Healing Combat Trauma

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.)

PTSD Elevates Risk of Other, Chronic Health Problems

Geisinger research finds that veterans suffering from posttraumatic stress disorder (PTSD) are as likely to have long-term health problems as people with chronic disease risk factors such as an elevated white blood cell counts and biological signs and symptoms.

However, few healthcare providers screen for PTSD in the same way as they screen for other chronic disease risk factors. “Exposure to trauma has not only psychological effects, but can take a serious toll on a person’s health status and biological functions as well,” Geisinger Senior Investigator Joseph Boscarino, PhD, MPH says. “PTSD is a risk factor for disease that doctors should put on their radar screens.”  (Click here to listen to a podcast of Dr. Boscarino discussing the study.)

For this study, Dr. Boscarino examined the health status of 4,462 male Vietnam-era veterans 30 years after their military service. Results are being published in the current edition of the Journal of Nervous and Mental Disease. The study finds that having PTSD was just as good an indicator of a person’s long-term health status as having an elevated white blood cell count. An elevated white blood cell count can indicate a major infection or a serious blood disorder such as leukemia.

The study also found that veterans with high erythrocyte sedimentation rate (ESR), which indicates inflammation, were also at risk. There was a similar finding for a possible indicator of serious neuroendocrine problems. While these disease markers are measured with a blood test, PTSD is commonly measured with a psychological test or a mental health examination.

This research comes as Geisinger is organizing a national conference on May 13 to address PTSD in combat veterans from rural parts of the country. Boscarino says that almost anyone who experiences a traumatic event can experience PTSD, meaning accident and disaster victims are also predisposed to the biological risk factors associated with PTSD. (Click here for the link to that conference.)

Although therapy doesn't necessarily have to be extensive, Boscarino says it should occur shortly after a person has experienced a traumatic event. Early treatment may be critical to avoiding depression, PTSD and substance abuse-related problems following trauma. “As the conflicts in the Middle East continue, we’re seeing a new wave of our service members who have posttraumatic stress,” says Boscarino, a Vietnam veteran. “If we don’t get these personnel help earlier, our research shows that they may experience more serious health problems down the road.”

Dr. Boscarino is one of the country’s leading authorities on PTSD and has published extensively on the topic. His prior research has established links between PTSD and the increased likelihood of death by unnatural causes and between PTSD and individual soldiers’ dexterity levels.

Founded in 1915, Geisinger Health System (Danville, PA) is one of the nation’s largest integrated health services organizations. Serving more than two million residents throughout central and northeastern Pennsylvania, the physician-led organization is at the forefront of the country's rapidly emerging electronic health records movement. Geisinger is comprised of three medical center campuses, a 700-member group practice, a not-for-profit health insurance company and the Center for Health Research—dedicated to creating innovative new models for patient care, satisfaction and clinical outcomes.

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Editor's Note: the figured featured in the statue is Asclepius, the ancient demi-god of medicine and healing.

Clinical Trials Underway on PTSD

Here's a list from the National Institutes of Mental Health ("NIMH"), government recipient of our tax dollars at work, of the clinical trials presently underway that are studying aspects of PTSD.  Not many of the studies having much to do with combat trauma (yet), it would seem.  In any case, here's a link to them: there are fourteen (14) clinical trials, total, including one with the somewhat rosy title of, "Using Affectionate Communication as a Response to Acute Stress."  Mmmmn, sign me up! :-) We can never have enough of that...  One or two do relate specifically to PTSD and combat trauma, including

• Effectiveness of Virtual Reality Exposure Therapy and D-Cycloserine to Treat Iraq War Veterans With Post-Traumatic Stress Disorder.
  Interventional study. This study will determine whether a combination of virtual reality exposure therapy and D-cycloserine will reduce post-traumatic stress disorder symptoms in Iraq war veterans. Ages 21-65. Location in Atlanta, GA.

Here's a link to a page of worthwhile information about PTSD on the NIMH's website, with links to other information worth reviewing, or keeping on hand to share with others.  One is, "Post-Traumatic Stress Disorder: A Real Illness" -- click here for that; and "Post Traumatic Stress Disorder Research Fact Sheet" -- click here for that.  (Lack of continuity in hyphenating style thanks to the NIMH, not this blogger.)

And, finally, If you're in the Bethesda, MD area, and you'd like to participate in an NIMH study (not necessarily the one above), click this link to learn more about how to participate.  Not all studies looking for participants take place in the D.C. area, though -- many are in other large metropolitan areas such as Atlanta and Boston -- so check the main site above for clinical trial topics and locations.

PTSD - Normal Reaction to Abnormal Events

Trying to catch up on some blog posting from a while back, here is a link to an excellent article from Salon magazine on PTSD, and why talk therapy doesn't really help it much -- and can actually make symptoms worse, at least initially.  The article, called "My Heart is Back," by Lynn Harris, also includes one of the few great explanations in print of how PTSD happens in the body, and takes a look at some treatments that do offer hope, with quotes from therapists who use them, including ones who were frustrated by what they couldn't offer their patients a few years back.  Quite an excellent, overall article about PTSD and how to overcome it - and worth keeping on hand to share with friends and foes alike who may not understand, or believe, in what PTSD or combat trauma really is.  (And the article, since it came out in 2004, talks about not just combat-triggered PTSD, but PTSD as a reaction to violent events over which we have no control.)

The gist of the article: "Talk therapy only increases the suffering for some trauma victims -- but alternative treatments offer new hope."  (The book highlighted here on the left, Invisible Heroes: Survivors of Trauma and How They Heal, by Belleruth Naparstek -- is written by one of the therapists quoted in the article.)

Some quotable quotes from the article, including these great ones, that sums it up: "PTSD is a normal reaction to abnormal events" -- and "what we do know is that susceptibility to PTSD has nothing to do with, say, cowardice, or weakness of character."

"[A]pproximately 5 million Americans who suffer from post-traumatic stress disorder." "In fact, more people may have PTSD today than anyone ever realized. But because of recent advances in biochemistry, brain imagery and epidemiology, researchers are finding out that all manner of conditions -- some psychiatric, but some also physiological, such as chronic pain -- can be traced to PTSD."

Here's what some of the experts quoted in the article say:

• "...People with PTSD aren't crazy, and they get better," says Belleruth Naparstek.  Today, in fact, their prognosis is the best it has ever been. For many years, "we didn't know how to help trauma survivors in any consistent way," says Naparstek. As she herself discovered while treating Frannie, "Talking about it -- the stock in trade of mental health professionals, pastors, good friends and spouses -- is not necessarily all that helpful, and can sometimes make symptoms worse."
• "PSTD is a normal reaction to abnormal events," says Beverly Donovan, a clinical psychologist at the Veterans Affairs Medical Center in Brecksville, Ohio, who runs an intensive treatment program for combat vets with PTSD.
• "When exposed to trauma, some people will have trouble letting go of the experience, but not because they want to dwell on it," says Steven Gold, Ph.D., director of the Trauma Resolution and Integration Program at Nova Southeastern University in Fort Lauderdale, Fla., and president of the International Society for the Study of Dissociation. "There are various techniques for helping people move beyond it, which may have as much to do with the body's reaction to the experience as with the mind's. A few years ago some of these therapies would have been considered 'alternative, but now the major specialists in treating trauma would consider them more mainstream."

And the patient who they featured in the article, who'd suffered numerous horrific traumas, back to back?  She's doing well. "My heart is back" -- "I'm connected to myself now."  Great news, and what we would wish for all trauma survivors with PTSD.  Be sure to read, and save, the article for future reference.

Heads Up: Traumatic Brain Injury ("TBI") and PTSD

There's a really excellent -- as in relatively comprehensive, considering -- article in today's USA Today called "Doctors Face Rash of Brain-Damaged Vets."  Unfortunately, what doctors are finding is that the two "signature wounds" of the current wars -- traumatic brain injury ("TBI") and post-traumatic stress disorder ("PTSD") can often occur together.  And even more unfortunately, the presence of both in the same person can complicate matters quite a bit.

As the article states, "Odd as it may seem, brain injury can protect against PTSD by blurring awareness of what happened.  But as memory improves, emotional problems can emerge..."

Certain symptoms that show up initially, such as headache, dizziness and balance problems -- perhaps more due to the TBI -- actually subside over time; whereas other symptoms -- including memory problems and 'irritability' -- probably more part of the PTSD complex of symptoms -- actually increase over time, according to data cited in the article, from a study conducted by Walter Reed Army Medical Center.

Current -- and future -- treatment programs are going to need to be able to effectively treat combat veterans who have undergone TBIs in such a way that they can also catch emerging PTSD, even if it comes out after the brain injury has optimistically "resolved."  Also dangerous: the fact that overall, occupational therapy needed to treat brain injury has been downgraded at many private hospitals and outsourced to nursing homes, according to an insider in the field.  With a growing number of combat veterans who've been exposed to TBIs now returning to civilian life, it's going to be important to care for them both within the VA system and also within the private hospital setting.  Affording treatment is going to be another ballooning cost of the war effort, but one that's crucial for us to get behind, in order to ensure that veterans are treated effectively.

Another issue that the article brings up is the number of times deployed military have been exposed to TBIs.  The article mentions vets experiencing at least "an explosion a month."  A few years back, doctors found that high school and college football players who experienced two or more concussions on the field in succession -- separated by days or even weeks -- were at much greater risk from serious injury, including death -- than had ever been thought.  And they started to talk about the cumulative effect of concussions, and how difficult it is for the body to heal from that.  Essentially, what combat veterans are going through now is the same thing: exposure to explosions, that causes an underlying stress on the brain, followed up sometimes by direct injury, such as TBIs.  Now we need to add into the mix PTSD as well, which can show up later, thanks to the body's own capacity to focus first on the TBI. 

Unraveling the complexities of this increasingly all-too-common scenario is going to take a lot of work, and patience, on everyone's part.  Even physicians in private practice are not used to seeing the level of TBIs that returning vets will be bringing into their practices.  The Centers for Disease Control ("CDC") even has an article on its website for doctors about recognizing and treating TBIs, but it doesn't yet reference the combat connection...Their handout, which might be worth vets and their families reading to familiarize themselves better with the subject, is called "Heads Up: Brain Injury in Your Practice - A Tool Kit for Physicians."