Scanning invisible damage of PTSD, brain blasts

By LAURAN NEERGAARD, AP Medical Writer Lauran Neergaard, Ap Medical WriterTue Nov 10, 3:02 am ET

WASHINGTON – Powerful scans are letting doctors watch just how the brain changes in veterans with post-traumatic stress disorder and concussion-like brain injuries — signature damage of the Iraq and Afghanistan wars.

It'swork that one day may allow far easier diagnosis for patients —civilian or military — who today struggle to get help for these largelyinvisible disorders. For now it brings a powerful message: Problems toooften shrugged off as "just in your head" in fact do have physicalsigns, now that scientists are learning where and how to look for them.

"There's something different in your brain," explains Dr. Jasmeet Pannu Hayes of Boston University, who is helping to lead that research at the Veterans Affairs' National Center for PTSD. "Just putting a real physical marker there, saying that this is a real thing," encourages more people to seek care.

Up to one in five U.S. veterans from the long-running combat in Iraq and Afghanistan is thought to have symptoms of PTSD. An equal number are believed to have suffered traumatic brain injuries, or TBIs — most that don't involve open wounds but hidden damage caused by explosion's pressure wave.

Manyof those TBIs are considered similar to a concussion, but becausesymptoms may not be apparent immediately, many soldiers are exposedmultiple times, despite evidence from the sports world that damage canadd up, especially if there's little time between assaults.

"Mybrain has been rattled," is how a recently retired Marine whom Hayesidentifies only as Sgt. N described the 50 to 60 explosions heestimates he felt while part of an ordnance disposal unit.

Hayes studied the man in a new way, tracking how water flows through tiny, celery stalk-like nerve fibersin his brain — and found otherwise undetectable evidence that thosefibers were damaged in a brain region that explained his memoryproblems and confusion.

It's a noninvasive technique called "diffusion tensor imaging" that merely adds a little time to a standard MRI scan.Water molecules constantly move, bumping into each other and thenbouncing away. Measuring the direction and speed of that diffusion innerve fibers can tell if the fibers are intact or damaged. Those fibersare sort of a highway along which the brain's cells communicate. Thebigger the gaps, the more interrupted the brain's work becomes.

"Sgt. N's brain is very different," Hayes told a military medical meeting last week. "His connective tissue has been largely compromised."

There'sa remarkable overlap of symptoms between those brain injuries and PTSD,says Dr. James Kelly, a University of Colorado neurologist tapped tolead the military's new National Intrepid Center of Excellence. It will open next year in Bethesda, Md., to treat both conditions.

Yes, headaches are a hallmark of TBI while the classic PTSD symptomsare flashbacks and nightmares. But both tend to cause memory andattention problems, anxiety, irritability, depression and insomnia.That means the two disorders share brain regions.

AndHayes can measure how some of those regions go awry in the viciouscycle that is PTSD, where patients feel like they're reliving a traumainstead of understanding that it's just a memory.

Whathappens? A brain processing system that includes the amygdala — thefear hot spot — becomes overactive. Other regions important forattention and memory, regions that usually moderate our response tofear, are tamped down.

"The good news is this neural signal is not permanent. It can change with treatment," Hayes says.

Her lab performed MRI scanswhile patients either tried to suppress their negative memories, orfollowed PTSD therapy and changed how they thought about their trauma.That fear-processing region quickly cooled down when people followedthe PTSD therapy.

It's work that hasimplications far beyond the military: About a quarter of a millionAmericans will develop PTSD at some point in their lives. Anyone candevelop it after a terrifying experience, from a car accident or hurricane to rape or child abuse.

Moreresearch is needed for the scans to be used in diagnosing either PTSDor a TBI. But some are getting close — like another MRI-based test thatcan spot lingering traces of iron left over from bleeding, thussignaling a healed TBI. If the brain was hit hard enough to bleed, thenmore delicate nerve pathways surely were damaged, too, Kelly notes.

  

  

January 26, 2009

Post Traumatic Stress, Addiction Go 
Hand in Hand

  

PTSD affects nearly 8 million Americans due to war, rape, gang violence, hurricanes, and more.

By Laurah Neergaard

Associated Press

  

WASHINGTON (AP) -- Reaching for a cigarette to cope with a flashback is all too common among sufferers of post-traumatic stress disorder. The nicotine hit may feel good but scientists say its brain action probably makes their PTSD worse in the long run.

Here's the rub: At least half of PTSD sufferers smoke, and others wind up dependent on alcohol, anti-anxiety pills, sometimes even illegal drugs. Yet too few clinics treat both PTSD and addictions at the same time, despite evidence they should.

Now studies are recruiting PTSD patients - from New England drug-treatment centers to veterans clinics in North Carolina and Washington - to determine what combination care works.

"It's kind of a clinical myth that you can only do one at a time or should only do one at a time," says Duke University PTSD specialist Dr. Jean Beckham, a psychologist at the Durham, N.C., Veterans Affairs Medical Center. "Everybody's afraid to have their patients quit smoking because they're afraid they're going to get worse. There's not a lot of empirical data about that."

And her research on how to break the nicotine-and-PTSD cycle raises a provocative question for a tobacco-prone military: Are people at higher risk of developing PTSD if they smoke before they experience the violent event or episode?

Post-traumatic stress disorder - which can include flashbacks, debilitating anxiety, irritability and insomnia - is thought to affect nearly 8 million Americans at any given time. Anyone can develop it after a terrifying experience, from a mugging to a hurricane, a car crash to child abuse. But PTSD is getting renewed attention because so many veterans returning from combat in Iraq and Afghanistan seem vulnerable. A study last year by the RAND Corp. research organization estimated nearly 20 percent of them, or 300,000 people, have symptoms of PTSD or major depression.

What's less discussed is that patients often don't realize they might have PTSD and try to relieve symptoms by self-medicating with alcohol, tobacco and other substance use - worsening habits that existed before the trauma or starting anew.

Addiction itself is a mental health disorder that causes changes in some of the same brain areas disrupted by mood and anxiety disorders like PTSD, says a new report on the co-illnesses from the National Institute on Drug Abuse. That argues for simultaneous treatment. Indeed, up to 60 percent of people in addiction treatment are estimated to have PTSD - although they seldom acknowledge symptoms - and they're three times more likely than other patients to drop out.

A handful of studies suggest combo care helps. One example: VA researchers in Connecticut gave the alcoholism drugs naltrexone and disulfiram to PTSD patients, and watched not only their drinking ease but their PTSD symptoms improve, too.

Then there's nicotine. It temporarily enhances attention when it hits the brain - one reason that members of military tell the VA's Beckham they smoke. Although PTSD patients say a cigarette helps their mood when they're having symptoms, the extra attention may be reinforcing bad memories.

"If you think about your traumatic event and you smoke your cigarette, you can think about it even better," explains the VA's Beckham.

Yet the NIDA report found combination care rare, partly because of our specialty-driven health system.

Another big reason: "The majority of people with PTSD don't seek treatment," Dr. Mark McGovern of Dartmouth Medical School told a NIDA meeting this month that brought together military and civilian experts to jump-start research.

"People try to swallow it or take care of it on their own and it just kind of gets out of control," agrees Bryan Adams, 24, who is working with the Iraq and Afghanistan Veterans of America to raise PTSD awareness.

Adams, now a business major at Rutgers University, was awarded a Purple Heart after being shot when his Army patrol was ambushed in Iraq in 2004. Back home he handled restlessness and irritability with increasing alcohol use. Only when he got into college did a checkup lead to a PTSD diagnosis and therapy. He quit excessive drinking as the PTSD improved, despite no formal alcohol treatment.

The new studies may prompt more merging of care:

-In Durham, Beckham is giving PTSD-suffering smokers either a nicotine patch or a dummy patch to wear for three weeks before they quit smoking. The theory: Steady nicotine release will blunt a cigarette's usually reinforcing hit to the brain, possibly helping both withdrawal symptoms and the intensity of PTSD symptoms.

-In some New Hampshire and Vermont substance-abuse clinics, McGovern is randomly assigning patients to standard addiction-only care or cognitive behavioral therapy traditionally used for PTSD. A pilot study found the cognitive behavioral therapy improved both PTSD symptoms and substance use.

-In Seattle, researchers at the VA Puget Sound Health Care System have PTSD therapists conducting smoking cessation therapy in the same visit. In a pilot study, those patients were five times more likely to quit cigarettes than PTSD patients sent to separate smoking programs.

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EDITOR's NOTE - Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

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PTSD: The Suffering Continues for Vets

  

The Vietnam War Put PTSD on the Map—It Has Not Gone Away

  

PUBLIC HEALTH

Harvard Medical Review

http://focus.hms.harvard.edu/2008/032108/public_health.shtml

Posttraumatic stress disorder (PTSD) did not officially exist when several Vietnam War veterans took the head of the U.S. Department of Veterans Affairs (VA) hostage in his own office one morning in 1975. Equipped with C-rations, portable toilets, and evidence, they hammered the door shut. They wanted his undivided attention to tell him the stories of the many returning soldiers who shared a distressing syndrome of nightmares, flashbacks, and anger that was driving some to suicide.

  

 
After that tactic did not succeed, their counseling group leaders took the vets and their case to meet with the chair of the American Psychiatric Association task force that was revising the psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Add the post-Vietnam syndrome to the next edition, they urged. This worked, eventually. PTSD entered the psychiatric lexicon in the 1980 DSM-III.

With that imprimatur, Congress passed legislation requiring the VA to provide mental health services and specialized PTSD treatment programs. Now, decades later, military and civilian mental health professionals can draw on evidence-based treatment and practice guidelines. The VA places a high priority on treating PTSD among returning Iraq and Afghanistan veterans. In contrast to the delayed diagnoses and services for Vietnam vets, experts are urging immediate postwar screening and preventive interventions.

Despite these advances, PTSD remains a legacy of Vietnam veterans. Almost 30 years after their return from Vietnam, 10 percent of veterans continue to experience severe PTSD symptoms, report Karestan Koenen, HSPH assistant professor of society, human development, health, and epidemiology, and her co-authors in the February Journal of Traumatic Stress.

“Our findings demonstrate that exposure to combat during the Vietnam War continues to place veterans at risk for a wide variety of adverse psychological and social outcomes,” Koenen and her colleagues write. “Persisting PTSD was associated with worse family functioning, more smoking and drinking, less life satisfaction and happiness, more mental health service use, and more nonspecific health complaints.”

The study helps fill the gap in understanding the long-term outlook of combat-related PTSD. The longitudinal follow-up study has implications for the new generation of war veterans and their health care providers.

Defining the Disorder 
March 20 marked the five-year anniversary of the United States–led invasion of Iraq by a multinational coalition. “What was planned as a short and decisive intervention in Iraq has become a grueling counterinsurgency that has put American troops into sustained close-quarters combat on a scale not seen since the Vietnam War,” The New York Times reported on Dec. 16, 2004, in a front page story titled, “A deluge of troubled soldiers is in the offing, experts predict.”
In a 2006 paper, a survey of 238,938 Army and Marine personnel returning from the Middle East found that 19 percent of those serving in Iraq and 11 percent of those serving in Afghanistan reported symptoms of PTSD and other mental health problems. The new study by Koenen provides a potential scenario of what the future may hold for them.

Koenen and her colleagues investigated factors and impacts related to PTSD over time as part of a larger project characterizing exposure to herbicides in Vietnam. The project is headed by co-author Jeanne Mager Stellman, now at the State University of New York Downstate Medical Center.

”Countless numbers of people have spent their lives suffering and don't know how or why to seek help.”

The data come from 1,377 people in a random sample of 12,000 American Legionnaires in six states who served in Vietnam or its surrounding waters or airspace between 1961 and 1975 and returned questionnaires. Stellman and her colleagues first surveyed them in 1984 and repeated the process in 1998.
The same definition of PTSD applied at both times. The disorder requires exposure to a traumatic event, such as combat, plus three clusters of symptoms—re-experiencing the traumatic event, avoidance of traumatic reminder and emotional numbing, and hyperarousal.

In 1994, the definition of trauma expanded to include people reacting with fear, helplessness, and horror not just to a traumatic experience of their own, but to news of a trauma experienced by someone else, said Richard McNally, professor and director of clinical training at the Harvard University Psychology Department. McNally served on the core committee overseeing that and other changes in the current version of the psychiatric manual, DSM-IV, but now he argues that the definition of trauma is so broad that the PTSD diagnosis has become misleading and ineffective for the larger population now included. This controversy does not apply to combat, which remains an unequivocal qualifying stressor, McNally said.

The Persistence of PTSD 
In Koenen’s study, the overall prevalence of severe PTSD dropped from 11.8 percent in 1984 to 10.5 percent in 1998. Among individuals, about half met PTSD criteria both times. High combat exposure was the strongest predictor for PTSD at both times.

The results from the Legionnaires cohort are consistent with a re-analysis of data from the National Vietnam Veterans Readjustment Study in Science in 2006. Using raw data from one-on-one interviews and cross-checking with military records, the researchers found 19 percent of the 1,200 vets had developed PTSD during their lifetimes and 9 percent were still suffering 11 to 12 years after the war. Koenen was a co-author on that paper, which appeared in Science two years ago.

It is hard to compare and contrast the different studies. They were conducted with different methods and on different populations. Koenen and her co-authors consider the Legionnaires the “best-case scenario,” because they are living in the community and functioning well enough to join a veterans’ support organization.

“Our data show a lifelong cost of war, ” said Stellman, who estimates the actual figures may be higher. “One of the hallmarks of PTSD is withdrawal and avoidance. Countless numbers of people have spent their lives suffering and don’t know how or why to seek help. ”

A recent report on trends in VA treatment of PTSD in the journal Health Affairs seems to confirm their findings. From 1997 to 2005, mental-health–service use among veterans of the Persian Gulf era has greatly increased, especially in the last five years and among younger veterans. Veterans from early service eras surprised researchers with a fivefold increase in use, especially among Vietnam vets with PTSD. The system is straining at the seams, the researchers observed. The increased demand seems to be met by fewer visits per veteran.

“The vast majority of men who served in the Vietnam theater are now in the 47- to 66-year age group and represent almost 13 percent of their generation,” Koenen writes. “This group’s demands on the health care system will likely increase as they age.” The brunt of the burden for diagnosing and referring veterans with PTSD is likely to fall on primary care providers, Koenen and others predicted.

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