Complex PTSD, STAIR, Social Ecology and lessons learned from 9/11- a conversation with Dr. Marylene Cloitre

Dr. Marylene Cloitre is the Associate Director of Research of the National Center for PTSD Dissemination and Training Division and a research Professor of Psychiatry and Child and Adolescent Psychiatry at the New York University, Langone Medical Center in New York City. She is a recipient of several honors related to her service in New York City following 9-11 and was an advisory committee member for the National September 11 Memorial Museum. She has specific expertise in complex PTSD and for the development and dissemination of STAIR (Skills Training in Affective and Interpersonal Regulation), a psychological therapy designed to help survivors of trauma.

Dr. Jain: What exactly is complex PTSD?

Dr. Cloitre:
Complex PTSD has a very long history, really pushed primarily by clinicians who looked at their patients and thought there’s something more going on here than PTSD.
In DSM-4, complex PTSD was recognized in the additional features where there is a mix of problems related to emotion regulation, self-concept and interpersonal relationships. After that, there was really no funding around investigating this further and the research for it has been spotty and it was sort of dying on the vine.

But with the development of a new version of ICD-11, there was an opportunity really to refresh consideration about complex PTSD. I was part of a work group that started in 2012, we looked at the literature and thought there seems to be enough data to support two different forms of PTSD , the classic fear circuitry disturbance and then this more general kind of disturbance in these three core areas of emotion regulation, self-concept and interpersonal relationships.

We proposed that there should be two distinct disorders: PTSD and complex PTSD and it looks like it’s been accepted and it will part of the ICD-11 coming out in the 2018.

Since the initial proposal, I’ve been working with many people, mostly Europeans, where ICD is more prominent than in the United States and there are now about nine published papers providing supporting evidence that these two distinct disorders.

Dr. Jain:
Can you summarize in which ways they’re distinct? So on a clinical level what would you see in complex PTSD?

Dr. Cloitre: Mostly we’ve been looking at latent class analysis which is a newish kind of data analytic technique which looks at how people cluster together and you look at their symptom profile. There are a group of people who very distinctly have PTSD in terms of re-experiencing, avoidance and hyperarousal and then they’re fine on everything else. Then you have another group of people who have these problems as well as problems in these three other areas.And then there are another group of people who, despite exposure to trauma, do fairly well.

What we’ve been seeing are these three groups in clinical populations as well as in community populations and adults as well as in children.

Overall, these latent class analyses are really showing that people cluster together in very distinctly different ways. I think the important thing about this distinction is, what’s next? Perhaps there are different clinical interventions that we want to look at to maximize good outcome. Some people may do very well with exposure therapy. I would say the PTSD clustered folks will do very well and have optimal outcome because that’s all that bothers them. For the other folks, they have a lot of other problems that really contribute to their functional impairment.

For me as a clinician as well as a researcher, I’ve always been worried not so much about the diagnosis of the person in front of me but about how well they’re functioning in the world. What I have noticed is you can get rid of the PTSD symptoms, for people with complex PTSD, but they’re still very impaired.
My motivation for thinking about a different diagnosis and different treatment is to identify these other problems and then to provide interventions, that target these other problems, for the goal of improving our day to day life functioning. If you don’t have ability to relate well to people because you mistrust them or are highly avoidant or if you think poorly about yourself these are huge issues then we need to target these issues in treatment.

Dr. Jain
Have you noticed that different types of trauma contribute to PTSD v complex PTSD?

Dr. Cloitre Yes, it does and it kind of makes sense that people who have had sustained and repeated trauma (e.g. multiple and sustained trauma doing childhood) are the ones who have complex PTSD.

Dr. Jain: Can you tell us a little bit about the fundamental philosophy that drove you to come up with STAIR and what evidence is there for it’s effectiveness?

Dr. Cloitre I came to develop STAIR as a result of paying attention to what my patients were telling me they wanted help with, that was the driving force. It wasn’t a theoretical model, it was that patients came and said,” I’m really having problems with my relationships and that’s what I need help with” or “I really have problems with my moods and I need help with that”.

So, I thought, why don’t we start there? That is why I developed STAIR and developed it as a sequence therapy while respecting the importance of getting into the trauma and doing exposure based work, I also wanted to engage the patient and respect their presented needs. That what it’s all about for me.
Overtime I saw a secondary benefit, that an improved sense of self and improved emotion regulation could actually impact the value of exposure therapy in a positive way.

In my mind, the real question is: What kind of treatments work best for whom? That is the question. There will be some people for whom going straight to exposure therapy is the most effective and efficient way to get them functioning and they’ll be happy with three or four sessions, just like some 9/11 survivors I saw. They only needed three or four sessions.

Other people might do better with combination therapies .

Dr. Jain The studies that you’ve done with STAIR can you summarize the populations you have used it for?

Dr. Cloitre: I began using STAIR + exposure with the population I thought would most need it which is people with histories of childhood abuse. In fact, our data show that the combination of skills training, plus exposure was significantly better than skills alone or exposure alone. So that’s very important. It also reduced dropout very significantly as compared to exposure, which is a continuing problem with exposure therapy especially for this population

Dr. Jain Can you speak to the social ecology/social bonds and PTSD, what the research world can tell us about the social dimensions of PTSD and how we can apply this to returning military members and veterans?

Dr. Cloitre: I think that social support is critical to the recovery of people who have been exposed to trauma and who are vulnerable to symptoms .We have enough studies showing that it’s the critical determinant of return to health.

I think we have done a very poor job of translating this observation into something meaningful for returning veterans. There is general attention that families are part of the solution and communities are part of the solution but it is vague –there isn’t really a sense of what are we going to do about it.

I think these wars (Afghanistan and Iraq) are very different than Vietnam, that’s where soldiers came back and they were called baby killers and had tomatoes and garbage thrown at them. You can really understand why a vulnerable person would spiral downwards into pretty significant PTSD and substance abuse.

I think we need to be more thoughtful and engage veterans in discussions about what’s most helpful in the reintegration progress, because there are probably really explicit things like, being welcomed home, but also very subtle things that we haven’t figured out about the experience.
I think on a community or family level, there’s a general awareness but we haven’t really gotten clear thinking or effective about what to do. I think that’s our next step. The parade and the welcome home signs are not enough.

I’ll give an example of what I witnessed after 9/11. The community around survivors feels awkward and doesn’t know what to do, so they start moving away. Combine this with the survivor who is sad or being irritable and so not the most attractive person to engage with. I say to patients sometimes, it’s a really unfair and unfortunate circumstance, that in a way, not only are you suffering but you’re also kind of responsible for making people around you comfortable with you.

I used to do STAIR because patients ask for it and also I thought,” oh well some people never had these social skills in the first place, which is why they are vulnerable with PTSD” but then I noticed that STAIR was useful for everybody with PTSD because I think the traumatized patient has an unfair burden to actually reach out to people in a process of re-engagement because the community and the family is confused. Others, strangers or say employers are scared. So they have to kind of compensate for the discomfort of others, which is asking a lot.

I think in our therapies we can say look, it’s not fair, but people feel uncomfortable around the veteran. They don’t know how to act and in a way you not only have to educate yourself about your circumstance but, in the end, educate others.

Dr. Jain Survivor perception of social support really matters. If you take a group of disaster survivors, we may feel well we’re doing this for them and we’re doing that for them but if the survivors, for whatever reason, don’t perceive it as being helpful it doesn’t matter. When I think about marginalized populations in our society, I don’t think to communicate to others about how to help you or how to support you is that simple.

Dr. Cloitre It’s very complicated because it is a dynamic. I think we need to talk to trauma survivors and understand what their needs are so that the community can respond effectively and be a match. Not everybody wants the same thing. That’s the real challenge. I think if survivors can be a little bit more compassionate, not only towards themselves for what they have been through but to others who are trying to communicate with them and failing.

Dr. Jain That can be hard to do when you’re hurting. The social ecology of PTSD is really important but it’s really complicated and we are not there, in terms of harnessing social ecology to improve lives.

Dr. Cloitre No. I think we’re just groping around in the dark, in a room that says the social ecology of PTSD is important. We don’t know how to translate that observation into actionable plans either in our individual therapies or in our family therapies and then in our community actions or policies.
But I do think that, in the individual therapy, recognizing the importance of trying to enhance perception of support where they’re real. Secondly, recognizing the burden that they have that’s unfair and try to enhance skills for communicating with people. Thirdly, having compassion for people who are out there who are trying to communicate but failing.
I have had a lot of patients who come, into therapy, and say,
” This is so ridiculous. They’re saying stupid things to me”.
And, I say,
“well at least they’re trying”
I think it’s important for the affected community to have the voice and take leadership, instead of people kind of smothering them with social support that they may or may not need.

Dr. Jain
I know you’re a native New Yorker and you provided a lot of service to New York City following 9/11. Can you speak about that work? And in particular what I’m really interested in is that body of research that emerged after 9/11 because I feel like that has helped us understand so much about disaster related PTSD.

Dr. Cloitre We found out was most people are very resilient. We were able to get prevalence rates of PTSD following 9/11, that in of itself was very important. I think that’s the strongest research that came out.

I think on a social level it broke open awareness, in this country and maybe globally, about the impact of trauma and about PTSD because it came with very little shame or guilt.
Some people say what was so different about 9/11? Well, because it happened to the most powerful country and the most powerful city then if it could happen to them it could happen anywhere. That was the response, there was not this marginalization, ”Well this is a victim circumstance and it couldn’t happen to me and they must have done something to bring it on themselves”.
There was a hugely different response and that was so key to the shift in recognition of the diagnosis of PTSD which then led to more general research about it. I think that that was huge.
Before 9/11, I would say I do research in PTSD and people would say, what is that? Now I say I do research in PTSD, not a single person ever asks me what that is. I mean I’m sure they don’t really know what it is but they never looked confused. It’s a term that is now part and parcel of American society.
9/11 revolutionized the awareness of PTSD and also the acceptability of adverse effects, as a result of trauma. There was new knowledge gained and also just a transformation in awareness that was national and probably global because the impact it had and the ripple effects on another countries.
I think those are the two main things.
I don’t think it’s really done very much for our thinking about treatment. I think we continue to do some of our central treatments and we didn’t get too far in really advancing or diversifying.
For me personally, I learned a lot about the diversity of kinds of trauma survivors. Very different people, very different reactions.
I think probably the other important academic or scholarly advance, was in the recognition of this blend of loss and trauma and how they come together. That people’s responses to death ,under circumstances of unexpected and violent death, has also advanced. In fact now ICD-11 there will be a traumatic grief diagnosis, which I think has moved forward because of 9/11. That’s pretty big.

Psilocybin as a treatment for cancer patients who are not depressed: the NYU study

psilocybinThe well orchestrated promotion of a modest and misrepresented pair of studies of using psilocybin with cancer patients raises lots of issues and should leave lots of people embarrassed.

A breakdown in peer review allowed unmoderated and misleading statements about the studies to appear in commentaries from an impressive array of leading psychiatrists. They embarrassed themselves by claiming the studies were well-designed trials and that the patients were clinically depressed.

There was a breakdown in the press’s evaluation of press releases from the studies, with journalists embarrassing themselves by passing on outrageously self-congratulatory statements by the authors without independently checking them. Journalists covering the story almost exclusively drew on a rich set of promotional materials from the authors’ institutions and added little else.

A lot of commentators in the social media, especially Twitter, embarrassed themselves by tweeting and liking others’ tweets with unbridled, uncritical enthusiasm for the claims of the authors. They obviously did not read the papers or read them carefully.

From the 1960s, the United States has had an irrational policy of criminalizing use of psilocybin. The articles and publicity campaign do not directly challenge this policy or call for decriminalization. Rather, they propose establishing a loophole by which people of means can obtain a diagnosis of adjustment disorder from a psychiatrist, receive a prescription for psilocybin (4-phosphoryloxy-N,N-dimethyltryptamine), and purchase an elaborate ceremony with lots of pseudoscientific trappings and mystical explanations. Use by others outside of this context will remain criminalized.

The publicity campaign can be seen as a larger effort by psychiatry to define dying as a mental health issue, routinely requiring their specialty expertise and services.

The articles’ justification for the trials runs roughshod over the existing literature, exaggerating psychiatric aspects of cancer, and minimizing the needs and preferences of cancer patients.

Hopefully, by the end of this blog and the next, I will convince readers that my assessments are more reasonable than they first appear.

Although published in a pay wall journal, both articles were made freely available, along with some of the laudatory comments, mostly from psychiatrists.

The first article is

Ross S, Bossis A, Guss J, Agin-Liebes G, Malone T, Cohen B, Mennenga SE, Belser A, Kalliontzi K, Babb J, Su Z. Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: a randomized controlled trial. Journal of Psychopharmacology. 2016 Dec 1;30(12):1165-80.

The trial’s freely available registration at ClinicalTrial.gov is available here.

In this first of two blog posts, I will center on this study. However, a forthcoming blog post will focus on the second article, comparing and contrasting it to another study in methods and interpretation :

Griffiths RR, Johnson MW, Carducci MA, Umbricht A, Richards WA, Richards BD, Cosimano MP, Klinedinst MA. Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of Psychopharmacology. 2016 Dec 1;30(12):1181-97.

The trial’s available registration is at ClinicalTrial.gov is available here. https://clinicaltrials.gov/ct2/show/NCT00465595

Distortions in coverage of the literature in the introduction to Ross et al study at NYU

 The introduction states:

Enduring clinically significant anxiety and/or depressive symptoms are common in patients with cancer, present in 30–40% of patients in hospital settings (Mitchell et al., 2011).

I debated Alex Mitchell, the author of this review to a packed audience at the International Association for Psycho-oncology meeting in Rotterdam.  Here are my slides.

I pointed out that these estimates are of self-reported symptoms, not clinical diagnoses, which is substantially lower. Although there is a modest elevation in self-reported symptoms immediately after diagnosis, there is a trajectory of rapid decline. Only about 12% of patients have heightened distress at six months, and is likely that many of those that do, had pre-existing psychological disorders or past histories. After the initial stress of a diagnosis, rates of distress among patients in an oncology waiting room approximate the rates of patients in primary care waiting rooms.

These symptoms are associated with a variety of poor outcomes, including medication non-adherence, increased health care utilization, adverse medical outcomes, decreased quality of life, decreased social function, increased disability, hopelessness, increased pain, increased desire for hastened death, increased rates of suicide, and decreased survival rates (Arrieta et al., 2013; Brown et al., 2003; Jaiswal et al., 2014).

These correlations are not established as causal, and mostly come from cross-sectional studies. Residual confounding and reverse causality are highly likely. Patients with more debilitating physical symptoms inadequately controlled pain register more distress. There is no evidence that treating depression increases survival rates or slows progression.

The introduction goes on to mention that effects of antidepressants have a slow onset and they are incompletely effective. The author should have noted that antidepressant treatment would be inappropriate for the patients with adjustment disorders that dominated their study sample.

…With a growing body of evidence linking higher levels of existential/spiritual wellbeing (in cancer patients) with improved quality of life and decreased depression/hopelessness/suicidality (Breitbart et al., 2000; McClain et al., 2003; Nelson et al., 2002), the need to develop effective therapeutic approaches to mitigate this domain of distress has become increasingly recognized within the disciplines of palliative care and psycho-oncology.

Hold on! The authors are introducing some pretty shabby research that psychiatrists should be addressing existential/spiritual well-being.Since when are existential/spiritual well-being issues psychiatric?

A number of manualized “existentially oriented psychotherapies” for cancer patients have been developed to address these existential/spiritual issues, with some empirical support from clinical trials (Lemay and Wilson, 2008), and several of these approaches were integrated into the therapy platform developed for this study.

I will pick up on this discussion in my next blog post. But in a previous blog post, I examined the largest trial (with 441 palliative care patients) for one of these “existential/spiritual” therapies.

That study found no differences in 22 different measures of distress (!) between a mental health professional delivering an existential/spiritual “dignity therapy” over standard palliative care or a client centered care delivered by a nurse. Nonetheless, in New York, you can find expensive continued education courses offered by psychiatrist for this dignity therapy.Having been evaluated in a large clinical trial does not necessarily make a treatment “evidence-based,” particularly when it only achieved no findings.

One of the problems acknowledged in that trial is that only a small proportion of palliative care patients had clinically significant anxiety and depression scales. This study is a particularly interesting comparison compared to the study of psilocybin for cancer patients. Palliative care patients in the larger study are arguably more confronting of an impending death than the patients in the psilocybin study. Yet the authors of the psilocybin study make a broad assumption that end-of-life is a time of considerable distress and a mental health issue.

Methods and results of the Ross et al study at NYU

Patients in the NYU Psilocybin Cancer Anxiety Study begin their hallucinatory experience wearing eyeshades and headphones as doctors encourage them to bear witness to an inner world - Photo and description provided by NYU Alumni News
Patients in the NYU Psilocybin Cancer Anxiety Study begin their hallucinatory experience wearing eyeshades and headphones as doctors encourage them to bear witness to an inner world – Photo and description provided by NYU Alumni News

Representing only about a third of the patients screened for the study, 29 patients were randomized to either psilocybin or niacin (vitamin B3) in a cross over design. The randomized patients were highly educated and almost half had a history of use of hallucinogens. Almost all patients (93%) indicated “white” as their race. No patients endorsed black, Hispanic, Asian, or Native American. All but five patients had diagnoses of adjustment disorder, and these other five had diagnoses of general anxiety disorder. Although about two thirds of the patients had stage III or stage IV cancer, the rest had stage I or stage II. is not clear why they allow such heterogeneity of patients expected survival time in their study. I suspect they had trouble recruiting patients.

Regardless, my immediate observation is that this is a highly unrepresentative sample. For psychiatry journal, it would usually be considered a misrepresentation to use “anxiety “ and “depression” in a title when we’re sample did predominantly not have diagnoses of major depression in clinical anxiety disorders. When did you last see “life-threatening” in the title of a paper in an oncology or even psycho-oncology journal? With the title, we already are seeing a bit of dramatization in the service of attracting more attention than a more accurate and conventional title.

Any sense of a double blinded study is undone by the use of niacin as a comparison/control. Patients would shortly discover whether they had been given vitamin B3 or a hallucinogenic drug in any research assistants would notice the difference.

The abstract mentions that the psilocybin and the vitamin B3 were administered after a preparatory psychotherapy session. The therapy was then delivered at during both the psilocybin and vitamin B3 treatments. Thus, that this is not simply treatment with psilocybin, but with a psilocybin/psychotherapy combination. There is not even minimal description of this psychological treatment in the article.

However,  if you go to the NYU Alumni Magazine, you’ll find an extensive interview and photos of some of the investigators. You’ll learn that both psilocybin and vitamin B3 are administered with a special ceramic chalice. Description of the psychotherapy is certainly what you would not expect for a manualized therapy. But the following section of the article is enlightening:

The NYU Psilocybin Cancer Anxiety Study is conducted in a serene space that seems more like someone’s living room than part of a bustling research clinic. There’s a couch strewn with ethnic-printed pillows, shelves stocked with oversize books of Tibetan art, framed landscape photographs, warm pools of lamplight, Buddha figurines, and, on dosing days, fresh fruit and flowers.

Notwithstanding the lovely room, psilocybin does present risks. Although it is not known to induce addiction, overdose, or withdrawal symptoms, some research has suggested it can bring about prolonged psychosis in people with a personal or family history of major mental illness, so such patients are carefully screened out of the study. In the session itself, there may be some physical side effects, such as nausea, dizziness, and tremors, but the more pronounced hazards are psychological. Periods of transient anxiety can occur as patients navigate the challenging psychological material related to cancer. More extreme reactions, such as paranoia and panic, can occur, but are rare and safeguarded against through careful preparation and a highly structured therapy session, much of which is influenced by the rituals of indigenous cultures that utilize psychedelic medicines.

Subjects start with a series of meetings with a male-female therapist dyad to build trust, establish familiarity, and set intentions. On the dosing day—there is one for placebo and one for the real thing, set seven weeks apart—a small container of psilocybin synthesized in a government-monitored laboratory and weighed daily according to strict DEA regulations is taken from an 800-pound safe. Twenty milligrams of powder, an amount precisely judged to increase the likelihood of a mystical experience, are measured and pressed into a pill, which subjects swallow from a ceramic chalice.

The drug starts to take hold after about half an hour and the subjects are encouraged to put on eyeshades and headphones, lie down, and ride the waves of music on a carefully curated playlist. The therapists sit quietly nearby. There’s often sobbing and sometimes laughter. After a few hours, subjects usually remove their eyeshades and start bearing witness to the inner world they’ve traversed.

This investigator’s New Age depiction of mechanism falls short of conventional scientific standards”

“People come out with an acceptance of the cycles of life,” Bossis says. “We’re born, we live, we find meaning, we love, we die, and it’s all part of something perfect and fine. The emergent themes are love, and transcending the body and this existence. In oncology, we’re pretty good at advancing life and targeting chemotherapies, but we’re not so good at addressing deep emotional distress about mortality. So to see someone cultivate a sense of acceptance and meaning, something that we all hope to cultivate over a 90-year life, in six hours? It’s profound.”

This study evaluated as a clinical trial

This study is grossly underpowered study, involving an unrepresentative sample of 29 patients whose only diagnosis was an adjustment disorder, with the exception of a few patients with generalized anxiety. Diagnoses of adjustment disorders are not validated nor have they received extensive study. If a patient has some distress with recent onset and they want to see a mental health professional, they can be given a diagnosis of adjustment disorder to justify treatment. For a while, that was a common practice in the Netherlands, but treatments billed for adjustment reactions are no longer allowed.

I’m sure where I got this phrase, but I sometimes refer to adjustment disorder as an acute compensatory reaction of psychiatrists seeking to bill for services.

The idea that this is a blinded trial is ridiculous. Very soon after administration of the drug,  patients and clinical and research staff knew whether the patients had received psilocybin or vitamin B3.

chalice used in studyA chalice was used to administer both psilocybin and vitamin B3. Once patients became unblinded by noticing any effects of the drug they had been given, the chalice added to the sense of this supposed to be a mystical experience. There is more than a little hokum in play.

We’re told little about the psychotherapy, but enough to reveal that it has strong nonspecific factors and should induce strong positive expectations.

Crossover designs provide weak evidence, particularly ones that are readily unblinded and if we are interested in any effects of the first treatment after the crossover. Patients immediately realized in the first session whether they were assigned to psilocybin or vitamin B3. Awareness of their first treatment assignment further unblinded them to the next phase of the trial. Patients who received psilocybin in the first session (and clinical and research staff assigned to them) knew that they were going to get. Because psilocybin was expected to have lasting effects, it would be predicted that patients assigned to the vitamin B3 in the second session would nonetheless exhibit the lowered self-reported symptoms, due to the effects of earlier psilocybin. So what was the point?

The crossover design means that any expected natural decline in distress will be folded into effect of treatment. That is, it’s well-known that the distress of cancer patients has a strong natural declining trajectory. That natural decline in distress will be interpreted as part of the effects of the treatment.

For each of the six primary outcome measures (HADS T, HADS A, HADS D, BDI, STAI S, STAI T), there were significant differences between the experimental and control groups (prior to the crossover at 7 weeks post-dose 1) with the psilocybin group (compared to the active control) demonstrating immediate, substantial, and sustained (up to 7 weeks post-dosing) clinical benefits in terms of reduction of anxiety and depression symptoms. The magnitude of differences between the psilocybin and control groups (Cohen’s d effect sizes) was large across the primary outcome measures, assessed at 1 day/2 weeks/6 weeks/7 weeks post-dose 1.

And:

Compared to the control, psilocybin produced mystical-type experiences, consistent with prior trials of psilocybin administration in normal volunteers (Griffiths et al., 2006, 2008, 2011).

Conflict of interest

 The authors declared no conflict of interest. However they indicate that a private foundation advocating use of psilocybin funded the study and professionals associated with this foundation provided preliminary review of the manuscript before it was published.

The foundation’s involvement in the funding study in vetting of the manuscript does not necessarily invalidate results reported in the manuscript, but readers have the right to be informed of this potential conflict of interest.

Coming up next: the Johns Hopkins study and integrated discussion

 Undoubtedly, ingesting psilocybin in a setting in which expectations are well structured can be a positive experience. I can say that from experience. Yet it is criminalized in the United States to sell, purchase, or ingest psilocybin. The study seems clearly aimed at creating a loophole for cancer patients who engaged psychiatrists. What’s wrong with that? What’s wrong with anybody being able to obtain psilocybin of assured purity and consume it in a pleasant safe environment with a knowledgeable guide whom they trust?

Suppose the cancer patient was a skeptic like myself and did not want to submit to the mumble jumble psychotherapy offered in this trial. Particularly if they were experienced taking psychedelics, as almost half of the patients were in the study, shouldn’t they be able to go to a primary care physician and get a prescription for psilocybin of known doses and purity, and go home and take it with a trusted friend or two? What if someone did not have cancer, but like many patients in primary care waiting rooms, had distress elevated to the degree that participants in the study did. Should they be allowed to self-administer psilocybin?

It’s a wise idea to take psilocybin with a knowledgeable friend in a context conducive to a good experience. Why should somebody have to involve a psychiatrist? People experience was psilocybin are aware in someone else’s experience is becoming anxiety provoking, and can usually appropriately distract them away and into a more pleasant experience.

It’s a wise idea not to go scuba diving alone, but to be accompanied by a knowledgeable friend. Should scuba divers also be required to take their psychiatrists along?

Okay, you as a reader may personally have no interest in taking psilocybin out of the presence of a psychiatrist anymore than having any interest in scuba diving, with or without a psychiatrist. You may even object to people doing so and considerate it foolish. But should the people, whether suffering from cancer or not, taking psilocybin at home with friends be subject to steep fines and jail time

We will next discuss the other study of psilocybin administered to cancer patients. We will also examine the larger issues of the commentaries that accompanied this set of articles and the press coverage that they were given.

In the meantime and afterwards, I certainly welcome back talk in comments on this blog.

 

 

 

 

 

 

 

 

The Golden Years: Traumatic Stress and Aging – An Interview with Joan Cook

Dr. Joan Cook is a clinical psychologist and Associate Professor in the Yale School of Medicine, Department of Psychiatry. She has specific expertise in the areas of traumatic stress and geriatric mental health. Dr. Cook has served as the principal investigator on four grants from the National Institute of Mental Health, as well as grants from the Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute. She is a member of the American Psychological Association (APA) Guideline Development Panel for PTSD and is the 2016 President of APA’s Division of Trauma Psychology.

 

Recently, I spoke with Dr. Cook about PTSD in older adults.

 

source: pexels
source: pexels

Dr. Jain: Can you comment on the unique methodological considerations for researchers doing PTSD research in the elderly?

 

Dr. Cook: There are a number of methodological considerations that researchers who want to study older traumatized individuals might want to think about beforehand. One issue in working with this current cohort of older (65 and above) adults is their potential denial or minimization of reporting of trauma and related symptoms. For some individuals in this current cohort, their traumas may have preceded the 1980 introduction of posttraumatic stress disorder (PTSD) into the official diagnostic classification. Thus they may associate more stigma or blame themselves for having experienced such event and/or having subsequent symptoms.

 

I think events such as the September 11th terrorist attacks, the wars in Iraq and Afghanistan, and Hurricane Katrina, have helped raise the national consciousness about trauma. But I still clinically come across older adults who lack an understanding of the potential effects of traumatic experiences or don’t accurately label such events as “traumatic.” In addition, there are also cognitive, sensory, and functional impairments that may affect the experience, impact, or reporting of trauma-related symptoms.

 

Dr. Steven Thorp, Heather Sonas and I (2011) provided some recommendations for conducting trauma and PTSD-related assessment and treatment with older survivors. This includes practical issues like the need for large, bold fonts in written assessment or therapy materials to increase readability and minimize frustration, using specific behaviorally anchored questions to assess for traumatic events, and the benefits of using more than one method of assessment (e.g., self-report, observation, caregiver report, and structured interviews).

 

source: pexels
source: pexels

Dr. Jain: Can you discuss the findings of Intimate Partner Violence (IPV) rates (and related PTSD) in older women versus younger women? How might these findings be explained (e.g. reporting bias, less public awareness, lack of resources to help older women)?

 

Dr. Cook: I’m so glad you asked this question! This is a topic that is near and dear to my heart. I’ve done a little research in this area but wish I had time and resources (grant support, interested collaborators) to do more.

 

In general, rates of IPV and related PTSD are lower in older as opposed to younger women. This may be due to more recent violent times in our society, for sure. But it also may be due to an interaction between reporting bias and cohort effects. The current cohort of older women may be less likely both to label IPV as such and to disclose such histories to health care providers. There also appears to be limited public awareness and fewer available services specifically designed for older IPV survivors compared to younger and middle-aged women.

 

A fairly recent systematic review that my colleagues and I conducted found that older women with IPV histories have greater psychological difficulties than older women who do not have these experiences. More specifically we also looked at data from a large nationally representative sample and found that one out of seven older women reported a history of physical or sexual assault, or both. And those who reported this type of traumatic history were generally more likely to meet criteria for past-year and lifetime PTSD, depression, or anxiety than those without such a history. Although IPV does not appear to be a widespread phenomenon in older women, it should not remain a “hidden variable” in their lives. I’d love to see more public attention, research, and clinical endeavors with older traumatized women.

 

Dr. Jain: Much of the studies of PTSD in older populations have been done in Veterans—do you think these findings are applicable to other populations of trauma exposed adults?

 

Dr. Cook: You’re right. The vast bulk of the empirical literature on older adult trauma survivors has been conducted on combat veterans and former prisoners of war. But there is a relatively decent sized research base on older adults who experienced Holocaust-related trauma earlier in their life and individuals who experienced natural or man-made disasters later in life. There is very little research on trauma in aging ethnic and racial minorities and, as explained above, less on physical and sexual abuse in older men and women.

 

I don’t think this means that the findings from the literature can never generalize. That would feel too extreme, right? But I think we need to sometimes exercise caution in our interpretation and recognize the limits of what we can and should say. I’m a researcher. I’m always looking to widen the representativeness of my samples (e.g., men/women, assessing for all types of trauma and a range of mental health and quality of life type outcomes, looking at people from varying SES, racial/ethnic backgrounds, and disability statuses) and to dive more into the nuances or intersectionality of those variables.

 

Dr. Jain: Can you talk about the correlation between PTSD and dementia? How robust are these findings? What other causal factors may be involved? What about the reverse—how does having dementia impact PTSD symptoms?

 

Dr. Cook: This is a hard one for me to answer. It’s intriguing data for sure, but there’s so much we don’t know. We know that older adults with PTSD perform more poorly across a range of cognitive measures, particularly processing speed, learning, memory, and executive functioning compared to older adults without PTSD.

 

Over the years there have been several case reports indicating that dementia may exacerbate existing PTSD symptoms. However in the past few years data from two recent large veteran datasets relatively indicate some evidence for a link between PTSD and dementia. In a sample of 181,000 veterans age 55 and over, those with PTSD were more than twice as likely to develop dementia over a six-year follow-up. In another study, almost 10,000 veterans age 65 and older were categorized according to PTSD status (yes or no) and having received a Purple Heart medal (yes or no). There was a greater incidence and prevalence of dementia in the older veterans with PTSD.

 

Some, however, believe that PTSD and dementia may share a third variable, intelligence, which may account for the link.

 

Dr. Jain: With regards to PTSD and older adults—what do you think are the top 5 questions/priorities for researchers to address in the coming 10-20 years?

 

Dr. Cook: The older adult population is increasing rapidly, and that changing demographic landscape will likely translate to an increased need for mental health services for older adults. Most randomized controlled trials investigating psychotherapy or pharmacotherapy for adults with PTSD do not typically include older individuals or sufficient numbers of them to examine age comparisons. A recent systematic review on psychotherapy for PTSD with older adults identified 13 case studies and seven treatment outcome studies. But this literature is disappointing in some ways. It has significant methodological limitations, including non-randomized research designs, lack of comparison conditions, and small sample sizes. One conclusion from this review was that select evidence-based interventions validated in younger and middle-aged populations appear efficacious with older adults. But while a number of the studies reported that older adults experienced a reduction of PTSD, depression, and anxiety symptoms, few experienced complete remission. It’s currently unclear if those treatments were not delivered in sufficient dose (i.e., intensity and frequency) to produce full benefit or if chronic, severe PTSD is harder to treat in older as opposed to younger adults.

 

Over the past decade there have been several epidemiological studies both in the United States and in several industrialized countries using representative samples of community dwelling adults and examining the prevalence and impact of traumatic experiences and PTSD with sufficient numbers of older adults to examine late-life age effects. Needless to say, this is very exciting and a significant advancement for both the traumatic stress and geriatric mental health fields. Now that we’ve done that I’d love to see more on the experience of trauma and expression of any related distress in the least healthy and potentially most “vulnerable” older adults—those with, physical, emotional, or cognitive impairment; those who are homebound; and long-term care residents.

 

Although the prevalence of full PTSD appears to be relatively low, there is some evidence to suggest that older adults may have clinically important PTSD symptoms. I think it would be great if we could invite subthreshold PTSD in the older adult population as well as trauma-related depression. There is a very robust literature on depression in older adults and only a handful of articles that look at the connection between depression and trauma.

 

Though older adulthood encompasses at least a 30-year age range, the vast majority of studies on older adult trauma survivors lump all of them into a generic older adult group. Ideally I would like to see more fine-grained analyses (even if they are exploratory) on young-old (65–74 years), middle-old (75–84 years) and old-old (85 years and older). This seems to be fairly low hanging fruit that most investigators could try to do.

 

I’ve also included other things in my wish list above.

Perinatal Psychiatry, Birth Trauma and Perinatal PTSD: An Interview with Dr. Rebecca Moore

It is now blatantly clear that a woman’s increased vulnerability to developing PTSD is closely linked to that fact that, when compared to a man, she is much more likely to be the victim of the toxic traumas of childhood sexual abuse, rape, and intimate partner violence. More recently another type of trauma that women are uniquely vulnerable to enduring is garnering increasing attention—the psychological trauma associated with giving birth.

 

Dr. Rebecca Moore is the lead psychiatrist for the Tower Hamlets Perinatal Mental Health service based in London, U.K. Her clinical interests include PTSD and birth trauma, premenstrual dysphoric disorder (PMDD), the treatment of anxiety and depression in the perinatal period, and supporting the parent infant bond. Dr. Moore is passionate about improving services for women traumatized by birth and hosts an annual forum on Birth Trauma in London in December each year. Her goal is to form networks with those working with families with Birth Trauma around the world to share knowledge and innovative practices.

 

I recently spoke with her to understand more about Birth Trauma and PTSD.

 

Dr. Jain: You are a perinatal psychiatrist who specializes in treating psychological aspects of birth trauma. Can you start by talking a little bit about what a perinatal psychiatrist does and why there is a specific need for this type of expertise for pregnant women? Can you comment specifically on your work with immigrant/refugee populations who may have high rates of mental health problems to begin with?

 

Dr. Moore: Perinatal psychiatrists work with women with new onset or preexisting moderate to severe mental health diagnoses through their pregnancy and up to a year after birth.

 

We are community based and work with women and their families to support their mental health through this vulnerable time period. This includes regular outpatient review, community nursing support, psychological support, and expertise around prescribing medication during pregnancy and breastfeeding, alongside monitoring the developing parent infant bond.

 

Perinatal services recognize the fact that for some women, pregnancy is a challenging time period and that certain disorders—Anxiety or Bipolar Disorder, for example—have high rates of relapse.

 

There is an increased risk of suicide after pregnancy, and suicide remains one of the leading causes of maternal death in the first 42 days after birth in the United Kingdom, as highlighted by the last MBRRACE-UK release “Saving Lives, Improving Mothers’ Care – Surveillance of Maternal Deaths in the UK 2011-13.”

 

Perinatal disorders often develop rapidly, and our team provides a rapid specialist response to these crises and can facilitate rapid treatment and admission to local Mother and Baby Units if needed. London has three Mother and Baby Units, but many areas of the country still have no provision at all, such as Wales or Northern Ireland.

 

I work within Tower Hamlets, a very deprived area in East London, with a young population who have higher than average numbers of children. Our population is growing rapidly, it is expected to grow by 26% over the next twenty years, and there is a high birth rate, around 5500 births per year, so the demand on our service grows yearly.

 

50% of our referrals are Bangladeshi women, which reflects our local population. We have a hugely transient population with people moving in and out of our area, and we have women within our service from all over the world who have often been exposed to war or huge trauma. We often work with interpreters and have to be extremely mindful of the cultural and spiritual aspects of our care.

 

Dr. Jain: When researching this topic of Birth Trauma, I ran into some issues regarding definitions: there appears to be considerable variability regarding what this term means. Can you offer a definition of Birth Trauma and also comment on how this is different from Postpartum PTSD?

 

Dr. Moore: You are right, there is not yet any standard diagnostic definition, and this can cause confusion as there is a significant difference between Birth Trauma and Postpartum PTSD regarding symptoms and treatment.

 

When a woman has a traumatic birth, I mean that there was something subjective about the birth that was traumatic. This does not have to be life threatening or medically traumatic. We are thinking of the psychological impact of that birth experience on the mother.

 

Birth Trauma definitions include “a negative and disempowering physiological & emotional response to a birth” or “when an individual (mother, father, or other witness) believes the mother’s or her baby’s life was in danger, or that a serious threat to the mother’s or her baby’s physical or emotional integrity existed.” I love Rachel Yehuda’s use of the term trauma as “a watershed event, an event that kind of divides your life into a before and after.”

 

Common themes include feeling unheard or not listened to, a lack of compassion from medical professionals, and feeling out of control or helpless.

 

Around 25% of all births in the UK are identified by women as being traumatic. This really strikes me, as it is such a high rate. In fact, if we look at the annual birth rate in the United Kingdom, this means around 173,000 women are traumatized after delivering per year.

 

Only 1% of births in the UK result in infant death or life threatening near-miss episodes, indicating that subjective understanding of the birth event is crucial.

 

One third of women present with sub-clinical trauma, and I believe it is essential to perceive trauma responses as being on a continuum.

 

For many women, these birth experiences will never be discussed or explored. Although women may not develop a diagnosable disorder, they will often experience significant levels of distress and symptoms may persist for many years without treatment. There is often a significant impact on women’s future pregnancies and birth experiences, and I have met women who only have one child because their first birth experience was so negative and they cannot contemplate coping emotionally in another pregnancy.

 

When we talk about Postpartum PTSD, we are talking about women who had a traumatic birth who then go on to develop all the diagnostic criteria we would expect in PTSD.

 

Around 1-6% of women who have a traumatic birth will go on to develop a diagnosable clinical episode of PTSD.

 

It’s also important to mention and think about birth partners who can also be traumatized by birth as well as mothers.

 

source: pexels
source: pexels

Dr. Jain: In your experience, what are the common pitfalls surrounding diagnosing Postpartum PTSD? How is it distinguished from the more well-known Postpartum Depression? What are the clinical markers for who is more vulnerable to developing Postpartum PTSD, and what are the associated resiliency factors?

 

Dr. Moore: Unfortunately, this is an issue we see time and time again in clinical practice. Many professionals know little about Birth Trauma or PTSD following birth, and services in the UK are very much focused on identifying Postnatal Depression.

 

If we think about the criteria needed to make a formal diagnosis of PTSD, there are clear differences in the symptoms needed to make a diagnosis of Postnatal Depression.

 

With Postpartum Depression we would look for core symptoms of pervasive low mood or anxiety, fatigue, and anhedonia, with possible altered sleep and appetite or suicidality.

 

In PTSD we would expect to see the key features of avoidance, intrusive memories, labile mood, nightmares, or flashbacks, and taking a history of the birth experience in depth would be key.

 

Research has been carried out into what makes someone more likely to develop PTSD following childbirth. These risk factors can be thought of as those that exist before the birth; the birth itself; and the type of support and care women get after birth.

 

Some women will be more vulnerable to a traumatic birth because of pre-existing problems, such as women with a history of psychiatric problems or previous trauma. There is also evidence that women with a history of trauma will be more vulnerable to PTSD following birth if they have inadequate support and care during the birth.

 

During birth, certain complications or events may be more stressful to women than others. Broadly speaking, women are more likely to get PTSD if they have an emergency cesarean or assisted birth (forceps or ventouse), although PTSD can develop after a vaginal delivery.

 

Other stressful aspects of birth, such as blood loss, a long labor, a high level of pain, or a large number of interventions, are not conclusively related to getting PTSD.

 

Women who feel out of control, helpless, or overwhelmed by events during birth, or who have poor care and support from midwives and doctors, are significantly more likely to get PTSD.

 

Following the birth, support from friends and family, and possibly that from healthcare professionals, may help women resolve their experiences and recover from a traumatic birth.

 

Studies have also highlighted an increased risk of developing postpartum PTSD with a stillbirth, the birth of a baby with a disability resulting from birth trauma, or a baby requiring a stay in the Neonatal Intensive Care Unit (NICU).

 

One of the strongest risk factors we know of is when women dissociate during birth. One woman I worked with spoke of dissociating in pregnancy and “losing all track of time” and “feeling like she was in a fog.” She believed her baby “had been born” and “taken out of the room without her consent” and felt overwhelmingly anxious, until suddenly she looked down and saw her pregnant bump and realized she was still pregnant.

 

The literature regarding resilience is unclear, and we still do not fully understand why some women develop PTSD after birth and some do not. Women come into labor with their own unique genetic make up, personal history, and own expectations of their labor and how it will proceed. To my mind the issue that often makes the most difference regarding the outcome is that psychological expectation and understanding of birth and how it is addressed and handled during labor. I have seen women who had long distressing labors with numerous physical interventions or complications who have not gone on to be traumatized as they have had one amazing healthcare professional with them through the whole process explaining, listening, and comforting them and hearing their fears or wishes voiced.

 

Dr. Jain: It appears to me there are a couple scenarios of how Postpartum PTSD might occur:

A woman already has PTSD (treated or untreated) and the psychological stressors associated with pregnancy/giving birth trigger a relapse of her PTSD symptoms

OR

The actual experience of giving birth is traumatic—either the mother’s life is threatened or she witnesses a threat to the life of her newborn.  This trauma then serves as the stressor, which can, in some cases, lead to PTSD.

Can you speak about other scenarios?

 

Dr. Moore: These are the most common routes to PTSD after birth that we see; the variance is in the individual stories and responses to trauma that we hear.

 

I think it’s important to flag up here that the woman’s life might not actually be in danger, it is her response to events that she perceives as traumatic, so she might have a non life threatening bleed but find that traumatic or it may be the after care that is traumatic—care on the postnatal ward, for example. What medical professionals might class as “normal” may be far from normal to the mother involved. Women have repeatedly spoken to me of this issue.

 

It is important to distinguish between women who feel angry about their birth experience and have irritability and intrusive thoughts about their birth, but who lack the other symptoms of PTSD.

 

Subclinical symptoms are really important in my opinion and incredibly common, and these women may not have diagnosable PTSD but must still be heard and listened to and supported.

 

Dr. Jain: If one does a Google search for Birth Trauma or Postpartum PTSD, it is impossible to ignore the number of self-help organizations, patient advocacy groups, and online support forums that pop up.  Indeed, prevalence statistics for Postpartum PTSD from Western studies are approximately 1 to 3%. From an epidemiological standpoint, this would make it quite common. Yet Postpartum PTSD is something that receives very little attention in medical schools and psychiatry training programs. Is this a case of medical science needing to catch up with what is happening every day on the frontlines?

 

Dr. Moore: Absolutely!

 

I think at present this is a really neglected area of teaching and training whilst being something that affects thousands and thousands of women each year here in England.

 

My sense is that this is changing. Certainly here we are starting to see Birth Trauma being discussed and talked about, and networks of professionals are coming together to push for more training and better awareness.

 

It’s something that I feel really passionate about, and locally I run a Birth Reflections Clinic to allow women to debrief after a traumatic birth and an Annual Birth Trauma Conference in London (this year December 9th 2016, which all are welcome to attend free of charge). I lecture medical students, psychiatrists, health visitors, and midwives, and I feel this is an area that should be a key part of the undergraduate and postgraduate curriculum.

 

Here in the UK we are really fortunate to have some amazing web forums, such as MatExp, which allows members to share best practices and knowledge. There are many excellent blogs by women writing about their own Birth Trauma, such as Unfold Your Wings or Ghostwritermummy, which helps raise awareness. There are also some nice sites sharing good birth experiences, which can be empowering for first time mothers to read and prepare for birth, such as tellmeagoodbirthstory.com.

 

Dr. Jain: Related to this, there appear to be some very real social and systemic phenomenon that may be exacerbating the issue of Postpartum PTSD: Unrealistic images/perceptions of what birth and motherhood should be driven by popular media/culture (similar to the propagation of unrealistic body images for women); the very high tech and invasive medical environment where many women in high income settings give birth; and advances in neonatal care and NICU care that have changed the way we treat and care for premature babies.

 

Dr. Moore: A question that is often asked is whether women have too high expectations of achieving a natural or drug-free birth, contributing to them being traumatized when birth does not go as expected. The answer to this is complex, but research studies point towards it not being the case. Firstly, women’s expectations are found, on average, to be similar to their experiences. That is, if a woman has broadly positive expectations, she is more likely to have a positive experience. Secondly, if unrealistic expectations were linked to PTSD, we might expect to find more trauma responses in first time mothers. This has been found, but subsequent analysis suggests it is due to the higher rate of intervention in these women. Finally, one study looked at this question directly and found that a difference between expectations and experience in the level of pain, length of labor, medical interventions, and level of control was not associated with PTSD symptoms. However, a difference between expected support from healthcare professionals and the level of care experienced was predictive of PTSD symptoms. Women don’t seem necessarily to be traumatized by the events of birth not happening as they expected, but are more affected when they do not receive the care they expect.

 

For many women I meet there is a real lack of honest conversations about the process of birth, and my sense is many women enter their labor emotionally unprepared for what might happen and have high expectations of what they want to happen, which may or may not be realistic.

 

I think there is a much greater need for midwives and obstetricians to have repeated conversations with women about birth and listen to women’s fears, hopes, and preferred choices.

 

The issue that comes up time and time again here is a lack of continuity of care and that women often see a different midwife at each visit, which means that these discussions don’t happen.

 

I personally encourage women to think in depth about their birth and the choices they may or may not like, whilst grounding any discussion in the reality of what might happen.

 

I personally think if women can afford it and would like it, that using an independent midwife or doula can be really beneficial and help provide a constant support and advocate throughout pregnancy and birth.

 

source: pexels
source: pexels

There is also no doubt that medical interventions and having a baby in the NICU play a role in trauma. There is a wealth of literature showing that these mothers and fathers are at increased risk of developing PTSD.

 

In 2013, Youngblut et al looked at parent health and functioning 13 months after infant or child NICU/PICU death. Parents (176 mothers, 73 fathers) of 188 deceased infants/children were recruited from 4 NICUs, 4 PICUs, and state death certificates 2 to 3 weeks after death. Data on parent physical health (hospitalizations, chronic illness), mental health (depression, PTSD, alcohol use), and functioning (partner status, employment) were collected in the home at 1, 3, 6, and 13 months after death. Thirteen months after infant/child death, 72% of parents remained partnered, 2 mothers had newly diagnosed cancer, alcohol consumption was below problem drinking levels, parents had 98 hospitalizations (29% stress related) and 132 newly diagnosed chronic health conditions, 35% of mothers and 24% of fathers had clinical depression, and 35% of mothers and 30% of fathers had clinical PTSD. More Hispanic and black mothers than white mothers had moderate/severe depression at 6 months after infant/child death and PTSD at every time point.

 

Lefkowitz et al looked at the prevalence of PTSD and depression in parents of infants in the NICU, identifying 86 mothers and 41 fathers who completed measures of acute stress disorder (ASD) and of parent perception of infant medical severity 3-5 days after the infant’s NICU admission (T1), and measures of PTSD and Postpartum Depression (PPD) 30 days later (T2).

 

35% of mothers and 24% of fathers met ASD diagnostic criteria at T1, and 15% of mothers and 8% of fathers met PTSD diagnostic criteria at T2. PTSD symptom severity was correlated with concurrent stressors and family history of anxiety and depression. Rates of ASD/PTSD in parents of hospitalized infants are consistent with rates in other acute illness and injury populations, suggesting the relevance of traumatic stress in characterizing parent experience during and after the NICU.

 

There is a wealth of excellent resources online for parents with babies in the NICU/Special Care Baby Unit (SCBU), such as Bliss, Headspace Perspective, and Tommy’s. These all offer a wealth of practical advice, including telephone support and local groups or buddy schemes.

 

Dr. Jain: What psychological interventions work for Postpartum PTSD? What about preventative measures (e.g. identifying high risk women or screening programs) or debriefing interventions?

 

Dr. Moore: There isn’t a standardized screening program as of yet in the UK. We screen women in our service but they only represent a minority of women. One also wonders how a woman may feel about being identified as “high risk” for developing perinatal trauma, and care would need to be taken to fully explain this risk in a nonthreatening or frightening way.

 

Psychological interventions that work in the postnatal period include the usual trauma focused psychotherapies, like cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR), and Compassion Focused therapy approaches are also frequently used.

 

Debriefing can be used and can help some women but not all—it very much depends on who is doing the debriefing and how it is done. Studies into the efficacy of debriefing have not identified any clear link with it leading to reduced maternal morbidity, and formal debriefing is not recommended. In 2011, Professor Ayers from City University, a leading expert in this area, found that 46 women with PTSD who had formal debriefing had reduced PTSD over time and a greater reduction in symptoms overall than women who had not been debriefed. Debriefing also led to reduction in negative appraisals but did not affect symptoms of depression. Therefore, results suggest that providing debriefing as a treatment to women who request or are referred to it may help to reduce symptoms of PTSD.

 

In my service we have a specialized pathway of care for women with a prior traumatic birth or those at risk, which includes regular review and having these long detailed discussions about birth. We have a specialist team of midwives who co-work cases with us to give extra support and an obstetric lead who reviews women prior to birth.

 

We offer informal debriefing postnatally and really take time and care to listen to women’s birth stories, and this is crucial. If needed we can then also add in specialist timely therapeutic interventions—we offer CBT, Compassion Focused Work, Yoga Therapy, Art Therapy, and Music Therapy in my service.

 

Dr. Jain: Finally, are there any biological or physiological factors associated with the act of giving birth itself (e.g. hormonal shifts, changes in adrenaline, cortisol, serotonin, or dopamine) that may be implicated in increasing vulnerability for developing PTSD during that particular life event?

 

Dr. Moore: That’s a very complex question that we don’t yet fully understand the answer to. There is as of yet little research on the specific area of perinatal PTSD, and we have to try to piece together what we know about the etiology of PTSD along with the large evidence base for depression after birth related to hormonal shifts.

 

Of course I am sure your readers will know the existing literature purely relating to PTSD that suggests that lower baseline cortisol at the time of a psychological trauma may facilitate over-activation of the central CRH-NE cascade, resulting in enhanced and prolonged stress responses which could then be accentuated by poor regulation of GABA, serotonin, and NPY. Altered norepinephrine and stress hormone activity may be involved in learning and extinction. This mixture of elevated noradrenergic activity and relative hypocortisolism may lead to the enhanced encoding of traumatic memories and the lack of inhibition of memory retrieval, both of which then trigger the re-experiencing phenomena in PTSD.

 

My own interest lies more in the role of the HPA axis in pregnancy and after birth. Much of the literature relates to depression, but there are studies now focusing on PTSD. It is likely that prenatal hormones are both markers of risk and causal factors in the development of postpartum depression.

 

During pregnancy the maternal hypothalamic-pituitary-adrenal axis undergoes dramatic alterations, due in large part to the introduction of the placenta, a transient endocrine organ of fetal origin.

 

Models are suggested, such as those by Professor Vivette Glover, where the positive feedback loop involving the systems regulating the products of the HPA axis results in higher prenatal levels of cortisol and placental corticotrophin-releasing hormone. Greater elevations in placental corticotrophin-releasing hormone are related to a disturbance in the sensitivity of the anterior pituitary to cortisol and perhaps to decreased central corticotrophin-releasing hormone secretion. Secondary adrenal insufficiencies of a more extreme nature may predict an extended postpartum hypothalamic-pituitary-adrenal refractory period, which in turn would represent a risk factor for the development of postpartum depression

 

During pregnancy we see a rapid rise in plasma estrogen and progesterone, coupled with a very large increase in plasma corticotrophin-releasing hormone (CRH), and an increase in cortisol. Levels of all these hormones drop rapidly at birth, as do serotonin levels. We can also assume that for most women, adrenaline levels will be raised for some of their birth experience.

 

We also need to add into this discussion the literature on the role of estrogen, and its role in fear conditioning and fear extinction. Estrogen calms the fear response in healthy women and, as illustrated by the work of Kelimer Lebron-Milad, the same is true for women suffering from PTSD. The higher the estrogen was in their blood when they trained on a fear-extinction task, the less likely women were to startle.

 

Progesterone is also known to have antiglucocorticoid properties and thus interfere with the HPA axis reactivity to stress. Studies have demonstrated a higher neuroendocrine response to stress (i.e., higher cortisol levels after ACTH administration) in women during the luteal phase of the menstrual cycle, indicating that the negative feedback of the HPA axis may be somewhat affected.

 

Further research is needed to understand the impact that changes in sex hormone levels may have on subjects’ behavioral and neuroendocrine ability to respond to stress. It could be plausible that abrupt changes in hormone levels (such as that observed in the immediate postpartum period) would alter not only the HPA axis response to a stressful event, but also the negative feedback necessary to avoid potential damages induced by prolonged exposure to “stress hormones.”

 

How all these strands connect is not yet fully understood, but to my mind women entering labor are subject to momentous physiological and psychological changes over a rapid time frame, which to some can lead to the development of their perinatal PTSD.

 

Why Lancet Psychiatry study didn’t show locked inpatient wards ineffective in reducing suicide

  • A well-orchestrated publicity campaign for a Lancet Psychiatry article promoted the view that locked inpatient wards are ineffective in reducing suicide.
  • This interpretation is not supported by data in the actual paper, but plays to some entrenched political stances and prejudices.
  • Hype and distortions in conventional and social media about this article are traceable directly to quotes from the authors in press releases from Lancet and from their university.
  • Mental Elf  posted a blog the day the embargo on reporting this study was lifted. The blog post and an associated Twitter campaign generated lots of social media attention. Yet, there is no indication that the blogger went beyond what was in press releases or compared the press releases to what was in the actual article.
  • Not many of the re-tweets and “likes” were likely from people who had read the original research.
  • The publicity orchestrated for this study raises issues about the ethics of promoting clinical and public policy with claims of being evidence-based when the audience does not have the ability to evaluate independently the claims by actually reading the peer-reviewed article.
king of heratrs poster
As seen in the popularity of this movie, many of us had romanticized views of emancipating psychiatric inpatients in the 60s – 70s. De-institutionalization and neglect of huge numbers of homeless persons with psychosis was the unanticipated result.

I obtained the article from interlibrary loan and the supplementary material from the authors. I appreciate the authors’ immediate responsiveness to my request.

[I delayed this blog post for a week because of indications that the article would be released from behind the pay wall, but apparently it has not been freed.]

In this blog post I identify important contradictions between the authors’ claims in the article and what they promoted in the media. The contradictions are obvious enough that someone other than the authors – the Lancet Psychiatry editor and reviewers – should have immediately caught them.

Spoiler: Claims supposedly based on sophisticated multivariate techniques that were applied to data from hundreds of thousands of patients were actually based on a paltry 75 completed suicides. These were a subsample of at least 174 that occurred in 21 hospital settings in the course of 15 years. Throwing way a chunk of the data and the application of multivariate analyses to such a small, arbitrarily chosen subsample is grossly inappropriate. Any interpretations are likely to be invalid and unreliable.

No one else seems to be commenting on these key features of the study, nor the other serious problems of the study that I uncovered when I actually examine the paper and supplements. Join me in the discovery process and see if you agree with me. Please let me know if you don’t agree with my assessment.

The promotion of the study can be seen as a matter of ideologically-driven mistreatment of data with the intention of promoting clinical and public policies that put severely disturbed persons at risk for suicide.

Regardless of where one stands as to whether severely disturbed persons should be prevented from hurting or killing themselves, this attempted manipulation of public policy should be viewed as objectionable.

In presenting what may be controversial points, I’ll start with editorials that were easily accessible. I’ll then delve into the paywalled article itself.

The press release from the authors’ University of Basil

This press release, Psychiatry on closed and open wards: The suicide risk remains the same  provided limited details of the study, but misrepresented the study’s finding of risk for suicide as being based on 350,000 patients.

The study’s last author declared his agenda in promoting the study:

Focus on ethical standards

“Our results are important for the destigmatization, participation and emancipation of patients, as well as for psychiatric care in general,” comments last author Undine Lang, Director of the Adult Psychiatric Clinic at UPK Basel. The results will also have an influence on legal issues that arise when clinics adopt an open door policy. In future, treatment should focus more on ethical standards that ensure patients retain their autonomy as far as possible, says Undine Lang. Efforts should also be made to strengthen the therapeutic relationship and joint decision-making with patients.

The press release from The Lancet

Distributed while the article was still embargoed, Locking doors in mental health hospitals does not lower suicide rate provided more details of the study, but more editorializing grounded in direct quotes from the authors:

Locking the doors of mental health hospitals does not reduce the risk of suicide or of patients leaving without permission, according to a study published in The Lancet Psychiatry.

Authorities around the world are increasingly using locked-door policies to keep patients safe from harm, but locked doors also restrict personal freedom.

European countries tend to follow traditional approaches in caring for patients in psychiatric care, because there has been little evidence so far that one method is better than another.

Similar outcomes whether doors are open or locked.

Of 349,574 patients, they selected 72,869 cases from each hospital type, or 145,738 cases altogether. Creating matched pairs enabled a direct comparison between hospitals.

Translation: to prepare the data for the statistical analyses the authors had planned, they threw away 203,836 cases, or 58.3% of the available cases.

And they concluded:

Findings revealed similar rates of suicide and attempted suicide, regardless of whether a hospital had a locked door policy or not. Furthermore, hospitals with an open door policy did not have higher rates of absconding, either with or without return. Patients who left an open door hospital without permission were more likely to return than those from a closed facility.

The press release next raised a dramatic question. But could these data answer it?

Do locked doors unnecessarily create a sense of oppression?

Given the similarity of outcomes between the two types of hospital, the researchers propose that an open door policy might be preferable.

“These findings suggest that locked door policies may not help to improve the safety of patients in psychiatric hospitals, and are not generally successful in preventing people from absconding. In fact, a locked door policy probably imposes a more oppressive atmosphere, which could reduce the effectiveness of treatments, resulting in longer stays in hospital. The practice may even lend motivation for patients to abscond.” -Dr. Christian Huber, of the Universitäre Psychiatrische Kliniken Basel, Switzerland

Of course, the study did not assess anything like “sense of oppression” and so cannot answer this question. As we will see when I discuss what I found in the actual paper, Dr. Huber’s characterization of his findings is untrue. Patients on locked wards did actually not have longer stays.

Since each hospital serves a specific location, there was no chance of higher-risk patients being allocated to hospitals with locked wards. This reduced the risk of bias.

This is also not true. An unknown proportion of the hospitals, probably most, had both locked and unlocked wards. There could easily have been strong selection bias by which patients was referred to a locked ward. We are not told whether patients could be referred into other catchment areas, but this information would be useful in interpreting the authors’ claims.

The authors warn that an open door strategy might not be appropriate everywhere, as mental health care provision differs in other ways, too, for example, how many beds are available, the percentage of acutely ill patients, and how long they are treated for.

Germany has around 1.1 psychiatric care beds for every 1,000 people, compared with 0.5 beds per 1,000 in the United Kingdom and 0.3 in the United States. Where there are fewer beds, patients who receive treatment are more likely to be severely ill and more at risk.

So, Germany has more than 3 times the beds/100 people than the USA and more than the twice the availability of beds in the UK. We can learn from other sources:

Germany is one of the countries with highest expenditure for mental health care in the world. However, in contrast to other western European countries, psychiatric treatment in Germany is still mainly provided by psychiatric hospitals, outpatient clinics and office based psychiatrists and only rarely by community mental health teams. As mental health policy, except the provision of pharmaceutical treatment, is the responsibility of the federal states, no national mental health plan exists. Therefore, community mental health care systems vary widely with regard to conceptual, organisational and economic conditions across the country. Moreover, the fact that different components of community mental health care are funded by different payers (and on different legal bases) hampers coordination and integration of services.

Studies largely conducted in other countries with organizations of care different than in Germany have consistently concluded that Assertive Community Treatment (ACT) programs are effective in reducing the need for inpatient treatment.

In order to keep the level of psychiatric inpatient treatment and institutional care as low as possible these services should be provided by multi-professional community mental health teams organized according to the principles of Assertive Community Treatment (ACT).

ACT programs keep persons with psychosis from being placed in psychiatric inpatient units like those studied in the Lancet Psychiatry and they lead to shorter hospital stays.

The Lancet Psychiatry article makes no mention of ACT in Germany. My inference is that implementation was not widespread during the study. If there are ACT programs in Germany, their influence on this data set is through an invisible hand.

Inpatient psychiatric beds are quite scarce in the US, even for patients and families willing to pay out of pocket. To deal with demand that is not met by psychiatric facilities, the Los Angeles jail has become the largest locked facility. Whether it not it was the intention of the Lancet Psychiatry, the ideology with which it is infused has served to make inpatient beds less available in the United States and greater reliance on jails instead of least restrictive, and more supportive settings for protecting persons with psychosis.

as Alabama cuts

Alabama sheriff
Just one of numerous results of a movement of resources away from mental health services for the severely impaired and vulnerable.

 

 

 

Inpatient hospitalizations in the United States are much shorter than in Germany. In some states, the mean length of stay is five days. Hospitalization has different goals in the US- only stabilization of the patient’s condition.

The means of killing oneself are also different between the US and Germany. Firearms are much more readily available in the US than in Germany, suggesting different means-restriction strategies for reducing suicide.

So, I cannot see the generalizability of the findings from the Lancet Psychiatry study to the US – or the UK, for that matter. Can you?

The Mental Elf: Locked wards vs open wards: does control = safety?

The Mental Elf advertises itself as offering “no bias, no misinformation, just what you need.” Its coverage of the study occurred the same day the embargo was lifted. Its coverage uncritically echoed what was in the press releases, adding some emotional and ideologically-driven amplification.

The reason usually given for wards being locked is that the people within them need to be kept safe; safe from harming themselves and safe from committing harm to others. Of course these are very real fears, but they are often wrongly magnified by a still sadly stigmatising media and public perception of severe mental illness.

There is certainly an uneasy tension between the Mental Health Act Code of Practice and the reality of locking up severely ill mental health patients, which is brought into sharp focus when we consider the lack of evidence for locked wards. The literature is primarily made up of expert opinion that insists safety is paramount, but fails to provide any compelling evidence that locking people up actually increases safety.

Let’s examine Mental Elf’s claim of the lack of “any compelling evidence that locking people up actually increases safety.” Presumably, he is referring to the lack of RCTs.

another without a parachuteI have been a scientific advisor to experimental studies like the US PROSPECT study and quasi-experimental European studies attempting to test whether suicidality could be reduced. Any such studies suffer from the serious practical limitation that suicide is an infrequent event. But to say there is no compelling evidence for restricting opportunities for acutely suicidal persons to hurt themselves is akin to BMJ’s spoof systematic review  finding no evidence from RCTs that parachutes reduce deaths when jumping of planes.

Neither RCTs nor the propensity analyses of administrative data that Mental Elf favors can produce “compelling data.”  As I will soon show, this study displays the pitfalls of propensity analyses.

We can systematically examine the contextual circumstances of particular deaths by suicide when they do occur, and make suggestions whether some sort of means restriction, including access to a locked  inpatient unit would have made a difference. We can also hold professionals in a decision making capacity legally responsible when they fail to avail themselves of such facilities, and we should.

The Mental Elf wrapped on a rousing, uncritical, and ultimately nonsensical note:

This is a novel and compelling study, conducted in Germany, but very relevant to any Western country that has a secure system for mentally ill inpatients.

Our obsession with security and safety in an ever more dangerous world is justified if you watch the TV news channels for any prolonged period of time. The world is after all full of war, terrorism, violent crime, child abuse; or so we’re led to believe.

I spent a very enjoyable day at City University last week, participating in the #COCAPPimpact discussions, which included some rich and very constructive conversations about therapeutic relationships. It doesn’t take much to appreciate that relationships (therapeutic or otherwise) are stronger and more equitable on open wards.

The Mental Elf website claims (8/5/20016) 215 responses to this post. All but a very few were approving tweets that did not depend on the tweeter having read the study.

The reference to TV news channels is at the level of evidence of a Donald Trump tweet in which he refers to something he saw on TV.

Taking a look at the actual article and its supplementary information.

Christian G. Huber, Andres R. Schneeberger, Eva Kowalinski, Daniela Fröhlich, Stefanie von Felten, Marc Walter, Martin Zinkler, Karl Beine, Andreas Heinz, Stefan Borgwardt, and Undine E. Lang. Suicide Risk and Absconding in Psychiatric Hospitals with and without Open Door Policies: A 15-year Naturalistic Observational Study. The Lancet Psychiatry, 2016 DOI: 10.1016/S2215-0366(16)30168-7

At the time of the media campaign, most people who wanted to access the article could only obtain its abstract, which you can click here  .

Why were there only 75 suicides being explained?

Much ado is being made of 75 suicides that occurred over a 15 year period across 21 hospitals. Suicides are an infrequent event, even in high risk populations. But why were only 75 available for analysis from a sample that initially consisted of 350,000 in this amount of time?

Let’s start with the 350,000 admissions that are misrepresented as “cases” in the official press releases. The article states:

The resulting dataset contained 349 574 hospital admissions from 177 295 patients.

models lockedPresumably, a considerable proportion of these patients had multiple admissions over the 15 years. Suicides were probably concentrated in the group with multiple admissions.  But some patients had only one admission. Moreover, some patients may have been admitted  to different types of facilities – locked versus unlocked –  on different occasions. Confusion is being generated, bias is being introduced, and valuable information is being lost about the non-independence of observations – i.e., admissions.

How many suicides occurred among these 349 574 hospital admissions? Readers cannot tell from the article. Table 4 states that multivariate analyses were based on predicting 79 suicides. Yet, going to supplementary materials, Table S1 indicates that the analyses were done without the matching requirements imposed by propensity analyses, there were 174 suicides to it explain. The authors aren’t particularly clear, but it appears that in order to meet the requirements of their propensity analysis, they threw away data on most of the suicides.

The exaggerated power of propensity analyses

The authors extol the virtues of propensity analyses:

We used propensity score matching and generalised linear mixed-effects models to achieve the strongest causal inference possible without an experimental design. Since patients were not randomly allocated to the different hospital types, causal inference between hospital type and outcomes might be biased—potential confounders could affect both the probability of relevant outcomes and the probability of a case having been admitted to a specific hospital type. The propensity score of patients reflects their probability of having been admitted to a hospital with an open-door policy rather than one with a locked-door policy.15 By matching cases from both hospital types based on their propensity score, datasets with similar distributions of confounders can be generated. These allow stronger causal inference when analysed.15

A full discussion of propensity analyses is beyond the scope of this blog post. I worry that I would lose a lot of readers here if I attempted one. But here is a very readable, accessible source:

Glynn RJ, Schneeweiss S, Stürmer T. Indications for propensity scores and review of their use in pharmacoepidemiology. Basic & Clinical Pharmacology & Toxicology. 2006 Mar 1;98(3):253-9.

It states:

It remains unclear whether, and if so when, use of propensity scores provides estimates of drug effects that are less biased than those obtained from conventional multivariate models. In the great majority of published studies that have used both approaches, estimated effects from propensity score and regression methods have been similar.

And

Use of propensity scores will not correct biases from unmeasured confounders, but can aid in understanding determinants of drug use and lead to improved estimates of drug effects in some settings.

One problem with applying analysis of propensity scores to the data set used in the Lancet Psychiatry is that there was a great deal of difficulty matching the admissions to different settings. Moreover, because it was an administrative data set, there are numerous unmeasured, but particularly crucial confounds that could not be included in the propensity matching or in the generalised linear mixed-effects model analyses thereafter. So, in using propensity analysis, the authors threw way most of their data without been able to achieve adequate statistical control for confounds.

We calculated propensity scores for all cases based on a model that included all clinical characteristics before admission as exploratory variables (age, sex, marital status, housing situation, living together with others, employment situation, main diagnosis, comorbid substance use disorder, comorbid personality disorder, comorbid mental retardation, self-injuring behaviour before admission, suicidal ideation before admission, suicide attempt before admission, type of admission, and voluntary admission). These calculations were done on a complete case basis, therefore 36 300 (10·4%) cases with missing covariate were excluded.

There is the temptation to ask “what is the harm in adjustments that involve the loss of only 10.4% of cases, particularly if better statistical control is achieved?” Well,

Overall, 72,869 pairs of matched cases could be created, resulting in a total matched set consisting of 145,738 cases from 87,640 individual patients for the analyses themselves.

So, the authors have lost a nonrandom selection of more than half the admissions with which they started, and they’ve lost the nonindependence of observations in this shrunken data set. Just look at the ratio of 145,738 “cases” to the 87,640 individual patients from which they came. There is a lot of valuable data being suppressed concerning the fate of individual patients when hospitalized in different settings.

How complete is the data available for matching and control of statistical confounds?

We calculated propensity scores for all cases based on a model that included all clinical characteristics before admission as exploratory variables (age, sex, marital status, housing situation, living together with others, employment situation, main diagnosis, comorbid substance use disorder, comorbid personality disorder, comorbid mental retardation, self-injuring behaviour before admission, suicidal ideation before admission, suicide attempt before admission, type of admission, and voluntary admission.

full clinical characteristicsLet’s look at baseline characteristics in Table 1 of the Lancet Psychiatry article. These are the only variables that are available for matching or controlling for statistical confounds.

Recall that the effectiveness statistical controls assumes that all relevant variables have been measured with perfect precision. Statistical control is supposed to eliminate crucial differences among patients so they can be assumed to be otherwise equivalent in likelihood of being admitted to a locked or unlocked ward for the basis of analysis and interpretation. Statistical control is supposed to equip us to make “all-other-things-being equal” judgments about the effects of being in a locked or unlocked ward.

 

Zero in on main and comorbid diagnoses. What kind of statistical voodoo can possibly be expected to level other differences between patients at higher risk for suicide like the 49% minority with schizophrenia spectrum or affective of disorder versus the others at considerably lower risk? How does it help that this large minority of higher risk patient is thrown in with lower risk patients with organic mental disorder (dementia or mental retardation) and “neurotic, stress-related and somatoform disorders”?*

If there’s any rationality to the German system of care (and I assume there is), at least some crude risk assessment would guide patients with lower risk into less restrictive settings.

And then there is the question of substance use disorder, which was the primary diagnosis for 67,811 (25·5%) of the patients going into locked facilities and 14,621 (18·7%);

Substance use disorder was the comorbidity for another 100 128 (36·9%) going into locked facilities and 28 363 (36·2%) going into unlocked facilities. Issues for substance use disorder and exit security on psychiatric wards are very different than for patients without such disorders. These issues in relationship to absconding  or dying by suicide are not going to be sorted by entering diagnosis into a propensity analysis or generalised linear mixed-effects model analyses of a data set shrunken by matching in a propensity analysis.

Postscript

I conclude that the data set is much less impressive and relevant than it first appears. There are not a lot of suicides. They occur in a heterogeneous population in a length of time in which the patterning of circumstances associated with these characteristics likely changed. Because it was the administrative data set, there were restricted opportunities for matching of patients or control of confounds. Any substantive interpretation of multivariate results requires dubious, unsubstantiated assumptions.

But more importantly, the data set does not provide much evidence for the ideologically saturated claims of the authors or their promoter, Mental Elf. They can pound their drums, but it is not evidence that they are announcing. And patients and their families in both Germany and elsewhere could suffer if the recommendations are taking seriously.

Note

*The “neurotic, stress-related and somatoform disorders” admissions to inpatient units are a distinctly German phenomenon. Persons from the community claiming “burnout” can be admitted to facilities overseen by departments of psychotherapy and psychosomatics. There is ample insurance coverage for what can be a spa-like experience with massage and integrative medicine approaches.

 

 

Military Sexual Trauma, Rape, PTSD, and Suicide: A conversation with Katie Webb

Among Americans, rape is the trauma that is most likely to lead to PTSD. The medical profession is becoming increasingly aware that sexual trauma represents a serious medical and mental health concern. Several years ago, in recognition of the downstream consequences of sexual trauma on veteran health, the VA healthcare system developed the position of a Military Sexual Trauma (MST) Coordinator. The MST coordinator is the point person, within any VA healthcare system, who provides education, outreach, and consultation to support MST survivors and the healthcare professionals who take care of them.

 

Katie Webb, L.C.S.W., is the Military Sexual Trauma Coordinator for the VA Palo Alto Health Care System. Katie received her Master’s Degree in Social Work from New York University. Prior to joining the Palo Alto VA, she served as Assistant Director at a community non-profit agency in New York City, working with survivors of interpersonal violence who have disabilities. Her clinical interests include the treatment of PTSD and comorbid diagnoses, intimate partner violence, military sexual trauma, and the implementation of telehealth technology to expand mental health care access to underserved communities.

 

I spoke with Katie about MST, PTSD, the risk of suicide, and how the VA experience can inform the national debate about college campus rape.

 

Shaili Jain: What is the definition of MST?

 

Katie Webb: MST stands for Military Sexual Trauma, and it’s defined as sexual assault or repeated threatening sexual harassment that occurs at any point during a veteran’s military service.

 

Shaili Jain: Obviously, this would apply to male veterans and female veterans. Does the definition depend on who the perpetrator of the crime is?

 

Katie Webb: Perpetrator identity doesn’t matter. It could be anyone from enemy combatant to a civilian, spouse, girlfriend, boyfriend, commanding officer, or fellow service member. Any perpetrator still qualifies as MST.

 

VA flagShaili Jain: Why do you think VA facilities need somebody in your position, someone who is an MST coordinator? What is the scope of the problem? Why has it become such a salient issue that we need a coordinator? What does your job entail?

 

Katie Webb: Increasingly, over the years the VA (and I think this parallels the process of society, too) is realizing that sexual trauma is a serious medical and mental health concern. It can lead to so many different physical and mental health diagnoses, and it is more likely to actually result in PTSD than combat trauma. So taking all of that into account, the VA is increasingly pushing it to the forefront of their priority, and they developed the position of MST coordinator several years ago. The MST coordinator is the point person within any VA healthcare system who can provide education, consultation, and support to the healthcare system that they’re in. I primarily work to provide education, outreach materials, training on new initiatives, and to consult with any healthcare provider who’s working with an MST survivor and needs some assistance. I also serve as the point person for anyone calling the VA Palo Alto healthcare system with questions – any survivors that call and are interested in getting engaged in care would contact me.

 

Shaili Jain: There have been a lot of really great big data studies in the VA recently, and some of them have identified risks associated with MST. I’m referencing the recent publication by Rachel Kimerling and her lab that was published in The American Journal of Preventative Medicine where they actually identified MST as a significant risk factor for suicide. Can you comment on that and how this research maps on to what we’re doing day to day in our clinical work with patients?

 

Katie Webb: The research was saddening but not surprising. It really just puts a research voice to what people who work with MST survivors already know and see, anecdotally – that there is a very positive relationship between MST and suicide. I think it really highlights the importance of being sure to address and assess for suicidality any time you’re working with someone who’s experienced Military Sexual Trauma, or any sexual trauma, and of keeping that as a very key piece of their care plan.

 

Shaili Jain: I guess what’s tricky is that MST is an experience and not an actual diagnosis or mental health condition. You can have someone who has an MST history but not necessarily a PTSD diagnosis. Yet there’s this correlation that they’re high risk for suicide. I think that’s where the seriousness of the situation can get diluted.

 

Katie Webb: It does, and it gets confusing because oftentimes people will come and they’ll ask for the MST treatment. We then have to further sub break it down and say, what symptoms are you experiencing in relation to this experience? Just like combat trauma is not a diagnosis, but that is easier to understand. There has to be education with healthcare professionals, veterans, and survivors so when they hear that (it is not a diagnosis) they’re not thinking it is not important. MST does matter, it is important, but what is most important is how it has impacted the survivor.

 

It is important to recognize that the dynamics of MST can be a little bit different than civilian trauma. Oftentimes, this is something that happens when someone is living away from their social supports, away from people they know, and their perpetrators are often within their new social support system. Unfortunately, the result of sexual trauma is that the victim is then isolated from their social support system at a time when they most need it. I think it makes a lot of sense that people would experience an increase in intensity of whatever mental health symptoms they’re having and make them more prone to suicide.

 

There’s a lot of stigma associated with identifying as an MST survivor. I think sometimes people can put their symptoms in silos and not necessarily make the connection to their experience of sexual trauma. This makes sense, as Rachel’s study mentioned something to the effect of suicidality was separate from any mental health diagnosis. So we need to pay attention to that for sure.

 

Shaili Jain: That there could be this hidden danger.

 

Katie Webb: Right. Not to make the false assumption that just because a patient is saying they do not have a mental health diagnosis does not mean that they’re not having normal reactions to trauma.

 

Shaili Jain: What are the top three take home messages for clinicians who are on the front line?

 

Katie Webb: Healthcare professionals are really busy, and so I think that’s part of the challenge.

 

First, it is really important that professionals set aside a little bit of time to educate themselves on this issue. I think we all need to be aware of the dynamics of MST. Be aware that for many MST survivors, they have not had positive or helpful responses from systems and peers when they have disclosed their MST history in the past and that can account for how they act around you, as a healthcare professional.

 

Be aware that they may be reticent to share details. They may downplay whatever it is that they’re reporting because of the responses they have received before. Just maintaining an open and non-judgmental stance can be really key in creating an environment that’s safe for people to get engaged with care. A good example would be regarding male survivors. I think the VA healthcare system can parallel society in that there is a myth that rape doesn’t happen to men. Invalidation of male rape can happen in really subtle ways in the healthcare setting – maybe a healthcare professional sees a male patient and assumes they do not need to do a screen for MST. Just being aware that oftentimes survivors have been ignored, not believed, or in an environment where they are made to think their experience could not have happened because they’re men.

 

Secondly, knowing screening is really important. Screen for MST and screen for suicidality. I know screening is done in primary care, but I like the idea of screening in mental health, too. Oftentimes, survivors think that MST is not a medical problem, so when primary care physicians screen for it patients will answer no because they view it as having nothing to do with their doctor’s visit.

 

Finally, after screening, I think educating and engaging the veteran and mitigating that past experience of feeling like they’re alone and like they don’t have social support is very important.

 

Shaili Jain: Do you think that nowadays there is less stigma around MST? From both sides, the healthcare professional and the patient?

 

Katie Webb: I think people want to be more open. I think their intentions are in the right place, but because sexual trauma is such a loaded topic, people carry around a lot of assumptions about what is sexual trauma and what isn’t.

 

For example, I was having a conversation with a really well intentioned healthcare provider who was talking about all the great work they had done with a sexual assault survivor, and they said, “You know, sexual harassment, that’s not really MST. That doesn’t count.”

 

So where was this coming from? It was coming from misperceptions about what it means to be sexually harassed. I think that’s really a challenge. I think there is still this innocent but dangerous assumption that this doesn’t happen to men or it may only happen to a certain type of man, but not a man’s man.

 

I think the education piece remains central.

 

LGBT flagShaili Jain: Can you share how MST has impacted lesbian, gay, bisexual, and transgender (LGBT) veterans?

 

Katie Webb: The research parallels some of the discrimination that LGBT people face in that there isn’t a lot of research on MST in LGBT veterans. We do know that, to some extent, LGBT veterans are more likely to have experienced childhood sexual abuse (CSA) than their heterosexual counterparts. CSA is also a risk factor for experiencing MST.

 

We know that the “don’t-ask-don’t-tell culture” created a very dangerous environment. Again, thinking about how social support is so key after trauma, if LGBT veterans can’t really be fully honest about who they are and then are often isolated from social support, that is not a good situation. We know that sexual minorities are targeted for MST in the military and then have little social supports in the aftermath. They are put in a bind – they can’t even state why they were targeted for MST for fear they might be discharged from the military.

 

I think it’s great that “Don’t ask, Don’t tell” was repealed. I think it’s great that they’re now allowing transgender people in the military. I think we also have to acknowledge it’s a really slow culture shift to match some of the policy changes. It would be reasonable to expect that some of that is still going on.

 

Also, when you factor in the stress of being a minority to begin with, that can mean you are more likely to have a mental health problem after a traumatic experience, too.

 

Shaili Jain: It strikes me that LGBT veterans who have MST would be very high risk for suicide.

 

Katie Webb: Right, and then when you think about that and you think about trauma sequelae and how those unhelpful responses might be even more extreme with the LGBT population, it makes total sense that they will experience a lot of mental health distress. Unfortunately, how that can get translated is, “There’s something really wrong with me.”

 

It’s our job to flip that and say, “No, you’re the one making sense, it is your surroundings that don’t.”

 

Shaili Jain: I cannot help but draw parallels between recent research reports of college campus rapes and military sexual trauma. From my perspective as a psychiatrist, there are some striking similarities between these two types of sexual violence. MST raises similar issues to college rapes in that victims are often inexperienced younger people who are living away from home for the first time and are thrown into environments where it may be unclear what types of behaviors and boundaries are acceptable.  There are also institutional factors that play a role in how the victim is treated and justice is served. Can you comment on these parallels? In particular, how generalizable is the VA experience to non-veteran populations?

 

Katie Webb: I agree, there are so many parallels. Probably with MST you see a little bit more extremity in everything.

 

For example, to some degree on college campuses, you’re living and working with your peers, just like in the military – you’re battle buddy is your room mate or your officemate or your chore mate. Both settings encourage unit cohesion, but I think in the military that’s more extreme because if your unit doesn’t get along, you’re more likely to die. I think in the military that creates this pressure, particularly on minorities, e.g. women, to bond in ways that definitely push the limit and push what’s acceptable.

 

I think you raise a very legitimate fact that younger people are still developing, they are still forming their schematics of how the world works. This is then used against them, as a tool that can be blaming. “Well, you don’t know how the world works. Maybe you misunderstood the situation.” Then that really creates this manipulative dynamic that I think perpetrators can use and systems can use, so that is a striking similarity.

 

Colleges and the military try to keep the issue within their system of discipline, whether it be campus police or a military court system. I think military survivors of sexual trauma and college survivors of sexual trauma are isolated and blamed. Oftentimes, the powers that be say, “Well, we responded. We kept the survivor safe by transferring them to a new base.” They transfer the victim away from people they know with detrimental impacts on their careers. Sometimes, a college student may transfer to a new college and interrupt their goals while perpetrators stay put. If the survivor chooses not to report, they may have to continue to co-exist with the perpetrator. The same thing can occur on college campuses.

Cortisol, the Intergenerational Transmission of Stress, and PTSD: An Interview With Dr. Rachel Yehuda

Source: http://www.dissociative-identity-disorder.net/w/images/PTSD.png
Source: http://www.dissociative-identity-disorder.net/w/images/PTSD.png

Cortisol, a stress hormone, is a key player in the subtle hormonal changes that have come to be associated with PTSD, and Dr. Rachel Yehuda, a neuroscientist and the director of the traumatic stress studies division at Mount Sinai School of Medicine in New York, has played a major role in advancing our scientific understanding of the role of cortisol in PTSD.

 

More recently, Dr. Yehuda also offered the PTSD scientific community a novel and intriguing idea: that the children of traumatized parents are at risk for similar problems due to changes that occurred in the biology of their parents, as a consequence of their trauma exposure. It is these epigenetic changes that are then transmitted to their children via a process called “intergenerational transmission.”

 

Recently, I spoke with Dr. Yehuda about cortisol, intergenerational transmission of stress, and the future of PTSD treatment and research.

 

Dr. Jain: You played a key role in re-conceptualizing the neuro-endocrine basis for PTSD after it became apparent that individuals with PTSD consistently have low cortisol levels. Can you speak a little bit about how robust a finding this is and what this means for clinical settings? How can we use cortisol levels in the diagnosis of PTSD? Can we use it to track if people are getting better?

 

Dr. Yehuda: The first published observation on cortisol in PTSD was in 1986 by John Mason and colleagues at Yale.  The group was interested to see if tracking stress hormone levels in patients admitted to the psych unit would aid in determining when patients might be safely discharged, so they measured cortisol levels in a wide range of psychiatric patients. Generally, cortisol levels were higher for patients at admission and then were much lower at discharge, which is what one would expect if cortisol is a marker of stress. However there were two groups of patients, one being patients with post-traumatic stress disorder, for whom this did not appear to be the case. The authors were surprised to find that in fact PTSD patients showed significantly lower cortisol levels at admission and discharge compared to patients with other diagnoses. I joined Yale a year after that finding appeared in the literature. Like many others, I found it curious that cortisol levels would be low and thought for sure there had be some mistake, because we would expect, if anything, that cortisol levels would be high in a stress disorder, particularly one in which there was comorbidity of depression. So I attempted a replication with Mason and his colleagues, and of course, we were able to replicate the low cortisol findings in several studies in the early 90’s.

 

What was so interesting, however, was how long it took the field to accept that the finding may reflect a reality. At the same time, and in the same patients, Mason and I observed elevated catecholamines. Neither Mason nor I had any trouble with the very first publication that catecholamine levels were higher in PTSD.  No one thought to question the finding because it was something expected—that people who are aroused and under stress have high levels of catecholamines, like norepinephrine. Yet the cortisol data from the samples were difficult for people to believe.   I guess when we hear something that makes sense to us, we do not need a lot of data. But we all questioned the low cortisol finding because it didn’t make sense, and then we questioned the methodology and so on. The reason the finding did not make sense, in the early 90s, was because the field of PTSD was new, and we didn’t really understand PTSD yet. There were really no epidemiological studies until the early 90’s, and even this very well accepted idea that PTSD only occurred in a subset of trauma survivors was not yet known. The prevailing concept was that PTSD always occurred following trauma exposure. But once there was a body of literature that showed that a lot of people are trauma exposed and only a smaller subset of those people get PTSD, the field could start speculating that perhaps low cortisol signals an abnormality that helps explain why recovery has not occurred. And when that happened, we began to ask what is cortisol’s role in stress, anyway? In turns out that one of the things that cortisol does in response to stress is that it helps contain the catecholamine system—it helps bring down the high levels of adrenaline that are released during fight or flight. Since we all know that adrenaline and norepinephrine are responsible for memory formation and arousal, not having enough cortisol to completely bring down the sympathetic nervous system, at the time when it is very important for a person to calm down, may partially explain the formation of traumatic memory or generalized triggers.

 

The second part of your question is what does this mean in a clinical setting and how can we use cortisol levels in the diagnosis of PTSD? At this moment, we cannot use cortisol levels to aid in diagnoses. They are too variable, and although there is a mean difference between PTSD and other groups, in every study that has been performed to date, there are a lot of overlapping data.   Furthermore, even the low cortisol levels in PTSD are well within the normal endocrinological range. The reason the low cortisol finding was important was that it led us down a trail of trying to understand why cortisol levels were low. Then it took us into the dynamics of the way that the hypothalamic–pituitary–adrenal (HPA) axis works and is regulated by the brain. Cortisol levels show natural variation during the day, and are affected by environmental perturbations. It is adaptive that cortisol levels vary , because cortisol helps regulate many bodily functions when we are stressed, and when we are not stressed. What we have been doing for the last 25 years is studying the underlying dynamics of cortisol levels. We have examined circadian rhythm changes that may determine how the brain regulates the release of cortisol over a diurnal cycle. We have looked at cortisol metabolism, to try to understand how cortisol is broken down into its various metabolites in the brain, liver, and kidney. But most of our studies have involved the glucocorticoid receptor and all of the genes and proteins that are involved in regulating the activity and sensitivity of that receptor. These studies have begun to give us an understanding that there is something really different about the stress system in PTSD, or in specific subtypes of people with PTSD,, but it is not going to be cortisol levels per se that are going to be useful to a clinician.

 

Dr. Jain: So the picture is much more complicated than what may have been originally conceptualized?

 

Dr. Yehuda: When we say low cortisol levels, an endocrinologist would cringe. In PTSD, cortisol levels are not lower than normal range. They are significantly lower on average compared to persons without PTSD, but the levels themselves are not abnormal. The cortisol levels in PTSD do not suggest that the adrenal gland is broken in any way or not releasing cortisol, but rather, given the normal range of cortisol, which is large—between 20 to 90 micrograms per 24 hours of urine—the means we would get in PTSD were in the 40s. Whereas, a straight mean would be more like in the 50s and 60s. We are not talking about an endocrine problem. We are talking about a tendency to be at the lower end which is within normal variability. Why this was newsworthy, again, was that we were expecting that it would be higher in a stress disorder, because cortisol is associated with stress. I personally would not use cortisol levels, not even 24-hour urinary cortisol levels, as a diagnostic marker. I would want to know a lot more about how the glucocorticoid receptor works. Is it more sensitive? What is the circadian rhythm like? What about cortisol metabolism? What about the genes that control cortisol and glucocorticoid functioning? So there is a potential to find biomarkers that relate to cortisol that may be clinically applicable—we have not given up on that idea at all. It’s just important to understand what kind of neuroendocrine or molecular neuroendocrine information is most relevant.

 

Dr. Jain: But it is not as simplistic as doing a blood test to diagnose PTSD.

 

Dr. Yehuda: Would that it were!

 

Dr. Jain: I know! But you offer a very important clarification: the pattern in PTSD is of lowER cortisol levels, not low cortisol.

 

Dr. Yehuda: Somehow statistically lower became low, but the devil is in the detail.

 

Dr. Jain: Absolutely, and that is why it is so valuable to talk to people like yourself.

 

Dr. Yehuda: Furthermore, the effect size of cortisol differences is small, too. In the Boscarino study (1995), he reported that cortisol was lower in PTSD, but there was a very small effect size. So it is not a diagnostic test. It is just a clue, and we used it exactly as a clue to unravel a deeper mystery.

 

Dr. Jain: I totally see that. My next question is about the potential role of cortisol in the treatment of PTSD. Maybe if you could speak about that a little bit. From a clinician point of view, that is really intriguing. It feels like immediate clinical applications might be on the horizon.

 

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Source: http://www.clker.com/clipart-9803.html

Dr. Yehuda: I see at least three or four ways that we could think about cortisol-based interventions. The first one might be prevention. That is the Zohar study, which is a study being conducted in Tel Hashomer hospital in Israel, headed by Dr. Joseph Zohar. When I first heard his idea of using cortisol in the ER to prevent PTSD, I have to admit I was skeptical, even though we are the ones that published that cortisol levels are lower in the immediate aftermath in persons who are more likely to develop PTSD. What Dr. Zohar said was, if that is true then we should be able to give cortisol during the “golden hours.” But I was nervous. Why? Because I think that hormonal response is something that you want to be very careful about changing, because the body has a wisdom. That is my general view of the world, but he convinced me that if you give a single really high dose of glucocorticoids within a 4-hour window of a trauma, then the effect that that might have would be to recalibrate the HPA axis in a way that provides enough cortisol to quiet down the sympathetic nervous system in a very organic and permanent way. Also, Dr. Hagit Cohen’s in Ben Gurion Medical School in Beer Sheva work with animal studies had shown that this might actually work to prevent PTSD if given during the “golden hours.”

 

Dr. Jain: By “golden hours” you refer to that 4-hour window after the trauma?

 

Dr. Yehuda: We do not know what the window is. In our study we said 4 hours. I do not know if it is 8 hours or 12 hours! We do not know if it is 2 days! Ironically, when people give benzodiazepines in the acute aftermath of a trauma, they are doing the opposite thing, as benzodiazepines lower cortisol levels. So even though in the short run, you may experience some relief, in the long run it just kicks the can down the road. Dr. Zohar’s idea is that by intervening early you can set a pathway towards recovery.

 

There have been other studies like this. In fact, the first observation of this was by a physician in Germany named Dr. Gustav Schelling. He was treating septic shock and using hydrocortisone as a treatment for septic shock. What he noticed was that those who had received high levels of glucocorticoids, which not everyone did, had fewer complaints of traumatic memories from their traumatic experience of being critically ill. He searched for an explanation and finally did a randomized clinical trial. He concluded that there were beneficial effects of administering high doses of glucocorticoids in the early aftermath of a trauma. So prevention is certainly one potential avenue.

 

But there are people who have given glucocorticoids not during the “golden hours,” but in a more sustained way over several weeks. They have also found potentially beneficial effects. We have just completed our study with Dr. Zohar and eagerly await the results. In this study we also measured biomarkers to see if treatment could be predicted.

 

Another way to effect changes in the HPA axis might actually be to block the glucocorticoid receptor. There is a trial that is ongoing now using a drug called mifepristone, which is a glucocorticoid receptor antagonist. You might know this drug by a different name. This study is being run by my colleague Dr. Julia Golier. You might know mifepristone as RU-486, or the abortion pill. RU-486 obviously has effects on the progesterone receptor, which is why it is an effective treatment to prevent pregnancy, but it also has effects on the glucocorticoid receptor. There is a trial that is ongoing now, ending August. The pilot study showed some benefit. What happens with that treatment is that you can block the glucocorticoid receptor and really recalibrate the ratio of peripheral to central cortisol. The beauty of that treatment is again you give it once or you give it for a very short period of time, and you look for recalibration effects. People like to take medications that way as opposed to every single day.

 

Another way to think about glucocorticoid treatments is to use cortisol as an augmenter of psychotherapy. We have been doing some studies where you give moderate doses of cortisol or hydrocortisone about half an hour before an exposure based treatment. The rationale for that is that glucocorticoids facilitate new learning. They facilitate extinction, and it could be that administration of moderate doses of hydrocortisone could really set the stage for doing better in exposure therapies. We found that in case reports in a small trial we conducted. What we found was that there were fewer drop-outs out of prolonged exposure therapy if they were given hydrocortisone compared to placebo. If that continues, that is a big deal, because we know that a lot of patients drop out of these treatments prematurely. Anything that makes somebody just stay in treatment is probably good.

 

Dr. Jain: Moving on to the next question then. There is this whole issue regarding lower cortisol levels being a pre-traumatic trait, like, somebody already has this and then they are trauma exposed and have a higher chance of developing PTSD. What are the implications of this for screening and resiliency programs in clinical settings?

 

Dr. Yehuda: We have an artificial view of what “pre-trauma” means. Pre-trauma of the event that we happen to be thinking about now? Many of us don’t consider enough what kind of early environmental events people have experienced before they present for effects of the trauma that they are coping with now.

 

We know that many people in the military have had traumatic experiences prior to being in the military, yet we define their pre-trauma cortisol as being pre- combat, as opposed to before they ever experienced any adversity.

 

I think this is a tough nut to crack. In our studies, we found that lower cortisol levels were present in rape victims who had had a prior assault. They are more likely to develop PTSD, but was their cortisol level already low? Is that why it did not climb up higher than it could have?

 

I think that these are important issues. Now, there was a fascinating study that was published by Mirjam van Zuiden and her group in the Netherlands that basically took a thousand soldiers, before they went into combat, and looked at cortisol and glucocorticoids receptor measures and markers, as well as genes and epigenetic markers of the glucocorticoid receptor. They found that low cortisol and enhanced glucocorticoid receptor sensitivity were predictors of people that had PTSD a few months later.

 

Now, of course, we do not know if they also had prior trauma. We do not know that, but that was a very elegant demonstration.

 

It is exactly as you say, but it is hard to unpack these things. At least we are getting closer to understanding that not all the action occurs at the time of the trauma. That the stage might be set in advance, we are actually an accumulation of our experiences, and we hold biologic changes and then use them to respond differently to traumatic events as they emerge in our lives.

 

Dr. Jain: That is very true. I like that phrase—it is setting the stage for subsequent trauma reactions. We have not figured out exactly how all those pieces come together.

 

Dr. Yehuda: There are a lot of people that are studying the effects of child abuse and early trauma even in the absence of PTSD. Their work is also supporting lower cortisol levels. It may be that low cortisol will impacts whether someone gets PTSD to a later trauma. The problem can be that when you study someone at one point in time and they have low cortisol but they don’t have PTSD, that does not mean that they will not develop PTSD if exposed to a trauma in the future. We do not know whether low cortisol measures are markers or predictors of the future, but I would suspect that there is a genetic component as well as an early environmental component that would make these markers predictors. That is one of the difficulties in conducting such studies. The challenge of clinical research is that we are looking at a few points in time and trying to make decisions as if we were looking at stable phenotypes, when we know that there is an awful lot of change that occurs within individuals in terms of their mental state, not to mention the fact that people often have really complex lives with a lot of things going on. So, you might be resilient following the first three events, and then the fourth one occurs and then you develop PTSD. We do not really know how useful these measures are, but there is probably a way that we can do more longitudinal prospective studies to get a flavor of that. I know that those are studies that are ongoing in the VA system, which is really good.

 

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Source: By File photo, Canwest News Service – http://article.wn.com/view/2009/03/19/Vitamin_B12_deficiency_linked_to_birth_defects/, Public Domain, https://commons.wikimedia.org/w/index.php?curid=6533001

Dr. Jain: That is great. Related to that and transitioning to this concept of this intergenerational transmission of stress: Your 2005 study with the women who were pregnant in the World Trade Center, it was fascinating to read that study. I thought that it was an elegant demonstration of this concept of intergenerational transmission of stress. It would be great if you could talk a little bit about that study. One question that came to mind was a question about the pre-trauma cortisol level in the women. I wondered if that was measured, and did you gather data on their earlier experiences with trauma? That was just one particular question I had, but if you could just discuss the study in general, because I think it was really a fantastic contribution to the literature.

 

Dr. Yehuda: We did not have a lot of information on the women. In fact, this whole study was post-hoc in a sense that the study was designed for a completely different reason. It was to monitor pregnant women to make sure they gave birth to healthy babies. Everyone was really concerned about the level of environmental toxins after 9/11. Somebody from the environmental medicine group reached out to me because they noticed that a lot of women were really not doing very well emotionally and psychologically.

 

So by the time I was involved, some of the women had already given birth, but there had been a lot of information about what trimester they were in, about any pregnancy complications, exposure to toxins, etc. etc. So we added to that an evaluation of PTSD. Then when they came in for their 7 month to 1 year wellness baby evaluation, we were able to get salivary samples from the mother and the child. By then it did not surprise us to see that mothers with PTSD had lower cortisol levels than mothers without PTSD. But what did fascinate us was that in the mothers that had lower cortisol, the babies also had lower cortisol, but that this was a trimester dependent effect and that it seemed to split out in the second and third trimester in mothers who had been exposed in the middle of the second trimester or exposed in the third trimester.

 

When we had those findings, a lot of possibilities opened up in terms of how cortisol levels might be transmitted from parents to child or from mother to child. We were not the first people to make this observation. There has been a literature that that has demonstrated that mothers who are exposed to under feeding before puberty have children and grandchildren that have metabolic problems. Since we knew that the women exposed to starvation during pregnancy also tend to give birth to children who were more prone to hypertension as adults, we knew that there was the possibility of in utero effects.

 

But what seemed to happen here was an example of glucocorticoid programming. In the middle of the second trimester of pregnancy, there is an enzyme that becomes expressed in the placenta. It is an enzyme that blocks the conversion of cortisol to its inactive metabolite, cortisone. The induction of this enzyme really helps protect the fetus from detrimental effects of maternal glucocorticoids, because the cortisol is broken down into its inactive metabolite, cortisone. The enzyme is called 11β-Hydroxysteroid dehydrogenase type 2. We had already been interested in studying this enzyme just because we were interested in cortisol metabolism. But it turns out that in mothers who are under stress, it is very possible that their enzyme levels and the amount of glucocorticoids they have could overwhelm the body’s ability to metabolize cortisol into cortisone and affect the fetus. That was one idea that we had, that there might be a transmission based on offspring response in utero to maternal levels of stress hormones.

 

The message is straightforward: mothers who are stressed during pregnancy can program the stress response of their offspring, in utero, and the offspring accommodates somehow to the level of stress hormone. That has become a very important issue also in our intergenerational studies. It has become one viable mechanism through which mothers may “transmit” different vulnerabilities (or resilience) to their offspring. One does not need to have actual trauma experiences post-natally in order to have some of the neuroendocrine features associated with PTSD and PTSD risk. And this means that pregnancy is an important time with great social implications for our society. I do not think that we think about pregnancy as the very important developmental event that it really is. Otherwise, we would be really taking much better care of traumatized pregnant women than we do.

 

Dr. Jain: Obstetrics care involves screening for gestational diabetes, congenital defects in the baby, and even screening for postpartum depression……

 

Dr. Yehuda: Yes, and we should screen for trauma, too.

 

Dr. Jain: Given how high the rates of trauma exposure are in the population, it is worthwhile screening for trauma in pregnant women.

 

Dr. Yehuda: Exactly.

 

Dr Jain: The other thing I wanted to ask about was early data indicating that exposure to trauma can impact the psychosocial functioning of second, maybe third generation offspring. I think there were some studies done with holocaust survivors. If you could speak a little bit to that, because obviously that has very widespread societal implications, too.

 

Dr. Yehuda: Yes, we have found that in the adult children of holocaust survivors, they are more vulnerable to psychopathology and this is true of offspring who have parents with psychiatric symptoms. In one study we were able to measure biological and epigenetic markers showing that there are effects on holocaust offspring, based on either maternal and in utero developmental factors, maternal exposure, or maternal and paternal PTSD.

 

Dr. Jain: In general, what would you feel are the important questions for trauma scientists to answer in the next one to two decades? What would be top on your list to prioritize?

 

Dr. Yehuda: Many decades ago when the field first conceptualized the diagnosis of PTSD, our response was to emphasize the commonalities in trauma survivors regardless of what their exposures were. But I think it is important now to go back and see in a more clear way whether combat veterans are or are not different than other trauma survivors, or if interpersonal violence leaves a unique biological scar compared to a natural disaster, or whether age at traumatization matters or duration of trauma matters.

 

We basically have a threshold phenomenon where if you are over the threshold of what constitutes a trauma, you could be in the category depending on if you have the symptoms that are the symptoms of PTSD, but that is not very nuanced. In my experience, although there are similarities between trauma survivors in their mental health profile, there are also really important differences.

 

Some of the treatments that we have developed may really work better for some groups rather than others. For example, it seems like prolonged exposure is a fantastic treatment for interpersonal violence in women, and then the question becomes, is it as good for combat veterans? Have we studied this carefully enough? Should we be tailoring treatments based on trauma type and not just whether or not a threshold for trauma and symptoms has been met? We have to start customizing this.

 

The other thing that I think is really important is this idea that the designation of PTSD is a static one, or that it is binary or not dynamic. We have to rethink that. Now that I have the perspective of having years in the field and seeing the same trauma survivors over a period of many years, even decades, I understand that the same person can at sometimes meet diagnostic criteria for PTSD while at other times, that person may not. Do we view the person as always at risk after s/he has recovered? Especially when you have recovered from something and you are asked about having had it in the past, your memory is not so good for how much you have suffered in the past when you are feeling good right now.

 

Sometimes, I have had the ability to actually do a diagnostic interview of someone, meet them 10 years later, ask them about their worst episode of PTSD, and if they are feeling fine today they won’t remember how bad it was. What does that mean for biological studies, for biomarkers, and for risk? Just the idea of whether the categories are binary or not, I think is something that we really want to look at.

 

Finally, I think we have been paying a lot of attention to the psychological aspect of trauma and not enough to the physical illness part—the fact that people who are exposed to combat may die at an earlier age, make poor behavioral health choices, and are more prone to hypertension, metabolic syndrome, inflammatory illness, cardiovascular disease, and cancer.  These cannot be coincidences, but may either be part of the trauma effects, or part of the PTSD effects. Why are we not more focused on the biomarkers that might help explain and reverse some of these illnesses? When will we start seeing PTSD and trauma exposure as the multisystem condition that it is and really try to integrate care plans that not only assess for nightmares, hyper vigilance, and concentration, but diet and exercise and hemoglobin A1c? These are markers for trauma survivors because they are at greater risk for all these issues, not to mention cognitive decline. What I would like to see is us incorporating a much more holistic approach to understanding the effect of trauma that does not divide the mind and the body into different spheres and really focuses on wellness in a much more broad way.

 

Dr. Jain: So that integration between the physical and the mental, even in the way we treat them. Right now, it is separated out into mental health and physical health.

 

Dr. Yehuda: It does not make sense. Many veterans that come for care do not take such good care of themselves. It is not a priority for them. They do not maybe eat as well as they could or they have really disrupted sleep. I would like us to think about trauma as something that really does affect the whole body and our behavioral health choices. We should think broad, because those are the things that are really very important to ward off long-term diseases.

 

Dr. Jain: Yes, and enhance overall quality of life, too.

 

Dr. Yehuda: I think patients talk about what we (as healthcare professionals) want to talk about, and we lead the conversation in a symptom focused way. The symptoms of PTSD are impairing, don’t get me wrong, I am just saying there is a greater range of problems than are contained in the PTSD diagnosis.

 

Dr. Jain: I could not agree with you more. I feel like it is in the air. We are on the verge of embracing it that way. We are just not quite there yet.

 

Dr. Yehuda: I completely agree with you, and I think that the reason for that is that as we do our research on a genome wide level, we identify that so many of the biomarker pathways that seem to be altered relate to inflammatory immune functions. The pathways that are being identified in people with PTSD are not just those that associate with psychiatric symptoms, but really affect much more bodily functioning. I think that is also a lesson, just to close the loop on this that has been learned from the glucocorticoid story in PTSD. Cortisol is not just about mental health. There are glucocorticoid receptors in almost every cell in the body. Cortisol has a myriad of different functions in different target tissues, mostly in the metabolic systems promoting fuel and energy. It is silly to just think about cortisol’s role in traumatic memory when cortisol is a ubiquitous hormone that has so many different roles.