John J. Kruzel - American Forces Press Service
2008-11-30

But after a life-threatening experience, some people's physiological thermostats recalibrate to a lower threshold. This heightened sensitivity is a hallmark symptom of post-traumatic stress disorder, an anxiety condition that manifests itself as a range of emotional and behavioral changes aimed at coping with the trauma.

The disorder can be seen in the example of a servicemember who returns to the United States after surviving an attack from a roadside bomb hidden in a pile of garbage in Iraq. Even away from the combat zone, a pile of trash along the highway -- what others motorists might consider commonplace -- can trigger a fight-or-flight response in the afflicted troop.

"With PTSD, there is this stress response system that goes into overdrive in response to things in the environment that it has come to associate with being in danger, and it turns up the heat," said Dr. Farris K. Tuma, chief of the Traumatic Stress Research Program at the National Institute of Mental Health.

A study released in April found that nearly 20 percent of Iraq and Afghanistan veterans report PTSD symptoms. Though each servicemember displays a "constellation of differences," the common thread among those diagnosed is the daily impairment of normal functioning that lasts at least six weeks, said Tuma, who oversees the joint Defense Department, congressional and National Institute of Health research program.

In addition to elevated levels of arousal, also known as hypervigilance, other PTSD characteristics include the avoidance of reminders and re-experiencing the event, Tuma said. These symptoms can come in the form of persistent frightening thoughts and memories of their ordeal, emotional numbing, sleep problems or detachment from others.

Biologically, PTSD changes neuro-endocrine levels, primarily in two parts of the brain, experts believe. The first is the amygdale, an almond-shaped mass of grey matter located in the temporal lobes just above the ears, which regulates aggression and fear.

The other affected area is a section of the prefrontal cortex, which is believed to dictate responses of avoidance and numbing.

Using functional magnetic resonance imaging, or fMRI, Army Col. (Dr.) Michael J. Roy, a medical internist and director of Military Internal Medicine, and his staff are able to show evidence of PTSD's neural pathways. Doctors can detect what areas of the brain are engaged by monitoring levels of oxygen use.

"I show you a picture of war on the screen, and that stimulates a certain part of your brain, which uses more oxygen," Roy said. "Very briefly, for maybe a couple of seconds, you see a decrease of oxygen in those cells. People with PTSD seemed to have increased activation in the amygdale and less inhibition in the frontal lobe."

Though the understanding of PTSD's neural routes and its medical treatment have greatly evolved since it was initially diagnosed in 1980, the relationship between war and psychological trauma was documented as early as Ancient Greece. In his epic poem "The Iliad," Homer shows protagonist Achilles ruminating after hearing of the death of his closest companion, Patroclus.

"My comrade is dead, who in my hut is lying mangled by the sharp spear, with his feet toward the door, and round him our comrades mourn, wherefore in my heart to no thought of those matters," Achilles says, adding, "I will force my soul into subjection as I needs must."

The dialogue is a textbook portrayal of the type of numbing and other features associated with the disorder, Roy said.

"Achilles really didn't want to go back to war, because his friend died," he said. "All the kinds of symptoms he describes there are PTSD."

PTSD was first brought to public attention in relation to war veterans, but the disorder affects the civilian population in larger numbers than military personnel. It can result from a variety of traumatic incidents such as mugging, rape, torture, child abuse, a plane crash or a natural disaster, according to the National Institute of Mental Health Web site.

"It's an equal-opportunity offender," said Tuma, adding that car accidents are the No. 1 cause of PTSD. He noted that among the civilian population, members of law enforcement and firefighters are especially susceptible.

Not every traumatized person develops full-blown, or even minor, PTSD. Symptoms usually begin within three months of the incident, but occasionally emerge years afterward. Some people recover within six months, while others have symptoms that last much longer, with the possibility the condition becomes chronic, according to the NIMH site.

PTSD affects about 7.7 million American adults, but it can occur at any age, including childhood. Women are more likely to develop PTSD than men, and there is some evidence that susceptibility to the disorder may run in families. PTSD often is accompanied by depression, substance abuse, or one or more of the other anxiety disorders, the NIMH reports.

Traditional methods of treatment are talk therapy, cognitive processing and exposure therapy, all of which help patients understand their feelings and develop skills to confront them, Tuma said.

In an average session of "imaginal" therapy, for instance, patients may be asked to close their eyes and provide a first-person account of their traumatic recollection as thoroughly as memory allows: what they saw, smelled and heard.

While this and other talk therapies offer some of the best, most proven forms of treatment, Tuma said, one problem is that there are insufficient numbers of trained medical providers. At the same time, the nature of the therapy itself - an emotionally tasking exercise - creates a barrier on the road to recovery.

Some PTSD sufferers don't fully reveal themselves during cognitive therapy sessions, which can result in ineffective treatment. Others find the treatment too daunting, and avoid treatment altogether.

At the psychiatric wing of Walter Reed Army Medical Center here, medical personnel are exploring less traditional forms of treatment including alternative healing rituals like acupuncture and aromatherapy -- methods that convey elements of relaxation and spiritual mindfulness, experts said.

They are also testing a therapy that lets soldiers re-live their traumatic experience in virtual reality. The upshot of "Virtual Iraq," and similar other types of treatment, is that those afflicted with PTSD can learn to become less sensitive to their painful and disturbing memories by confronting them.

Other health practitioners, meanwhile, are in the early phases of a therapy that combines pharmacology and a treatment known as extinction learning. This method involves unlearning the linkages between harmless cues that trigger reminders of the trauma, and replacing them with new memories -- all while taking the drug Cycloserine, an antibiotic that has been found to accelerate the learning process, Tuma said.

He added that developing newer and better treatments represents the current phase of PTSD research, including the emphasis on better understanding the relationship between neuro-circuitry and pharmacology. One therapy involves giving the endocrine mechanism a "shock to the system" so that memories of the event do not get as strong a toehold.

Tuma said doctors are studying the value that early intervention has on treating PTSD. Some have floated the idea of making a Web-based tool to facilitate early screening and diagnosis. Early detection, Tuma said, can prevent the disorder from snowballing and leading to other problems like alcoholism, homelessness, divorce and financial problems.

Unfortunately, PTSD does not alert the human body with early warning signs in the way that tingling in the left arm might warn of an ensuing heart attack. For this reason, Tuma said, researchers are developing tools to predict when somebody is at high-risk for developing the disorder.

The interagency group Tuma heads received a bonus of $300 million in fiscal 2008, and similar funding in fiscal 2009, which was dictated by Congress. From Tuma's perspective, funding should primarily focus on risk prediction, which currently is a small player as it relates to veterans and the Defense Department.

"The glass is maybe not half-full yet, but it's improving," he said of the comprehensive effort to stem PTSD.

A sustained effort is needed to ensure that PTSD treatment and research continue to evolve, Tuma said.

"Throwing some resources at new research and propping up new service programs is right, is a good thing to do," he said. "But the scars of these kind of conflicts are not easily mended and patched up and moved on within a couple of years.

"The kind of services and programs we're talking about probably are going to have to be around for a while. Sustained investment and attention is key."

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