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