Bernards Voices

Nature’s Eric Olson interviews Kerry Ressler’s on his research published in Nature 470, February 24, 2011:

Why do some people develop post-traumatic stress disorder, but others emerge from a horrific event relatively unscathed? A molecule involved in orchestrating the brain’s response to stress may hold the key to this difference.

Women are 30 to 50 per cent more likely to develop PTSD than men. (The interview doesn’t address the episodic nature of PTSD. I don’t believe this research tell us anything about an episode’s frequency or intensity–for example, a flashback triggered by a car back fire. Nor does it address the extent with which anxiety episodes are chronic and worsen over time. I have my own personal obsession, I guess would be the word, about whether levels of estrogen and how they change over a woman’s lifetime, impact the intensity of her anxiety or depression.)

During the interview, PTSD is mentioned often by the interviewer, but the researcher, Kerry Ressler, doesn’t seem to differentiate between PTSD, panic and generalized anxiety disorders, as well as depression. The biological factors (the protein: Pituitary adenylate cyclase-activating polypeptide (PACAP), and its modulation by estrogen) impact fear inhibitors and stress responses independent of which anxiety disorder is being discussed. But it does appear that research was conducted on “heavily traumatized subjects,” rats, mice? Why? Because the symptoms were easier to induce and observe? Because the name PTSD is more eye-catching in headlines and grant applications?

Fast forward to minute 6:38 of the podcast:

Related transcript.
Research article abstract.

Dr. Ressler:

I don’t necessarily think that the symptoms at the final common pathway of symptoms level, there is necessarily a difference between men and women, but what we are increasingly learning about complex brain disorders is that there is probably many different ways to get to that disorder.

Finding any sort of treatment [for TBI], much less a cure, has not been easy. But some neuroscientists now see great potential in techniques of manipulating the brain’s “neuroplasticity,” its propensity to rearrange its neuronal structure in response to behavior and stimuli.

Earlier this year, the Department of Defense awarded a $2 million grant to Brain Plasticity Inc. to study the effectiveness of Posit Science software in restoring memory and attention in victims of traumatic brain injury, or T.B.I. Posit Science, based in San Francisco, is one of several companies, including Nintendo and Luminosity, that sell brain health software products to consumers.

In Turning to Software to Help Treat Brain Injuries – NYTimes.com, Gordy Slack reports (June 17, 2011) such software could potentially help Traumatic Brain Injury patients and also those who have been determined to have autism, Parkinson’s disease, schizophrenia and other psychiatric and neurological diseases.

“This is the beginning of a revolution,” said Michael Merzenich, the co-founder and chief scientist of Posit Science; the president of Brain Plasticity; and a celebrated University of California, San Francisco, neuroscientist who pioneered the idea of neuroplasticity.

“There is a big gap between the claims and the evidence,” said Dr. Doraiswamy [a Duke University psychiatrist], who said he doubted whether short-term improvements in memory would last longer than the three-month period most studies test.

“If they were a drug,” he said of the software, “they would have been pulled from the market.”

The malfunctioning brain, or what Dr. Merzenich calls the “noisy” brain, is like a radio that, for any number of reasons, is badly tuned to its intended station. The objective of his software, he says, is to clarify a strong signal by repeatedly practicing simple tasks, like recognizing repeated visual patterns.

Theoretically, the brain training software could address both cognitive problems and post-traumatic stress, said Henry Mahncke, Posit Science’s chief executive, a neuroscientist and a former student of Dr. Merzenich.

Records from [an "obscure" government] database, provided to The Bay Citizen under the Freedom of Information Act, show that the V.A. is aware of 4,194 Iraq and Afghanistan veterans who died after leaving the military. More than half died within two years of discharge. Nearly 1,200 were receiving disability compensation for a mental health condition, the most common of which was post-traumatic stress disorder.

via Troubled Veterans and Early Deaths After Iraq – NYTimes.com.

The V.A. database does not include veterans who never applied for benefits or who were not receiving benefits at the time of their death, according to the agency. The V.A. said it also did not keep track of the cause of death.

From May 10th, The New York Times, Alastair Gee reports that “Hazy Recall as a Signal Foretelling Depression”

–in studies under way at Oxford and elsewhere, scientists are looking … to gain new insights into the diagnosis and treatment of depression. They are focusing not on what people remember, but how.

The phenomenon is called overgeneral memory, a tendency to recall past events in a broad, vague manner. “It’s an unsung vulnerability factor for unhelpful reactions when things go wrong in life,” said Mark Williams, the clinical psychologist who has been leading the Oxford studies.

Some forgetting is essential for healthy functioning — “If you’re trying to remember where you parked the car at the supermarket, it would be disastrous if all other times you parked the car at the supermarket came to mind,” said Martin Conway, a cognitive psychologist at the University of Leeds in England. But, a chronic tendency to obliterate details has been linked to longer and more intense episodes of depression.

This is one of my posts, which is just a string of excerpts from the article, but the article is clear, really speaks for itself.

And an unusual paper suggests that overgeneral memory is a risk factor for post-traumatic stress disorder. Scientists at the University of New South Wales in Sydney, Australia, assessed 46 firefighters during their initial training and again four years later, when all had experienced traumatic events like seeing comrades injured or killed. Those who could not recall the past in specific detail during the first assessment were much likelier to have developed the disorder by the later one.

Is overgeneral memory the chicken or the egg? “perhaps overgeneral memory exists in the first place … to block particular traumatic or painful memories.”

Without detailed memories to draw upon, dispelling a black mood can seem impossible. Patients may remember once having felt happy, but cannot recall specific things that contributed to their happiness, like visiting friends or a favorite restaurant.

Some experts think such insights could also be helpful in treating depression. For example, Spanish researchers have reported that aging patients showed fewer symptoms of depression and hopelessness after they practiced techniques for retrieving detailed memories.

Dr. Williams has found that specificity can be increased with training in mindfulness, a form of meditation increasingly popular in combating some types of depression. Subjects are taught to focus on moment-to-moment experiences and to accept their negative thoughts rather than trying to avoid them.

December 23, 2009: Neuropod podcasts.

At minute 17:53 in the podcast, there is an interest discussion on how fear memories can be replaced with safer memories. This relates to future, cognitive behavioral therapies, for disorders like PTSD.

Here is a link to the related article in 12/9/09 Nature.

The authors tweaked the timing of extinction therapy so they could take advantage of the fragile reconsolidation period — a window of malleability that opens about three minutes after the memory is reactivated, but closes a few hours later.

Meanwhile, people who got the extinction training 6 hours — instead of 10 minutes — after the reminder, or who got no reminder at all, still showed a significant fear response the next day and the next year.

The Lancet, May 15 2010 editorializes:

Nicola Fear and colleagues examine the effect of deployments to Iraq and Afghanistan on the mental health of military personnel from 2003 to 2009. The study provides a follow-up to the group’s 2006 Lancet papers, which assessed the health of armed forces deployed in Iraq from 2003 to 2005. The investigators show that the most common mental health problems reported by personnel continue to be alcohol misuse and common mental health disorders, rather than probable post-traumatic stress disorder. And, overall, the prevalence of mental health disorders in the UK armed forces remains stable.

While there is not an epidemic of PTSD among regular service personnel, “hazardous drinking, both before and after deployment, continues to be a serious problem for regular service men and women.”

And “deployed reservists still have a higher prevalence of probable post-traumatic stress disorder than non-deployed reservists.”

Listen to the podcast.

The 2009 study was substantial: 17,000 surveys were sent out and the team received 9,990 responses. The study was funded by the Ministry of Defense, and the only restrictions that were placed on the team was to excluded Special Forces.

Reuters picked up the story:

Around 4 percent [of regulars] suffered PTSD, 20 percent had symptoms of common mental disorders which would not normally need medical attention, and 13 percent were misusing alcohol, it found.

The podcast says these %s were higher than those found in the normal population.

“We’re not seeing this tidal wave of mental health problems, as was predicted, and (our findings) definitely don’t reflect what’s being seen in the U.S,” Nicola Fear, who also worked on the study, told a London briefing.

Matthew Hotopf, also from King’s, said the differences between the U.S. and the UK were “quite striking” and may be due to the fact that U.S. troops often deploy for longer periods — up to 15 months, rather than the 6-month deployments usual for British forces.

Fear said the team found no increased prevalence of PTSD in soldiers who had been deployed more than once, but they did find a slight rise in rates of stress disorder as the time since troops’ return from deployment increased.

From 4% to 6% up to four years later.

Patrick Hennessey contributes this commentary in the Times, “What shall we do with the drunken soldier?”

So does the Army have a drink problem? On paper the statistics seem persuasive. But Audit is obviously a crude measure so I wasn’t surprised or concerned. After returning from any conflict life is pretty topsy-turvy; getting a bit more drunk a bit more often was part of that experience for myself and many of my colleagues. I imagine the findings would be very similar for students finishing a long sets of exams or anyone else returning from a prolonged period of stress and enforced abstemiousness.

Hennessey suggests various explanations for the “apparent” difference between mental health problems for US vs UK for returning service men and women:

the US military’s reliance on reservists (who tend to be more vulnerable because they lack the support of a regular unit); the longer tours undertaken by US formations (12 months, at times even 15 months, compared with usually six for most British units); and, perhaps, the greater exposure of US units to intense combat, particularly in Iraq between 2004 and 2007.

In The New York Times, October 21, Deborah Weiner reports a web-based program which “offers six half-hour lessons on managing post-deployment combat stress and symptoms of depression.”

A narrator guides users through the lessons, with each segment focused on a coping strategy, like scheduling activities and breaking down tasks into small steps. Participants answer questions, get homework and check in with peer counselors via instant messaging. Between sessions, they receive text messages, e-mails and phone calls encouraging them to complete assignments.

“Today’s service members often are more comfortable accessing resources online,” Col. Robert W. Saum of the Army, director of the Defense Center for Excellence for Psychological Health and Traumatic Brain Injury, wrote in an e-mail. “Web-based, peer-to-peer programs build on the time-honored buddy system that has existed within the military for decades.”

Suggests practical coping strategies:

• avoiding anxiety-producing situations
• increasing pleasurable activities

My therapist says this to me all the time: treat yourself to something fun, nice, pleasurable. A massage. Tennis. A walk in the forest. Playing cards with your friends.

Not everyone, however, is sold on online programs.

“The extent to which Web-based interaction is the same as, better, or worse than face-to-face interactions is the central question in our society now,” said Dr. Joseph Yount, clinical psychologist and coordinator of the P.T.S.D. Clinic at the Jesse Brown Veterans Administration Medical Center in Chicago. “Is Vets Prevail the way of the future, or do Web-based interactions lack something so meaningful that only happens when people are together?”

I posted on internet-delivered therapy in the UK which requires writing to communicate with the therapist. There were advantages: “writing requires pausing/reflection/editing” … there is “evidence that writing, as a therapy, helps recovery from trauma.”

Web-based therapy lowers barriers of entry: it is easy, cheap, private … outside the scrutiny of friends and family. Readers of my posts know that I am focused on making that first call for help as easy as possible, and internet delivered services seem to be part of the solution.

Also in Thursday’s Bernardsville News is an interview with ex-marine, Cpl. Justen Townsend.

Months spent in the theater of war have taken their toll and now Townsend, a Lebanon township resident who suffers from post traumatic stress disorder, is trying hard to adjust to the rhythm of everyday life.

Joined by Stefan Neustadter and Brenda Forte, both licensed clinical social workers, Townsend will speak about his condition and experiences during Mental Health Week. The program will begin at 1pm, Wednesday May 12th at the YMCA, 140 Mount Airy Road, Basking Ridge.

Please view the calendar to see the other events for the week. We’re going morning, noon, afternoon and evening.

“Nighttimes are the worst, when I just can’t sleep,” said Townsend. “I had trained myself so well to fight off that heavy feeling of tiredness in order to stay awake. I just got too good at it. That’s what you do when you’re the gunner in that turret….You just watch, listen and wait.”

The first, from the New York Times Magazine is an essay, Mind Over Meds, by a noted psychiatrist who was forced to rethink his approach to treatment, which has been heavily influenced by a growing trend in the psychiatric community that emphasizes drug therapy over psychotherapy/counseling. On Monday, May 10th, at 1:00 pm, Paul Rosenberg, MD, a psychiatrist affiliated with Morristown Memorial Hospital, will be speaking on “The Role of the Psychiatrist: How to Know When One is Needed”. It wil lbe interesting to hear his thoughts on this trend and to find out whether he, too, has felt pressure by managed care to shorten his visits with patients and to prescribe more anti-psychotic medication.

The second article Feeling Warehoused in Army’s Trauma Care Units: GIs Depict Life of Pills and Isolation, relates to the Mental Health Week presentation, “Time and Again: Reliving Trauma”, which will feature talks by Corporal Justen Townsend of the US Marines and Stefan Neustadter, MSW, LCSW, who has worked with military veterans for more than 30 years. Brenda Forte, LCSW, a specialist in the most current treatments for trauma, is also part of the presentation which is scheduled for Wednesday, May 12, at 1:00 pm. The article offers a disturbing portrait of the Warrior Transition Battalion in Colorado Springs, where, again, the emphasis appears to be on prescribing medication rather than providing needed support and counseling.

In the first article, Daniel Carlatt writes:

over the course of the decade following my residency, my way of thinking about patients had veered away from psychological curiosity. Instead, I had come to focus on symptoms, as if they were objective medical findings, much the way internists view blood-pressure readings or potassium levels. Psychiatry, for me and many of my colleagues, had become a process of corralling patients’ symptoms into labels and finding a drug to match.

Leon Eisenberg, an early pioneer in psychopharmacology at Harvard, once made the notable historical observation that “in the first half of the 20th century, American psychiatry was virtually ‘brainless.’ . . . In the second half of the 20th century, psychiatry became virtually ‘mindless.’ ”

Forces [other than modern Psychiatric training] are at work as well. Insurance companies typically encourage short medication visits by paying nearly as much for a 20-minute medication visit as for 50 minutes of therapy. And patients themselves vote with their feet by frequently choosing to see psychopharmacologists rather than therapists. Weekly therapy takes time and is arduous work. If a daily pill can cure depression and anxiety just as reliably, why not choose this option?

In studies by Helen Mayberg, a professor of psychiatric neurology at Emory University, depressed patients given cognitive behavior therapy showed decreased activity in the frontal lobe, the brain center that might be responsible for the overmagnification of life’s problems that leads to depression in some patients. And they showed increased brain activity in parts of the limbic system, a brain region associated with strong emotion. But Mayberg found that when patients were given medication, their brain activities changed in the opposite direction, stimulating the frontal lobe and damping down the limbic system. “Our imaging results suggest that you can correct the depression network along a variety of pathways,” she said.

On NPR’s Science Friday, December 11th, 2009, Ira Flatow interviews Elizabeth Phelps, Professor, Department of Psychology New York University. The podcast is short, only 12 minutes, and it is remarkably clear and informative.

To listen to the podcast, go to http://www.sciencefriday.com/program/archives/200912116, and clik the play button in the upper left hand corner under Listen.

Researchers report a non-invasive, drug-free technique to erase a bad memory in the human brain. Writing this week in the journal Nature, the researchers describe using a behavioral modification technique to remove a simple fear memory in people. The key appears to lie in when the technique is applied. Reactivating a memory, the team found, appears to open a “reconsolidation window,” a time-limited period during which the memory can be changed. We’ll talk with one of the team members about the finding, and how it may aid victims of trauma.

The current conventional talk-therapy for dealing with phobias and Post Traumatic Stress Disorder (PTSD) is called Systematic Desensitization therapy or Extinguishment. This is the old get back up on the horse that threw you therapy. Dr Phelps says that the problem with this therapy is that it creates two memories–the original fear memory and a new one that is safe–and when faced with the stimulus (you see the horse) the two memories compete with each other causing further anxiety and tilting your brain towards choosing the fear memory.

The current consensus of memory is that each time you recall a memory you change it slightly. There is a window of time, called consolidation, where the new, revised memory is processed–tagged, sorted, labeled stored in the right place in the brain. When you recall the fear memory, and then create a new version of that memory during that consolidation window, this research shows that you can replace the original fear memory, instead of creating an extra, competing version of it. (That consolidation window opened, in this study, 10 minutes after recalling the original fear memory.

We can imagine therapies (versus meds) that could be created to do this. This is an example we can understand of how drug-free, non-invasive therapy might work.

Phobias and PTSD involve fear and trauma memories.

At HOP’s (Healthy Outcome Partnership) upcoming Mental Health Week (May 10th – 15th), we will have two or three speakers on PTSD. Listening to this podcast is a nice introduction to potential PTSD therapies.

I highly encourage you to listen to this short podcast.