Healing Combat Trauma

Mind Body Medicine: Healing the Wounds of War

When I started this blog over two years ago now, I was hoping that somehow James S. Gordon, M.D., and the Center for Mind-Body Medicine which he founded in Washington, DC, would somehow get involved in the prospect of bringing mind-body medicine to the troops.  Gordon is a Harvard-trained psychiatrist, with impeccable credentials, who has a lifetime interest in expanding patient care into new areas, particularly Complementary and Alternative Medicine (CAM), and mind-body medicine in particular.  (Mind-body medicine is a shorthand way of re-combining the two "halves" of medicine perhaps unjustly sundered in an arbitrary Cartesian mind-body split.  Much of Eastern thought, rather than Western, never saw them divided at all.)  In a previous lifetime, where I interviewed luminaries in the natural medicine field, Gordon was a favorite interviewee - smart, genial and with a very forward-thinking grasp of what mind-body medicine could accomplish.  Gordon, who was featured in the Bill Moyers series on PBS, Healing and the Mind, was a frequent lecturer at the Smithsonian Institution in Washington, DC, and for years had served as the head of the White House Commission on Complementary and Alternative Medicine.  He is also a Clinical Professor in the Departments of Psychiatry and Family Medicine at Georgetown University Medical School.

But more to our purposes, when war broke out in Kosovo, he and the Center for Mind-Body Medicine (CMBM) took their methods into the region, creating a program called "Healing the Wounds of War," to help war-torn schoolchildren and their caregivers manage the trauma they had undergone, through a sustained, devastating conflict.  What I was hoping -- and I kept checking the CMBM website periodically to find out -- was that they would leapfrog off their successes with PTSD in Bosnia and Kosovo, and Israel and the Middle East, and develop something geared to PTSD in servicemembers, and the conflicts in Afghanistan and Iraq.  For years, nothing was obvious (yet), but here's some of their success with children in Kosovo.  Notice what symptoms the program helped with, how impressive the statistics are, and make the conceptual leap to how this might help with combat veterans and/or their families:

The clinical efficacy of the CMBM program with traumatized children has been repeatedly demonstrated. In a pilot study in which high school teachers in the Suhareka region of Kosovo used the CMBM model, levels of posttraumatic stress disorder in high school students were reduced from an average of 88% to 38% in only six weeks (read the research, published in Journal of Traumatic Stress, April 2004, linked here). Participants have also reported the following documented effects of CMBM trainings, including: the alleviation of their own stress and trauma; decreases in anxiety and depression; increased optimism; decreased anger; and increased capacity to help others.

You can read more about the program's specific successes, here.  Or, you can read a general overview of the program and what's involved, here.  You can also read Dr. Gordon's bio, here.

The Dose-Response Relationship with PTSD: More Combat = More PTSD, Earlier Study Shows

"If you aim for simplicity, you must first master complexity" -- said the 17th century Chinese painter, Wang Kai. Almost 400 posts in on this blog, I still enjoy the moments when something profoundly complex like combat trauma is nevertheless reduced to something quite simple to understand.  Here's one such observation: the more combat one is exposed to, the greater the chances of experiencing PTSD.  Makes sense, doesn't it?  Although we've talked about that concept recently on this blog -- with a great graphic that shows the linear relationship quite profoundly, that entry linked here -- here's another, earlier study that says the same thing, in an article linked here.

Researchers who went back and analyzed two conflicting, large-scale studies of PTSD -- one done by the Centers for Disease Control (CDC), the other the National Vietnam Veterans' Readjustment Study -- found, among other things, that although "most veterans who experienced very highly traumatic events did not develop PTSD," still, the more war trauma a veteran experienced, the higher a veteran's odds of developing PTSD.  Researchers called this the "dose-response relationship," and said their work, going back over the two major studies and attempting to reconcile their findings, found that it was "even stronger than previously reported."

SOURCES: Dohrenwend, B.P. Science, Aug. 18, 2006; Vol. 313: pp. 979-982. McNally, R.J. Science, Aug. 18, 2006; Vol. 313: pp. 923-924.

Army Broadens View of Possible PTSD Therapies, Includes Complementary and Alternative Medicine

A Military.com article published on May 29th reports on the U.S. Army's increasing openness to non-traditional therapies to treat PTSD.  The article by Bryant Jordan is called, "East Meets West in Army Mental Therapy," and it quotes Col. Elspeth Ritchie on the Army's increasing openness to options beyond traditional counseling and medication, to include items like yoga, acupuncture, meditation, and of course, virtual reality. The headline is positive, but in truth, the Army may be taking only baby steps towards including nontraditional therapies, often known as Complementary and Alternative Medicine (CAM).

(Some "definition of terms" is in order.  "Alternative medicine" means treatment choices other than conventional medicine, to be used instead of conventional medicine; "complementary medicine" means treatment choices to be used in addition to conventional medicine -- so the term "CAM," or "Complementary AND Alternative Medicine" is meant to be inclusive of both approaches.  This ends up being an important distinction, because responsible M.D.s are often more in favor of patients adding complementary therapies in to their treatment protocol, rather than replacing a conventional treatment protocol with fully alternative therapies. "Complementary" is misspelled in the Military.com article as "complimentary," which further confuses the terminology.) 

The article states that "Therapies that are "kind of tried and true" remain at the forefront of treating Soldiers with behavioral problems, [Col.] Ritchie said. These include behavioral therapy and exposure therapy -- where patients are "exposed" by degrees to scenarios that may be at the core of the problem -- and medication."  And it further quotes Col. Ritchie as saying that although CAM therapies "are interesting, we don't have the hard data to show which therapies are useful for what population. So we're really in the research phase of this for yoga, acupuncture and some other therapies."

The Military.com article is linked here.  A previous article by Noah Shactman in Wired magazine on March 25 discussed similar material, and mentions a Department of Defense grant opportunity with a closing date of May 15, providing $4 million in funds to study therapies with possible benefits for PTSD and/or TBI, including but not limited to "music, animal-facilitated therapy, art, dance/movement, massage therapy, EMDR program evaluation, virtual reality, acupuncture, spiritual ministry, transcendental meditation, yoga and other novel approaches."  (The grant opportunity announcement is linked here.)  According to the Wired article, reading from the grant application, the Army is willing to contemplate as well the potential effectiveness of "biologically-based treatments, botanicals, and nutritional supplements for enhancing cognitive function and mood in patients with trauma spectrum disorders, including TBI and/or PTSD, depression, anxiety, and/or substance dependence/abuse," and adds, "Even proposals for wild-sounding "therapies using bioenergies such as Qi gong, Reiki, distant healing and acupuncture" would be accepted."  The Wired article is linked here.

I'm unclear whether the Army is leading the way of all the military branches in considering the potential of CAM for PTSD; but whether it is or isn't, kudos to it for being reasonably open-minded.  One of the problems that seems to keep coming up with PTSD is that no one obvious choice comes up in treating it, that works every time.  There are a variety of pharmaceutical drugs that are prescribed, but no one remedy in particular appears to be the wonder drug, or cure-all.  (You hear the frustration about this when you listen to the stories of combat veterans who are taking a handful of pills to combat PTSD, sometimes as many as 20 or 30 separate medications - a scary cocktail, indeed.)  Other approaches for PTSD, such as talk therapy, cognitive therapy, EMDR, etc., all have their place in the pantheon of treatments, and each has their adherents/proponents, but again, there doesn't seem to be a one-size-fits-all, cure-all for PTSD.  In the absence of the medicinal "silver bullet" that cures all PTSD, it's great that the Army is at least embracing the concept of possible adjunct therapies, while asking them to prove themselves clinically, as much as possible.

In the following weeks, we will report on complementary and alternative therapies that appear to have some benefit in treating PTSD; in addition to the more mainstream approaches that are already in use.  (Virtual reality is another type of treatment entirely: dependent on technology, it doesn't fit the typical rubric of CAM, nor should it.)

More Combat = More Trauma, and More Chance of Developing PTSD, Study Shows

For anyone who's every wondered about whether troops' increased exposure to combat trauma results in greater chances of their developing PTSD, the answer is a definite "yes," according to a study released in the February issue of the Psychiatric Times, linked here.  The article from which excellent graphic (left) is taken is entitled, "Posttraumatic Stress Disorder in Veterans," and it makes the point that cumulative exposure to combat trauma predicts PTSD in a linear fashion.  Less exposure (fewer firefights) -- lower rates of PTSD; higher exposure (greater number of firefights) -- higher rates of PTSD.  According to the article, it really is that simple.

The article's authors cite an earlier published report of OIF (Iraq) and OEF (Afghanistan) servicemembers, and found high rates of exposure to both "traumatic situations and combat."  "According to the study, about 33% of soldiers in Afghanistan and 71% to 86% of soldiers in Iraq experienced a firefight. PTSD rates ranged from 6.2% for veterans of Afghanistan's OEF to more than 12% for OIF veterans. The risk of PTSD was found to increase linearly with the number of firefights (see graphic, above). Having been wounded, a condition previously found to be predictive of PTSD, was also significantly associated with PTSD. As is commonly found in patients with PTSD, rates of depression and alcohol use also increased following combat exposure."

When we think of tragic stories of what we can only assume to be PTSD-fueled incidents in the news -- the recent suicide of Marine SSgt. Travis Twiggs, the arrest of Marine LCpl. Eric Acevedo for murder, and others like them -- we should really stop to pause and wonder, how many times have these servicemembers been deployed, for how long have they been in combat, and to what have they been exposed (meaning, how many firefights)?  Twiggs, it turns out, had done four(!) tours of Iraq, and one of Afghanistan (earlier reports mentioned four total, but they were wrong); Acevedo had done three tours of Iraq by the time he was 22, including one that involved a horrific battle, where 10 members of his battalion died on a single day, and several others were wounded.  To not take the effects of their cumulative exposure -- what they saw, did, were witness to -- is just unconscionable.  We have a very love-hate relationship with the glory of serving in this country: we glorify our military heroes for their astounding feats of endurance (Brad Kasal, the Marlboro Marine, etc.), but we also equally unreasonably vilify them when they crack under the all-too-obvious strain.  It seems like what we need most of all is just the sober estimation: the more servicemembers have gone through -- and suffered -- the more we can expect them to have problems later on, with developing PTSD.  As noted Australian Vietnam War researcher Hedley Peach said in a slightly different context, what we're really looking at here is not something unusual -- it's the generic effects of combat.

The Killer Headache: Migraines, PTSD and Increased Risk of Suicide among Veterans, Teens

Remarkable scientific data first reported over a year ago -- which seems to have created nary a flicker of interest in the media, though it absolutely should have -- links veterans' experience of migraine headaches with likelihood of experiencing PTSD, depression and anxiety.  Similar research in teens -- and many combat veterans, after all, are barely out of their teens -- indicates that those who suffer migraine headaches most frequently are also at greatest risk for suicide.

In soldiers:

Soldiers returning from combat in Iraq who have migraine headaches are more than twice as likely to also have symptoms of post-traumatic stress, depression or anxiety than soldiers who do not have migraines, The study involved 3,621 United States Army soldiers who were given a health screening questionnaire within 90 days after returning from one year of combat duty in Iraq. A total of 2,167 of the soldiers, or 60 percent, completed the questionnaire. Of those, 19 percent screened positive for migraine headaches, 32 percent screened positive for depression, 22 percent screened positive for post-traumatic stress disorder, and 13 percent screened positive for anxiety.

The researchers found that 50 percent of those with migraine also had depression, compared to 27 percent of those without migraine. A total of 39 percent of those with migraine also had post-traumatic stress disorder, compared to 18 percent of those without migraine. And 22 percent of those with migraine also had anxiety, compared to 10 percent of those without migraine.

"Previous studies in non-military populations had revealed a higher prevalence of certain psychiatric conditions, such as depression and anxiety, among people with migraine," said study author Maj. Jay C. Erickson, MD, PhD, of Madigan Army Medical Center in Tacoma, WA. "We hypothesized that there would be a similar relationship between migraine and psychiatric conditions in soldiers. The precise reasons for such an association are not fully understood, but may be related to similarities in the mechanisms underlying migraines and some psychiatric disorders."

The study also found that those with migraine and depression also had more frequent headaches than those who had migraine with no depression -- an average of 3.5 headache days per month for those with depression compared to 2.5 days per month for those with no depression. The findings were similar for those with migraine and post-traumatic stress disorder.

"These findings should alert health care providers, especially those affiliated with the military or veteran health care systems, about the frequent association of migraine headaches and psychiatric conditions in soldiers returning from deployment," Erickson said. "We recommend that health care providers who evaluate combat veterans for headaches perform mental health screening in order to ensure that psychiatric disorders are identified and properly treated. All soldiers returning from deployment presently undergo mental health screening."

This research was presented at the American Academy of Neurology's 59th Annual Meeting in Boston, April 28 -- May 5, 2007. Full citation: American Academy of Neurology (2007, May 4). For Iraq Veterans, Migraines May Be Sign Of Other Problems. ScienceDaily. Retrieved May 30, 2008, from http://www.sciencedaily.com­ /releases/2007/05/070503075228.htm

For teens:

Teens who have chronic daily headache, especially those with migraine headaches, are at greater risk for suicide than teens who don't have migraines, according to a study published in the May 1, 2007, issue of Neurology®, the scientific journal of the American Academy of Neurology. Teens with migraine are also more likely to have other psychiatric disorders such as depression and panic disorder.

Reported in ScienceDaily, May 1, 2007.  Full citation: American Academy of Neurology (2007, May 1). Teens With Migraine At Greater Risk Of Suicide. ScienceDaily. Retrieved May 30, 2008, from http://www.sciencedaily.com­ /releases/2007/04/070430181213.htm

Professor Hedley G. Peach (Australia)

BSc(Hons) (Wales), MBBCh (Wales) PhD(London), FFPH(UK)
University of Melbourne

(Retired) Professor, School of Public Health, Queensland University of Technology, Kelvin Grove, Queensland, AUSTRALIA.

Professor Hedley Peach is a Visiting Consultant at the Ballarat Base Hospital, and Professional Fellow at the University of Melbourne.

Professor Hedley Peach qualified as a doctor in Wales where he became interested in the social causes of illness. This interest led him to train in community medicine at the renowned St. Thomas's Hospital in London where he worked for seven years as a lecturer/senior lecturer. In 1985 he migrated to Australia where he was Foundation Professor of Tropical Health at James Cook University for three years and, subsequently, Professor of Community Medicine at Melbourne University for fourteen years. He retired earlier this year but continues as an honorary Professorial Fellow of Melbourne University. He has been interested in the nexus between religion, spirituality and health for a number of years. In 2002, he wrote the first article on this topic to appear in the Medical Journal of Australia to stimulate debate on how the medical profession should respond to research and recommendations from the USA. He has authored book chapters and papers on spirituality and women's health, the religions of rural Australians, and other topics. He has given many radio and newspaper interviews on spirituality and health. He is the author of several books, including The Epidemiology of Common Diseases and Disablement in the Community, as well as the leading author of more than 100 articles in scientific journals. He is a member of the National Heart Foundation's expert group on psychosocial causes of heart disease.

Dr. Ecstasy Will See You Now

An article in yesterday's Sunday Times (London, UK) talks about the drug, Ecstasy, as having therapeutic potential for treating severe, unremitting PTSD.  The article, which is titled "Ecstasy is the Key to Treating PTSD," by Amy Turner, is linked here.  The drug in question is more properly known as MDMA, or 3,4-methylenedioxy-N-methylamphetamine, pictured here.

The article says that MDMA's potential therapeutically wasn't noticed until 1976, "when the American chemist Alexander Shulgin tried it on himself. He noted that its effect, “an easily controlled altered state of consciousness with emotional and sensual overtones”, could be ideal for psychotherapy, as it induced a state of openness and trust without hallucination or paranoia. It quickly became known as a wonder drug, and began to be used widely in couples therapy and for treating anxiety disorders. None of these tests was “empirical” in the scientific sense – no placebos, no follow-up testing – but anecdotally the results were almost entirely positive."

The therapeutic potential for treating PTSD is apparently to be found, according to the article, "in the trust it establishes."  One researcher familiar with the drug, quoted in the article, states:

“Many people with PTSD have a great deal of trouble trusting anybody, especially if they’ve been betrayed by someone who abused their trust, like a parent or a caregiver,” he says. “MDMA has this effect of lowering fear and defenses. It also allows more compassion for oneself and for others. People can revisit the trauma, feel the original feelings but not be retraumatized, not feel overwhelmed or have to numb out to cope with it.”

This is obviously good news for PTSD sufferers.  The study is still in its early phases, and the reality is, that if PTSD is able to be treated with one or just a few doses of MDMA, versus potentially years of psychotherapy and/or lengthy courses of pharmaceutical antidepressants, etc., this news is likely to be welcomed more warmly by patients eager to get well than by healthcare providers who previously expected to be providing maintenance doses of psychotherapy and/or pharmaceutical care for years to come.

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The formal study analyzing MDMA's therapeutic effects on PSTD is being conduced by Michael and Annie Mithoefer, under the auspices of MAPS, the Multidisciplinary Association for Psychedelic Studies, linked here.  While this might sound like a highly "hippy dippy" research project, the reality is, the other day I called a research group at the University of Arizona's Department of Psychiatry, and listened to a recorded message about a trial of psilocybin and OCD.  (See article, linked here.)  Mainstream medicine is apparently, if only slightly, open to studying the therapeutic uses of controlled substances.  In the meantime it's important to note that the street drug, Ecstasy, which may or may not be based on MDMA, depending on the purity, is not a substitute for taking part in a clinical trial like the Mithoefers', and there is always considerable risk in attempting to self-medicate any serious health condition, especially with illicit drugs.  Read the Sunday Times article, linked here -- it's quite informative.  And keep track of this ongoing research, which looks promising for some sufferers.

Editor's Note: In a feeble attempt at true-to-life humor, this was the license plate I saw recently on a very nice, late model Acura, parked in the driveway at a state veteran's home.  Perhaps it was just a visiting DJ.

Acupuncture May Help PTSD Sufferers

Acupuncture May Help Symptoms of Posttraumatic Stress Disorder

A pilot study by researchers at the University of Arizona's Department of Psychiatry shows that acupuncture may help people with posttraumatic stress disorder. Posttraumatic stress disorder (PTSD) is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat.

Michael Hollifield, M.D., and colleagues conducted a clinical trial examining the effect of acupuncture on the symptoms of PTSD. The researchers analyzed depression, anxiety, and impairment in 73 people with a diagnosis of PTSD. The participants were assigned to receive either acupuncture or group cognitive-behavioral therapy over 12 weeks, or were assigned to a wait-list as part of the control group. The people in the control group were offered treatment or referral for treatment at the end of their participation.

The researchers found that acupuncture provided treatment effects similar to group cognitive-behavioral therapy; both interventions were superior to the control group. Additionally, treatment effects of both the acupuncture and the group therapy were maintained for 3 months after the end of treatment.

The limitations of the study are consistent with preliminary research. For example, this study had a small group of participants that lacked diversity, and the results do not account for outside factors that may have affected the treatments' results.

Michael Hollifield, Nityamo Sinclair-Lian, Teddy D. Warner, and Richard Hammerschlag, "Acupuncture for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial." The Journal of Nervous and Mental Disease, June 2007.

PTSD Complicates Healthcare, Increases Utilization and Costs

PTSD ASSOCIATED WITH MORE, LONGER HOSPITALIZATIONS AND GREATER MENTAL HEALTH USE

Boston, MA—Researchers from Boston University School of Medicine (BUSM) and Boston Medical Center (BMC) have found post-traumatic stress disorder (PTSD) is associated with more hospitalizations, longer hospitalizations and greater mental healthcare utilization in urban primary care patients. These findings appear in the current issue of Medical Care.

Prior studies suggest that trauma exposure and PTSD have considerable impact on health care use and costs. Most of this research, however, has focused on male veterans and female sexual assault victims but the impact on healthcare use in other populations is uncertain.

The researchers interviewed a sample of primary care patients to examine overall prevalence of traumatic exposure and select behavioral health outcomes in addition to PTSD, including major depression, substance dependence and chronic pain. The interview included demographic questions, the Composite International Diagnostic Interview (version 2.1 PTSD module), the Chronic Pain Definitional Questionnaire, the Patient Health Questionnaire (to measure depression) and the Composite International Diagnostic Interview-Short Form (for drug and alcohol dependence).

Among the participants, the researchers found that 80 percent had one or more trauma exposures. Compared to participants with no trauma exposure, subjects exposed to trauma were significantly more likely to be males, unmarried, have substance dependence and depression. They also had more mental health visits than those with no trauma exposure.

Among the participants, 22 percent had current PTSD. Compared to participants without PTSD, those with PTSD were significantly more likely to be female, to have an annual income of less than or equal to $20,000, have substance dependence and depression. PTSD participants also had more hospitalizations and mental health visits.

According to the researchers, among urban primary care patients PTSD is associated with greater health care use: both mental health visits and hospitalizations. “Unexpectedly, trauma exposure by itself was not associated with increased healthcare utilization apart from mental health visits, a finding which was attenuated after adjusting for PTSD,” said lead author Anand Kartha, MD, an assistant professor of medicine at BUSM. “This may be due to the fact that the non-traumatized to whom we are comparing the traumatized patients, have complex social milieu leading to high utilization,” added Kartha.

“PTSD has a cost beyond the specific mental health symptoms,” said senior author Jane Liebschutz, MD, an associate professor of medicine and social and behavioral sciences at BUSM and a primary care physician at BMC. “PTSD may be on the causal pathway between trauma experiences and negative health consequences. These findings are relevant in light of the PTSD prevalence not only in our returning veterans, but in areas of urban poor,” she added.

This study was supported in part by the Robert Wood Johnson Foundation and by the National Institute on Drug Abuse.

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Editor's Note: Anand Kartha, M.D., the study's main author, served a two year fellowship (2003-2005) at then Veterans Admininstration Hospital in Boston, Massachusetts, where his healthcare systems area of focus was "predictors of re-hospitalization/Utilization of health care resources in post-traumatic stress disorder."

Women Veterans and Military Sexual Trauma

A study reported in the Journal of General Internal Medicine in 2006 compared rates of Post-Traumatic Stress Disorder (PTSD) in female veterans who had Military Sexual Trauma (MST) with rates of PTSD in women veterans with all other types of trauma.  (The full title of the article is "DSM-IV Diagnosed Posttraumatic Stress Disorder in Women Veterans With and Without Military Sexual Trauma.")

Women subjects were recruited via health appointments and/or a mailing, and completed questionairres about their military service and their health and trauma history.  The results were shocking: Ninety-two percent (92%) reported at least one (1) trauma. Forty-one percent (41%) had experienced MST, either alone or with other trauma, and 90% had other trauma, with or without MST. Overall, 43% of subjects with trauma had PTSD. And most importantly, those women veterans who had endured military sexual trauma had higher rates of PTSD.  Sixty percent (60%) of those with MST had PTSD; 43% of subjects with other traumas (with or without MST) had PTSD. Military sexual trauma and other trauma both significantly predicted PTSD in regression analyses (P = .0001 and .02, respectively) but MST predicted it more strongly. Prior trauma did not contribute to the relationship between MST and PTSD.

The study concluded, "Findings suggest that Military Sexual Trauma (MST) is common and that it is a trauma especially associated with PTSD."  To read the article itself, click here.  (The citation for the study is: J Gen Intern Med.  2006;21(S3):S65-S69.)

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(Quoting from the study):

Rape is a violent crime with long-lasting consequences that is often perpetrated against women. At particular risk are women working within male-dominated environments such as the Armed Services, which, despite a recent influx of women, continue t