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Vol. LXI, No. 4
February 20, 2009
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Forum Explores Post Traumatic Stress

Dr. Joel Scholten
Dr. Joel Scholten

A recent Staff Training in Extramural Programs (STEP) forum in Natcher Bldg. explored “Post Traumatic Stress Disorder: What Are the Facts?”

A devastating anxiety disorder, PTSD can occur after experiencing or witnessing combat, abuse and assault, terrorist attacks, accidents or natural disasters.

“Post traumatic stress disorder patients are 6 times more likely to attempt suicide than the general population,” said Dr. Terence Keane of the behavioral science division at the National Center for PTSD.

PTSD affects millions of Americans every year. Symptoms include nightmares and flashbacks, emotional numbing, avoidance and agitation.

Keane presented diagnostic tools and outlined risk factors such as event severity, poor social support, adverse childhood events, gender (women being at higher risk) and low socioeconomic status.

PTSD has a number of comorbidities (diseases that occur along with it) and it’s important to tease these apart. Keane explained how alcoholism or depression, for example, might precede PTSD, accompany onset or follow it.

Focusing on military PTSD, major depression and traumatic brain injury (TBI), Dr. Lisa Jaycox of the Rand Corp. cited nearly 20 percent of service members and veterans who have returned from Operations Iraqi Freedom and Enduring Freedom as having “a current mental health condition.”

In this otherwise healthy young cohort, “exposure to combat trauma is the best predictor for both PTSD and depression,” she said.

PTSD can cause long-term damage to a veteran’s health, career and relationships. Yet while we know more than ever about treatment, 47 percent of veterans with PTSD or depression did not seek care; of those who did, half did not receive even “minimally adequate” services.

In addition, 57 percent of those reporting a probable TBI while deployed say they were never evaluated by a doctor for a brain injury.

Gaps in access and quality of care are “substantial.” These issues, said Jaycox, go beyond Department of Defense and Veterans Administration health systems. She called for more research, more effective care and more care providers.

“It’s a pipeline issue,” she said.

Reviewing PTSD among civilians, Dr. Dean Kilpatrick of the Medical University of South Carolina explained “why we should care.”

Not only are civilians the vast majority of the U.S. population, but also civilians of all ages, including children, experience events that can cause PTSD.

PTSD panelists Dr. Lisa Jaycox (l) and Dr. Dean Kilpatrick PTSD panelists Dr. Dennis Charney (l) and Dr. Terry Keane

PTSD panelists include (from l) Dr. Lisa Jaycox, Dr. Dean Kilpatrick, Dr. Dennis Charney and Dr. Terry Keane.

“Exposure to violence among adolescents and young adults is not rare,” he said. “What is rare is finding someone who has only been exposed to one type of event.”

The more one is exposed, the greater the likelihood one will have other disorders such as depression, substance abuse and delinquency.

“You watch them 7 years later, and 1 out of 5 have been revictimized,” he said.

The initial injury “impairs their ability to size up danger,” he continued. “It’s an independent risk factor.”

In studies of American prisoners of war in North Vietnam, Mt. Sinai Medical Center’s Dr. Dennis Charney offered moving portraits of human resilience.

A more recent study of Special Forces candidates showed neurochemical response patterns to acute stress. In the junctions, or synapses, between nerve endings were genetic variations that influenced neurotransmitters—chemicals in our bodies that affect mood and ability to cope.

“We’re going to develop a list of genes that add to vulnerability on one hand,” he said, “and resilience, on the other, to extreme stress.”

He also offered “the resilience prescription,” which included optimism, “cognitive reappraisal” and a supportive social network.

What of clinical implications for TBI and PTSD?

Dr. Joel Scholten of the VA showed that while most of the TBIs in the U.S. are caused by falls, accidents and assaults, the most common cause in active duty personnel is blasts.

There are 1.4 million TBIs in the U.S. per year. Around 85-90 percent are mild, but mild doesn’t mean harmless.

A TBI can result in problems with cognition, behavior and emotion. Patients may also suffer from physical problems such as chronic headache, dizziness and blurred vision.

The overall frequency of symptoms is greater with blast than, say, car accident.

“There’s something about the blast,” Scholten said. Moreover, “the most common symptoms of mild TBI and PTSD are identical,” he said.

PTSD and TBI can co-exist, even in the absence of a memory of the event. This makes evaluation “very, very challenging, because you rely on the patient’s self-reported history, and it may be 5 years after deployment,” Scholten added.

Treatment includes medication and cognitive behavioral therapy. But much still needs to be done.

For example, “no medications are specifically FDA-approved for either TBI or PTSD sleep disturbance,” Scholten said, calling for an interdisciplinary, team approach.

“[Patients] just want to be young and healthy and back to normal,” he said. “We need to find one clinical entity—for example, headache—to draw them in and get them involved in their care.” NIHRecord Icon

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