We Now Know Where PTSD Lives in the Brain

“Isaiah” asked if there was anything new that might help him.

Isaiah was an older man who'd had a violent childhood. Decade after decade, he experienced terrible nightmares. He was emotionally reactive with his partner. He had suicidal thoughts. He was “jumpy.” He had PTSD. In fact, he had one of the worst cases of PTSD I had ever seen, and I specialize in hard cases.

He couldn’t tolerate the standard treatments. Medications hadn’t made much difference and left him with intolerable side effects. The kind of talk therapy known to work in PTSD required him to intentionally remember his horrifying childhood, a mental activity he understandably wanted to avoid. The times he had tried it had, it seemed, only made it worse. He asked if I could help him.

Where PTSD Lives

Source: Siddiqi et al / PubMed Preprint

I happened to know something that only about a dozen people in the world knew. I told him we had just discovered a new circuit that might control PTSD and that we could stimulate it with transcranial magnetic stimulation (TMS). I explained: Our colleagues at Harvard had looked at a database of Vietnam veterans. Normally, when soldiers experience a serious combat wound, they are at high risk for PTSD. But some wounds, it seemed, protected the soldiers from PTSD. Shrapnel through certain special regions of the brain seemed prevent PTSD. This network, it seemed, was where PTSD lived. Our colleagues had looked back at old brain stimulation data—the closer treatment was to this newly discovered network, the more improvement patients had with PTSD.

Patient #1

I was very clear. He would be the first person in the world to have this treatment. I explained the rationale for the target, and I could give him statistics on our patients who had had stimulation in a similar location, but he would be patient #1 in the world. It truly was going out into the unknown.

He agreed.

We found a general map and applied it to Isaiah's brain

Source: Siddiqi et al / PubMed Preprint

We scanned his brain. We looked at 21 minutes of the flow of blood in his brain while he was at rest using an MRI. We looked for patterns. We took the circuit map from the Vietnam veterans and then applied it to his brain. There it was. The first-ever PTSD target. For him, it landed just above the middle of his forehead.

He flew out to our clinic for about a week. We delivered Holistic Optimized Personalized Expedited (HOPE-TMS), structured after the Stanford-developed SAINT-TMS—10 minutes of TMS every hour for 10 hours a day. During our intensive treatments, moods are hard to judge. Are people happy that they’re finally being listened to? Or are our technicians really nice? Or is it a nice “vacation” away from normal life? I’m sometimes skeptical of improvements during the treatment week.

At my first follow-up visit with him, I held my breath. Would the first-ever neuro-navigated TMS treatment for PTSD work?

It did. He was transformed. A lifetime of PTSD melted away with a week of treatment.

Precision Psychiatry and Designed Treatments

The most important thing about this story is that it wasn’t serendipity. We didn’t just get lucky. We didn’t happen to notice someone getting better when we were trying to treat something else. We helped this patient on purpose. We are living out the dreams of the last century of psychiatrists: we are starting with the brain and actually targeting treatments.

For targeted PTSD treatment, many questions remain. One successfully treated patient is only the beginning of a journey. Much more work needs to be done before we have full confidence in the target. With depression treatments, we know they generally last a long time and re-treatments work well; we don't know how long this treatment lasts or if re-treatments are effective. We also need to do more studies to confirm that this is really effective.

Access to These Treatments

Our office offers the neuro-navigated version (about one-third of our accelerated patients fly in for treatment from across the U.S.), but even conventionally targeted TMS has been shown effective for those with depression and PTSD. Many people today can get their insurance company to cover TMS and most cities have clinics that can provide it.

Post-Traumatic Stress Disorder Essential Reads

Trapped in War Zones

The Trauma Paradox

Actually Stopping the Cycle of Trauma

The world continues to be a hard place. Millions of people experience truly traumatizing experiences daily, some of which evolve into PTSD. Then, if that’s not bad enough, we know that hurt people hurt people. The emotional reactivity that is a symptom of the condition makes those with PTSD more likely to harm those they love, passing on the trauma from generation to generation. But it needn’t be this way. We now have a new tool to stop it.

When you experience trauma, it affects your whole self, including physical signs in your brain and your body. The body may keep the score, but now, at least sometimes, we can reset the counter. We have, for the first time, mapped PTSD. We know where it lives. We can knock on its door and tell it to leave.

Imagine we develop this technology further and get it paid for. Imagine we treat more people who have PTSD and most get into remission. Imagine that we don't allow PTSD to "move in." Today, trauma surgeons fix broken bones after a physical trauma, preventing improper healing—maybe we can have brain stimulation doctors stopping psychological trauma from forming PTSD. Maybe we don't have to keep on accepting that this type of misery will always be with us.

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