MODERN MEDICINE RESPONDS
Zeroing in on post-traumatic stress
Make the invisible visible. In psychiatrists’ offices and medical imaging suites, London researchers are zeroing in on the anguish of post-traumatic stress disorder (PTSD) — what it actually looks like, both in the body and the brain.
They’re studying civilians, war veterans and emergency workers, but their cutting-edge research holds promise for all Canadians grappling with the often-debilitating fallout of exposure to traumatic events and experiences. “To understand PTSD, it’s not just a brain disorder, but it’s a brain, mind and body disorder,” said Dr. Ruth Lanius, a PTSD researcher at Western University and Lawson Health Research Institute, the research arm of St. Joseph’s Health Care London and the London Health Sciences Centre. There’s an opportunity in modern medicine, Lanius said, to blend the clinical diagnosis of PTSD — that is, a determination made by a doctor based on a patient’s signs and symptoms — with a quantifiable diagnostic measure such as a brain scan, obtained from magnetic resonance imaging. “In the past, people with mental illness, all their symptoms were invisible and I think that really contributed to the stigma of mental illness,” she said. “You can now visibly see that something is wrong with the brain.” PTSD can take a few different forms. In some patients, an episode can raise their heart rate, make them feel hyperactive, anxious or filled with intense emotions such as fear, guilt or shame. In others, the disorder can make them feel numb and detached from the world around them. Pinpointing which PTSD response a patient has is key, Lanius said, because it means doctors can tailor treatment to address it. Her latest research does just that. Based on an eight-minute resting brain scan of a patient, Lanius and her research team have developed an algorithm that can differentiate between the hyperactive and dissociative forms of PTSD and a brain without the disorder. “We can predict with a 92-percent accuracy what predominant subtype of PTSD people have,” she said. “I think that’s very promising .... It could really tailor that individualized approach.” Lanius also is using brain scan technology to see if it can help restore her patients’ sense of emotional control, a feeling that can be lost when trauma unfolds and as PTSD takes hold.
Study participants are shown trauma triggers while in the brain scanner. In real time, researchers track activity in an emotional centre of the brain. The level of brain activity is shown to the patient on a thermometer graphic inside the scanner. “If the thermometer goes up, they know that that region of the brain, while they ’re being triggered with trauma reminders, is being more active and then they employ strategies to decrease that emotional reactivity,” Lanius said. “This real-time re-regulating of the brain, I think, directly translates also into really having an increased sense of control, ‘I can change the chaos that is happening in my brain, mind and body.’ ” But the brain scans have more than just scientific value, researcher and psychiatrist Don Richardson said. “We’re understanding the brain to a greater degree to better understand how PTSD affects the brain,” he said. “For many patients, I think, that’s reassuring. That it’s not an illness of weakness, but it’s actually something that we can see on some of the neuro-imaging.” Richardson is the lead doctor at St. Joseph’s Health Care London’s operational stress injury clinic. The program at St. Joe’s Parkwood Institute — open only to veterans, active military members, RCMP officers and their families — sees about 850 clients a year. St. Joseph’s also has clinic locations in Toronto and Hamilton. While the program focuses on people in the military and law enforcement, research done at the clinic — they’ve been at it for more than a decade now — has had a major impact on PTSD treatment in the civilian population. “It’s absolutely transferable,” Richardson said. “Most of what we know from PTSD came from the military.”
More than a century ago, many soldiers returning from the First World War — a bloody four-year conflict that changed the nature of war itself — reported severe, lingering psychiatric symptoms from the horrors they saw.
Back then, it was called “shell shock.” Nearly 10,000 Canadians were diagnosed with the poorly understood condition during the war. The medical community honed its knowledge of the condition through the Second World War and the Vietnam War. In 1980, PTSD first appeared by that name in the third edition of the Diagnostic and Statistical Manual of Mental Disorders, a widely used compilation of criteria to classify mental disorders published by the American Psychiatric Association. But even after decades of study, there are still many facets of the disorder researchers are trying to understand. Compared to civilians with the disorder, military-related PTSD doesn’t always respond as well to psychotherapy and medication, Richardson said. The concept of so-called moral injury — the trauma that can come from being put in situations where you’re asked to do something you consider wrong or immoral — that some military members report, could be a factor in why their PTSD can be challenging to treat, Richardson said. “We don’t really know why, so that is one of the areas we want to research,” he said.
The clinic often encounters challenging, extreme or complicated cases of PTSD in patients who were once the picture of health. “You have individuals that were really high-functioning and healthy, because in order to be in the military, you’re screened for certain illnesses in the first place,” Richardson said.
But there’s one other thing that makes veterans and active military personnel a rewarding group to study, Richardson said.
“I think it’s part of the culture of the military that even though they might not benefit themselves, it’s a way of giving back,” he said. “I think that’s really what’s driving a lot of individuals to participate.” With all the research, from brain scans to examinations of the impact of moral injury, the goal is to change the lives of PTSD patients around the world with the made-in-London findings, Richardson said. There are still so many things to explore, Lanius said. “I love learning along with my patients,” she said. “I think it’s really important to always remain humble about what we don’t know.”