The Latest and Greatest in Treatment for PTSD
The magic bullets and cutting edge innovation for treating PTSD
Posted Jul 23, 2014
I am frequently asked to talk about PTSD to professional audiences and, without exception, always get a post talk question asking about my experience with some experimental intervention that someone read about somewhere in a newsmagazine or heard about from the T.V.
Internally, I always groan.
Having just spent 60-90 minutes pouring over carefully crafted PowerPoint slides that contain information about the evidence base for the treatments of PTSD and what best practices consist of, why I am always confronted with a zealous audience member who is obsessed with the new, the innovative, or the magic bullet?
In the interest of full disclosure, I have to share my viewpoint as being that of a health services researcher. I approach PTSD treatment with a basic belief that we already have pretty good treatments, and the issues with getting better outcomes for PTSD lie more in how we implement those treatments, the limitations of the systems that provide care, massive issues of access to care (i.e. those who need care the most simply can’t access it for a myriad of reasons), and healthcare disparities (that an individual’s outcomes for PTSD are more likely linked to their zip code as opposed to their genes/neurotransmitters).
In short, I usually have a healthy skepticism toward the experimental or magic bullets type of treatments for PTSD, which often get a lot of media attention and can be very seductive to the brain of a researcher or clinician who spends their days trying to help individuals who live with PTSD.
Please note: MANY of these approaches are still considered EXPERIMENTAL, and I am listing them in no particular order of importance.
1. Mind – Body Practices for PTSD
Mind Body practices are increasingly used to offer symptom reduction for PTSD. Approaches such as Yoga, Tai Chi, Mindfulness Based Stress Reduction, Meditation, and Deep breathing are some examples. There are about 16 rigorous studies that have been done to date, most of which have small sample sizes. Whilst early findings suggest such practices can have a beneficial impact on symptoms like intrusive memories, avoidance, and increased emotional arousal, there is insufficient evidence to support their use as standalone treatments, though they can be recommended as an adjunctive treatment.
2. Cervical Sympathetic Blockade and Stellate Ganglion Block for PTSD
In 2008, reports started to emerge about a minimally invasive manipulation of sympathetic nerve tissue in patients with PTSD that relieved their anxiety. The procedure consisted of injecting a local anesthetic into sympathetic cervical nerve tissue at the C6 level and was apparently accompanied by immediate relief by the patient. In 2012, a case series was reported where treatment resistant veterans with PTSD were given a stellate ganglion block and also a pre and post intervention CAPS. After the intervention, 5/9 of the patients experienced significant improvement; these benefits diminished over time and the benefits were not universal. Controlled trials are currently underway to investigate this intervention further.
Virtual Reality exposure therapy utilizes real time computer graphics, body tracking devices, visual displays, and other sensory input devices to give the patient the experience that they are immersed in a virtual environment. It is an enhanced version of the imaginal exposure typically utilized as a part of trauma-focused psychotherapies. In 2001 an open clinical trial of Virtual Reality exposure therapy yielded promising results. It is currently being studied under controlled conditions.
D-Cycloserine is a partial agonist of the NMDA receptor (a brain receptor that plays an essential role in learning and memory). It has been used to treat social phobia and panic disorder and to enhance the effects of psychological therapies for those disorders. Preliminary data suggests it can be a useful adjunct in addition to evidence-based psychotherapies for patients living with severe PTSD.
Ketamine is a non-barbiturate anesthetic and antagonist at the NMDA receptor that is typically administered intravenously. It has been used for years for patients with severe burns and it was, in this use, that its dissociative properties became apparent. Retrospective studies show that those who received Ketamine after a traumatic event were less likely to develop PTSD. It has been postulated that Ketamine may disrupt the process via which traumatic memories are laid down. A 2014 JAMA study reported on a RCT which demonstrated a rapid reduction in symptom severity following Ketamine infusion in patients with chronic PTSD.
In an experimentation with packaging, British researchers compressed versions of trauma-focused psychotherapies for PTSD into a seven day intensive treatment. This was found to work as well as treatment as usual, which is the same treatment delivered once a week, over 12 weeks. Such an approach was postulated to be more efficient and convenient and was associated with faster improvement in symptoms and lower dropout rates.
Memantine is a non-competitive NMDA antagonist that is thought to protect the glutamergic destruction of neurons and hence prevent the hypothesized neurodegeneration in the hypothalamus, which contributes to the memory issues related to PTSD. In a 2007 open label small trial, Memantine was found to be associated with some encouraging outcomes. Double blind placebo controlled trials are pending.
Copyright: Shaili Jain, MD. For more information, please see PLOS Blogs