Scientists find heightened attention to surprise in veterans with PTSD
January 9, 2018
Science Daily/Virginia Tech
Scientists have found that people with PTSD have an increased learning response to surprising events. While most everyone reacts to surprise, people with PTSD tend to pay even more attention to the unexpected.
Fireworks on nights other than the fourth of July or New Year's Eve might be nothing more than inconsiderate neighbors, but for veterans with Post Traumatic Stress Disorder (PTSD), the shock of noise and light may trigger a deeply learned expectation of danger.
Scientists at the Virginia Tech Carilion Research Institute (VTCRI) have found that people with PTSD have an increased learning response to surprising events. While most everyone reacts to surprise, people with PTSD tend to pay even more attention to the unexpected.
The study was published this week in eLife, an open-access journal published by the Howard Hughes Medical Institute, the Max Planck Society, and the Wellcome Trust.
"Disproportionate reactions to unexpected stimuli in the environment are a core symptom of PTSD," said Pearl Chiu, an associate professor at the VTCRI and the lead author on the study. "These results point to a specific disruption in learning that helps to explain why these reactions occur."
Chiu and her team used functional MRI to scan the brains of 74 veterans, all of whom had experienced trauma while serving at least one combat tour in Afghanistan or Iraq. Some of the study participants were diagnosed with PTSD, while others were not. In the functional MRI, participants played a gambling game, in which they learned to associate certain choices with monetary gains or losses.
"Computer science and mathematics have given us new tools to understand how the brain learns. We used these tools to study whether and how learning might play a role in PTSD," said Chiu, who is also an associate professor of psychology in Virginia Tech's College of Science. "These results suggest that people with PTSD don't necessarily have a disrupted response to unexpected outcomes, rather they pay more attention to these surprises," Chiu said.
The researchers found that people with PTSD had significantly more activity in the parts of their brains associated with how much attention they paid to surprising events when the learning task threw an unexpected curve ball their way.
"Fireworks unexpectedly going off after a person has exchanged fire in the field can trigger an over-estimation of danger," said Brooks King-Casas, an associate professor at the VTCRI who co-led the study. "Particularly for individuals with PTSD, unexpected surprising events -- noise or otherwise -- could be a matter of life or death. The study shows that while everyone is affected by unexpected events, in PTSD extra attention is given to these surprises."
King-Casas is also an associate professor of psychology in Virginia Tech's College of Science and an associate professor in the Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences.
Earlier studies have connected greater attention to perceived threats and unexpected events in PTSD, but the mechanistic underpinning of this hypersensitivity to unexpected outcomes have been unclear until now.
"The work by Brown and colleagues is an important step forward to be able to differentiate the brain and behavioral processes that are affected as a consequence of post-traumatic stress," said Martin Paulus, a medical doctor and the scientific director and president of the Laureate Institute for Brain Research in Tulsa, Oklahoma. He was not involved in this study. "The finding that individuals with PTSD have difficulty appropriately allocating attention to their environment when it changes has clear implications for the development of novel behavioral interventions."
Vanessa Brown, first author on the paper and a graduate student in the department of psychology in Virginia Tech's College of Science, said that both the behavioral and neural findings show that people with PTSD pay more attention to surprise while learning.
"This disrupted learning increases with more severe PTSD," said Brown, who is conducting her dissertation research in Chiu's laboratory at the VTCRI. "Now that we understand how attention to surprise plays a role in PTSD, we may be able to refine our assessment tools or develop new interventions that target specific learning disruptions in people with PTSD or other psychiatric disorders."
https://www.sciencedaily.com/releases/2018/01/180109090251.htm
Veterans with PTSD have an increased 'fight or flight' response
May 15, 2017
Science Daily/The Physiological Society
Young veterans with combat-related post-traumatic stress disorder (PTSD) have an increased 'fight or flight' response during mental stress, according to new findings.
The team at Emory University School of Medicine, led by Dr Jeanie Park, believe that this contributes to the increased risk of high blood pressure and heart disease in PTSD patients.
PTSD is prevalent in both military and civilian populations. The lifetime prevalence of PTSD in US adults is 7.8% and around 14% in post-9/11 veterans. PTSD patients are known to have a higher risk for developing high blood pressure and cardiovascular disease.
The researchers also found that veterans with PTSD had higher adrenaline levels and less control of their heart rate in response to blood pressure changes. While previous studies have suggested that the sympathetic nervous system- the 'fight or flight' response- of veterans is overactive, this study was the first to measure this increased activity directly and provide a potential mechanism behind this response.
Dr Park and her team took these measurements while the participants experienced two types of mental stress. First-person war images and sounds shown through virtual reality goggles recreated mental stress related to PTSD. Mental arithmetic elicited mental stress un-related to PTSD.
They studied the physiology of post-9/11 veterans, 14 of whom had PTSD and 14 who did not. They measured blood pressure, performed an electrocardiogram (EKG), and recorded sympathetic nerve activity directly in real-time using electrodes placed inside a large nerve. This technique is called microneurography and is considered the gold-standard method for assessing sympathetic nervous system activity in humans.
Commenting on the study, Dr Park said: 'To protect patients against high blood pressure and heart disease, we need to first understand how their physiology malfunctions. We can then identify potential treatments.'
'This study looked specifically at veterans with combat-related PTSD, so the findings do not necessarily apply to non-veterans with PTSD, nor to patients with non-combat-related PTSD,' she added.
https://www.sciencedaily.com/releases/2017/05/170515091210.htm
Hope for veterans with an overlooked form of post-traumatic stress disorder
Clinical study finds excellent treatment response to standard psychotherapy in veterans with subclinical PTSD
March 17, 2016
Science Daily/Medical University of South Carolina
In an article published in the March 2016 issue of the Journal of Anxiety Disorders, investigators in the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina (MUSC) report that veterans who fall just below the threshold for a diagnosis of post-traumatic stress disorder (PTSD) respond to a psychotherapy regimen better than those with full PTSD. The study highlights the need to recognize veterans suffering from an overlooked condition called subclinical PTSD. "The study shows not only that we can treat those experiencing subclinical presentations of PTSD, but also that those with subclinical PTSD may actually respond better to treatment than those with more severe forms of the disease," says MUSC investigator Kristina Korte, Ph.D., who is the first author on the article. MUSC co-authors include Ron Acierno, Ph.D., Daniel F. Gros, Ph.D., and Nicholas P. Allan, MS.
Just like patients with full PTSD, those with subclinical PTSD have experienced a traumatic event and are regularly re-experiencing it, often in nightmares or flashbacks. Patients with full PTSD also experience hyperarousal (i.e., they are easily startled) and avoid reminders of the event, for example by withdrawing from social interaction or turning to substance abuse. In addition re-experiencing the event, patients with subclinical PTSD may exhibit either hyperarousal or avoidance, but not both.
Psychologists began noticing this pattern more frequently in the nineties in veterans returning from the first Iraq War, and even more frequently in veterans returning from Iraq and Afghanistan in the last decade. As researchers have learned more about these patients over time, varying and sometimes conflicting symptoms have provided an incomplete picture of the disorder and how to treat it. Further confounding the issue is that those with subclinical PTSD are often excluded from clinical trials testing treatments for PTSD--patients with only some symptoms of PTSD commonly aren't included in the healthy control group or in the group with full PTSD. As a result, there is still no standard psychotherapy for treating subclinical PTSD as there is for full PTSD.
The researchers devised an intuitive approach -- Why not treat subclinical PTSD patients with one of the standard evidence-based psychotherapy tools already being used in PTSD patients? They enrolled 200 patients with combat-related PTSD symptoms from the Ralph H. Johnson VA Medical Center located adjacent to MUSC, identifying those with either subclinical or full PTSD. For eight weeks, patients received intensive weekly sessions of behavioral activation and therapeutic exposure therapy, designed to lessen their PTSD symptoms by helping them safely re-experience and resolve elements of the original trauma. Psychologists rated the patients' PTSD symptoms and had patients rate their own symptoms before, during, and after the eight weeks.
The results were encouraging. Those with subclinical or full PTSD each experienced a real drop in PTSD symptoms after treatment. The striking result was in how much those symptoms dropped: 29% in those with subclinical PTSD as compared to 14% with full PTSD.
It may seem obvious that patients with a less severe form of PTSD would respond better to standard psychotherapy, but the implications for treatment extend beyond that. PTSD symptoms often worsen over time; as they do, treatments become less effective at reducing symptoms. In this context, subclinical PTSD could be seen as "early-stage" PTSD, in that treatment might be more effective when the disorder is caught early.
Gros' group hopes these early studies can move beyond men in combat to civilians of both sexes.
"It is our hope that providing treatment for subclinical PTSD could have a significant impact on the cost-effectiveness of treating this common disorder," says Korte. "It could lead to the prevention of more intractable forms of PTSD that can occur when subclinical PTSD goes untreated."
https://www.sciencedaily.com/releases/2016/03/160317084553.htm
Impact of sleep disturbance on recovery in veterans with PTSD and TBI
August 21, 2015
Science Daily/Boston University Medical Center
Poor sleep may impact treatment and recovery in veterans with Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI). A review of extensive research on sleep in TBI and PTSD has found that sleep-focused interventions can improve treatment outcomes in veterans.
Led by researchers at Boston University School of Medicine (BUSM) and VA Boston Healthcare System, the review article currently appears online in the journal of Clinical Psychology Review.
Sleep difficulty is a primary symptom of both PTSD and TBI and has been found to affect the severity of both conditions. TBI patients can suffer from permanent sleep problems regardless of the severity of their initial injury. Approximately 40 to 65 percent of individuals have insomnia after mild TBI, while patients with sleep difficulties are at a higher risk of developing PTSD. Despite recent attention, sleep has been understudied in the veteran population.
The review found that poor sleep often persists in veterans after resolution of their PTSD and mild TBI symptoms, but few treatments and rehabilitation protocols target sleep specifically. "In these veterans, sleep disturbances continue to adversely impact daily functioning and quality of life. "PTSD, TBI, and sleep problems significantly affect functional status and quality of life in veterans returning from combat," explains lead author Yelena Bogdanova, PhD, assistant professor of psychiatry at BUSM add VA title.
According to the researchers sleep is critical for restorative processes and evaluation of sleep problems should be integral to the clinical management of PTSD and TBI. "Understanding sleep problems and their role in the development and maintenance of PTSD and TBI symptoms may lead to improvement in overall treatment outcomes," added Bogdanova. "Future research efforts," she proposes, "should target the development of sleep-focused interventions."
http://www.sciencedaily.com/releases/2015/08/150821111053.htm
Cures for PTSD often remain elusive for war veterans
August 4, 2015
Science Daily/NYU Langone Medical Center / New York University School of Medicine
New light shed on the 'invisible wounds of war'
Our nation's veterans continue to suffer emotional and psychological effects of war -- some for decades. And while there has been greater attention directed recently toward post-traumatic stress disorder, and more veterans are seeking help, current psychotherapy treatments are less than optimal, according to a new narrative review.
In a review of medical literature over a 35-year period, researchers from the Steven and Alexandra Cohen Center for Post-Traumatic Stress and Traumatic Brain Injury -- a program in the Department of Psychiatry at NYU Langone Medical Center -- and other institutions found that non-medical approaches to treat PTSD were effective in some patients but not in others, suggesting a need for broader, more personalized approaches to care.
The researchers looked at randomized clinical trials of psychotherapy for military-related PTSD to examine which psychotherapies improve symptoms. This included, in particular, a review of trials of two commonly-used, evidence-based treatment models: cognitive processing therapy (CPT) and prolonged exposure (PE) therapy.
Searches were conducted via PubMED, PsycINFO, and PILOTS for randomized clinical trials of individual and group psychotherapies for PTSD in military personnel and veterans published from January 1980 to March 2015. Of 891 publications initially identified, 36 were included in the JAMA Narrative review, representing 2,083 participants.
"Our findings showed that PE and CPT are not as broadly effective as we might have once thought or hoped," says Maria M. Steenkamp, PhD, assistant professor of psychiatry at NYU Langone and lead author of the study. "As many as two-thirds of veterans receiving CPT or PE keep their PTSD diagnosis after treatment, even if their symptoms improve. So there is room for improvement."
"The emotional effects of war are gaining attention," says Charles R. Marmar, MD, the Lucius Littauer Professor and chair of psychiatry at NYU Langone, director of its Cohen Veterans Center, and the senior author of the JAMA study. "And there are veterans from all wars who are struggling, not just those who most recently served in the wars in Iraq and Afghanistan."
In fact, recently released findings from another study led by Dr. Marmar and published July 22, 2015 in JAMA Psychiatry --the National Vietnam Veterans Longitudinal Study--found that over 270,000 Vietnam veterans -- 40 years since the end of that war -- are still suffering from clinically important levels of PTSD symptoms, and one-third of those have a current, major depressive disorder.
"There is a pressing need for innovation in treatments for PTSD and TBI to protect a new generation of veterans," adds Dr. Marmar.
Dr. Steenkamp suggests that the JAMA study indicates there is still much to learn about how to optimize PTSD treatments of veterans. "It is clear that there is no one-size-fits-all approach," she says. "Ideally, we have to move toward clinical options that match patients to treatments, based on their preferences and their comfort with talking about their trauma. One thing we do know is that veterans are unlikely to benefit unless they complete a full course of treatment. Finding ways to develop treatments that align with patient needs and preferences is important."
The U.S. Veterans Administration and the U.S. Department of Defense have been funding such approaches to treatment, Dr. Marmar says. "There are encouraging findings that while therapies that focus on processing trauma are generally effective for veterans who complete that course of treatment, there are alternatives for veterans who are emotionally unprepared to confront their war-zone experiences," he adds.
Understanding the underlying mechanisms that occur in specific patients is key. A novel five-year multicenter study led by NYU Langone's Cohen Veterans Center is looking into objective biological markers of PTSD and TBI in returning soldiers of the wars in Iraq and Afghanistan. The goal is to transform the way mental health disorders are diagnosed by identifying specific brain imaging and blood and other biological markers that can tell clinicians definitively that a person is suffering from PTSD or TBI or a combination. Presently, there is no single valid diagnostic test that can independently confirm either diagnosis. Stanford University, Emory University and the U.S. Department of Defense Systems Biology Program at Fort Detrick, Maryland are partners in this research.
"Collectively, these studies may bring us one-step further in tailoring treatment to the individual, monitoring progress, and measuring long-term effectiveness," Dr. Marmar says.
http://www.sciencedaily.com/releases/2015/08/150804142738.htm
Some Vietnam vets currently have PTSD 40 years after war ended
July 22, 2015
Science Daily/The JAMA Network Journals
While it has been 40 years since the Vietnam War ended, about 271,000 veterans who served in the war zone are estimated to have current full posttraumatic stress disorder (PTSD) plus subthreshold war-zone PTSD and more than one-third have current major depressive disorder, according to an article.
The study by Charles R. Marmar, M.D., of the New York University Langone Medical Center, and colleagues builds on the National Vietnam Veterans Readjustment Study (NVVRS), which was implemented from 1984 through 1988 (about 10 years after the war ended). The authors' National Vietnam Veterans Longitudinal Study (NVVLS) is the first follow-up to NVVRS. There were 1,839 veterans from the original study still living at the time of the NVVLS from July 2012 to May 2013 and 78.8 percent (n=1,450) of the veterans participated in at least one phase of the study.
The authors estimate a prevalence among male war zone veterans of 4.5 percent for a current PTSD diagnosis based on the Clinician-Administered PTSD Scale for DSM-5; 10.8 percent based on that assessment plus subthreshold PTSD; and 11.2 percent based on the PTSD Checklist for DSM-5 items for current war-zone PTSD. Among female veterans, the estimates were 6.1 percent, 8.7 percent and 6.6 percent, respectively.
The study also found coexisting major depression in 36.7 percent of veterans with current war-zone PTSD.
About 16 percent of war zone Vietnam veterans reported an increase of more than 20 points on a PTSD symptom scale while 7.6 percent reported a decrease of greater than 20 points on the symptom scale. "An important minority of Vietnam veterans are symptomatic after four decades, with more than twice as many deteriorating as improving," the study notes.
The authors conclude: "Policy implications include the need for greater access to evidence-based mental health services; the importance of integrating mental health treatment into primary care in light of the nearly 20 percent mortality; attention to the stresses of aging, including retirement, chronic illness, declining social support and cognitive changes that create difficulties with the management of unwanted memories; and anticipating challenges that lie ahead for Iraq and Afghanistan veterans," the study concludes.
Editorial: Measuring the Long-Term Impact of War Zone Military Service
In a related editorial, Charles W. Hoge, M.D., of the Walter Reed Army Institute of Research, Silver Spring, Md., writes: "This methodologically superb follow-up of the original NVVRS cohort offers a unique window into the psychiatric health of these veterans 40 years after the war's end. No other study has achieved this quality of longitudinal information, and the sobering findings tell us as much about the Vietnam generation as about the lifelong impact of combat service in general, relevant to all generations."
http://www.sciencedaily.com/releases/2015/07/150722115520.htm
High risk of sleep apnea in young veterans with PTSD
May 19, 2015
Science Daily/American Academy of Sleep Medicine
The probability of having a high risk of obstructive sleep apnea increased with increasing severity of post-traumatic stress disorder symptoms (PTSD), a new study of young US veterans shows. The study involved 195 Iraq and Afghanistan veterans who visited a Veterans' Affairs outpatient PTSD clinic for evaluation. Results show that 69.2 percent of participants had a high risk for sleep apnea, and this risk increased with PTSD symptom severity.
The study involved 195 Iraq and Afghanistan veterans who visited a VA outpatient PTSD clinic for evaluation. Results show that 69.2 percent of participants had a high risk for sleep apnea, and this risk increased with PTSD symptom severity. Every clinically significant increase in PTSD symptom severity was associated with a 40 percent increase in the probability of screening as high risk for sleep apnea.
"The implication is that veterans who come to PTSD treatment, even younger veterans, should be screened for obstructive sleep apnea so that they have the opportunity to be diagnosed and treated," said co-principal investigator Sonya Norman, PhD, researcher at the San Diego VA, director of the PTSD Consultation Program at the National Center for PTSD, and an associate professor of psychiatry at the University of California San Diego School of Medicine. "This is critical information because sleep apnea is a risk factor for a long list of health problems such as hypertension, cardiovascular disease and diabetes, and psychological problems including depression, worsening PTSD and anxiety."
The American Academy of Sleep Medicine reports that obstructive sleep apnea is a common sleep disease afflicting at least 25 million adults in the U.S. Sleep apnea warning signs include snoring and choking, gasping or silent breathing pauses during sleep. The AASM and other partners in the National Healthy Sleep Awareness Project, which is funded by the Centers for Disease Control and Prevention, urge anyone with symptoms of sleep apnea to visit http://www.stopsnoringpledge.org to pledge to "Stop the Snore" by talking to a doctor.
The study idea was initiated by Tonya Masino, MD, who was the first to recognize that a surprising number of younger veterans who were coming to the clinic for PTSD treatment also were presenting with sleep apnea symptoms. Study results are published in the May 15 issue of the Journal of Clinical Sleep Medicine.
Ninety-three percent of study participants were men, and their mean age was 33 years. Sleep apnea risk was evaluated using the Berlin Questionnaire, and PTSD was assessed using the PTSD Checklist Stressor Specific Version (PCL-S) questionnaire. Analyses controlled for potential confounders such as older age, smoking status, and use of central nervous system depressants.
According to the authors, younger veterans with PTSD are rarely screened for sleep apnea and frequently remain undiagnosed. They noted that the mechanism underlying the relationship between sleep apnea and PTSD in military veterans is unclear. However, potential factors that may connect the two disorders include disturbed sleep in combat, prolonged sleep deprivation, sleep fragmentation and hyperarousal due to the physical and psychological stressors of combat, the chronic stress from PTSD, or the sleep disturbances caused by OSA. Longitudinal studies are needed to examine the temporal relationship between sleep apnea and PTSD.
The study was led by Norman and co-principal investigator Abigail Angkaw, PhD. The lead author of the study is Peter Colvonen, PhD.
According to the National Center for PTSD of the U.S. Department of Veterans Affairs, PTSD symptoms such as nightmares or flashbacks usually start soon after a traumatic event, but they may not appear until months or years later. Symptoms that last longer than four weeks, cause great distress or interfere with daily life may be a sign of PTSD. To get help for PTSD, veterans can call the Veterans Crisis Line at 1-800-273-8255 and press 1, text 838255, contact a local VA Medical Center, or use the online PTSD program locator on the VA website.
http://www.sciencedaily.com/releases/2015/05/150519182243.htm