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Post Traumatic Stress Disorder 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
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