SEIZING AN ALTERNATIVE Toward an Ecological Civilization June 4-7, 2015 Section IX: Reimagining and Reinventing Bodily-Spiritual Health Dimensions of Post Traumatic Stress Disorder
(Western Perspective)
Bob Ireland, MD, DMin, MA, BS Dimensions of PTSD
• Biological Memory Enhancement and Fear Conditioning: A Model of PTSD
Specific environmental features (conditioned stimuli) may be linked to a traumatic event (unconditioned stimuli) such that re-exposure to a similar environment produces a recurrence of the symptoms of anxiety & fear.
Dennis Charney, Psychobiological Mechanisms of Resilience and Vulnerability: Implications for Successful Adaptation to Extreme Stress, Am J Psychiatry 161:2, Feb 2004 Memory Modulation is Adaptive • Mammals can store memories with higher strength according to the importance of the experience
Roger Pitman, Biol Psychiatry, 1989; 26:221-223 Memory Modulation is Adaptive
Neuro-modulators enhance memory consolidation & reinforce extinction-resistant conditioned responses
Roger Pitman, Biol Psychiatry, 1989; 26:221-223 Failure to consolidate memories may decrease intensity of conditioned responses
Roger Pitman, Biol Psychiatry, 1989; 26:221-223 In response to stress & panic, Locus Coeruleus neurons release the neurotransmitter, norepinephrine (NE) to several parts of the brain. (quick response)
In addition, the adrenal glands slowly release NE into the bloodstream (sustained response)
Roger Pitman, Biol Psychiatry, 1989; 26:221-223 and David Nutt, J Clin Psych 2000;61(supl 5)24-29 Norepinephrine from the locus coeruleus activates the amygdalae (rapid effect)
as does Norepinephrine from adrenal medullae (sustained effect)
Roger Pitman, Biol Psychiatry, 1989; 26:221-223 and David Nutt, J Clin Psych 2000;61(supl 5)24-29 Catacholamines (as NE) stimulate peripheral afferent vagal beta- receptors
(80% of vagus nerve fibers are “Northbound”)
Roger Pitman, Biol Psychiatry, 1989; 26:221-223 and David Nutt, J Clin Psych 2000;61(supl 5)24-29
Vagal afferents innervate the Nucleus Tractus Solitarius (NTS)
Roger Pitman, Biol Psychiatry, 1989; 26:221-223 and David Nutt, J Clin Psych 2000;61(supl 5)24-29 NE
NTS NE Vagus
NTS fibers also innervate Amygdala via NE
From www at: http://www.driesen.com/Copy_of_limbicsystempic.jpg on 13 Aug 05 Detecting and Encoding Memories
David Nutt, J Clin Psych 2000;61(supl 5)24-29 Memory: Excitatory > Inhibitory Flow
In most neurons, there is a balance between excitatory (glutamate) and inhibitory (GABA) transmission
When excitatory transmission occurs, Ca enters the neuron triggering phosphorylation of protein kinases leading to long-term synaptic changes which induce memory and sensitization
David Nutt, J Clin Psych 2000;61(supl 5)24-29 Examples of Enhanced Memories • Encounters with snakes • Witnessing trauma • Assaults • MVA
Examples of Enhanced Memories
Encountering bodies Motor Vehicle Accidents Early Childhood Sexual/Physical Abuse Lasting Changes in Stress Response
ACTH Cortisol Heart Rate
Christine Heim, JAMA, Aug 2, 2000, Vol 284, No 5 Influence of life stress on depression: moderation by a polymorphism in 5-HTT gene
Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H, McClay J, Mill J, Martin J, Braithwaite A, Poulton R. Medical Research Council Social, Genetic, and Developmental Psychiatry Research Centre, Institute of Psychiatry, King's College London, PO80 De Crespigny Park, London, SE5 8AF, UK. Science. 2003 Jul 18;301(5631):386-9
ABSTRACT In a prospective-longitudinal study of a representative birth cohort, we tested why stressful experiences lead to depression in some people but not in others. A functional polymorphism in the promoter region of the serotonin transporter (5-HT T) gene was found to moderate the influence of stressful life events on depression. Individuals with one or two copies of the short allele of the 5-HT T promoter polymorphism exhibited more depressive symptoms, diagnosable depression, and suicidality in relation to stressful life events than individuals homozygous for the long allele.
This epidemiological study thus provides evidence of a gene-by-environment interaction, in which an individual's response to environmental insults is moderated by his or her genetic makeup.
Dimensions of PTSD
• Diagnostic Criteria
Diagnostic and Statistical Manual of Mental Disorders 5th Edition, American Psychiatric Association, 2013 DSM-5 Criteria for PTSD DSM-5 Criteria for PTSD DSM-5 Criteria for PTSD DSM-5 Criteria for PTSD
DSM-5 Criteria for PTSD Problems w/DSM-5 Criteria
• DSM-5 PTSD definition no longer requires people to feel “traumatized” at first exposure
• Patients who report a severe trauma may receive this diagnosis whether or not symptoms are actually related to the event
• It is unclear regarding the extent to which PTSD is a reaction to trauma, as opposed to uncovering of a temperamental vulnerability to stress…. It is well established that most people exposed to trauma, even severe trauma, never develop PTSD, and those who do usually have past symptomatology.
The Intelligent Clinician’s Guide to DSM-5, Joel Paris Oxford University Press, 2013, pp. 125-128. PTSD Review Psychological Constructs
PTSD and Spiritual Injury PTSD Spiritual Dimensions
http://www.ptsd.va.gov/professional/provider-type/community/fs-spirituality.asp Primary Prevention of PTSD • Eliminate all injurious activities • Eliminate the practice of organized, armed
conflict Jonathan Shay, MD, PhD Primary Prevention of PTSD
• Eliminate/reduce domestic violence • Earthquake/storm-”proof” all buildings • Enhance safety of all mass transit • Take all violent criminals off streets • Et cetera Secondary Prevention of PTSD --After the Disaster-- Possible Protection From PTSD
• Loss of consciousness (e.g. coma) • Those “knocked out” by the trauma may be protected from PTSD, especially if they recover in an area where trauma is not witnessed • Memories not encoded
David Nutt, J Clin Psych 2000;61(supl 5)24-29 Possible Protection From PTSD • After spine trauma who is more likely to develop PTSD? A paraplegic or quadriplegic? Possible Protection From PTSD
• PTSD researchers have noted those intoxicated during an MVA seldom develop PTSD • Catecholamine toxicity may not occur
Roger Pitman et al, ISTSS Annual Meeting, Nov 2000, San Antonio, TX Possible Protection From PTSD
• Alcohol has 2 protective actions – Potentiates GABA receptors (inhibition) – Blocks glutamate (excitatory) NMDA receptor • Traditional “choice” of combat troops and aviators post combat trauma
David Nutt, J Clin Psych 2000;61(supl 5)24-29 Secondary Prevention of PTSD
• NO acute intervention proven to reduce PTSD – CISD potentially harmful – Non-arousing “psychological 1st aid”? • Potential usefulness of drugs – Beta-blockers w/in 4 hrs post trauma – Prazosin to reduce nightmares – D-Cycloserine (improves ability to learn safety) • Tertiary prevention only
Roger Pitman, Stress Hormones and the Amygdala in PTSD: Possible Implications for Secondary Prevention, Plenary Session of International Society for Traumatic Stress Studies, San Antonio, TX 19 Nov 2000 What about Tertiary Prevention of PTSD?
David Nutt, J Clin Psych 2000;61(supl 5)24-29 Acute Interventions: “P.I.E.S.”
• Proximal – Near forward operating area—stay in theater • Immediate – Before disintegration when functional decline • Expectant – Planned return to unit in 1 to 3 days – Non-patient status – Non-pathologizing • Simple – No uncovering techniques – “3 hots & a cot” Dr. Zahava Solomon Tel Aviv • 20 years later, PTSD trended directly related to # of “PIES” principles applied • Number of PIES Applied: PTSD rate – 0 48% – 1 38% – 2 33% – 3 25%
Frontline Treatment of Combat Stress Reaction: A 20-Year Longitudinal Evaluation Study Zahava Solomon, Ph.D., Rami Shklar, Ph.D., and Mario Mikulincer, Ph.D. Am J Psychiatry, Dec 2005 Institute of Medicine Evidence for PTSD Efficacy is Inadequate for:
• Alpha blocker • EMDR* • Anticonvulsants • 2nd g. antipsychotics • Cognitive Restructuring • Benzodiazepines • Coping Skills Training • MAOIs – Phenelzine • Therapy in group formats – Brofaramine • SSRIs* • Other Antidepressants • Other drugs *Recommended by VA/DoD PTSD CPG – Naltrexone – Cycloserine – Inositol
Treatment of PTSD: An Assessment of the Evidence, IOM Oct 2007 Pre-publication Copy: Uncorrected Proofs Evidence is Sufficient to Determine Efficacy in the Treatment of PTSD for Only ONE Modality
Exposure Therapies
Treatment of PTSD: An Assessment of the Evidence Institute of Medicine, October 2007, S-6 PTSD as a Learning Disability
Failure to Learn Safety in the face of one’s trauma cues Exposure Therapy in safe environment iPhone app for 1st Responders Psychological 1st Aid (PFA)
• “PFA Mobile” (free) – https://itunes.apple.com/us/app/pfa- mobile/id551079424?mt=8 • Other online Psychological 1st aid resources: (free) – 6 hour interactive course at: • http://learn.nctsn.org/course/index.php?categor yid=11 PFA Key Actions: Promote Safety Calm & Comfort Connectedness Self-Empowerment
http://www.ptsd.va.gov/professional/manuals/manual-pdf/pfa/PFA_2ndEditionwithappendices.pdf Psychological Resiliency The Bio-Resiliency Guru Charney, Psychobiological Mechanisms of Resilience and Vulnerability: Implications for Successful Adaptation to Extreme Stress, Am J Psychiatry 161:2, Feb 2004 Outlines Neural Mechanisms related to Resilience and Vulnerability to Extreme Stress and Proposes a Research Agenda to Analyze the Integration of Mechanisms
Dennis Charney, Psychobiological Mechanisms of Resilience and Vulnerability: Implications for Successful Adaptation to Extreme Stress, Am J Psychiatry 161:2, Feb 2004 “Brain as an organ devoted to taking effective action”
“Arousal Modulation and Control of the ANS” via Ventral Vagal Complex George Bonanno, Loss, Trauma and Human Resilience: Have We Underestimated the Human Capacity to Thrive after Extremely Aversive Events? American Psychologist, Jan 04 Traits Facilitating Resilience
• Optimism • Active coping style in • High Intellectual Fnx response to stress • Effective self-regulation • Ability to convert of emotions traumatic helplessness • Effective self-regulation into learned helpfulness of attachment behaviors • Social support • Positive self concept • Ability to disclose • Altruism emotions
Richardson GE, (2002), J Clin Psychiatry, 56. Masten & Coatsworth, (1998), Am.Psych, 53. Bell CC, (2001) J Adol Health, 29. All cited by Dennis S. Charney, MD, at NEI Congress 2005, 20 Feb 05.
Ideally, we should maintain Multiple Levels of Well Being*
• Physical Well Being • Well Being at Play • Psychological Well • Well Being in Our World Being • Self-Transcendent Well • Well Being at Work Being (“Spirituality”) • Relationship Well Being
If we suffer loss in one domain, we may continue to have satisfying experiences in others
*Well Being, 1992, Howard Clinebell “Pathways to Resilience”
• “Hardiness” • “Repressive Coping” • “Positive Emotion and Laughter” • “Self-Enhancement”
George Bonanno, Loss, Trauma and Human Resilience: Have We Underestimated the Human Capacity to Thrive after Extremely Aversive Events? American Psychologist, Jan 04 “Hardiness” • Sense of being in charge of one’s fate – CONTROL (Self-directedness) • Engaged in meaningful goals & activities – COMMITMENT • Rather than view stress as a threat, view as a – CHALLENGE
Waysman M, Schwarzwald J, Solomon Z. Hardiness: an examination of its relationship with positive and negative long term changes following trauma, Journal of Traumatic Stress, July 2001,Vol 14, No 3, p 545. Repressive Coping Style: An Advantage? • Israeli study demonstrated less PTSD in MI victims w/ a repressive coping style • In response to threat, “repressors” have low anxiety (but anxious per biofeedback) and high defensiveness • Repressive style was not associated with gender, education, previous trauma, nor severity of MI
Repressive Coping style, Acute Stress Disorder, and PTSD after Myocardial Infarction. Ginzburg K et al. Psychosomatic Medicine (Sep-Oct 2002) 64:748- 757. Repressive Coping Style: An Advantage? • Re: Acute Stress Disorder (ASD) – Repressors reported lower levels of dissociation, avoidance, and hyper-arousal than non-repressors • PTSD Rates at 7 months: – Repressors = 3.6% – Non-Repressors = 17-20% • Repressor style was more predictive of PTSD than severity of Acute Stress Disorder
Coping style, ASD, and PTSD after MI. Ginzburg K et al. Psychosomatic Medicine (Sep-Oct 2002) 64:748-757. http://www.researchgate.net/profile/Karni_Ginzburg/publication/11139720_Repressive_coping _style_acute_stress_disorder_and_posttraumatic_stress_disorder_after_myocardial_infarction/li nks/0deec53aa60b922d9f000000.pdf
Active Resiliency Training
• Resilience self-assessments • Resilience skills building • Higher education (positive psychology) • Mass media – Internet training – Newspapers (e.g. USA Today) – Television (Dr. Jon Kabat-Zinn/Mindfulness) “Positive Emotion & Laughter”
can help reduce levels of distress following aversive events both by quieting or undoing negative emotion and by increasing continued contact with and support from important people in the…person’s social environment George Bonanno
George Bonanno, Loss, Trauma and Human Resilience: Have We Underestimated the Human Capacity to Thrive after Extremely Aversive Events? American Psychologist, Jan 04 “Self-Enhancement”
George Bonanno, Loss, Trauma and Human Resilience: Have We Underestimated the Human Capacity to Thrive after Extremely Aversive Events? American Psychologist, Jan 04
• “It is true that science can teach us how to avoid certain dangers and that there are some sufferings which it can successfully combat; it would be most unjust to deny that it is a powerful helper to men;
but there are many situations in which it must leave a man to his suffering and can only advise him to submit to it…” Sigmund Freud, A Weltanschauung? Come, my friends, 'T is not too late to seek a newer world. Push off, and sitting well in order smite The sounding furrows; for my purpose holds To sail beyond the sunset, and the baths Of all the western stars, until I die. It may be that the gulfs will wash us down: It may be we shall touch the Happy Isles, And see the great Achilles, whom we knew.
Tho' much is taken, much abides; and tho' We are not now that strength which in old days Moved earth and heaven, that which we are, we are; One equal temper of heroic hearts, Made weak by time and fate, but strong in will To strive, to seek, to find, and not to yield. Alfred Lord Tennyson Ulysses Discussion