Friday, May 28, 2010

PTSD: The State of Treatment

This is the second part of a series on Post Traumatic Brain Syndrome.  Let me recap last week and expand on what we know about the neurobiological mechanisms (how the brain works) of PTSD, and then discuss treatment strategies.

When something stressful happens, the brain prepares the body for action.  The hypothalamus, pituitary gland, amygdala, locus ceruleus and opioid system all release hormones to speed up respiration, raise blood pressure, reduce sensitivity to pain, all useful conditions for the proverbial fight or flight.

Under normal stressors, as soon as these hormones are released, feedback systems go into operation.  The hypothalamus tells everybody else that their job is done and they can back off.

These hormones, especially cortisol, damage brain structures, notably the hippocampus, whose job is to regulate emotion and to perform the "that was then, this is now" function.  I named it that, and am very proud of it.  My own brain has almost no "that was then, this is now" function.  Pretty much zip.

The healthy brain has its own repair system, brain-derived neurotrophic factor (BDNF).  I know it's a mouthful, but it plays a big role in brain health.  So bear with me.  BDNF rebuilds the damaged brain cells in the hippocampus.  You see, the healthy brain is not a stable state.  It changes all the time to respond to new conditions.  Then it rebalances.  And all is well.

When a brain experiences repeated, constant and/or extreme stress, the feedback system can become overwhelmed and stop functioning.  The adrenal glands continue to release cortisol after the danger has passed, further damaging the hippocampus and also depleting endorphins (pain reducers).  BDNF has too much work to do, gets depleted and its source damaged.  Under these conditions the brain has difficulty recovering from the damage.  The depletion of BDNF, by the way, is now considered by many to be the issue in depression, replacing the simple "not enough serotonin" theory.

The gold standard treatment for PTSD is a combination of antidepressants, anti-anxiety medications, and Cognitive Behavioral Therapy (along with all the other self-care strategies, exercise, sleep, mindfulness, healthy diet, abstaining from street drugs and alcohol...)

Antidepressants are helpful because the neurobiological mechanisms of PTSD are pretty much the same as the neurobiological mechanisms of depression.  While the problem is not about the quantity of serotonin per se, increasing serotonin does seem to help the brain generate more BDNF.  BDNF then repairs the brain over time.  That is why, even though antidepressants quickly increase the serotonin on board, it still takes several weeks for the person to feel better.  BDNF needs time to do its job.  Scientists are now looking for more direct ways to increase BDNF, which may have fewer side effects than the medications that work indirectly to increase serotonin.  We can only hope.

Anti-anxiety medications are used to interrupt that stress cycle that is not righting itself on its own, to reduce the production of these hormones and prevent the damage they cause.

Cognitive Behavioral Therapy (CBT) is a general term for a variety of therapies that focus on thoughts and behaviors.  One version is called Rational Emotive Therapy.  Aaron Beck called his style Cognitive Therapy, operating on the theory that thoughts give rise to emotions, not the other way round.  Change the thought, the interpretation of facts, and you change the feeling.  In Cognitive Therapy, the therapist asks the client to examine the facts supporting the client's negative conclusion which led to the negative emotion.  If sufficient evidence does not support the conclusion (that the world is a dangerous place and everybody is out to get me, for example), then the thought can be corrected.  Over time, with practice and homework, the client learns to ask him/herself the therapist's questions, and eventually to eliminate the automatic negative thoughts (ANTs) that have created so many automatic negative feelings.

The underlying theory, that thought gives rise to emotion, seems to me, at the very least, misleading.  In the hierarchy of the brain, the amygdala (reptilian brain) is the first responder, the fastest to go into action.  The amygdala signals the hippocampus (mammalian brain), the source of emotion.  The frontal cortex (homo sapien brain), the origin of thought, is the last on the scene.  According to both the evolutionary and the physiological time line, emotion gives rise to thought.

Nevertheless, CBT works, because the brain can be trained to interrupt out of control anxiety reactions, sometimes so automatically that the mind doesn't realize it happened.  Last July, my Mother Amygdala, Have Mercy Upon Us post reported a study that compared the brains of women who had been depressed and recovered with those who had never been depressed.  When exposed to a stressor, fMRIs showed that the amygdalas of the formerly depressed women became activated.  For those who had never been depressed, their amygdalas were quiet.  Instead, the action was in the prefrontal cortex, the part of the brain that makes judgments.  Both groups reported the same thoughts and feelings, even though their brains were functioning differently

So the brain can learn to change its feelings with new thoughts, with one very important caveat -- the inappropriately active amygdala continues to do its damage, albeit less.  It can be brought under control once thought intervenes.  People who do CBT do relapse.  They spend more time between relapses than those who are treated with medication alone.  And that is a very good thing.  But they relapse.

On May 16, 2010 USA Today reported that the Army had 10,222 mental health hospitalizations last year, accounting for almost 19% of all Army hospitalizations.  Recently Defense Secretary Robert Gates said that "health care costs are eating the Defense Department alive."  In this environment, the exploration of potential treatments for PTSD has found a sense of urgency.

A variety of newer techniques are related to CBT.  The essential idea is that the brain has established a direct track from the traumatic memory to the disturbing emotion, but that another track can be laid with less emotion and less distress attached to it.

In Eye Movement Desensitization and Reprocessing therapy (EMDR), the therapist waves a finger in front of the client's following eyes, while the client recounts the traumatic event.  This is supposed to desensitize the memory.  The brain can process just so much at one time.  The waving finger distracts the client from the troubling emotions.  So a less emotion-laden memory of the traumatic event is recorded.  EMDR got a lot of press for a while.  Unfortunately, those who do research have not been able to replicate the anecdotal claims of relief.  Which is a shame, because if you could get relief by watching a moving finger, wouldn't you try it?  Similar techniques substitute tapping or counting for the finger.

The therapeutic value of Neuro-Linguistic Programming seems more obvious.  [The websites I found by googling NLP were nearly incomprehensible.  PTSD for Dummies does a better job to explain it -- my source for a number of these therapies, and very useful for a general audience view of the bigger picture.]  The sequence from triggers/to memories/to emotions is true of positive events, as well as traumatic ones.  For example, the smell of suntan lotion (trigger) makes me think of summer (memory) and feel calm (emotion.)  NLP  turns this phenomenon to the good, training your mind to go some place other than the trauma place when confronted by triggers.

Here is an example, the NLP method called "anchoring."  I have a set of intrusive memories of a particular person and place, triggered by very common experiences, not PTSD level traumas, but hurtful anyway.  So I have decided to experiment with anchoring.  It occurred to me today that when I was with this person in this place, I was almost always wearing red shoes.  (I have this thing about red shoes, and many, many pleasant associations with red shoes, from my earliest memories.)  So today whenever these hurtful memories intrude, I am focusing on my red shoes, whichever pair that comes immediately to mind.  We'll see how it goes.  So far so good.

These techniques (the nay-sayers might call them gimmicks) are multiplying.  De-sensitization, distraction from emotion, and substitution of a different... well, a different something are common themes, making them offspring or cousins of Cognitive Behavioral Therapy.  Some may have value for some people, though they are not standing up to research.

And then there is good old-fashioned psychotherapy, talking it out, exploring your "issues" and relationships.  Let's not count it out just because it's so hard to come up with a research protocol to test it.  It hasn't been shown to be as effective as CBT, but works well when combined with it.

Maybe the value is not in any of these techniques so much as in the relationship with the therapist doing it.  Ah, the dread "placebo effect," healing that your own body accomplishes because you believe in the healer.  The placebo effect provides 75% of the therapeutic value of antidepressants.  So why quibble about it in non-pharmacological treatments?  The point is, if what works is in the relationship, then get into a therapeutic relationship, already! -- Of whatever stripe makes sense to you.

Last, but not least (at least in practice) are street drugs and alcohol.  These have been tested over and over through the centuries by self-medicating sufferers.  They don't work.  There is no placebo effect.  They just do not work.

Next week: Prevention.

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