The Most Promising PTSD Treatment You've Never Heard Of
Innovating by fusing biological and psychological approaches.
Posted Jan 13, 2021
Not all stress is bad. A moderate level of stress can be a motivator and can enhance how we perform complex tasks. However, too much stress, the kind that comes from unaddressed trauma, impairs performance. When stress is at peak levels, we literally lose sleep. Our ability to concentrate is affected, in both the short and long term.
To really appreciate how much stress can impact our ability to take in new information, think about it like this. Just for a moment, imagine that you had to go see your doctor to get test results on whether or not you have a serious medical diagnosis that could greatly affect your quality of life. There is a reason why your doctor’s office might recommend that you bring a trusted family member or friend to your appointment. If the news is not good, it is common to become overwhelmed by stress, which can then cloud our ability to hear anything else a doctor says, including crucial instructions about next steps.
Many mental health providers like myself have worked with patients who are living in a chronic state of “survival mode,” where decisions are made in a “fight or flight” context. Sometimes we can see it on their face, like when we see them constantly scanning the room for threats. And sometimes, when we sense they are not fully with us in the present moment in therapy, it’s because they’re not - they are paying attention to something else in their mind’s eye that we can’t see, often related to a past trauma.
When our patients are in the wrong mind state, when they are overrun with adrenaline and unable to calm down, they are not prepared to receive and integrate psychological insights. For many years, before I learned about stellate ganglion block, I did my best to help my patients using empirically supported therapies, while many of them were in a state of what I call “chronic threat response.”
Once we understand the impact of high levels of anxiety on how our patients can engage in therapy, we can see how reducing their level of anxiety could change everything about their experience in therapy. Stellate ganglion block (SGB) involves injecting a common anesthetic medication into a cluster of nerves in the neck, which seems to restore calm to an over-active fight or flight system. SGB, as an intervention for trauma symptoms, arose from a line of thought that views PTSD as a largely biological condition with psychological and emotional components maintained by a damaging shift in normal biological functions.
Psychological trauma exposure results in a biological injury where people become stuck in “fight or flight” mode—potentially for years, or even decades. While PTSD has often been described as an “invisible wound,” it is in fact visible in certain types of brain scans. And it is not only visible, it’s treatable. Dr. Michael Alkire, the Chief of the Anesthesiology Service within the VA Long Beach Healthcare system, translates his 2015 study findings as follows: “There are changes in the brain that can be related to changes in symptoms that relate to what SGB does to brain functioning. This early result – based on a small sample – suggests that the changes in symptoms were related to the changes in amygdala/hippocampal functioning induced by the SGB.”
SGB has been used to successfully treat thousands of military service members suffering from symptoms associated with PTSD (Lynch, 2020). Within the civilian sector, Dr. Eugene Lipov and I have co-treated approximately 50 patients to date, as part of countless others he has treated prior to our collaboration. With SGB and therapy together, our patients have shown a much greater ability to apply psychological insights and maintain the gains of a successful course of therapy. This is a new model for trauma care—the fusion of biological and psychological care among allied healers.
There are at least three advantages when trauma is addressed in a collaborative way.
1. Better Outcomes
As healers, we do our best within our scope of expertise, but part of the responsibility we hold is to recognize the boundaries of this expertise. Advances in neurobiological models of PTSD can allow us to deploy more effective treatments for addressing PTSD that combine biological and psychological treatment in a strategic way.
Research has shown consistently that SGB can reduce PTSD symptoms by 50%* and is particularly helpful in improving symptoms of irritability, surges of anger, difficulty concentrating, and trouble falling or staying asleep (Lipov & Ritchie, 2015; Navaie, et al, 2014). A randomized clinical trial published in JAMA Psychiatry this year demonstrated twice the effect of SGB as compared to sham (placebo) injection (Rae Olmsted, et. al, 2020). The magnitude of effect and high success rates of SGB are compelling.
The skills of mental professionals are needed more than ever, perhaps especially during the window of time following SGB. A successful SGB procedure allows patients to do the work that continues to be necessary. They might be calmer, but work is still needed to help them reorganize their thought patterns and learn new ways of relating to others.
When patients are no longer overwhelmed with chronic anxiety, they are much more willing to engage in new behaviors that improve their relationships. They can approach things that previously felt totally overwhelming to them.
2. Overcoming Barriers to Care
Stigma is a substantial obstacle to many who suffer from trauma symptoms. Of course, the nature of trauma itself involves fear and avoidance, which are additional barriers to care. Many patients who might benefit from our services are initially unwilling to seek talk therapy due to fear of such stigma.
However, many of these same patients are open to interventions that use a biological approach. SGB can help patients who would otherwise continue to suffer needlessly to become more willing to engage in therapy.
Further, when treatment is done through this collaborative model, the development of trust can be accelerated through something that I refer to as “the transfer of trust.” That is, one can gain immediate trust and make quantum leaps in therapy when a patient is referred by a co-treating provider that has already earned the trust of that patient. This transfer of trust accelerates the timeline for therapeutic gains, thus preventing weeks—or months—of additional struggle in patients’ lives.
3. Reduced Dropout
In the fields of medicine and psychology, the mythology of the solitary healer is strong. In medicine, this takes the form of the town doctor who addresses all ailments, fictionalized in television programs and novels. In psychology, the image of Freud with a single suffering patient laid out on a couch is iconic.
Yet the change to a team approach has many advantages for patients. When patients are received—and treated—by a team of collaborating professionals, they may experience a feeling of wrap-around care, of being held and supported by a “unit” rather than an individual. This becomes especially helpful when patients are current or former military service members, who are accustomed to unit-based support. Patients benefit from the input of multiple lines of expertise. When their care is supported by a team of people investing in their healing, they may feel more accountable to their role in the healing process. In other words, they drop out of care less frequently.
There is an overlooked cost to less effective and more protracted treatments for trauma. Patients who have struggled with trauma for many years often struggle with hopelessness. Understandably, some patients may also experience suicidal thoughts and urges when they cannot visualize hope of relief for their symptoms. They may feel a burst of hope that propels them to enter treatment, but when relief does not come for many weeks or months, their hope can take a lethal hit.
SGB turns this dynamic on its head. Instead of patients having to wait to “habituate” to repeated retelling of their trauma story or waiting 6-12 weeks for a medication to take effect, SGB can immediately restore a feeling of hope.
When we specifically use stellate ganglion block in combination with psychological care, patients often report an immediate and sustained burst of hope within a single day as they feel significant symptom relief from SGB. This relief gives some of them the edge they need to fully engage in therapy.
The burst of hope they feel after SGB can propel them forward in therapy, creating increased openness and ability to invest in furthering the gains they can make with a psychologist or other co-treating mental health provider. With a team approach, the whole is truly greater than the sum of its parts.
Innovation in trauma care is critical, especially right now, when trauma due to COVID-19, natural disasters, the political climate, and the pressures of modern society, is rampant. Those who suffer from trauma deserve the best care we can provide, care that is practical, effective, and informed by modern neuroscience.
Getting the best outcomes requires us to re-situate ourselves not as a solitary expert but as team members who work to get the best outcomes for those we serve. Care that fuses the expertise of those providing biological and psychological interventions like stellate ganglion block hold game-changing promise for relief from suffering. This is the new model we need in medicine. And it is what our patients deserve.
On January 19, 2021 I will be giving a free talk describing Stella’s use of stellate ganglion block, it’s history, the outcomes we’ve observed, its safety and efficacy, and the advantages of using SGB in combination with talk therapy and with mind-body approaches.
Please consider yourself invited and feel free to share this invitation with your network. Here is the link to register.
Lipov EG, Navaie M, Brown PR, et al. Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review. Mil Med. 2013; 178(2):260–4. 10.
Mulvaney, Sean W.; Lynch, James H.; Hickey, Matthew J.; Rahman-Rawlins, Tabassum; Schroeder, Matthew; Kane, Shawn; and Lipov, Eugene. (2014). Stellate ganglion block used to treat symptoms associated with combat-related post-traumatic stress disorder: A case series of 166 patients. Military Medicine, 179, 1133-1140.
Navaie, Maryam, Keefe, Morgan S., Hickey, Anita H., McLay, Robert N., Ritchie, Elspeth Cameron, and Abdi, Salahadin. (2014). Use of Stellate Ganglion Block for Refractory Post-Traumatic Stress Disorder: A Review of Published Cases. Journal of Anesthesia and Clinical Research, 5, 4.
Lynch, J. (2020). Stellate ganglion block treats posttraumatic stress: An example of precision mental health. Brain and Behavior; 10;e01807. wileyonlinelibrary.com/journal/brb3.
Alkire, M. T., Hollifield, M., Khoshsar, R., Nguyen, L., Alley, S.R., and Reist, C. (2015). Neuroimaging Suggests that Stellate Ganglion Block Improves Post-Traumatic Stress Disorder (PTSD) Through an Amygdala Mediated Mechanism, ted at the Anesthesiology Annual Meeting, October 24, 2015.
Olmsted, Kristine L. Rae, Bartoszek, Michael; Mulvaney, Sean; McLean, Brian; Turabi, Ali; Young, Ryan; Kim, Eugene; Vandermaas-Peeler, Russ; Kelley Morgan, Jessica; Constantinescu, Octav; Kane, Shawn; Nguyen, Cuong; Hirsch, Shawn; Munoz, Breda; Wallace, Dennis; Croxford, Julie; Lynch, James H.; White, Ronald; Walters, Bradford B. (2019). Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial. JAMA Psychiatry, 77(2):130-138.