January 27, 2012
New Treatments to Combat Post-Traumatic Stress Disorder
By: Jared DeFife, Ph.D.
With PTSD affecting almost 7% of American adults and few effective treatment options available, research into innovative approaches to PTSD treatment is expanding rapidly. “The Shrink Tank” blog at Psychology Today explores some of the most promising approaches, including MDMA-assisted psychotherapy.
Originally appearing here.
In the wake of disasters, accidents, abuses, and war, trauma survivors can face a host of problems including intrusive memories, nightmares, insomnia, irritability, hypervigilance, and emotional detachment. Individuals struggling with these PTSD symptoms describe substantial disruptions in their physical, social, and emotional well-being. They find it hard to go to work, spend time with their families, or take meaningful control of their lives.
PTSD affects almost 7% of America’s adult population. That figure is nearly doubled in young adult veterans returning from Operation Iraqi Freedom. While there have been some significant advances in mental health treatments for PTSD, nearly half of patients who enroll in treatment either drop out or remain symptomatic. Given those figures and a growing tide of soldiers returning home from combat operations abroad, researchers are working to identify new and innovative treatment approaches for recovery from PTSD.
Virtual reality exposure: The belief in the therapeutic power of confronting the source of one’s anxieties and fears is as old as the practice of psychotherapy itself. New technology, however, has given this a decidedly modern twist. While it’s easy to recreate the feared situation in therapy with a patient with a fear of heights or elevators, creating an opportunity for veterans to confront and gain mastery over their battlefield experiences has not been. Researchers at Emory University and the Georgia Institute of Technology were the first to create a Virtual Vietnam to treat veterans with PTSD. Over the years, they have developed this technology to create a 360-degree digital environment complete with the sights and sounds of a Middle East conflict zone, including gunfire noises, radio chatter, and aircraft flyovers. A vibrating chair can even mimic the feeling of distant explosions or Humvee driving, all within the safe confines of the therapy office. During these treatment sessions, veterans are able to engage their senses in a more modulated, controlled, and secure way while gaining insights and new perspectives through talking about their experiences. This work has demonstrated some early and promising results from simple phobias to PTSD, including in some who had failed to respond to other treatments based on imaginal exposure. Virtual reality programs have been adapted for use with survivors of the World Trade Center or other terrorist attacks and even for motor vehicle accidents.
Tetris: Forget Angry Birds, Tetris was the original addictive digital time-suck. Oxford University researchers claim that the colorful puzzle block game can serve as a “cognitive vaccine” against intrusive traumatic memories. In a series of experiments, researchers exposed non-clinical volunteers to graphic and traumatic film scenes. After the film, volunteers were assigned to either play Tetris, complete a Pub Quiz video game, or do nothing and asked to record any intrusive memories of the film images occurring to them throughout the week. Participants who played Tetris had significantly fewer intrusive memories than those who did not. The researchers propose that the visuospatial task of fitting Tetris blocks into incessantly growing piles uses up the brain’s visual resources and interferes with its ability to encode visual trauma memories that are the building blocks of symptomatic re-experiencing and flashbacks. Before you dust off that old Nintendo Game Boy, note that the findings are preliminary, without independent replication yet, and based on healthy undergrad volunteers exposed to video clips instead of actual trauma survivors. Still, this innovative and intriguing line of research points to the possibility of simple and proactive approaches to preventing or reducing PTSD development.
Old drugs, new bottles
Currently, there are only two FDA-approved medications for the treatment of PTSD [sertraline (Zoloft) and paroxetine (Paxil)]. The evidence on the effectiveness of these anti-depressant medications and other medications used “off-label” for PTSD-related symptoms is limited and the medications often come with problematic side effects that many users find disagreeable. Instead, researchers are rounding up some unusual suspects and looking at new uses for some already well-known drugs.
D-cycloserine (DCS): DCS is a broad-spectrum antibiotic which has been used in clinical trials to improve learning in rats and humans. DCS helps activate NMDA receptors in the brain which are associated with learning and memory formation. DCS-treated rats are able to learn fear extinction more quickly, taking far fewer trials to stop being afraid of a non-harmful stimulus (e.g. a flashing light) that they had once been taught to fear (by pairing the light with a loud noise, for example). While stress responses in traumatic situations such as combat are appropriate and even adaptive, the problem with PTSD is that extremely heightened fear responses continue to occur in non-life threatening situations (such as in a noisy restaurant or when a loud truck drives by). Exposure to non-threatening but anxiety-provoking situations offers a chance to regulate these fear responses, and DCS may accelerate this process. When used with therapeutic exposure sessions or virtual reality exposure, DCS seems to enhance treatment effectiveness for phobias and panic disorder and may do the same for PTSD (though very preliminary results are uncertain).
MDMA: On the streets it’s known as Ecstasy, but in the research lab it’s known as 3,4-Methylenedioxymethamphetamine, or MDMA. This illegal recreational psychedelic party drug associated with raves and mind-numbing trance music is believed by some to have potential therapeutic benefits. After years of campaigning, researchers from the Medical University of South Carolina and the Multidisciplinary Association for Psychedelic Studies in California got the FDA and DEA to approve a small pilot clinical trial of MDMA administration for treatment resistant PTSD sufferers. Under close clinical monitoring and in conjunction with intensive psychotherapeutic engagement, 20 participants were randomized to two administrations of either MDMA or placebo. While the trial was extremely small and the results anything but conclusive, 83% of the MDMA group exhibited substantial treatment response compared to 25% in the placebo group.
Distress tolerance therapies: One major aspect that differentiates PTSD from other normative reactions to traumatic experiences is the presence of emotional detachment/numbing/dissociation. The body’s emotional system seems to log off or anesthetize in an effort to cope with the overwhelming stress of traumatic events. Unfortunately, this shutting down can cause drastic consequences for everyday functioning. Therapies like Dialectical Behavior Therapy, Acceptance and Commitment Therapy, or Mindfulness approaches focus on reducing emotional avoidance, tolerating distressing affects, and engaging in life with full, focused and controlled attention and acceptance.
Interpersonal and family therapies: While a number of standard PTSD psychotherapies prioritize exposure methods, some individuals are reluctant to undergo re-experiencing approaches or are turned off by such treatments. Not all psychotherapy for PTSD needs to be trauma-focused, however. Like most problems, PTSD occurs in a social context and comes with unique interpersonal costs and challenges. PTSD symptoms are related to intimate relationship troubles, relational detachment, and even interpersonal aggression. Social support is a strong buffer against the development of PTSD symptoms following a trauma, and couples and family-oriented interventions help individuals engage and enlist their families and social supports in recovery. These treatments can help rewrite dysfunctional family scripts and engender trust, agency, and security. Present-centered approaches focus on current adaptations to symptomatic problems while interpersonal therapy works on adapting to problematic role transitions following traumatic events or interpersonal role disputes with significant others at work or at home. The effectiveness of these approaches illustrates that problematic trauma reactions can be managed with less of a focus on the traumatic past and more of an eye toward interpersonal adaptation and post-traumatic growth.
The above approaches suggest innovative and compelling potentials for treating PTSD and its related problems. For now, however, these treatments remain mostly experimental (in some cases, illegal) and in need of further refinement and validation. For more information on PTSD and treatment, visit NIMH’s website. For help, consult a mental health professional in your area.
Cukor, J., Spitalnick, J., Difede, J.A., Rizzo, A., & Rothbaum, B.O. (2009). Emerging treatments for PTSD. Clinical Psychology Review, 29(8), 715-726.
Holmes, E.A., James, E.L., Kilford, E.J., & Deeprose, C. (2010). Key steps in developing a cognitive vaccine against traumatic flashbacks: visuospatial Tetris versus verbal Pub Quiz. PloS one, 5(11), e13706.
Mithoefer, M.C., Wagner, M.T., Mithoefer, A.T., Jerome, L., & Doblin, R. (2011). The safety and efficacy of±3, 4-methylenedioxymethamphetamine-assisted psychotherapy in subjects with chronic, treatment-resistant posttraumatic stress disorder: The first randomized controlled pilot study. Journal of Psychopharmacology, 25(4), 439-452.
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