples to these criteria in order to more accurately categorize traumatic events.

“Knowing exactly what trauma is can help us to better know who is a trauma survivor and who is not,” said Marx. “It is critical that we know this for the purposes of understanding the disorder as well as being better able to help those who are survivors of trauma.”

Material adapted from Boston University Medical Center.

An important component of anxiety disorders, including PTSD, is the formulation of memories associated with fear. Therefore, researchers hypothesized that sleep deprivation after exposure to an aversive event might eliminate the associated fear, due to the lack of memory consolidation that would typically occur during sleep.

Researchers evaluated healthy volunteers who were shown video clips of both safe driving and unexpected motor vehicle accidents. Half of the volunteers were then deprived of sleep while the other half received a normal night’s sleep.

Later testing sessions revealed that sleep deprivation eliminated the fear-associated memories through both fear recognition and physiological fear reactions, suggesting a possible therapy for individuals with PTSD or other anxiety disorders.

Dr. Kenichi Kuriyama, corresponding author, explained: “Sleep deprivation after exposure to a traumatic event, whether intentional or not, may help prevent PTSD. Our findings may help to clarify the functional role of acute insomnia and to develop a prophylactic strategy of sleep restriction for prevention of PTSD.”

“It would be nice if the benefits of sleep deprivation upon fear learning could be produced more easily for survivors of extreme stress,” noted John Krystal, M.D., Editor of Biological Psychiatry and Professor and Chair of Psychiatry at Yale University. “New insights into the neurobiology of sleep dependent learning may make it possible for these people to take a medication that disrupts this process while leaving restorative elements of sleep intact.”

Further research is necessary, but these findings indicate that sleep deprivation is a promising avenue for the possible treatment and prevention of PTSD.

Material adapted from Elsevier.

Reference
The article is “Sleep Deprivation Facilitates Extinction of Implicit Fear Generalization and Physiological Response to Fear” by Kenichi Kuriyama, Takahiro Soshi, and Yoshiharu Kim. The authors are affiliated with the Department of Adult Mental Health, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan. The article appears in Biological Psychiatry, Volume 68, Number 11 (December 1, 2010), published by Elsevier.

The Flashback
“PTSD is a condition that sometimes arises after a severe trauma,” explains Dr. Naish, “generally when the person fears their own death, or experiences the death of others close to them.” One of the worst symptoms is the ‘flashback’. It’s like ‘a hallucination,’ says Dr. Naish, “it gives people vivid images of the scene, as if they are there, it’s very frightening.” There are many theories but the most physiological one suggests that while in normal circumstances our memory is organised by the hippocampus, at moments of heightened arousal, such as extreme fear, the amygdala takes over.

Reactivating parts of brain
The experience of a traffic accident where someone is trapped in a car, with petrol leaking and the danger of it igniting, could be revived as a flashback by the smell of petrol for example. Dr. Naish explains that it is believed the amygdala may be reactivating the same parts of the brain that were active at the time, and this seems to happen with PTSD. Dr Naish’s research was partly prompted by seeing some studies suggesting that people with PTSD are more than averagely hypnotisable.

Switching hemispheres
He designed glasses which used LEDs on each side which flashed a light (with a one millisecond gap), and the wearers have to say which side came on first. Normal subjects used both hemispheres of the brain to process the information, and if there was a dominant side it tended to be the left. However, in the tests the more hypnotisable people, ‘switched around completely, now they were faster on the right side, implying in some sense they were switching to right hemisphere processing.’ His study revealed that people with PTSD had a pattern of responses similar to people in a hypnotic state. The glasses could be used to spot who may be at risk. Dr Naish stresses this is early research, but the data looks promising.

Material adapted from The British Council.

Download / Reference
Sandström, A. (2010). Neurocognitive and endocrine dysfunction in women with exhaustion syndrome (to download, scroll down to the bottom of the page where it says “in thesis”). Umeå University Medical Dissertations.

Kristen Lester, the lead author of the study published in the Journal of Consulting and Clinical Psychology and a researcher at the National Center for PTSD, used two randomized, controlled studies of cognitive-behavioral therapy for the treatment of women with sexual assault and sexual abuse histories. These two studies were collapsed in order to gain a sufficient sample size to compare women of differing ethnic backgrounds. Ultimately, there were only enough Caucasians and African-American women in the sample to compare (rather than also examining people from other ethnic backgrounds).

Lester and her colleagues were not unsurprised to see that the dropout rate was higher for African-Americans as this is a finding of other studies. However, they were surprised to find that African-American women, even when taking into account those who had dropped out of treatment, were able, as a group, to reduce their PTSD to levels similar to the Caucasian women, who were more likely to stay in the protocol. A closer examination of the data showed that the differences between the two groups was primarily due to the greater improvement in symptoms of African-American who dropped out compared to Caucasian women who failed to complete treatment.

A tentative explanation for what seems like contradictory findings is that African-American women may have been more motivated to seek treatment, given the stigma associated with seeking help for psychological symptoms among the African-American community. Therefore, they may have been able to benefit more quickly given their high motivation level. A related but alternative explanation is that African-American women had a high expectancy for treatment being beneficial if they were to get to the point of actually seeking services. This is in line with the premise of solution-focused therapy, a strengths-based counseling model, in which “pretreatment change” is considered a factor to exploit. The idea is that the very act of committing to an appointment to seek help often makes people feel better. Asking about “what has already changed between the time you made the appointment and now” builds momentum on the change that has already occurred.

The researchers of the study were unable to test if “therapist matching,” seeing if therapists and clients being matched on ethnicity contributed to African-American retention, because there were so few African-American therapists.

Reference
Lester, K., Artz, C., Resick, P., & Young-Xu, Y. (2010). Impact of race on early treatment termination and outcomes in posttraumatic stress disorder treatment. Journal of Consulting and Clinical Psychology, 78, 480-489.

These are some of the conclusions drawn from a research conducted by David Cantón Cortés, at the Department of Evolutionary and Educational Psychology of the University of Granada, and led by professors Fernando Justicia Justicia and José Cantón Duarte. In their study, which was developed in collaboration with the University of Cambridge (United Kingdom), they analyzed how different cognitive variables affect the development of symptoms of post-traumatic stress disorder. To such purpose, a sample of victims of child sexual abuse was used.

Concretely, the researchers analyzed the moderating role of coping strategies, the impact of the sense of guilt and of blaming others, and the feelings triggered by sexual abuse. This research proved that long-term psychological adjustment of victims of child sexual abuse greatly depends on some cognitive factors, and on their interaction. Further, this study helped to determine under what circumstances (associated to situations of sexual abuse) these cognitive factors have higher impact.

1.500 University Students
To carry out this study, 1,500 female university students were asked to answer an anonymous test developed by University of Granada researchers. Thus, information from 160 women that had been victims of child abuse was obtained. These cases constituted the convenience sample of the study.

The study conducted by Cantón Cortés is innovative, since it not only analyzes the role of cognitive variables in the psychological adjustment of victims of child abuse, but it also analyzes the role of such variables, according to the circumstances of the abuse. That is, the study describes the conditions that make such cognitive variables have higher impact on psychological adjustment.

The researcher states that the results “may be useful for the clinical treatment of victims of child abuse, since it allows the identification of three intervention areas extremely valuable, both for their impact on adjustment, and because they can be modified (coping strategies, sense of guilt, feelings caused by sexual abuse)”.

Part of the results of this research will be published soon in the journal Child Abuse & Neglect, one of the most relevant and influential journals specialized on child sexual abuse.

Material adapted from University of Granada.

Using a technique called magnetoencephalography (MEG), which involves analysing the occurrence of magnetic charges given off when neuronal populations in our brain connect and communicate, the researchers have undertaken clinical trials to try and find differences between brain activity of PTSD sufferers and those with a clean bill of mental health.

The trials involved 80 subjects with confirmed PTSD, many of whom suffer the affliction following military service in Vietnam, Afghanistan, and Iraq, 18 subjects in PTSD remission, and 284 healthy subjects.

All participants were required to wear the MEG helmet while fixating on a spot 65 cm in front of them for 60 seconds.

The researchers from the Minneapolis Veterans Affairs Medical Center and the University of Minnesota, led by Apostolos P Georgopoulos and Brian Engdahl, found a difference between communication in the temporal and parieto-occipital right hemispheric areas of the brain. The temporal cortex, in accordance with earlier findings on the effects of its electrical stimulation during brain surgery, is thought to be responsible for the re-living of past experiences.

Of particular interest to the scientists however is that the brains of the sufferers were in this hyperactive state despite no immediate external stimulation, as the trial subjects were purposefully put into a ‘task-free state’.

The researchers write, “Remarkably, the differences we found between the PTSD and the control groups were documented in a task-free state. Without evoking traumatic experiences, and, therefore, reflects the status of steady-state neuronal interactions.”

The research is one further step in the attempt to ‘biomark’ PTSD, particularly as the results gathered from subjects in remission followed a similar but less pronounced pattern to those with PTSD confirmed as their primary diagnosis, in contrast to the healthy subjects.

This latest research was funded by the U.S. Department of Veterans Affairs.

Material adapted from Institute of Physics.

A lesson plan for resilience
Because children are surprisingly resilient, if given the proper tools, they can move past traumatic experiences more easily than adults.

Prof. Slone studied children who underwent daily rocket attacks from Gaza or other forms of political violence. She compared children who appeared more well-adjusted to those who exhibited more severe psychological trauma, and determined which qualities made the difference. With the results of this research, she developed a series of workshops to enhance those elements that helped children deal with the stress of conflict.

After the workshops, children who attended were better able to stand up in front of their peers and candidly discuss their anxieties about the conflict they experienced, engaging with the group to form strategies for dealing with problems that arose. This exercise dramatically improved their psychological healing process, she says.

A four-fold approach
For her workshops, Prof. Slone identified four of the most important resilience factors: mobilizing appropriate support; attributing meaning to the traumatic experience; developing self-efficacy and problem-solving skills; and improving self-esteem. Next, she developed a school-based intervention program to help students develop and utilize the desired qualities. She and her fellow researchers created a workbook for each factor, she explains, and held training sessions with teachers. Through a four-to-six week workshop process, the children were led through a variety of activities designed to improve each quality.

Analyzing pre- and post-workshop questionnaires, interviews, and evaluations, Prof. Slone and her fellow researchers determined that in addition to developing the individual resilience factor each workshop focused on, the students displayed less anxiety and aggressive behavior, a better sense of well-being, and improved social interaction and academic performance.

Teachers as well as students benefited from the workshops, says Prof. Slone. Prior to implementing this program, teachers had no method for talking to their students about the traumatic symptoms they observed. Teachers reported that the workshops enhanced their ability to help their students with difficult issues, and even improved class and school morale.

Helping children around the world
Although the program would need to be modified to account for cultural differences, says Prof. Slone, similar programs can be introduced in schools internationally. She believes that her workshops give teachers the tools they need to communicate with their students about difficult issues, and allow children to better psychologically handle the traumas to which they may have been exposed. This could help children deal with the effects of events such as 9/11 or the London Underground bombings.

The first step, explains Prof. Slone, is to determine what resilience factors benefit the children in a given society or culture. Once these factors are identified, the workshops can be adapted to help foster these particular factors. “This type of secondary intervention has the potential to be effective for a wide variety of trauma exposure,” she says. “And it is possible to enhance resilience factors in large populations of children. They’re lessons that can last a lifetime.”

Material adapted from American Friends of Tel Aviv University.

The intervention, called the Child and Family Traumatic Stress Intervention (CFTSI) also reduced PTSD symptoms in children – which can include reliving a traumatic experience, sleep disturbances, emotional numbness, angry outbursts, or difficulties concentrating – and promoted recovery more quickly than a comparison intervention.

“This is the first preventative intervention to improve outcomes in children who have experienced a potentially traumatic event, and the first to reduce the onset of PTSD in kids,” said lead study author Steven Berkowitz, MD, associate professor of Clinical Psychiatry at the University of Pennsylvania School of Medicine and director of the Penn Center for Youth and Family Trauma Response and Recovery. “If this study is replicated and validated in future studies, this intervention could be used nationally to help children successfully recover from a traumatic event without progressing to PTSD.”

In the study, 106 children ranging from 7 to 17 years in age and a caregiver were randomly assigned to receive the four-session Child and Family Traumatic Stress Intervention or a four-session supportive comparison intervention, both provided within 30 days following exposure to a traumatic event. Children were referred by police, a forensic sexual abuse program, or the local pediatric emergency department in an urban city in Connecticut.

The CFTSI intervention began with an initial baseline assessment to measure the child’s trauma history and a preliminary visit with the caregiver, focusing on their essential role in the process. Within the sessions, there is a focus on improving communication between the child and caregiver, as well as other supportive measures. At the end of the next two sessions, the clinician, caregiver and child, decide on a homework assignment to practice certain coping skills. The behavioral skill components provide techniques to recognize and manage traumatic stress symptoms.

Future studies will need to validate the effectiveness of this intervention, but researchers hope that brief and effective interventions like CFTSI can be applied early to prevent the development of PTSD.

Material adapted from University of Pennsylvania School of Medicine.

Professor Richard Griffiths and Christina Jones from the University of Liverpool, UK, worked with an international team of researchers to conduct a randomized controlled trial into the effectiveness of the diaries in 352 patients from 12 hospitals in 6 different European countries. Griffiths said, “On average 1 in 10 patients who stay more than 48 hours in intensive care will develop PTSD. It is likely that the fragmentary nature of their memories and the high proportion of delusional memories, such as nightmares and hallucinations, make it difficult for patients to make sense of what has happened to them. These memories are frequently described as vivid, realistic and frightening and may even involve patients thinking that nurses or doctors tried to kill them. Hard evidence of what really happened, in the form of a diary filled out by the treatment staff, may help to allay these fears”.

During the study, 162 patients were randomly assigned to receive diaries, and they were found to be less than half as likely to develop PTSD as the control group. The diaries were completed daily by nursing staff and relatives using everyday language and accompanying photographs were taken. After discharge from intensive care, a nurse talked the patient through the diary entries. According to Griffiths, “Diaries are not without cost; there has to be a commitment from the staff to write something in the diary every day and take photographs when important changes happen. In addition an experienced nurse is needed to go through the diary with the patient to ensure that they understand its contents, but this is not significantly more than might have been provided by an unstructured discussion in the past. Compared with providing formal therapy to all patients struggling to cope with their experiences, diaries are likely to be highly cost-effective”.

Material adapted from Biomed Central Limited.

Reference/Download
Christina Jones, Carl Backman, Maurizia Capuzzo, Ingrid Egerod, Hans Flaatten, Cristina Granja, Christian Rylander, Richard D Griffiths and The RACHEL group. Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial. Critical Care 2010, 14:R168 doi:10.1186/cc9260

However, Dr. Isabelle Mansuy and colleagues provide new evidence in the current issue of Biological Psychiatry that some aspects of the impact of trauma cross generations and are associated with epigenetic changes (i.e., the regulation of the pattern of gene expression, without changing the DNA sequence.)

They found that early-life stress induced depressive-like behaviors and altered behavioral responses to aversive environments in mice. Importantly, these behavioral alterations were also found in the offspring of males subjected to early stress even though the offspring were raised normally without any stress. In parallel, the profile of DNA methylation was altered in several genes in the germline (sperm) of the fathers, and in the brain and germline of their offspring.

“It is fascinating that clinical observations in humans have suggested the possibility that specific traits acquired during life and influenced by environmental factors may be transmitted across generations. It is even more challenging to think that when related to behavioral alterations, these traits could explain some psychiatric conditions in families,” said Dr. Mansuy, lead author on this project. “Our findings in mice provide a first step in this direction and suggest the intervention of epigenetic processes in such phenomenon.”

“The idea that traumatic stress responses may alter the regulation of genes in the germline cells in males means that these stress effects may be passed across generations. It is distressing to think that the negative consequences of exposure to horrible life events could cross generations,” commented Dr. John Krystal, Editor of Biological Psychiatry. “However, one could imagine that these types of responses might prepare the offspring to cope with hostile environments. Further, if environmental events can produce negative effects, one wonders whether the opposite pattern of DNA methylation emerges when offspring are reared in supportive environments.”

Further research will be necessary to answer those questions, but these findings open a new door in the emerging field of neuroepigenetics.

Material adapted from Elsevier.

Reference
“Epigenetic Transmission of the Impact of Early Stress Across Generations” by Tamara B. Franklin, Holger Russig, Isabelle C. Weiss, Johannes Gräff, Natacha Linder, Aubin Michalon, Sandor Vizi, and Isabelle M. Mansuy. Franklin, Russig, Weiss, Linder, Vizi, and Mansuy are affiliated with the Brain Research Institute, Medical Faculty of the University of Zürich, Zürich, Switzerland, and the Department of Biology, Swiss Federal Institute of Technology, Zürich, Switzerland. Gräff is affiliated with the Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, Massachusetts. Michalon is affiliated with the Preclinical CNS Research, Hoffmann Laroche, Basel, Switzerland. Biological Psychiatry, Volume 68, Issue 5, 1 September 2010, Pages 408-415, Stress, Neuroplasticity, and Posttraumatic Stress Disorder, doi:10.1016/j.biopsych.2010.05.036

“We found Veterans with PTSD had twice the chance for later being diagnosed with dementia than Veterans without PTSD,” said Mark Kunik, M.D., M.P.H., a psychiatrist at the Michael E. DeBakey VA Medical Center, Texas, USA, and senior author of the article. “Although we cannot at this time determine the cause for this increased risk, it is essential to determine whether the risk of dementia can be reduced by effectively treating PTSD. This could have enormous implications for Veterans now returning from Iraq and Afghanistan.”

The study included 10,481 Veterans at least 65 years of age who had been seen at the VA Medical Centre at least twice between 1997 and 1999. Outpatient data were gathered for all identified patients until 2008. Subjects who had been wounded during combat (with and without a PTSD diagnosis) were also identified to provide a group with confirmed injuries and combat experience. A group with two visits, but no PTSD or combat related injuries, was identified for purposes of comparison.

36.4% of the Veterans in this study had PTSD. 11.1% of those with PTSD but not injured, and 7.2% of those with PTSD and injured, had dementia, compared to 4.5% and 5.9% respectively in the non-PTSD groups. These results remained significant after other risk factors of dementia were taken into account like diabetes, hypertension, heart disease, stroke, etc.

“Despite the increased risk for those with PTSD, it is noteworthy that most Veterans with PTSD did not develop dementia during the period we studied,” said Salah Qureshi, M.D., a staff psychiatrist and investigator with the Houston VA Center of Excellence and first author of the article.”It will be important to determine which Veterans with PTSD are at greatest risk and to determine whether PTSD induced by situations other than war injury is also associated with greater risk.”

The authors note there could be several explanations for their findings. It could be that cognitive impairment in PTSD is an early marker of dementia, having PTSD makes one more likely to get dementia, or PTSD and dementia have some characteristics in common. They emphasize the need for further study with a broader sample in the civilian population.

In an editorial accompanying this paper, Dr. Soo Borson of the University of Washington Medical Centre, Washington, highlights the need for further research to explain the association and also the wider significance of these findings, “Confirmation of a causal link between PTSD and cognitive impairment in late life would have enormous global implications in a world facing a rising societal burden of dementia, a shrinking workforce to sustain its economies, and the difficulties of containing human violence. Soldiers and other U.S. war veterans are just one of many groups exposed to deeply traumatizing experiences with lifetime effect.”

Material adapted from Wiley-Blackwell.

“Most returning veterans don’t have PTSD or difficulty with anger or aggressiveness, but for the small subset who do, this study helps to identify related risk factors,” said Eric Elbogen, PhD, lead author of the study, an assistant professor of psychiatry in the UNC School of Medicine and a staff psychologist at the VA Medical Center in Durham, N.C.

“The data showed that PTSD symptoms such as flashbacks or avoiding reminders of a trauma were not consistently connected to aggressiveness,” said Elbogen. “Instead, we found that post-deployment anger and hostility were associated with PTSD hyperarousal symptoms: sleep problems, being ‘on guard,’ jumpiness, irritability, and difficulty concentrating.”

From interviews with 676 veterans, Elbogen and VA colleagues identified features associated with anger and hostility, which result in increased risk of post-deployment adjustment problems as veterans transition to civilian life.

Veterans who said they had difficulty controlling violent behavior were more likely to report witnessing pre-military family violence, firing a weapon during deployment, being deployed more than 1 year, and experiencing current hyperarousal symptoms. There was an association with a history of traumatic brain injury, but it was not as robust as the relationship to hyperarousal symptoms. Elbogen said, “Our data suggest the effects of traumatic brain injury on anger and hostility are not straightforward.”

Veterans with aggressive urges were more likely than others to report hyperarousal symptoms, childhood abuse, a family history of mental illness, and reexperiencing a traumatic event. Difficulty managing anger was associated with being married, having a parent with a criminal history, and avoiding reminders of the trauma, as well as hyperarousal symptoms.

“As we learn more about risk factors and how to manage them, we’ll be helping not only the veterans but their families and society at large. Veterans with these adjustment problems should seek help through the VA so we can best serve those who have served our country” Elbogen said.

Material adapted from University of North Carolina School of Medicine by CFisher.

“Identification of the biologic underpinnings of PTSD will be crucial for developing appropriate psychological and/or pharmacological interventions, particularly in the wake of an increasing number of military veterans returning home following recent wars worldwide.”

The findings are published today online in Proceedings of the National Academy of Sciences (PNAS).

Previous studies have found that lifetime experiences may alter the activity of specific genes by changing their methylation patterns. Methylated genes are generally inactive, while unmethylated genes are generally active.

The new study is the first large scale investigation to search for trauma-induced changes in the genes of people with PTSD. DNA samples were obtained from participants in the Detroit Neighborhood Health Study (DNHS), a longitudinal epidemiologic study investigating PTSD and other mental disorders in the city of Detroit. The researchers analyzed the methylation patterns of over 14,000 genes from blood samples taken from 100 Detroit residents, 23 of whom suffer from PTSD.

The analysis found that participants with PTSD had six to seven times more unmethylated genes than unaffected participants, and most of the unmethylated genes were involved in the immune system.

The observed methylation changes in the immune system genes were reflected in the PTSD participants’ immune systems: levels of antibodies to a herpes virus were high in PTSD patients, indicative of a compromised immune system.

While people who experience severe trauma will exhibit a normal stress response, in PTSD, the stress response system becomes deregulated and chronically overactive causing compromised immune functioning. PTSD has long been linked to increased risk of numerous physical health problems – including diabetes and cardiovascular disease. This paper suggests why PTSD is so strongly associated with physical health problems – trauma exposure causes epigenetic changes in immune system genes and thus, compromised immune functioning putting individuals at risk for a host of disorders.

“Our findings show that PTSD may be associated with epigenetic changes in immune-system genes. If this is the case, these clusters could provide clues to our understanding of how a traumatic event changes gene expression, thus altering immune function and resulting in other possible physiologic alterations,” says Dr. Galea.

Material adapted from Columbia University’s Mailman School of Public Health by CFisher.

The study found that 589 survivors, or 9 percent, reported significant functional impairment and clinical distress as well as symptoms consistent with a full diagnosis of PTSD. In comparison, eight siblings, or 2 percent, reported impairment, distress and PTSD symptoms. The study is published in the May issue of the journal Pediatrics.

“Childhood cancer survivors, like others with PTSD, have been exposed to an event that made them feel very frightened or helpless or horrified,” said Dr. Margaret Stuber, a professor of psychiatry and biobehavioral sciences, a Jonsson Cancer Center researcher and first author of the study. “This study demonstrates that some of these survivors are suffering many years after successful treatment. Development of PTSD can be quite disabling for cancer survivors. This is treatable and not something they have to just live with.”

Affected survivors reported symptoms such as increased arousal, phobias, startling easily, being hyper vigilant, avoidance of reminders of their cancer diagnosis and treatment, being on edge and suffering extreme anxiety. They also reported that the symptoms kept them from functioning normally.

Other studies have looked for PTSD in childhood cancer survivors while they’re still children or adolescents, but the percentage reporting symptoms is far less, about 3 percent, Stuber said.

There could be several reasons for the discrepancy. Today’s treatment regimens employ less toxic treatments and rely far less on whole head radiation for brain tumors, causing far less trauma to the young patients. Additionally, the improved supportive care available today may result in fewer physical and cognitive late effects from treatment.

The survivors in Stuber’s study often underwent far harsher treatment regimens commonly used in the 1970s and early 1980s, and within the group studied, those that underwent the more toxic and damaging therapies reported more cases of PTSD.

Another possible reason that more of the young adults reported PTSD symptoms is because they’re facing the stressful situations typical for people at that age – finding a job, getting married, starting a family. That stress may exacerbate the PTSD, Stuber said.

“It may be that symptoms, clinical distress and functional impairment only emerge among the more vulnerable childhood cancer survivors as they contend with the developmental tasks of young adulthood and the added challenges of the late effects of treatment,” the study states. “The relative protection of the parental home is diminished as young adult survivors face the challenges of completing their education, finding a job, getting health insurance, establishing long-lasting intimate relationships and starting a family.”

And because many of the patients in the study underwent harsh therapies, they often suffer from significant late effects – infertility, cognitive impairment, stunted growth. This add to stress levels as well. Those that suffer from cognitive impairment may find it impossible to go to college or to land a good job that earns them an adequate income.

“These survivors may find that can’t get health insurance. They may be reluctant to put themselves on the marriage market because they’re sterile. Those that can have children may be afraid of passing their ‘bad genes’ onto their children. Some treatments affect growth, so some survivors may be shorter and heavier than their peers,” Stuber said. “They may feel like they’re damaged goods.”

Treatment options such as therapy and medication are available to help the survivors manage their symptoms. But addressing the issue will not be simple, Stuber said.

“People who had more intense treatment are more likely to have these symptoms because their treatment was more traumatic,” Stuber said. “And because more damage was done to their bodies, it makes it more difficult to have a good life later. It’s all interdigitating.”

Video
A link to a video interview with the researcher is here.

Material adapted from University of California – Los Angeles by CFisher.

More than 230,000 Iraq and Afghanistan war veterans sought treatment for the first time at VA healthcare facilities nationwide between 2002 and 2008. More than 20 percent of these veterans, almost 50,000, received a new PTSD diagnosis. Treatments that have been shown to be effective for PTSD typically require 10-12 weekly sessions. VA follows these recommendations, however, fewer than ten percent of those Iraq and Afghanistan veterans with newly diagnosed PTSD complete this recommended “dose” of PTSD treatment. When the time frame was expanded to a year rather than four months, fewer than thirty percent of the veterans completed the recommended course of treatment.

The study showed that there are groups of veterans that are less likely to receive adequate care than others, such as male veterans (compared to female veterans), veterans under twenty-five years old, veterans who received their PTSD diagnoses from primary care clinics (requiring referral to a mental health program), and veterans living in rural areas.

Dr. Karen Seal, head researcher for the study and practitioner at the San Francisco Veteran Affairs Medical Center, says that while the majority of veterans with PTSD attend at least one mental health follow-up visit, there are still substantial barriers to care that prevent the majority from completing what is considered an adequate course of PTSD treatment. Many of obstacles are system-level or are personal barriers resulting in lack of patient follow-up on appointments, etc.

The study doesn’t account for care that veterans may be receiving outside of the VA, such as care received at Vet Centers or other community-based clinics. The study concludes there is further need for the VA and other healthcare systems to develop new and innovative ways to overcome barriers to care in delivering these effective mental health treatments. The success of VA’s most recent efforts to enhance PTSD care cannot be determined from the study’s findings, which cover the period through 2008 only.

Material adapted from Wiley-Blackwell by CFisher.

The ability to objectively diagnose PTSD is the first step towards helping those afflicted with this severe anxiety disorder. PTSD often stems from war, but also can be a result of exposure to any psychologically traumatic event. The disorder can manifest itself in flashbacks, recurring nightmares, anger, or hypervigilance.

With more than 90 percent accuracy, researchers were able to differentiate PTSD patients from healthy control subjects (250 people with clean mental health) using the MEG. All behavior and cognition in the brain involves networks of nerves continuously interacting – these interactions occur on a millisecond by millisecond basis. The MEG has 248 sensors that record the interactions in the brain on a millisecond by millisecond basis, much faster than current methods of evaluation such as the functional magnetic resonance imaging (fMRI), which takes seconds to record.

The measurements recorded by the MEG represent the workings of tens of thousands of brain cells. This recording method allowed researchers to locate unique biomarkers in the brains of patients exhibiting PTSD.

The findings are published January 20 in the Journal of Neural Engineering and led by Apostolos Georgopoulos, M.D., Ph.D., and Brian Engdahl., Ph.D. – both members of the Brain Sciences Center at the Minneapolis VA Medical Center and University of Minnesota.

“These findings document robust differences in brain function between the PTSD and control groups that can be used for differential diagnosis and which possess the potential for assessing and monitoring disease progression and effects of therapy,” Georgopoulos said.

Besides diagnosing those with PTSD, the researchers also are able to judge the severity of how much they are suffering, which means the MEG may be able to be used to gauge the how badly patients are impacted by other brain disorders.

It is likely that the study will be replicated and administered to a larger group to assure the accuracy of its results.

This work, specifically on detecting post-traumatic stress disorder, follows success in detecting other brain diseases, such as Alzheimer’s and multiple sclerosis, using MEG, as reported in September 2007.

Material adapted from University of Minnesota by CFisher.

Extreme stressors such as experiencing abuse or witnessing violence can make children isolate themselves from family and friends, feel disconnected from reality, experience intrusive thoughts about the trauma and struggle in school. “Post-traumatic stress is not only about the traumatic memories; it really affects daily living,” said Carrion, who is an associate professor of child and adolescent psychiatry at the School of Medicine and director of Stanford’s early life stress research program. The research will be published online Dec. 8 in the Journal of Pediatric Psychology. (The paper’s Digital Object Identifier, or DOI, is 10.1093/jpepsy/jsp112.)

The findings could be an important step toward better monitoring of PTSD treatments, which include psychotherapy techniques such as teaching relaxation exercises, helping children to construct a cohesive story about the traumatic event and helping them learn to cope with reminders of the trauma. Right now, psychologists assess such treatments by looking for improvements in symptoms, but that’s a problem because the symptoms can fluctuate from day to day. “That method has the disadvantage that we don’t know what’s happening at the neural level,” Carrion said.

To observe how kids’ brains work after trauma, Carrion’s team used functional magnetic resonance imaging to compare 16 young people who had PTSD symptoms with a control group of 11 normal youths. The scientists scanned the brains of the 10- to 17-year-old subjects during a simple test of verbal memory. Subjects read a list of words, then saw a similar list with new words added, and were asked which terms were present on the original list.

The hippocampus worked equally well in stressed and control subjects when the word list was first introduced. However, subjects with PTSD symptoms made more errors on the recall part of the test and showed less hippocampus activity than control subjects doing the same task.

Subjects with the worst hippocampus function were also most likely to experience a specific set of PTSD symptoms: Such impairment of the hippocampus was strongly correlated with “avoidance and numbing” symptoms of PTSD, including difficulty remembering the trauma, feeling cut off from others and lack of emotion.

Parents and other caregivers may find the new discoveries useful as they tend to traumatized children, Carrion said, particularly when children respond to trauma by withdrawing from people who are trying to help. Parents may sometimes misinterpret this behavior as a child’s attempt to retaliate, when it actually represents an overload of the brain’s normal mechanism for handling fear. “When parents understand that PTSD is real, they don’t take it as personally,” he said. “They become more available to their kids. That’s good because the kids need them.”

In the future, physicians and scientists may be able to use fMRI scans of the hippocampus to identify children who are at high risk of PTSD after mass catastrophes, added Carrion, who has consulted on response teams for natural disasters such as Hurricane Katrina and the February 2009 wildfires in southeastern Australia. However, larger studies of brain activity in pediatric PTSD are still needed to give a more detailed understanding of the disorder.

It’s already clear that untreated PTSD can interfere with a child’s normal brain development and increase the risk of other psychiatric conditions such as depression and substance abuse, Carrion concluded. “Early intervention is critical for children with post-traumatic stress,” he said.

Material adapted from Stanford University Medical Center by CFisher.

In March 2008, I along with other talk show hosts, was invited by Christian Solidarity International to visit Sudan on a humanitarian mission. Being very impressed with their work and continued dedication to freeing people in slavery after a catastrophic 22 year civil war, I was glad to have the opportunity to participate.

Ellen With Village

Given the state of this war ravaged region, there is a tremendous lack of professional assistance to the people who are very poor and without life’s basics that we tend to take for granted.

Having some training and experience with trauma, I thought teaching Coherent Breathing would make a huge difference in the incredibly difficult lives of these women and men.

Due to the lack of practitioners, Coherent Breathing is probably the only PTSD intervention that these war survivors will have access to in the foreseeable future.

The formal program began in late October 2009. All participants are requested to take a PTSD symptom evaluation every six weeks. While initial survey results are not all in yet, it is clear that everyone has suffered major effects of this decades long conflict.

We began the program in Southern Sudan in Mobil-Aweil, East County. Currently, participants come five days a week to receive instruction and breathe while listening to the RESPIRE-1 CD. We explained how the sound on the CD (2 Bells) was made by bringing a Tibetan bowl to demonstrate. Many of the participants travel long distances to participate and are paid ten dollars a week, this small stipend helping to pay for food and other expenses.

Within a couple of days participants were finding that the practice of Coherent Breathing was helping them manage their thoughts more effectively and achieve a new degree of calm. On November 17th, I received this email update:

Women Breathing

“Hi Ellen,

John talked to Dr. Luka just today and checked in on the breathing program.  Dr. Luka said the breathing program on his side of town is going well.  He said the clients are taking it seriously and it seems to benefit them.  Dr. Luka said he wasn’t sure if it was medical or psychological, but the women seem to benefit from the community and support of the breathing sessions.  He said he has not heard of any issues at Pastor Matthew’s end of the program and, to the best of his knowledge, it is going well there too.  It seems like it is off to a good start and at least some of the clients are taking it seriously and benefiting from it.  I’m pleased to hear this!

Yours,
Elliott Daniels
Washington Representative
Christian Solidarity International”

We will continue to update you as to the progress and impact of this important initiative!

Like many of us, I tend to have the most personal growth during and after a personal crisis. Twenty years ago I was experiencing a very difficult time in my own life. During this time, I met Anne Gehman, a Spiritualist minister. She introduced me to the mental healing movement of the late 1800’s. I spent many years of “off” time combing The Library Of Congress and Harvard University’s Widener Library.

During the long hours of the Monica Lewinsky scandal I would go there  for a bit of sanity and it was there that I found the work of Yogi Ramacharaka (William Walker Atkinson). By then I had moved from working in the mental health field to working as a reporter and talk media personality covering the White House.

That’s when Anne Gehman and I decided to work on a book of self help techniques. The book was almost finished but sat on the self for almost ten years until I hit another personal crisis and through Dr. Lauri Liskin became familiar with the work of Dr’s. Richard Brown, Patricia Gerbarg, and the practice of Coherent Breathing.

Ellen Breathing With Group

Coherent Breathing worked immediately and I became a “born again breather.” While showing my reporting staff the Coherent Breathing web site (www.coherence.com) I noticed that Stephen Elliott, author of The New Science of Breath had dedicated his work to the man whom I’d written so much about ten years before, Yogi Ramacharaka. Like so many things in life, the answer to my anxiety and depression had been right under my nose. It gave me the final impetus to finish the book which is now in the final editing stage.

My first book, The Other Side Of The Family- A Book For Recovery From Incest, Abuse, and Neglect, is about recovering from trauma inflicted within the family.

Thank you for your attention and thank you Christian Solidarity International,

Ellen Ratner