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Responding to Violence, Suicide, Psychosis and Trauma

Open Courses “Trauma: Post-incident Staff Support”

The Post-incident Staff Support course is now available to individual applicants through SITRA:

    SITRA – Post-incident Staff Support

Trauma: post incident support staff

24 May 2012, Southampton

14 November 2012, Southampton

Suitable for all managers and supervisors who have responsibility for supporting staff after an incident at work e.g. an assault, a suicide, an allegation.

By the end of the course participants should:

• Have a good understanding of the psychological and emotional needs of staff following an incident at work

• How to prepare themselves in anticipation of an untoward incident at work

• Be clear as their own role in the immediate aftermath of incident

Trainer: Dr Iain Bourne

Price: member £89/ non-members £129

Book now

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Filed under: Impact Training, trauma, , , , , ,

Open Courses “Trauma”

The “Trauma” course is now available to individual applicants through SITRA:

SITRA – Trauma

Trauma: frontline staff

16 April 2012, Southampton

23 October 2012, Southampton

For anyone who wishes to gain a clearer overview of psychological trauma, whether it is the result of a recent overwhelming event, or the effect of prolonged childhood trauma.

By the end of the course participants will:

• Understand the difference between Type 1 traumas (recent overwhelming events) and Type 2 traumas (prolonged/repeated childhood abuse)

• Understand how both types of trauma lead to different outcomes and support needs in adult life

• Be aware of the range of strategies available to assist service users, both immediately and in the long-term

Trainer: Dr Iain Bourne

Price: member £89/ non-member £129

Book now

Filed under: Impact Training, trauma, , , , ,

New PTSD program answers need for comprehensive treatment

July 02, 2009

Jul 02, 2009 (DEFENSE DEPARTMENT DOCUMENTS AND PUBLICATIONS/ContentWorks via COMTEX) — 7/1/2009 – LANDSTUHL REGIONAL MEDICAL CENTER, Germany (AFNS) — Symptoms of combat stress and post-traumatic stress disorder for wounded warriors include continual nightmares, avoidance behaviors, denial, grief, anger and fear.

Some servicemembers battling these and other symptoms, can be treated successfully as an outpatient while assuming their normal duties, but for others; however, returning to work and becoming their old selves again were challenges recognized by several mental health professionals across the European theater.

“We were looking at how we can best meet the needs of our clientele, and we were identifying that a lot of the Soldiers needed more than once a week outpatient, individual therapy and probably needed more than once or twice a week group therapy,” said Joseph Pehm, the chief of Medical Social Work at Landstuhl Regional Medical Center.

The solution came in the creation of an intensive eight-week therapeutic Post-Traumatic Stress Disorder Day Treatment Program called “evolution” that began in March 2009 at LRMC. During the eight-hour days, patients enrolled in the program participate in multiple disciplines and interests, including art therapy, yoga and meditation classes, substance abuse groups, anger and grief management, tobacco cessation, pain management and multiple PTSD evidence-based practice protocols.

“I am a great believer in the kitchen sink, meaning I throw everything, including the kitchen sink, and something will stick,” said Dr. Daphne Brown, chief of the Division of Behavioral Health at LRMC. “And so we’ve come with all the evidence-based treatment for PTSD that we know about. We’ve taken everything that we can think of that will be of use in redirecting symptoms for these folks and put it into an eight-week program.”

Doctor Brown, Mr. Pehm and Sharon Stewart, a Red Cross volunteer who holds a Ph.D. in psychology, said the program is designed from research into the effects of traumatic experience and mirrors successful PTSD programs at Walter Reed Army Medical Center and the Department of Veterans Affairs, as well as programs run by psychologists in the U.S.

“We are building on the groundbreaking work that some of our peers and colleagues have done and just expanding it out,” Doctor Brown said.

During treatment, patients begin the day with a community meeting where they discuss how well they feel and any additional issues or concerns since their last meeting. The remainder of the day depends on the curriculum scheduled for that week.

The first few weeks focus on learning basic coping skills such as how to reduce anxiety and fight fear, as well as yoga and meditation for relaxation. Eye Movement Desensitization and Reprocessing, an evidence-based practice for treating PTSD, is also conducted during the early phases of the treatment program.

“The concept behind EMDR is that, essentially, memories become fixed in one part of our brain and they maintain their power and control over our emotions as long as they are fixed there,” Doctor Brown said. “And if we can activate a different part of the brain while we’re experiencing that memory, we can help to remove some of that emotional valence from it. So we use physiological maneuvers to activate both sides of the brain.”

The goal at the beginning of the PTSD program is to provide patients with a number of tools they can use to help them calm down when feeling overwhelmed, especially before more intense therapy begins in the latter weeks. Cognitive processing therapy is used throughout the program. EMDR and prolonged exposure therapy are also available on an individual basis at the Soldier’s request. All three techniques are research-based treatments.

When life-changing events occur, Doctor Brown said perceptions about the world may change. For example, before Soldiers experience combat trauma they may think the world is safe. Following combat, a Soldier’s perceptions may change; a majority of the world may now seem unsafe. Cognitive processing therapy attempts to readdress experiences and reshift a Soldier’s perceptions.

Prolonged exposure therapy is behaviorally based and addresses a Soldier’s fears, which are seen as reflex reactions to a stimulus. To decondition the reactions, a patient is continually exposed to the stimulus by retelling the story repeatedly, minus the negative outcome. Doctor Brown compared it to riding a roller coaster over and over again to overcome a fear of roller coasters.

“So they’re getting EMDR, they’re getting cognitive processing therapy, they’re getting individual therapy, they’re getting group therapy, they’re getting education, anger management, self-esteem, relationship issues, grief and loss, yoga, meditation exercise, skill building — a little bit of everything across the board,” Doctor Brown said. “Not everything’s going to resonate with everyone who comes through, but something’s going to resonate for everyone who comes through.”

In addition to the overall core curriculum, Doctor Brown and her staff have programs such as pain management, relationship enrichment and tobacco cessation to help individualize treatment.

“The core of the group and individual education is consistent for everyone,” Doctor Brown said. “But we recognize that every patient is different, and we have to tailor make it to give an individualized treatment plan. We don’t keep people in pain management if they’re not in pain. We don’t give them tobacco cessation if they’re not smoking. So we do try and tailor as much of it as we can.”

Spirituality, relationship enrichment and gender-specific issues are also areas of focus.

“The program is holistic,” Mr. Pehm said. “It looks at people from different spheres, not just the medical model because everything is impacted when someone has combat stress or PTSD; not just the individual Soldier, but everybody who comes in contact with them.”

The intensity, length and “kitchen sink” qualities are not the only aspects that make this program unique, Doctor Brown said. It is a joint military and civilian effort accomplished entirely by volunteers. The staff is as diverse as the therapy options, and includes chaplains, social workers, Red Cross volunteers, psychiatrists, a nurse practitioner, enlisted psychiatric technicians, and graduate students. Brown said having a sundry of personnel keeps the program fresh and the staff excited.

“The patients get perspectives from people from a number of different backgrounds,” Doctor Brown said.

Thus far, the staff outnumbers the program’s participants.

“By design we started out small, and we were able to establish a really good working relationship with the local Warrior Transition Unit people … It’s been a wonderful working relationship with them,” Mr. Pehm said.

Evolution is currently on it second eight-week course, with five patients enrolled. The first class had four. The goal is to keep the class size small in order to benefit from the program’s intensity. Thinking small also helps keep the impact large by successfully returning Soldiers to their units, while also expanding access outside the WTUs. However, Mr. Pehm said they would like to expand the program to include patients from throughout the European Command.

“Ideally, we’d like to max it at about 10 because it is so intensive,” Doctor Brown said. “These are folks we hope to remediate and return to the Army to be functional members again. Also, if they go back to their communities and their providers or spouses see the changes that have come about, that will increase the willingness or desire of more people to be here.”

Though few have completed this young program, signs of success have already started to surface.

“With the last group, the shift from ‘I have to be here’ to ‘I’m so glad I came’ was really phenomenal,” Mr. Pehm said.

“One of them said that he didn’t think he was getting anything out of the program,” Doctor Brown said. “It was about week six until he saw himself react differently to a situation that came up, and watched himself do it differently using skills that he didn’t know he learned. He went, ‘Wow, maybe I am getting something out of this.'”

It is too early, and the numbers are too small, to generalize the early trends, but self-completed PTSD checklists showed a significant decrease in reported symptoms for three of the four patients in the first cohort. Additionally, anxiety and depression symptom measures decreased.

“The whole idea is that we know all the changes aren’t going to take place here,” Doctor Brown said. “But we hope we give them enough learning to send them in a different direction. My hope is that we can build a program to provide valid, effective treatment to folks who have put themselves in harm’s way at the request of their country, and help them live happier and better lives.”

Filed under: Other Mental Health, trauma, , , ,

Professor helps train mental-health workers in Iraq

July 04, 2009

Victims of traumatic events sometimes get so hung up thinking about what happened to them that they can’t let go of their torment.

Rigid, “black-and-white kinds of thoughts” play over and over in their minds and keep them from moving forward in life, says University of Richmond researcher Kristen P. Lindgren.

“Those kinds of thoughts can keep people stuck in their lives,” she said.

A licensed clinical psychologist, Lindgren has studied a technique called cognitive processing therapy that helps people escape those thoughts.

She worked at the Department of Veterans Affairs hospital in Seattle with veterans of wars from Vietnam to Iraq. They suffer from post-traumatic stress disorder and depression, and Lindgren says the therapy was so helpful that the VA plans to use it as a treatment model nationally.

And now, it might also help victims of torture in Iraq.

Lindgren, an assistant professor of psychology at UR for the past year, recently spent eight intensive days training mental-health workers in the Kurdish region of Iraq.

Their goal is to help victims of the violence waged against the people of Kurdistan during the 1980s and 1990s.

It was the most attentive class she has ever had, Lindgren said. The workers, primarily physician assistants at community clinics who have limited opportunities for advanced training, were eager to learn new techniques.

“I’ve never had a group of students who were so focused and literally writing down every word,” she said.

Lindgren describes herself as “very much the junior partner” on the pilot project organized by Johns Hopkins University. The team included Johns Hopkins researchers Paul Bolton and Judith K. Bass, as well as Debra Kaysen, Lindgren’s mentor when she did postdoctoral studies at the University of Washington.

Lindgren hopes that if the mental-health workers find that the technique helps their patients, she can return to Iraq within the year to expand the training.

The therapy technique encourages people to identify thoughts that are stuck in their minds and to challenge that way of thinking, she said.

The patients learn to come up with thoughts that are more flexible but believable.

“It’s not about thinking with rosecolored glasses,” she said.

Lindgren is optimistic the treatment will help the Kurds. In Iraq, the technique had to be adapted to account for cultural differences. Self-esteem, for example, didn’t translate very well. “The closest we could get was respect,” Lindgren said.

They also had to account for illiteracy because the technique involves written homework for patients.

If the therapy with those adaptations proves successful in Iraq, that should help answer lingering questions about its worth back home, she said. Because the technique is research-based and developed in university settings, some still question how well the therapy works in the real world, she said.

“If this is not the real world, I don’t know what is in terms of getting outside the ivory tower.”

——

Contact Karin Kapsidelis at (804) 649-6119 or kkapsidelis@timesdispatch.com. To see more of the Richmond Times-Dispatch, or to subscribe to the newspaper, go to http://www.timesdispatch.com. Copyright (c) 2009, Richmond Times-Dispatch, Va. Distributed by McClatchy-Tribune Information Services. For reprints, email tmsreprints@permissionsgroup.com, call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.

Filed under: Other Mental Health, trauma, , , , ,

Writing After Terrorist Attack Has Positive Medium Term Effects

ScienceDaily (Mar. 18, 2009) — A new study has analysed the expressive writing of terrorism victims to analyse their psychosocial processes following the terrorist attacks in New York and Madrid. Despite the cultural differences of the people involved, the results show that the feelings and thoughts experienced following this type of traumatic event are universal.


The people who experienced the September 11 terrorist attacks in New York and the March 11 2004 train attacks in Madrid needed to be able to express their feelings, thoughts and emotions. The aim of the study published in the International Journal of Clinical and Health Psychology was to compare how people from both nations reacted to such violent acts through expressive writing.

“After the Madrid attacks we were unfortunate enough to be able to ask people who had lived through this experience, either directly or indirectly, what they thought and how they felt following the terrorist attacks,” Itziar Fernández, the study’s author and a professor at the National University of Distance Education (UNED), told SINC.

“Following the attacks, there was a great fear that people would be affected by post-traumatic stress disorder. In the end, however, although they were in shock, people were able to deal with had happened and adapt to the situation,” says the researcher.

Based on the comments recorded by 325 people living in the United States and 333 in Spain, the researcher and her team looked into how both groups put their feelings and thoughts into words.

A linguistic analysis of the texts, carried out by using the Linguistic Inquiry and Word Count (LIWC) programme, showed that the victims who benefited most from recording the traumatic events were those who use more cognitive words (introspective and causal ones), use a high number of positive emotional words, and changed the use of pronouns and references to themselves.

The results show that feelings about the events (anger, impotence, fear) were similar between the two countries during a period between the third and eighth weeks after the attacks, both inclusive.

However, the data collected does show a significant difference. “While the Americans had a more individualistic view of events, the Spaniards talked more about social processes.” For example, there were not the same enormous public demonstrations following September 11 as there were following the attacks in Spain.

The study concludes that writing about a traumatic event can have positive effects over the medium term (from two months afterwards). Although the participants’ symptoms worsened over the short term (relating an event makes people relive it, and worsens their negative emotions), they felt better and paid less visits to the doctor over the medium and long term.

The effect was the opposite in the case of excessive consumption of media coverage of such an event, however. Data about news consumption throughout the population following the attacks showed that, over the long term (two months after the Madrid attacks), people who were repetitively viewing images of the attacks felt worse than those who rarely watched the television.

Tackling post-traumatic stress

The benefits of talking about traumatic events forms part of cultural belief systems. Therapists always seek to make people reconstruct a narrative and a testimony about what has happened. They are asked to talk about their lives before the traumatic event, and to reconstruct images and their sensations and feelings in order to give them meaning (why and how the event took place).

The first studies of post-traumatic stress disorder (PTSD) were conducted following the Vietnam War (1958-1975). It is a psychological illness classified within the group of anxiety disorders, which arises as a result of exposure to a traumatic event involving physical harm.

PTSD, which is diagnosed two months after a stressful life event, is a severe emotional reaction. It is characterised by symptoms such as loss of appetite, sadness and disturbed sleep, and lasts for more than two months after the event.


Journal reference:

  1. Itziar Fernández, Darío Páez y James W. Pennebaker. Comparison of expressive writing after the terrorist attacks of September 11th and March 11th. International Journal of Clinical and Health Psychology, Vol. 9, Nº 1, pp.89-103, 2009
Adapted from materials provided by Plataforma SINC, via AlphaGalileo.

Filed under: Other Mental Health, trauma, , , , ,

New Strategy To Weaken Traumatic Memories

ScienceDaily (Mar. 17, 2009) — Imagine that you have been in combat and that you have watched your closest friend die in front of you.  The memory of that event may stay with you, troubling you for the rest of your life.  Posttraumatic stress disorder (PTSD) is among the most common and disabling psychiatric casualties of combat and other extremely stressful situations. People suffering from PTSD often suffer from vivid intrusive memories of their traumas.

Current medications are often ineffective in controlling these symptoms and so novel treatments are needed urgently.  In the February 1st issue of Biological Psychiatry, published by Elsevier, a group of basic scientists shed new light on the biology of stress effects upon memory formation.  In so doing, they suggest new approaches to the treatment of the distress related to traumatic memories.  Their work is based on the study of a drug, RU38486, that blocks the effects of the stress hormone cortisol.

Using an animal model of traumatic memory, investigators at the Mount Sinai School of Medicine show that treatment with RU38486 selectively reduces stress-related memories, leaving other memories unchanged.  They also found that the effectiveness of the treatment is a function of the intensity of the initial “trauma.”  Although this particular study was performed in rats, their findings help to set the stage for trials in humans.

Cristina Alberini, Ph.D., corresponding author on this article, explains how their findings will translate into developing clinical parameters: “First, the drug should be administered shortly before or after recalling the memory of the traumatic event. Second, one or two treatments are sufficient to maximally disrupt the memory. Third, the effect is long lasting and selective for the recalled memory. Finally, the time elapsing between the traumatic experience and the treatment seems to be an important parameter for obtaining the most efficacious treatment.”

Dr. John Krystal, Editor of Biological Psychiatry and affiliated with both Yale University School of Medicine and the VA Connecticut Healthcare System, discusses the significance of the findings: “When treating PTSD, clinicians often attempt to reduce the negative distortions of traumatic memories so that people can better cope with their traumas.  The new study by Taubenfeld and colleagues suggests that blocking the effects of cortisol may be one strategy to promote the ‘normalization’ of traumatic memories.”  Dr. Alberini agrees, noting that “these results suggest that carefully designed combinations of behavioral and pharmacological therapies may represent novel, effective treatments for PTSD or other anxiety disorders.”


Adapted from materials provided by Elsevier, via AlphaGalileo

Filed under: Other Mental Health, trauma, , ,

Psychologist Says There Is No ‘Right’ Way To Cope With Tragedy

Article Date: 18 Feb 2009

After a collective trauma, such as Thursday’s crash of Continental Flight 3407, an entire community (or even the nation) can be exposed to the tragedy through media coverage and second-hand accounts, according to Mark Seery, Ph.D., University at Buffalo assistant professor of psychology. “Individuals potentially suffer negative effects on their mental and physical health, even if they have not ‘directly’ experienced the loss of someone they know or have not witnessed the event or its aftermath in person,” Seery says. In this type of situation, it is common for people to think that everyone exposed to the tragedy will need to talk about it, and if they do not, they are suppressing their “true” thoughts and feelings, which will only rebound later and cause them problems. This is not always the case, Seery explains. “Expressing one’s thoughts and feelings to a supportive listener can certainly be a good thing, whether it is to family and friends or to a professional therapist or counselor. However, this does not mean that it is bad or unhealthy to not want to express thoughts and feelings when given the opportunity.” Seery’s perspective results from his research of people’s responses following the terrorist attacks of 9/11. He and colleagues studied a national sample of people, most of whom did not witness the events in person or lose a loved one. They did, however, experience the events through media coverage. “We found that people who chose not to express at all or who expressed only a small amount in the immediate aftermath of the tragedy were better off over the following two years than people who expressed more. Specifically, they reported lower levels of mental and physical health symptoms.” From this research Seery concludes there is no single correct or healthy way to deal with a tragedy such as the crash of Flight 3407, which claimed 50 lives. “People are generally resilient and have a good sense of what coping strategies will work for them,” Seery says. “If they need to talk, they will talk, and friends and family can help by listening supportively. At the same time, they should not force the issue or make anyone feel like something is wrong with them if they do not want to talk about it.”

Article adapted by Medical News Today from original press release.

The University at Buffalo is a premier research-intensive public university, a flagship institution in the State University of New York system and its largest and most comprehensive campus. UB’s more than 28,000 students pursue their academic interests through more than 300 undergraduate, graduate and professional degree programs. Founded in 1846, the University at Buffalo is a member of the Association of American Universities. Source: Patricia Donovan University at Buffalo

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Understanding Posttraumatic Stress Disorder: An Expert Interview With Doug Zatzick, MD


Dr. Barclay: How prevalent is PTSD in the United States and worldwide; how is the prevalence changing with time; and what are the demographics?

Dr. Zatzick: According to the National Comorbidity Survey in 1995,[1] which is one of the best studies of PTSD prevalence in the United States to date, 5% to 10% of US civilians have PTSD at some point during their lifetime (approximately 5% of men and 10% of women). In the population of injured trauma survivors, in whom I do most of my research, about 20% have symptoms consistent with PTSD. We have a paper this month in the Annals of Surgery[2] showing that at 12 months after injury, a little over 20% of injured trauma survivors hospitalized at US level I trauma centers had symptoms consistent with PTSD and about 6% had depression. Both disorders were independently associated with significant impairments across all functional outcomes, including physical function (activities, such as climbing stairs and getting around in the community), social function (interacting with family and friends), and returning to work and productive activity.

There have been many studies of worldwide prevalence of PTSD. In a study of one group of returning veterans of the current Central Asian conflicts, incidence of symptoms consistent with a current diagnosis of PTSD was about 11% to 18%.[3]

Worldwide, there have been a lot of studies in conflict areas where the incidence of PTSD is much, much higher.[4] For civilians in conflict-ridden areas, the incidence of PTSD is very high because of the high prevalence of exposure to recurrent traumatic life events.

Dr. Barclay: What are the clinical challenges involved in diagnosing and managing PTSD overall?

Dr. Zatzick: I work at a level I trauma center that is also an inner-city safety-net hospital. Therefore, I often consult on injured patients, low-income ethnically diverse patients, and first-generation Americans who have immigrated to the United States after experiencing major trauma in their countries of origin. So, for example, in the setting of an outpatient visit for PTSD after a motor vehicle accident in which there were no severe injuries or extreme incidents, such as the death of another person. If such patients are medically stable, with no major preexisting medical or psychiatric problems, and was not exposed to multiple recurrent traumatic events before the injury, and has a good support system and reasonable life circumstances, they should do very well with CBT for PTSD, especially if they are motivated for treatment. Examples of types of CBT for PTSD include exposure and cognitive processing therapy. Medications, particularly the selective serotonin reuptake inhibitors (SSRIs), may also be effective in some patients, although there have been some recent questions about their efficacy in PTSD.

The challenges in management of PTSD are more complicated in alternative real-world scenarios, such as an acute trauma center or combat zone. For example, when an accident survivor has undergone surgery, is being managed in the intensive care unit, has opiates on board for pain, and will be undergoing months of rehabilitation, that’s complicated. There are multiple, competing demands on their time that push the patient in directions where they may not be ready to get psychotherapy, and addressing PTSD in this setting is much more difficult.

In a disaster zone, for example, if the patient has been evacuated, is a refugee and can’t get to [a pharmacy] for a prescription, and can’t get to a therapist’s office because even finding a therapist is a major challenge…

Dr. Barclay: How effective are currently available treatments for PTSD?

Dr. Zatzick: For patients with a single episode of trauma, good social support, no severe or recurrent trauma history, and no comorbid history of substance abuse — who are not avoiding treatment and will come to every CBT session — the odds are that they will respond to CBT. However, the response rate may be much lower if there are a lot of complicating factors. There is some evidence that the specific serotonin uptake inhibitor class of antidepressants may also be efficacious treatments for PTSD (SSRIs), yet the evidence base is not as solid as for CBT. (See American Psychiatric Association PTSD guidelines and British NICE PTSD guidelines.)

Dr. Barclay: What are the safety and tolerability issues with currently available treatments for PTSD?

Dr. Zatzick: The SSRIs have side effects, including headache, sexual side effects, and gastrointestinal upset. Disturbed sleep is often an issue with PTSD itself, and the SSRIs may exacerbate that. There have been some studies showing that prazosin may be useful for nightmares/sleep when given with an SSRI and it is not habit-forming, but it may cause orthostatic hypotension.

Even CBT is not totally free from adverse effects because a lot of people don’t like going back in their imagination and re-experiencing the event. Some patients drop out of therapy because it is so anxiety-provoking, but for those who stick it out, it’s really a great treatment.

Dr. Barclay: Are there new drugs for PTSD in the pipeline, and how do you think they will compare with currently available treatments?

Dr. Zatzick: I mentioned prazosin earlier. For early PTSD interventions I would love to see a drug that would relieve pain right away and also target the anxiety symptoms of PTSD. We see a lot of people at the trauma center who are in pain, so if you can say to them, “here is a medicine that will help your pain today, and in 4-6 weeks it may also help your anxiety,” that would be great. It’s hard to sell starting an SSRI that won’t become effective for 4-6 weeks, especially when that patient already has a lot of opiates on board. Adherence is not likely to be that good. There are other drugs, like propranolol, that work rapidly to lower blood pressure, heart rate, and autonomic response but have no effect on pain, which is the patient’s primary complaint. I would like to see better molecules that simultaneously target pain and anxiety that aren’t habit-forming.

Dr. Barclay: Please comment on the clinical implications of your own research in PTSD, and on directions for future research.

Dr. Zatzick: Our research, set in US level I trauma centers nationwide, is looking at PTSD and functional impairment after injury. We’re trying to improve return to work and other measures of function after traumatic injury and PTSD. We’ve shown that PTSD can affect return to work and other functional ability after injury, and we’re trying to intervene and improve people’s PTSD and reduce their alcohol consumption. PTSD and depression together are really bad in terms of patients being able to return to work.

Dr. Barclay: What is the current burden of PTSD related to the Iraq and Afghanistan wars in terms of prevalence, disability, and healthcare costs?

Dr. Zatzick: I’m currently consulting on grants involving studies of veterans. There are complicated issues in veteran populations concerning being redeployed, multiple recurrent trauma, and comorbid alcohol use.

Dr. Barclay: What role does increasing treatment of active-duty combat troops with psychoactive medications play in PTSD during combat and after discharge?

Dr. Zatzick: I’m not a military psychiatrist, but if I were assigned to a combat unit, I’d be concerned about the side effects of psychoactive medications.

Dr. Barclay: Are there identified factors predisposing troops to PTSD, and are these screened for or should they be screened for before sending troops to combat?

Dr. Zatzick: Luckily, studies are now being done of the National Guard and other troops before they go to combat, so we can get a better idea of factors predisposing troops to PTSD. The big risk factor in both the Vietnam and Iraq conflicts has been shown to be physical injury. Screening for previous psychiatric disorders before deployment may be helpful.

Dr. Barclay: What future directions do you believe are important for PTSD research?

Dr. Zatzick: The genetics of PTSD are important to understand. Optimizing delivery of healthcare services, depending on the target population, is important.

A key point to study is intervention reach, meaning the ability to capture patients in a specified particular target population. If you’ve just been in a motor vehicle accident, for example, and you need a month of rehabilitation, it will take a while for you to get to the psychologist’s or psychiatrist’s office for CBT, so medications might be better in the meantime, and may have greater reach to the target population of interest.

We need to understand how to tailor the intervention to the context of the particular situation. What type of intervention can you do in the Red Cross mental health tent or in a war zone? Future research needs to address stepped collaborative care, meaning how to deal with posttraumatic concerns in their context first, such as reuniting with their family after combat, getting their home back after a hurricane, or getting your wound sewn up and getting antibiotics after a traumatic injury. This type of care management helps us build a therapeutic relationship and gets people into PTSD therapy. So step 1 is engagement, and then evidence-based PTSD treatment follows as step 2.

References

  1. Kessler RC, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060. Abstract
  2. Zatzick D, Jurkovich GJ, Rivara FP, et al. A national US study of posttraumatic stress disorder, depression, and work and functional outcomes after hospitalization for traumatic injury. Ann Surg. 2008;248:429-437. Abstract
  3. Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351:13-22. Abstract
  4. de Jong JT, Komproe IH, Van Ommeren M, et al. Lifetime events and posttraumatic stress disorder in 4 postconflict settings. JAMA. 2001;286:555-562. Abstract

Interviewer Affiliation: Laurie Barclay, MD, is a freelance reviewer and writer for Medscape.

Interviewee Affiliation: Doug Zatzick, MD, Associate Professor, University of Washington, School of Medicine, Seattle, Washington; Director, Attending Consult Services, Harborview Medical Center, Seattle, Washington

Disclosure for Interviewer: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Disclosure for Interviewee: Doug Zatzick, MD, has disclosed no relevant financial relationships.

Filed under: trauma, Uncategorized, ,

Vitamin D and mental disorders linked

Kate Benson October 8, 2008

A lack of vitamin D has long been linked to depression, but researchers believe it may contribute to psychiatric conditions such as personality disorders and post-traumatic stress disorder.

A study of more than 50 patients at a private psychiatric clinic in Geelong found that almost 60 per cent were suffering a severe vitamin D deficiency and 11 per cent were moderately deficient, prompting researchers to question whether vitamin D supplements could reduce mental illness across the board.

The study, published in the Australian And New Zealand Journal Of Psychiatry, found the 53 patients, who suffered bipolar disorder, depression, post-traumatic stress disorder or schizo-affective disorder, had vitamin D serum levels about 29 per cent lower than a group with no mental illness.

This story was found at: http://www.smh.com.au/articles/2008/10/07/1223145432802.html

Filed under: trauma, Violence, , , ,

Brain Cells Related To Fear Identified, Paving The Way For More Effective Treatment Of Post-Traumatic Stress And Other Anxiety Disorders

ScienceDaily (July 11, 2008)— The National Institute of Mental Health estimates that in any given year, about 40 million adults (18 or older) will suffer from some form of anxiety disorder, including debilitating conditions such as phobias, panic disorders and post-traumatic stress disorder (PTSD).


It is estimated that nearly 15 percent of U.S. soldiers returning from Iraq and Afghanistan develop PTSD, underscoring the urgency to develop better treatment strategies for anxiety disorders.  These disorders can lead to myriad problems that hinder daily life – or ruin it altogether – such as drug abuse, alcoholism, marital problems, unemployment and suicide.

Functional imaging studies in combat veterans have revealed that the amygdala, a cerebral structure of the temporal lobe known to play a key role in fear and anxiety, is hyperactive in PTSD subjects. Potentially paving the way for more effective treatments of anxiety disorders, a recent Nature report by Denis Paré, professor at the Center for Molecular and Behavioral Neuroscience at Rutgers University in Newark, has identified a critical component of the amygdala’s neural network normally involved in the extinction, or elimination, of fear memories. Paré’s laboratory studies the amygdala and how its activity impacts behavior. His research was published online by Nature on July 9, 2008 and is scheduled to appear in the print edition later in July.

Earlier research has revealed that in animals and humans, the amygdala is involved in the expression of innate fear responses, such as the fear of snakes, along with the formation of new fear memories as a result of experience, such as learning to fear the sound of a siren that predicts an air raid.

In the laboratory, the circuits underlying learned fear are typically studied using an experimental paradigm called Pavlovian fear conditioning. In this research model on rats, a neutral  stimulus such as the sound of a tone elicited a fear response in the rats after they heard it paired with an noxious or unpleasant stimulus, such as a shock to the feet. However, this conditioned fear response was diminished with repetition of the neutral stimulus in the absence of the noxious stimulus. This phenomenon is known as extinction. This approach is similar to that used to treat human phobias, where the subject is presented with the feared object in the absence of danger.

Behavioral studies have demonstrated, however, that extinction training does not completely abolish the initial fear memory, but rather leads to the formation of a new memory that inhibits conditioned fear responses at the level of the amygdala. As such, fear responses can be expressed again when the conditioned stimulus is presented in a context other than the one where extinction training took place.

For example, suppose a rat is trained for extinction in a grey box smelling of roses, and later hears the tone again in a different box, with a different smell and appearance.  The rat will show no evidence of having been trained for extinction. The tone will evoke as much fear as if the rat had not been trained for extinction.

“Extinction memory will only be expressed if tested in the same environment where the extinction training occurred, implying that extinction does not erase the initial fear memory but only suppresses it in a context-specific manner,” notes Paré.

Importantly, it has been found that people with anxiety disorders exhibit an “extinction deficit,” or a failure to “forget.” However, until recently, the mechanisms of extinction have remained unknown.

As reported by Nature, Paré has found that clusters of amygdala cells, known as the intercalated (ITC) neurons, play a key role in extinction. His findings indicate that ITC cells inhibit amygdala outputs to the brain stem structures that generate fear responses. Indeed, Paré and his collaborators have shown that when ITC cells are destroyed with a targeted toxin in rats, extinction memory is impeded, mimicking the behavior seen in PTSD.

 The significance of this finding derives from earlier results suggesting that PTSD reflects an extinction deficit and that the amygdala is hyperactive in this disorder. As a result, it might be possible to compensate for this abnormality and facilitate extinction with pharmacological interventions that enhance the excitability of ITC cells to inhibit amygdala outputs.

Paré’s research is supported by a $1,487,897 grant from the National Institute of Mental Health. The research project was carried out in collaboration with Rutgers graduate students Ekaterina Likhtik and John Apergis-Scoute, post-doctoral student Daniela Popa, and research assistant G. Anthony Fidacaro.


Adapted from materials provided by Rutgers University.

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