PTSD: Current Status, Key Challenges and Promising Treatments

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Yuval NeriaPost-traumatic Stress Disorder (PTSD) frequently occurs after the experience of traumatic events such as wars, disasters, acute medical events, and domestic violence. It is known as the signature disorder of combat and disaster.  Lifetime prevalence PTSD is substantial, estimated as approximately 8% in the United States, with a prevalence of about 4% in any given year  Among U.S. military personnel, frequently exposed to traumatic events, PTSD rates are even higher ranging from 19% to 22%. Military personnel are at higher risk for experiencing traumatic events, including exposure to combat, injury, loss, captivity, and sexual abuse. Consequently, PTSD is a common syndrome among veterans, and is frequently associated with functional impairment. Veterans with PTSD often suffer from a wide range of additional psychiatric symptoms including depression and substance and alcohol abuse.

PTSD symptoms are often persistent and disabling unless there is a timely targeted intervention. Symptoms of PTSD are wide-ranging and can affect trauma-exposed people in a number of debilitating ways. They include re-experiencing of the traumatic event (including intrusive thoughts, nightmares and flashbacks), avoidance of thoughts of the traumatic event and people, places, or other stimuli that evokes the trauma, changes in cognitions such regarding the world and yourself, hypervigilance, hyperarousal (including irritability, concentration difficulties, and disrupted sleep), and increases in troubling thoughts and negative feelings. PTSD is commonly associated with functional impairment, substance abuse, suicidal ideation, and increased utilization of medical care.

While a number of psychotherapies and pharmacotherapies for PTSD have been developed, research has consistently shown that more than one-third of PTSD patients never fully remit, even if treated. Meta-analysis of psychotherapy for PTSD has found short-term improvements compared to baseline only in about 50% to 60% of patients, with the majority continuing to have substantial residual symptoms. The efficacy of medication in PTSD is also unclear, with a critical lack of advancement in the psychopharmacologic treatment of the disorder. Only 20–30% of PTSD patients experience a complete remission following pharmacotherapy. Importantly, research has shown that among military personnel with PTSD, treatment reach is low to moderate, with a high percentage of service members not accessing care or not receiving adequate treatment.

Researchers in the field have raised a call to action to validate novel interventions that will improve treatment engagement and retention among veterans and family members. Here I would like to highlight three promising treatments that may address some of the above problems.

Attention-Bias Modification Treatment for PTSD:  Emerging research has demonstrated a relationship between biased attention to threat and PTSD.  Attention-bias relates to how people focus their attention; research shows that people with high levels of anxiety tend to focus on negative information in their environment. This knowledge has motivated the development of a novel therapy, attention-bias modification treatment (ABMT), currently provided at Columbia Psychiatry thanks to the generous support of SFTT. ABMT is designed to modify patients’ threat bias, i.e., change their attentional habits, with the use of a computer program. Participants with PTSD and attention bias towards or away from threat (documented by the dot probe task) undergo a 4-week (8-sessions) course of ABMT or an inactive Attention Control Program. Findings from this study are about to be published in the near future.

Interpersonal Psychotherapy for PTSD: Interpersonal Psychotherapy (IPT) is a time-limited, evidence-based treatment, has previously shown efficacy in treating major depressive disorder and other psychiatric conditions. Rather than focusing on the trauma, as in exposure based treatments, IPT focuses on the patient’s current life events and social and interpersonal functioning for understanding and treating symptoms. This treatment currently provided at Columbia Veterans Center, is a novel use of IPT as treatment for PTSD. Evidence from studies conducted at Columbia Psychiatry suggests IPT may relieve PTSD symptoms without focusing on exposure to trauma reminders. Hence, IPT offers an alternative for patients who avoid or do not respond to exposure-based approaches. Interpersonal Psychotherapy focuses on two problem areas that specifically affect patients with PTSD: interpersonal difficulties and affect dysregulation. The treatment help the patient identify and address problematic affects and interpersonal functioning, and to monitor treatment response.

Equine Assisted Treatment for PTSD. Equine-Assisted Therapy for PTSD (EAT-TSD) is a unique, group treatment that might reduce symptoms of PTSD, particularly individuals who encounter difficulty in more traditional treatments. In EAT-PTSD, a mental health professional and an equine specialist work together to guide participants with PTSD through a series of structured activities with a horse. Presently this treatment is studied at Columbia Psychiatry as part of the Man O War Project . It is an eight-week study aimed to examine how well EAT-PTSD works for veterans with PTSD. Treatment groups consist of 4-6 veterans at a time. 90-minute EAT sessions take place at the Bergen Equestrian Center in Leonia, New Jersey. Columbia Psychiatry provides transportation to treatment sessions. Treatment does not include riding horses. Through various interactive exercises with the horses, the veterans learn how their actions, intentions, expectations, and tone have an impact on their relationship with the horses (and ultimately with the people in their lives). Over the course of treatment, the equine specialist and the mental health professional assist veterans in drawing connections between what the horses may be doing, thinking, or feeling, and their own PTSD symptoms, increasing emotional awareness and ability to regulate emotions and behaviors, and learning to more effectively interact with the horses, and by extension other people as well.

Contributed by Dr. Yuval Neria
Stand For The Troops Special Medical Advisor
Professor of Medical Psychology, Departments of Psychiatry and Epidemiology
Research Scientist, The New York State Psychiatric Institute
Director of Trauma and PTSD Program, The New York State Psychiatric Institute
Director of Columbia-NYP Military Family Wellness Center
College of Physicians and Surgeons
Columbia University Medical Center

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The Unknown Soldier

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Released in 1968 by the Doors, the Unknown Soldier was considered an antiwar song and banned on many radio stations. The song, however was more of dig at the American media and the way that the Vietnam conflict was televised into our homes and became a part of our daily lives. The lyrics “Breakfast where the news is read/ Television children fed/ Unborn living, living dead/ Bullets strike the helmet’s head” portrays how the news of the Vietnam War was being presented to ordinary people.

Jim Morrison sings about how in the late 60’s American families stared at violent television images, watching a world far away where the unknown soldier is shot, yet life at home went on as usual.  The entire scenario seems to normalize the war. People were numb and continued to live their normal lives while their soldiers were dying. The fact that the soldier has no identity is also a strong message to the ignorance and lack of emotion that people had towards the men who were fighting ‘for them.’ And as we all know, the soldier who had no name came home to an unwelcoming party.

Today, military conflicts continue to play out daily on our televisions, our cell phone news feed and throughout social media.  This time those who are called to duty are welcomed home but soon forgotten by an overwhelmed VA and by the very people they serve. Today our veterans are faced with homelessness, mental health issueseducational hurdles, long waits and scandalous policies at the VA, and a military suicide rate of 22 a day.

It’s true that today’s veterans have never been more respected, unlike those who returned from Vietnam. But unlike Vietnam veterans many Americans have no personal connection to anyone who has served or is serving in the Armed Forces.  Many organizations have hit the media and social outlets to drum up support for Veterans in need but again, America’s eyes have glazed over to the  issues faced by our Veterans.  Even when it was discovered that a nonprofit claiming to help veterans at risk was misappropriating funds, there was little or no public reaction. And so, it seems the numbness prevails.

Forty years later the unknown soldier is the one struggling with PTSD. The unknown soldier is the one whose life was a daily pill that is now an addiction.  The unknown soldier is homeless. The unknown soldier is the one who suffers in silence. The unknown soldier is one of 22 each day that takes his own life.

Perhaps it’s time the unknown soldier had a name and America a plan to support those who served.

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Drs. Paul Harch and David Cifu Spar over Hyperbaric Oxygen Therapy

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Well over a year ago, Dr. Paul Harch, one of the leading experts in Hyperbaric Oxygen Therapy (“HBOT”) published an authoritative report entitled “Hyperbaric oxygen in chronic traumatic brain injury:  oxygen, pressure and gene therapy” for the U.S. National Library of Medicine (Medical Gas Research).

In this report (a lengthy extract is printed below), Dr. Harch argues persuasively over the many benefits of using HBOT in treating brain injury:

Hyperbaric oxygen therapy is a treatment for wounds in any location and of any duration that has been misunderstood for 353 years. Since 2008 it has been applied to the persistent post-concussion syndrome of mild traumatic brain injury by civilian and later military researchers with apparent conflicting results. The civilian studies are positive and the military-funded studies are a mixture of misinterpreted positive data, indeterminate data, and negative data. This has confused the medical, academic, and lay communities. The source of the confusion is a fundamental misunderstanding of the definition, principles, and mechanisms of action of hyperbaric oxygen therapy. This article argues that the traditional definition of hyperbaric oxygen therapy is arbitrary. The article establishes a scientific definition of hyperbaric oxygen therapy as a wound-healing therapy of combined increased atmospheric pressure and pressure of oxygen over ambient atmospheric pressure and pressure of oxygen whose main mechanisms of action are gene-mediated. Hyperbaric oxygen therapy exerts its wound-healing effects by expression and suppression of thousands of genes. The dominant gene actions are upregulation of trophic and anti-inflammatory genes and down-regulation of pro-inflammatory and apoptotic genes. The combination of genes affected depends on the different combinations of total pressure and pressure of oxygen. Understanding that hyperbaric oxygen therapy is a pressure and oxygen dose-dependent gene therapy allows for reconciliation of the conflicting TBI study results as outcomes of different doses of pressure and oxygen.

Not surprisingly, Dr. David Cifu, Senior TBI Specialist in the Department of Veterans Affairs’ Veterans Health Administration, gave the standard stock answer from the spin doctors at the VA that:

There is no reason to believe that an intervention like HBOT that purports to decrease inflammation would have any meaningful effect on the persistence of symptoms after concussion. Three well-controlled, independent studies (funded by the Department of Defense and published in a range of peer reviewed journals) involving more than 200 active duty servicemen subjects have demonstrated no durable or clinically meaningful effects of HBOT on the persistent (>3 months) symptoms of individuals who have sustained one or more concussions. Despite these scientifically rigorous studies, the clinicians and lobbyists who make their livings using HBOT for a wide range of neurologic disorders (without scientific support) have continued to advocate the use of HBOT for concussion.

To Dr. David Cifu’s stock VA response, Dr. Harch responded as follows:

The charge is inconsistent with nearly three decades of basic science and clinical research and more consistent with the conflict of interest of VA researchers.  A final point: in no publication has the claim regarding effectiveness of HBOT in mTBI PPCS been predicated on an exclusive or even dominant anti-inflammatory effect of HBOT. Rather, the argument is based on the known micro-wounding of brain white matter in mTBI, and the known gene-modulatory, trophic wound-healing effects of HBOT in chronic wounding.  The preponderance of literature in HBOT-treated chronic wound conditions, is contrary to Dr. Cifu’s statement of HBOT as a “useless technology.”

As a layman, Dr. Harch’s detailed rebuttal (see FULL RESPONSE HERE) completely destroys Dr. Cifu’s “non-responsive” comment to the scientific points raised in Dr. Harch’s report.  In my view, it goes beyond the traditional “professional respect” shown by peers:  Dr. Harch was pissed off and, in my opinion, had every right to be.

Not surprisingly, Dr. Cifu has not responded to the irrefutable arguments presented by Dr. Harch.

The discussion of HBOT is not a subject of mild academic interest.  Specifically,  Veterans are being deprived of hyperbaric oxygen therapy because Dr. David Cifu and his cronies at the VA are misrepresenting the overwhelming evidence that suggests that HBOT restores brain function.

Why?  Indeed, that is the $64 question.

It is difficult to forecast how this academic drama will play out.  Nevertheless, I suspect that David Ciful will eventually be viewed by Veterans as performing a similar role within the VA as Alvin Young, aka “Dr. Orange.”

I hope and pray this is not the case.  On behalf of tens of thousands of Veterans who are denied HBOT treatment for PTSD and TBI by the clumsy and sloppy claims of Dr. Cifu and others within the VA, please “do the right thing” and lend your support to HBOT as a recommended VA therapy for treating brain injury.

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