BSSR Lecture Series: PTSD Treatment and Prevention


Uploaded by NIHOD on 07.06.2012

Transcript:
GOOD AFTERNOON.
THANK YOU FOR COMING.
MY NAME IS MIKE SPITLE IN THE
OFFICE OF BEHAVIORAL AND SOCIAL
SCIENCE RESEARCH AND IT'S A
PLEASURE TO INTRODUCE
DR. BARBARA ROTHBAUM.
DR. ROTHBAUM IS PROFESSOR IN
PSYCHIATRY AT THE EMORY SCHOOL
OF MEDICINE, DEPARTMENT OF
PSYCHIATRY AND BEHAVIORAL
SCIENCES AND DIRECTOR OF THE
TRAUMA AND ANXIETY RECOVERY
PROGRAM AT EMORY.
DR. ROTHBAUM SPECIALIZES IN
RESEARCH AND TREATMENT OF
INDIVIDUALS WITH ANXIETY
DISORDERS PARTICULARLY FOCUSING
ON POST TRAUMATIC STRESS
DISORDER.
SHE'S AUTHORED OVER 200
SCIENTIFIC PAPERS AND CHAPT
ERGS, PUBLISHED FOUR BOOKSES ON
THE TREATMENT OF PTSD AND TWO
OTHERS ON ANXIETY AND RECEIVED
THE DIPLOMATE FROM THE AMERICAN
BOARD OF BEHAVIORAL PSYCHOLOGY.
PAST PRESIDENT OF THE
INTERNATIONAL SOCIETY OF
TRAUMATIC STRESS STUDY, ON THE
SCIENTIFIC ADVISORY BOARD FOR
DISORDERS ASSOCIATION OF AMERICA
AND THE OBSESSIVE COMPULSIVE
FOUNDATION AND BOARD OF
DIRECTORS FOR ADAA AND IS
PIONEER IN THE APPLICATION OF O
VIRTUAL REALITY TO TREATMENT OF
PSYCHOLOGICAL DISORDERS.
WILL YOU PLEASE HELP ME WELCOME
DR. ROTHBAUM.
[APPLAUSE]
>> THANK YOU.
CAN EVERYBODY HEAR ME OKAY?
I HAD BEEN TOLD I'M TOO SHORT TO
STAND BEHIND A PODIUM SO I WILL
STAND NEXT TO IT.
I WANT TO THANK YOU FOR INVITING
ME AND AS MANY ACADEMICS WHO OWE
A DEBT OF GRATITUDE TO NIH, NIH
-- ASK ANYTHING AND IF I CAN DO
IT I WILL.
I ALSO WANT TO THANK YOU, ONE OF
MY PATIENTS WE'RE SCHEDULING
SOME THINGS AND YOU KNOW I WAS
GOING TO GO -- SHE KNEW I WAS
GOING TO GO AWAY AND SPEAK AND
SHE SAID DON'T -- O SHE'S IN FOR
FEAR OF PUBLIC SPEAKING.
SHE SAYS AREN'T YOU SCARED TO
SPEAK PUBLICLY?
MY FEAR IS THE OPPOSITE, NO ONE
SHOWING UP.
SO THANK YOU FOR SHOWING UP AND
ALLAYING THAT FEAR.
SO WE'RE GOING TO TALK
SO FIRST
DISCLOSURE, I'M GOING THE TALK
ABOUT VIRTUAL REALITY, EMORY AND
GEORGIA TECH TOOK US AND START
AD START UP COMPANY, I'M FULL
TIME AT EMORY BUT THERE'S A
COMPANY VIRTUALLY BETTER.
THE VIRTUAL IRA WAS NOT CREATED
BY VIRTUALLY BETTER BUT I
DISCLOSE AND DISCLOSE.
SO MOST OF US THINK OF PTSD AND
THE WAR VETERANS DISEASE.
IT IS CERTAINLY A HUGE PROBLEM
BUT ESTIMATES 7 ARE 70% WILL UNS
GO A TRAUMATIC NEFNT OUR
LIFETIME CAPABLE OF PRODUCING
PTSD.
IT DOESN'T MEAN 70% OF US END UP
WITH PTSD, BUT IT DOES MEAN THAT
TRAUMA IS UBIQUITOUS AND THE
ESTIMATES ARE ABOUT 10% OF THE
POPULATION IN THE UNITED STATES
AT ANY POINT IS SUFFERING FROM
PTSD.
SO FIRST LET'S TALK A LITTLE BIT
ABOUT WHAT PTSD IS.
IN THE DSM III AN 3,R, PTSD IS
THE ONLY ANXIETY DISORDER THAT
EXTERNAL EVENT IS PART OF THE
DIAGNOSTIC CRITERIA.
SO IT INCLUDES THE DEFINITION OF
THE TRAUMA.
THE DSM III AN 3,R, THE
DEFINITION OF TRAUMA WITH
OUTSIDE WITH RANGE OF USUAL
HUMAN EXPERIENCE SO IT'S A
VARIED AUDIENCE, ANY LAWYERS IN
THE AUDIENCE?
SO WE'RE OKAY TO RASH THE
LAWYERS?
SO FOR EXAMPLE, IF SOMEONE WENT
TO COURT AFTER A MOTOR VEHICLE
ACCIDENT AND ALSO CLAIMING PTSD,
THE LAWYERS ARE SAYING MOTOR
VEHICLE ACCIDENTS AREN'T OUTSIDE
THE RANGE OF USUAL HUMAN
EXPERIENCE, THEREFORE THEY CAN'T
HAVE PTSD.
THEN DEPENDING ON WHAT
STATISTICS YOU LOOK AT, 1 IN 4
OR 1 IN 5 WOMEN CAN BE THE
VICTIM OF SEXUAL ASSAULT IN
THEIR LIFETIME AND LAWYERS SAY
THAT'S NOT OUTSIDE THE RANGE OF
HUMAN EXPERIENCE SO WE NEED TO
GET RID OF THAT DEFINITION AND
WE REPLACED IT WITH WHAT I THINK
OF AS THE EXLAX DEFINITION.
GRU EAR AS OLD AS I AM YOU MIGHT
REMEMBER THE OLD EXLAX
COMMERCIALS, REGULAR IS WHAT'S
REGULAR FOR YOU.
SO WE TRIED TO CHANGE IT TO
TRAUMATIC IS WHAT'S TRAUMATIC
FOR YOU.
AND ACTUALLY THAT IS THE BEST
PREDICTOR WHO GETS PTSD SO WE
COULD BE WALKING DOWN THE STREET
TOGETHER AND GET HELD UP, YOU'RE
SURE HE WANTS OUR MONEY, WILL
LEAVE US ALONE, I'M SURE HE'S
CRAZY ON CRACK AND WILL KILL US.
PEOPLE WILL SAY WE HAVE BEEN
THROUGH THE SAME EVENT BUT WE
HAVEN'T.
BECAUSE IN YOURS YOUR LIFE
WASN'T IN DANGER AND MINE IT
WAS.
SO IT'S IMPORTANT TO ASSESS
WHAT WERE YOU SCARED OF?
WHAT DID YOU THINK COULD HAPPEN
TO YOU?
IN GENERAL THE WAY I SEE PTSD IS
THE PEOPLE ARE HAUNTED BY
SOMETHING THAT HAPPENED TO THEM
IN THEIR PAST.
AND THE HAUNTING NATURE COMES
OUT IN THE REEXPERIENCING
SYMPTOMS.
PEOPLE WILL THINK ABOUT IT WHEN
THEY DONE WANT TO THINK ABOUT IT
AND IT KNOCKS THEM OFF KILTER.
NIGHTMARES I HAD ONE YOUNG WOMAN
WHO HATED HER NIGHTMARE SO MUCH
SHE WOULD DO EVERYTHING SHE
COULD TO STAY AWAKE ALL NIGHT
LONG, FINALLY FALL ASLEEP
EXHAUSTED AT 6 A.M., NOT A WAY
TO BE FUNCTIONAL IN THE REST OF
HER LIFE.
FLASH BACK.
PEOPLE HEARD VIETNAM VETERANS
HEARING A CAR BACKFIRE AND
HITTING THE GROUND.
I WORK WITH SEXUAL ASSAULT
SURVIVORS AND A LOT OF THEIR
FLASH BACKS ARE SEXUALLY
INDUCED.
IT COULD BE MOVING O WHISPERING
A CERTAIN WAY AND IT CAN SEND
THEM BACK THERE.
IN GENERAL, PEOPLE WITH PTSD ARE
VERY AVOIDANT.
THEY DON'T WANT TO THINK OR TALK
ABOUT IT.
NOTHING TO REMIND THEM OF IT.
SOMETIMES I CAN COME ACROSS
SOMEBODY AND ESPECIALLY ACTUALLY
IN OUR CURRENT VETERAN
POPULATION WHO CAN TALK ABOUT IT
SEEMINGLY EASILY AND I REALIZE
THEY HAVE CUT THEMSELVES FROM
THEIR EMOTIONS AND IT'S LIKE
THEY'RE GIVING A POLICE BLOT OR
REPORT OR SOMEONE ELSE'S SAD
STORY AND THEY'RE SHUT DOWN FROM
EMOTIONS.
PSYCHOGENIC AMNESIA IN EXTREME,
PEOPLE DON'T KNOW WHAT HAPPENED.
ONE OF THE EXAMPLES I SAW WHEN I
WAS WORKING IN PHILADELPHIA, A
RAPE VICTIM REMEMBERED
ENCOUNTERING THE ASSAILANT ON
THE STAIRWELL, NEXT THING IT WAS
45 MINUTES LATER SHE WAS BACK IN
HER APARTMENT, NO RECOLLECTION,
ANYTHING BAD HAD HAPPENED.
HER FIRST CLUE WAS WHEN SHE WHEN
TO THE BATHROOM AND HAD CUTS ON
HER THIGHS.
IT WAS A MONTH AND A HALF LATER
SHE WAS ABLE TO REMEMBER WHAT
HAPPENED.
AND I SHOULD ADD AN ASTERISK
BECAUSE IT TURNS OUT SHE WAS
ALSO THE VICTIM OF CHILDHOOD
SEXUAL ABUSE AND MORE PRONE TO
DISSOCIATE.
BUT I SEE IT ALONG A CONTINUE
WUM.
PEOPLE WILL SAY I COULDN'T GET
AWAY SO I LEFT MY BODY.
I WAS LOOKING DOWN ON MY BODY OR
OUTSIDE THE VEHICLE LOOKENING
AND I SEE THIS ALONG THE SAME
CONTINUUM.
THESE ARE THE NUMBERING SYMPTOMS
OF PTSD AND A BIG OVERLAP WITH
DEPRESSION.
I DON'T THINK THAT NUMBERING IS
JUST THE ABSENCE OF A RESPONSE.
I THINK NUMBERING CAN BE A
RESPONSE IN AND OF ITSELF.
IN A FEW MINUTES I'LL TELL YOU
ABOUT TREATMENT THAT WE USE A
LOT, EXPOSURE THERAPY AND
SOMETIMES IN THAT OUR GUYS WILL
TELLS I'M NUMBERING OUT NOW.
AND I THEY TELL THEM STAY WITH IT AND
IT WILL PASS.
AND SOMETIMES THEY CAN TELL YOU
WHERE IN THEIR BODIES THEY'RE
FEELING NUMB.
A LOT OF SLEEP PROBLEMS WITH
PTSD AND A LOT OF REASONS FOR
SLEEP PROBLEMS.
WE MENTION NIGHTMARES.
ALSO PTSD IS AN ANXIETY
DISORDER.
IF YOU'RE SCARED, NIGHTTIME IS A
REALLY SCARY TIME.
THE HOUSE IS QUIET, EVERYBODY IS
ASLEEP.
VERY EASY TO MISINTERPRET THOSE
NOISES AN THINK MY GOSH, IS
SOMEBODY TRYING TO GET IN, DO I
CALL 911 AND THEY PLAY OUT THE
MANEUVERS IN THEIR HEAD.
NOT A WAY TO REPLAX AND -- RELAX
AND GET TO SLEEP.
SOME PEOPLE THAT I SEE, THAT I
THINK FUNCTION WELL WITH PTSD,
ONE WAY THEY DO IT IS STAY VERY
BUSY ALL DAY LONG.
SO AT NIGHT WHEN THEY'RE LAYING
DOWN, AND ALL OF THESE
DISTRACTIONS THAT HAVE BEEN
HOLDING THESE THOUGHTS AT BAY
ARE CLEARED AWAY, THESE THOUGHTS
COME FLOODING BACK TO THEM.
DIFFICULTY CONCENTRATING.
I THIS THINK OF A KID, I WENT TO
TEXAS A AND M UNIVERSITY AFTER
THE BONFIRE COLLAPSE AND ONE OF
THE STUDENTS THERE WAS ALSO EMT
RESPONDER.
HE SAID BEFORE THE CLAPTION HE
HAD 3.0 GPA, AFTER THE BOND FIRE
COLLAPSE HE HAD A .6 GPA.
THE WAY HE DESCRIBED HIS
DIFFICULTY CONCENTRATING.
HE SAID HE WOULD TRY TO DO
READING ASSIGNMENTS AND THEY
WERE JUST WORDS ON A PAGE, HE
COULDN'T PUT THEM TOGETHER TO
MAKE ANY SENSE OUT OF THEM.
HYPERVIGILANCE AND EXAGGERATED
STARTLE.
I THINK A LOT OF TIMES -- HELLO,
MICHAEL.
I USED TO WORK WITH MICHAEL IN
PENNSYLVANIA BEFORE WE WENT A
LITTLE BIT -- I WENT FARTHER
SOUTH.
I THINK A LOT OF TIMES EVEN
AFTER WE SUCCESSFULLY TREAT THE
PTSD, I THINK PEOPLE ARE LEFT
JUDGE PIER HAHN BEFORE HAHN.
THE WAY I SEE THAT, YOU JUST
DON'T GO THROUGH THESE TYPES OF
EVENTS THAT LEAD TO PTSD AND
WALK THROUGH LIFE AS CALMLY AS
YOU DID BEFORE.
SO ACTUALLY THIS DATA IS FROM
PENNSYLVANIA.
IF YOU REMEMBER PTSD FIRST CAME
ABOUT AS AN OFFICIAL DIAGNOSIS
IN 1980.
THE DSM III.
SO IT WAS IN RESPONSE TO THE
LARGE NUMBER OF VIETNAM VETERANS
WITH PTSD.
IT WAS RETROSPECTIVE, VERY MALE,
SO WE DID A STUDY TRYING TO
PERSPECTIVELY PLOT THE COURSE OF
PTSD SO WE MA ET WITH FEMALE --
MET WITH FEMALE RAPE VICTIMS AN
ASSESSED PTSD FOR 12 WEEKS.
SO WE WERE VERY SURPRISED TO SEE
IN THE FIRST WEEK FOLLOWING THE
ASSAULT, 94% MET SYMPTOMATIC,
NOT DURATION BUT SYMPTOMATIC
CRITERIA FOR PTSD.
SO WHAT THAT SAYS TO ME, THOSE
SYMPTOMS, THAT'S THE NORMAL
RESPONSE TO TRAUMA.
SOMEBODY HOLDS A KNIFE TO YOUR
THROAT AND SAYS DON'T SCREAM OR
I'LL CUT YOU YOU'LL HAVE
PROBLEMS SLEEPING AND PROBLEMS
CONCENTRATING AND BE SCARED TO
GO OUTSIDE BY YOURSELF, THAT'S
NORMAL.
SO WHAT WE WANTED TO FIGURE OUT
IS WHEN A NORMAL RESPONSE TO
TRAUMA ENDS, AND A PSYCHOPATH
PATH LODGE -- PSYCHOPATHOLOGICAL
RESPONSE THAT DIAGNOSIS AN
TREATMENT BEGINS.
SO WE FOLLOW OVER TIME AND WE
WERE SURPRISED TO FIND THREE
MONTHS LATER 12 WEEKS LATER
ALMOST HALF MET THE FULL
CRITERIA FOR PTSD.
SO WHAT WE DID IS WE DIVIDED UP
THE DATA FROM WEEK 12 AND WENT
BACKWARDS.
TOP LINE REPRESENTS PEOPLE WITH
CHRONIC PTSD, BOTTOM REPRESENTS
PEOPLE WHO DON'T END UP WITH
PTSD.
IF WE WANT THE TERM RECOVER WE
CAN USE THAT LOOSELY.
THEN IT TELLS A DIFFERENCE
STORY.
EVERYBODY STARTS HIGH, EVERYBODY
COMES DOWN A LOT IN THE FIRST
FOUR WEEKS.
THAT HAVE, IF YOU LOOK AT THE
BOTTOM LINE THE PEOPLE WHO
RECOVER, THEY CONTINUE TO
IMPROVE STEADILY ACROSS TIME.
IF YOU LOOK AT PEOPLE WITH
CHRONIC PTSD, AFTER WEEK FOUR
THEY DON'T CHANGE.
THEY DON'T GET WORSE BUT THEY
DON'T GET BETTER.
THIS IS LED SOME OF US TO THINK
OF PTSD AS DISORDER OF
DISTINCTION.
FEAR AND ANXIETY IS A NORMAL
RESPONSE TO TRAUMA.
FOR MOST THAT FEAR EXTINGUISHES
OVER TIME FOR SIGNIFICANT
MINORITY, IT DOESN'T.
THE GOOD THING ABOUT THAT, WE
KNOW A LOT ABOUT EXTINCTION
TRAINING.
SO EXTINCTION TRAINING IN
RODENTS IS ANALOGOUS TO EXPOSURE
THERAPY IN HUMANS.
SO NOW I SWITCH AND TALK ABOUT
THAT.
SO ACTUALLY THIS IS FROM
EMBARRASSING MICHAEL A SECOND
BECAUSE THIS IS BASED ON
EMOTIONAL PROCESSING THEORY AND
HAS EVERYONE IN THIS ROOM HAS
NOT READ BACK TO 1986, WHEN I
READ IT WAS ONE OF THESE PAPERS
THAT I WAS PROUD TO KNOW YOU
GUYS AND I WISH I HAD WRITTEN.
I THOUGHT IT MADE SO MUCH SENSE.
SO THE IDEA BEHIND THAT IN
EMOTIONAL SPROASESSING THEORY OF
PTSD, WHEN SOMETHING IMPORTANT
HAPPENS TO US, WE NEED TO
EMOTIONALLY PROCESS IT.
USE A MINOR EXAMPLE.
SAY ON YOUR WAY INTO WORK, YOU
HAD A CLOSE CALL IN A CAR.
FIRST PERSON YOU SIGH IN
ENINVESTIGATOR YOU MAY TALK
ABOUT IT.
THEN YOU SEE THE SEC AT WORK AND
YOU SAY MAN THIS JEEP CAME OUT
OF NOWHERE.
BY THE END OF THE DAY YOU'RE NOT
TALKING ABOUT IT ANY MORE.
YOU PROCESSED IT.
YOU TALKED ABOUT IT ALL YOU NEED
TO.
BLOW THAT UP ABOUT A THOUSAND
TIMES AND THAT'S WHAT WE HAVE
WITH PTSD.
I THINK THERE ARE VARY ROWS ROWS
-- VARIOUS REASONS FOLKS WITH
PTSD HAVEN'T BEEN ABLE TO
PROCESS IT.
SOME IS FEAR AND ANXIETY, IF IT
MAKES ME FEEL BAD TO THINK ABOUT
IT OR TALK AIN'T MY NAM -- TALK
ABOUT IT MY NATURAL INSTINCT IS
THE TO AVOID IT.
BUT THAT DOESN'T MAKE IT
AMENABLE TO PROCESS.
ALSO SOCIAL CONVENTIONS.
OUR SOCIETY IS NOT VERY GOOD
ABOUT TALKING ABOUT ANYTHING
NEGATIVE.
I LOOK WHERE PEOPLE CAN TALK
ABOUT BREAST CANCER AND WEAR
PINK RIBBONS AN THINK HOW MANY
DECADES IT'S GOTTING TO THAT
POINT AND PEOPLE AREN'T TALKING
ABOUT THAT AND CERTAINLY NOT THE
TYPES OF EVENTS THAT LEAD TO
PTSD.
I THINK THIS IS A LARGE PART OF
WHAT HAPPENED TO OUR VIETNAM
VETERANS.
ONE GUY TOLD US AS HIS PLANE WAS
TAKING OFF YOU HAVE FROM SAIGON,
THERE ARE WALKING MORTARS
FOLLOWING IT SO HE BARELY
ESCAPES WITH HIS LIFE.
LESS THAN 24 HOURS LATER H'S
BACK IN THE STATES AND HIS
PARENTS LIVING ROOM WATCHES WHAT
HE SAID AND I BELIEVE HIM WERE
LIES ON THE EVENING NEWS ABOUT
THE WAR.
SO CHANCE TO TALK ABOUT IT,
DEBRIEF, DECOMPRESS, NOTHING.
AND IT WAS AN UNPOPULAR WAR.
SO NOBODY WANTED TO HEAR ABOUT
THAT.
EVEN THOUGH IT'S A CLAY SHAI, I
THINK FOR -- CLICHE FOR THE
WORLD WAR II VETERAN IT IS LONG
BOAT RIDE HOME WAS VERY
THERAPEUTIC.
THEY STAYED WITH THE SAME FOLKS
THEY SEIVED WITH, THEY SPENT
THESE WEEKS TOGETHER, THEY COULD
GRIEVING TO IF THEY LOST BUDDIES
THEY CAN TALK AND PROCESS IT.
WHEN THEY GOT BACK TO THE STATES
THEY WERE MORE READY TO REENTER
SOCIETY AND THEY REENTERED
SOCIETY AS HEROES.
SO PEOPLE WANTED THE TO HEAR
THEIR STORIES.
SO ALL THESE REASONS THEY DON'T
GET TO PROCESS IT AND SO IT JUST
FESTERS.
THAT'S HOW I SEE THAT IT HAUNTS
THEM.
SO WHAT WE THINK IS REQUIRED FOR
GOOD PROCESSING ACTIVATE THE
MEMORY, BRING IT UP BUT THEN PUT
IT BACK DIFFERENTLY.
YOU DON'T WANT TO ACTIVATE IT
AND GET PEOPLE SCARED AND
TRIGGERED AND PUT IT BACK THE
SAME WAY.
YOU WANT THEM TO LEARN SOMETHING
DIFFERENT.
SO THERE'S SEVERAL WAYS TO
ACTIVATE THE MEMORY.
WE HAVE FOUND EXPOSURE IS GOOD
AT ACTIVATING MEM RISM WE ASK
PEEP TOM GO BACK IN THEIR MIND'S
EYE TO THE TIME OF THE TRAUMATIC
EVENT AND WE COUNT IT OUTLOUD IN
THE PRESENT TENSE OVER AND OVER
AND OVER.
WE TAPE RECORD IT AND GIVE THEM
A TAPE TO LISTEN TO.
FOR HOME WORK TO BE PRACTICING
AND DOING MORE EXPOSURE EVERY
DAY AT HOME.
WE ALSO DO WHAT'S CALLED IN VIVO
EXPOSURE IN REAL LIFE.
FOR EXAMPLE, EXPOSING THEMSELVES
TO SITUATIONS REALISTICALLY SAFE
THOUGH I TRY NOT TO USE SAFE
VERSUS DANGEROUS WITH PTSD
FOLKS, FOR EXAMPLE, MOTOR
VEHICLE ACCIDENT SURVIVOR NOT
WANTING TO DRIVE AGAIN OR DRIVE
THAT CAR OR DRIVE THROUGH THAT
INTERSECTION.
THINGS THEY WANT TO BE ABLE TO
DO AND SCARED TO SINCE THE
TRAUMATIC EVENT.
AND I'LL ALSO TALK TODAY ABOUT
VIRTUAL REALITY EXPOSURE
THERAPY.
SO YOU WANT IT TO BE A
THERAPEUTIC EXPOSURE.
YOU WANT IT TO CHANGE SOMETHING.
AN EXAMPLE UNRELATED TO THIS, A
DOG GETS BITTEN BY A DOG AND
DEVELOPS A DOG FOABIA. IF YOU
PUT HIM IN A ROOM WITH A DOG
HEAN RUNS OUT CRYING IT'S AN
EXPOSURE BUT NOT THERAPEUTIC
EXPOSURE.
NOTHING CHANGED.
YOU WANT TO PUT HIM IN A ROOM
WITH A CUTE PUPPY, LET HIM STAY
IN THAT ROOM LONG ENOUGH TO
LEARN IN HERE AND IN HERE THAT
THAT ANIMAL POSES NO THREAT.
THEN MAYBE GRADUALLY INCREASE
THE TYPE OR KIND OF DOG TO KEEP
THAT LEARNING, TO LEARN THAT
ANIMAL POSES NO THREAT.
I WON'T GO THROUGH ALL THE
EVIDENCE TBLU'S MORE EVIDENCE
FOR EXPOSURE -- THERE'S MORE
EVIDENCE FOR EXPOSURE THERAPY IN
THE TREATMENT OF PTSD THAN ANY
OTHER INTERVENTION.
WE HAVE TWO FDA APPROVED
MEDICATIONS FOR PTSD AND THE
INSTITUTE OF MEDICINE REPORT
FROM 2007 I THINK.
THOUGH I HAVE ISSUES WITH THAT
REPORT, THEY CONCLUDED THAT
EXPOSURE THERAPY WAS THE ONLY
ONE THAT HAD THE STRENGTH OF THE
EVIDENCE TO SAY IT CAN BE
RECOMMENDED FOR PTSD.
SO NOW I'M GOING BACK, THE FIRST
TIME WE TRIED TO APPLAUD VIRTUAL
REALITY, EXPOSURE THERAPY TO
PTSD IT WAS WITH VIETNAM
VETERANS.
WE FIGURED AT THAT POINT THEY
WERE ALREADY KIND OF A CRUSTY
GROUP, THOSE STILL IN TREATMENT
OR STILL HAD PTSD.
WE THOUGHT WE MIGHT NEED A
POTENT STIMULUS AND TRY THAT FOR
THEM.
FIRST, WHAT IS VIRTUAL REALITY?
IS IT A MULTI-MEDIA INTERACTIVE
COMPUTER ENVIRONMENT BUT MORE
THAN THAT, BECAUSE THE USER
EXPERIENCES A SENSE OF PRESENCE
IN THAT ENVIRONMENT.
SO I COULD TAKE A PICTURE OF
THIS ROOM AND YOU GET A SENSE OF
THIS ROOM.
I COULD TAKE A VIDEO AND YOU GET
A LITTLE BETTER SENSE BUT NOT
PRESENT IN THIS ROOM.
IF I HAD THIS ROOM IN VIRTUAL
REALITY YOU WOULD FEEL PRESENT
IN THIS ROOM SO WE THINK THAT'S
USEFUL FOR EXPOSURE THERAPY.
IT'S EASIER TO SHOW YOU.
SO PEOPLE WEAR A HEAD MOUNT
DISPLAY, A STRAP HELMET WITH TWO
TELEVISION SCREENS IN FRONT OF
EACH EYE, EARPHONES AND A
POSITION TRACKER SO JUST AS I
MOVE MY HEAD AND MY VIEW CHANGES
IN REALITY, SO IT DOES IN
VIRTUAL REALITY, I USED TO CALL
IT A CHEAP TRICK AND COMPUTER
SCIENTISTS DON'T LIKE THAT.
THIS RAISED PLATFORM, IT HAS A
BASE SHAKER, A WOOFER, A SPEAKER
UNDERNEATH IT SO IT PRODUCES
VIBRATIONS.
SO IT LOOK LIKE THIS GUY IS IN
THE VIRTUAL AIRPLANE AND WE
DON'T REALIZE BUT A LARGE PART
OF THE INFORMATION WE GET IN THE
AIRPLANE AND STIMULATION WE FEEL
THE ENGINES, WE FEEL THE LANDING
GEAR COMING UP WE FEEL THE
TURBULENCE.
SO YOU CAN FEEL THAT IN THE
VIRTUAL HUMVEE YOU CAN FEEL THE
VIBRATIONS FROM THE VEHICLE.
YOU CAN FEEL THE VIBRATIONS FROM
EXPLOAGS OR FROM THE HELICOPTER.
THE THERAPIST IS ABLE TO SEE
EVERYTHING ON THE MONITOR THE
PATIENT CAN SEE IN THE HEAD
MOUNT DISPLAY SO WE CAN COMMENT
APPROPRIATELY.
FOR SOME, THE WOMAN ON THE RIGHT
IS HOLDING A HAND HELD SENSOR OR
JOY STICK.
SO FOR SOME ENVIRONMENTS THEY --
WE'LL USE THAT AND CAN MANEUVER
IN THE VIRTUAL ENVIRONMENT.
SO FOR THE FIRST TIME WE DID IT
WE DID THE EXPOSURE TO THE MOST
TRAUMATIC VIETNAM MEMORYINGS BUT
WITH EYES OPEN AND IMMERSED IN
THE VIRTUAL VIETNAM.
WE HAD TWO SCENARIOS, ONE WAS A
VIRTUAL CLEARING SURROUNDED BY
JUNGLES THAT MOST REFER TO AS
LANDING ZONE.
THESE ARE EARLY SCREEN SHOTS OF
IT.
AND ANOTHER WAS A VIRTUAL HUEY
HELICOPTER THAT COULD FLY OVER
JUNGLES, OVER RICE PATTIES,
COULD FOLLOW A RIVER.
>> VERY FIRST PATIENT.
VIRTUAL VIETNAM (INAUDIBLE).
(INDISCERNIBLE) (INDISCERNIBLE)
>> NOT GOING TO THE HEAR THEM
SAY WHAT HE SAYS AT THE END, IT
SEEMS LIKE IT ISN'T BOTHERING
ME.
I THINK THAT'S THE MOST WE CAN
HOPE FOR.
MOST PATIENTS COME TO ME, THEY
WAN IT TO NEVER HAVE HAPPENED,
NOT REMEMBER IT BUT THAT'S NOT
REALISTIC.
THE BEST WE CAN HOPE FOR SEEMS
LIKE IT ISN'T BOTHERING ME.
SO WE DID A SMALL OPEN CLINICAL
TRIAL WITH THE VIETNAM VETERANS
IN THE MID '90s AND FOUND
STATISTICALLY SIGNIFICANT
HOPEFULLY CLINICALLY
SIGNIFICANT, OUR COLLEAGUES MET
FRIEDMAN AT THE NATIONAL CENTER
FOR PTSD, HAVE AN ALGORITHM THEY
FIGURED OUT ARC TEN POINT
DIFFERENCE ON THE CAP.
THE CLINICIAN ADMINISTERED PTSD
SCALE IS CLINICALLY SIGNIFICANT.
SO THIS IS A SELF-REPORT MEASURE
OF PTSD.
SO SINCE THAT TIME, NOW A NUMBER
OF PEOPLE AROUND THE WORLD ARE
USING VIRTUAL REALITY TO TREAT
DIFFERENT FORMS OF PTSD.
MY COLLEAGUE JOANNE DEFITI HZ A
VIRTUAL WORLD TRADE CENTER IN
MANHATTAN THEY USE TO TREAT
SURVIVORS OF THE 9/11 ATTACKS.
SO NOW I'M GOING TO SHIFT AROUND
AND TALK FOR THE REST OF THE
TIME ABOUT TRANSLATIONAL
RESEARCH THAT WE'VE DONE.
AND YOU'LL SEE HOW I PUT IT ALL
TOGETHER HOPEFULLY.
THE DECYCLE SERENE, I HAVE THE
GOOD FORTUNE OF WORKING WITH
NICE AN SMART COLLEAGUES AT
EMORY, AND THEY FOUND DEPSYCH
CASH FLOW SERINE IS AN AGONIST,
IN RODENTS FACILITATED THE
EXTINCTION OF FEAR.
IT'S AN OLD TUBERCULOSIS DRUG,
AN ANTIBIOTIC.
SO SINCE IT WAS FDA APPROVED FOR
HUMANS WE COULD TRY T IN HUMANS.
I'LL TELL YOU ABOUT THE OTHERS.
THEY FOUND MIKE DAVIS' MAIN
MEASURE THE FEAR POTENTIATED
STARTLE.
THE AUSTRALIA GROUP ALSO FOUND
THAT IT WORKS ON FREEZING.
AND WHAT WAS REALLY COOL, THE
AUSTRALIA GROUP FOUND THAT IF
YOU ADMINISTER THE DECYCLE SOAR
REEN RIGHT AFTER THE EXTINCTION
TRAINING, THAT IT ALSO
FACILITATES DECREASE OF FEAR IN
EXTINCTION TRAINING SO THE
IMPLICATIONS FOR US CLINICALLY
MAYBE HAVE A GOOD EXPOSURE
THERAPY SESSION AND YOU TELL
YOUR PATIENT HERE, TAKE THIS.
BECAUSE THEN MAYBE -- MAYBE IT'S
THE RECONSOLIDATION PHASE WHERE
THEY'RE LEARNING AND WHERE THE
DECYCLE SERENE IS HAVING IMPACT.
SO WE USE VIRTUAL REALITY
BECAUSE ONE OF THE ADVANTAGES WE
SAW THE VIRTUAL REALITY, A LOT
OF TIMES DOING PSYCHOTHERAPY
RESEARCH, THE PSYCHOTHERAPY PART
IS A LITTLE BIT SOFTER.
METHODOLOGICAL.
WHAT WE COULD DO WITH THE
VIRTUAL REALITY IS EXACTLY
CONTROL THE DOSE OF EXPOSURE
THERAPY AND MAKE SURE EVERY
PATIENT GOT EXACTLY THE SAME
EXPOSURE AND SAME DOSE SO WE
COULD CONTROL IT THAT WAY.
WE DID IT FOR FEE OF HEIGHT
BECAUSE IT WAS A FAIRLY CLEAN
DISORDER TO START WITH THE FIRST
TEST OF DECYCLE SERINE IN HUMAN.
THIS DOESN'T DO MUCH FOR ME.
IF YOU'RE SCARED OF HEIGHTS AND
HAD IT RENDERED IN THE VIRTUAL
REALITY THEY HAVE TO WALK OUT ON
THE CAT WALK AND IT DOES GET
PEOPLE SCARED.
SO THE YELLOW ARE PEOPLE WHO
RECEIVE THE DECYCLE SERENE, BLUE
PEOPLE RECEIVE THE DRUG.
THIS IS THE SUDS UNIT AING SITY
GOING UP SO THE HIGHER THE
NUMBER ON THIS ONE, THE HIGHER
THE THE ANXIETY.
THE VIR CHILL FLOOR.
AS YOU WOULD EXPECT, ANYBODY IN
A HEIGHT SITUATION SCARED OF
HIEG IT IS HIGHER THE FLOOR
GOES, THE HIGHER THE ANXIETY
GOES.
YOU CAN ALSO SEE THIS IS IN THE
FIRST SESSION, THE DRUG IS NOT
SEDATIVE IN ANY WAY WHICH IS
WHAT WE WANT.
THE DRUG SEEMS TO DO NOTHING IN
AND OF ITSELF ONLY TO HAVE IT)
BOARD DURING EXPOSURE THERAPY
SESSION.
SO WHAT WE DID IS WE
PURPOSEFULLY UNDERDOSED EXPOSURE
THERAPY.
WE KNOW EXPOSURE THERAPY IS
EFFECTIVE SO WE GAVE TWO DOSE,
TWO SESSIONS OF EXPOSURE THERAPY
AND THAT MEANT THEY ONLY GOT TWO
DOSES OF THE MEDICATION, TWO
PILLS, ONE RIGHT BEFORE EACH
SESSION.
SO THAT WAS IN THE FIRST
SESSION, THIS WAS IMMEDIATELY
POST TREATMENT.
THE BLUE ARE FOLKS GOT PLACEBO.
NOW WE'RE TALKING ABOUT CHANGE
IN ANXIETY T. PLACEBO FOLKS
DIDN'T CHANGE MUCH POST
TREATMENT AND WE KNEW WE WERE
UNDERDOSING EXPOSURE THERAPY,
ONLY GAVE THEM TWO SESSIONS BUT
THE FOLKS THAT RECEIVED THE
DECYCLE SERENE DECREASED ANXIETY
MORE.
THIS IS AFTER TWO PILLS, TWO
SESSION, THIS IS A WEEK LATER SO
NOT ON DRUG.
IF YOU LOOK AT -- WE BROUGHT
THEM BACK IN THREE MONTHS LATER,
THE FOLKS WHO GOT THE PLACEBO
ARE ABOUT THE SAME, PRETTY MUCH
WHERE THEY CAME IN AND THE FOLKS
WITH DECYCLE SERINE MAINTAINED
SIGNIFICANT IMPROVEMENT.
WE SAW THIS ON PRETTY MUCH EVERY
MEASURE THAT WE LOOKED AT.
SO THIS IS -- WE DIDN'T ASK THEM
TO EXPOSE THEMSELVES IN REAL
LIFE TO HEIGHT SITUATION BUT AT
THE THREE MONTHS FOLLOW-UP WE
ASKED IF THEY HAD, HOW MUCH THEY
EXPOSED THEMSELVES, THE FOLKS
WITH DECYCLE SERE REN REPORTED,
EXPOSING THEMSELVES TO HEIGHT
SIGNIFICANTLY MORE.
THEIR GAL VONNIC SKIN RESPONSE
FLUCTUATION, HOW MUCH THEY'RE
SWEATING, A PSYCHOPHYSIOLOGICAL
RESPONSE.
IT DIDN'T CHANGE IN THE FOLKS
WITH PLACEBO AN DECREASED
SIGNIFICANTLY IN THE FOLKS WITH
DECYCLE SERINE AND WHAT'S COOL
IS THE CHANGE IN THIS SWEATING
PSYCHOPHYSIOLOGICAL RESPONSE WAS
RELATED TO HOW MUCH THEY EXPOSED
THEMSELVES IN HEIGHT.
AT THAT THREE MONTH POINT.
THIS WAS JUST THE THREE MONTH
FOLLOW-UP DATA I SHOWED YOU AND
A NUMBER OF GROUPS AROUND THE
WORLD HAVE TESTED DECYCLE SERE
REN WITH DIFFERENT GROUPS AND
DIFFERENT EXPOSURE THERAPY.
I THINK THE LINES LOOK ABOUT THE
SAME.
THIS IS WITH THE BOSTON GROUP
WITH SOCIAL ANXIETY DISORDERCH
THIS IS WITH THE AUSTRALIAN
GROUP WITH SOCIAL ANXIETY
DISORDER.
THIS IS WITH OBSESSIVE
COMPULSIVE DISORD OAR AND
ANOTHER GROUP ABSCESSSIVE --
OBSESSIVE COMPULSIVE.
IT DOESN'T MAKE THERAPY BETTER
BUT A LOT OF TIMES IT MAKES
THERAPY FASTER.
THAT WE THINK IS AN ADVANTAGE.
SO THE CURRENT TRIAL WE'RE
DOING, NIMH FUNDEDDED, TAWCH.
IT'S -- THANK YOU VERY MUCH.
IT'S ONGOING NOW VETERANS WITH
PTSD VETERANS FROM IRAQ AND
AFGHANISTAN.
AGAIN, WE'RE PURPOSEFULLY
UNDERDOSING THE EXPOSURE
THERAPY, USING THE VIRTUAL
REALITY EXPOSURE THERAPY,
THEY'RE GETTING SIX SESSIONS
TOTAL.
SO FIVE OF VIRTUAL REALITY AND
THAT MEANS ONLY FIVE PILLS.
SO EITHER GETTING THE DECYCLE
SERINE OR PILL PLACEBO OR A DRUG
WITH A DIFFERENT MECHANISM OF
ACTION THAT LOTS OF PATIENTS ARE
ON OR IN SOME WAYS ARE ASKING
FOR WITH THEIR SYMPTOMS,
ALPRAZOLAM, XANAX.
A LOT OF PATIENTS ARE ON BEZOs
OR WANT THEM BECAUSE THEY
EXPRESS ANXIETY PROBLEMS
SLEEPING.
A LOT OF PROBLEMS, DON'T LIKE
THE PATIENTS ON BENZO BECAUSE WE
WANT TO SEE THE ANXIETY LEVEL
COME DOWN AND NOT ATTRIBUTE TO A
PILL.
SO PEOPLE THAT DON'T WORK WITH
VETERANS WONDER IF THIS IS WHAT
THEY SAW IN IRAQ OR AFGHANISTAN.
HOW IS IT THEY GET SO TRIGGERED
HERE?
WE'RE COLLIELY -- MOST OF WHERE
WE WORK NOT (INAUDIBLE) A COMBAT
ZONE.
BUT YOU FIGURE THIS IS WHAT THEY
SEE HERE.
AND I THINK IT'S FAIRLY SIMILAR
UP HERE IN ATLANTA YOU GOT TO
DRIVE.
WE DON'T HAVE A VERY GOOD PUBLIC
TRANSPORTATION SYSTEM AND OUR
GUYS ARE GETTING TRIGGERED ALL
THE TIME DRIVING, ON THE
INTERSTATES AN TRAFFIC JAMS AN
UNDERPASSES AND OVER PASSES AN
TRASH ON THE SIDE OF THE ROAD.
SO THEY ARE REALLY GETTING
TRIGGERED ALL THE TIME.
SO WHAT WE DO IS SIMILAR TO THE
VIRTUAL VIETNAM.
SO BACK IN THEIR MINDS'S EYE TO
THE WORST EVENTS FROM IRAQ,
DESCRIBE IT OUTLOUD, WITH THEIR
EYES OPEN AND THE THERAPIST IS
MATCHING WHAT THEY'RE DESCRIBING
WE HAVE A VIRTUAL HUMVEE AND
CITY.
WE CAN PUT THEM IN WHATEVER
POSITION IN THE HUM IF DRIVER,
OR PASSENGER WE CAN PUT THEM IN
THE TURRIC.
WE CAN CHANGE TIME OF DAY,
CREATE SMOKE, PUT THEM IN’N‡NIGHT
VISION GOGGLES.
THIS I'M GOING TO WARN YOU THIS
IS TAKEN OFF THE INTERNET, A
CLIP OF AN ACTUAL I.E.D SO IF
ANYONE SERVED IT COULD BE
UPSETTING AND THERE'S SOME BAD
LANGUAGE IN IT.
(INDISCERNIBLE)ç
>> THIS IS JUST A CLIP THAT I
GOT FROM SKIP RUSSO, HIS GROUP
AT USC DEVELOPED THE VIRTUAL
IRAQ.
IT'S NOT MEANT TO MATCH THAT, WE
USE THESE CLIPS FOR THE
PSYCHOPHYSIOLOGICAL MONITORING,
AND ASSESSMENT WE DO AT
DIFFERENT POINTS.
THIS IS A CLIP THAT INCREASES IN
SEVERITY ANTHROS EVERYTHING AT
SOMEBODY.
WHEN WE'RE USING IT
THERAPEUTICALLY, IF THEY'RE
DRIVING DOWN THE ROAD, IED ON
THE RIGHT, (INAUDIBLE).
THAT'S WHAT WE DO.
WE'RE NOT GOING TO PRODUCE ALL
OF THIS.
ALSO SHOWS BLOOD.
I THINK WE CAN TALK ABOUT THAT
AFTERWARDS.
NOT CREATING -- I DON'T WANT TO
EXPOSE PEOPLE TO ANYTHING.
(INDISCERNIBLE)
>> THIS IS DR. GREG REAGER, HE
HAS A BETA VERSION OF THE
VIRTUAL IRAQ IN IRAQ GIVING US
FEEDBACK.
SO I LIKE IT WHEN OUR GUYS PUT
IT ON AND THEY SAY THIS IS JUST
WHAT IT LOOKED LIKE.
THIS WAS JUST OUR VERY FIRST
GUY, THIS WAS NOT ON MEDICATION
OR FIRST PATIENT WE WERE
PILOTING THROUGH THE PROGRAM,
THE VIRTUAL IRAQ, HE ONLY HAD
FOUR SESSIONS AND WE SAW 56%
DECREASE IN HIS CAP SCORE.
CLINICIAN ADMINISTERED PTSD
SCALE.
AND A SIMILAR DECREASE IN HIS
SELF-REPORT.
IT'S INTERESTING HE GOT
REDEPLOYED AFTER WE TREATED HIM,
WHICH IS WHAT PEOPLE WANT -- HE
WAS A NATIONAL GUARDSMAN.
SO THIS IS FROM ABOUT TWO OR
THREE WEEKS AGO SO WE ENTERED A
FEW MORE FOLKS THAN THIS.
THIS IS AN ON GOING TRIAL.
WE HAVEN'T BROKEN THE BLIND YET,
SO THIS SMAINLY A MAIN EFFECT OF
THE VIRTUAL REALITY EXPOSURE
THERAPY.
AND WE MIGHT EXPECT AT THE END
OF THE DAY WE'LL SEE TO MAYBE
HAVE THREE DIFFERENT LINES MAYBE
WITH WITH THE DECYCLE SERENE
PLACEBO AND ALPRAZOLAM.
BUT IN THE SIX SEXES FIVE OF THE
VIRTUAL -- SIX SESSIONS FIVE
VIRTUAL REALITY ARE DECREASING
THEIR PTSD SYMPTOMS.
THIS IS THE PTSD SYMPTOM SCORE A
SELF-REPORT MEASURE THEY FILL
OUT AT EVERY SESSION SO GOING
THE SAME WAY.
JUST TO SHOW YOU'RE DATA WE'RE
WORKING WITH COLONEL MIKE ROY
WHO USED TO BE AT WALTER REED
BUT NOW THERE'S NO MORE WALTER
REED SO AT BETHESDA NAVAL
MEDICAL CENTER.
HE DID A STUDY USING VIRTUAL
REALITY WITH ACTIVE DUTY GUYS
WITH T BIRKS AND PTSD AND
LOOKING AT IMAGING.
AND SAW CHANGES, NORMALIZATION
IN EVERY REGION OF INTEREST
AFTER THE TREATMENT.
WHICH I THINK IS INTERESTING.
SO LOOKING AT ANOTHER MEASURE,
STARTLE L REACTIVITY THAT
ACTUALLY MICHAEL KOZAK USED TO
DO A LOT, ASK HIM ABOUT STARTLE
OF WARDS, NOT ME.
AND -- AFTERWARDS, NOT ME.
THIS IS A TRANSLATIONAL MEASURE
BECAUSE MIKE DAVIS MEASURES FEAR
POTENTIATED STARTLE IN THE RATS
AND HEP BUILT THIS CAING, -- AND
HE BUILT THIS CAGE.
I HAVE NOT WANTED TO PUT A
PERSON IN A SIMILAR CON CONTRAPTION
SO THIS IS HOW WE MEASURE WITH
HUMAN, THE EYE BLINK RESPONSE
AND WE CAN TAKE OUT THE
PSYCHOPHYSIOLOGICAL MEASURES.
THIS IS VERY EARLY DATA, JUST
THE FIRST SEVERAL PEOPLE FOR
WHICH THE HUMVEE WAS THEIR
PRIMARY TRAUMA OCCURRED IN THE
HUMVEE AND THEIR STARTLE IS
DECREASING OVER TIME.
AND JUST PUTTING THAT TOGETHER
WITH THESE FOLKS, CAP SCORE, YOU
CAN SEE THE PTSD AND THEIR
STARTLE ARE DECREASING
SIMILARLY.
THIS IS JUST A CASE STUDY, WE PI
GUR EVERYBODY LIKES SQUIGGLY
LINES SO THIS IS JUST ONE GUY, I
HAVE NO IDEA WHAT CONDITION HE'S
IN, WHICH MEDICATION HE GOT.
HIS CAPS WHEN FROM O 103 AT
PRE-TREATMENT TO 68 POST
TREATMENT.
YOU CAN SEE THAT.
AND I KNOW– + WILn
READ, SO THE TOP RED LINE IS
SKIN CONDUCTTANTS, THE MIDDLE IS
STARTLE, THE EYE BLINK AND THE
BOTTOM IS HEART RATE THAT'S
PRE-TREATMENT AND THAT'S POST
TREATMENT.
AND I'LL GO BACK.
SO PRE-TREATMENT SKIN
CONDUCTANCE, STARTLE, HEART
RATE.
AND POST TREATMENT.
AGAIN, JUST -- WE HAVE NO IDEA
OF HIS CONDITION BUT YOU CAN SEE
THERE'S SOME DECREASE
RESPONDING.
SO NOW I'M GOING TO SWITCH AND
TALK ABOUT EARLY INTERVENTIONS
BECAUSE I HAVE BEEN -- I SPENT
MY ENTIRE CAREER WORKING ON
TREATMENTS AND TESTING
TREATMENTS FOR CHRONIC PTSD
WHERE I LOVE TO GO IS PREVENTING
IT.
OBVIOUSLY THE PRIMARY WAY TO
PREVENT IT IS EXPOSURE
PREVENTION TO TRAUMATIC EVENTS.
THAT'S NOT GOING TO HAPPEN.
LIFE IS DANGEROUS.
WE'RE NOT GOING TO PREVENT WARS
UNFORTUNATELY BUT IF WE CAN
FIGURE AN EARLY INTERVENTION,
THAT'S ALSO FUNDED BY NIMH,
THANK YOU VERY MUCH.
SO AGAIN REMEMBER I SHOWED YOU
THIS.
LOOKING AT FOLKS IMMEDIATELY
AFTER A TRAUMATIC EVENT, IN THIS
CASE IT WAS RAPE.
WE FIGURED IT'S A DISORD OAR OF
EXTINCTION.
AND SO IF YOU GO BACK, THIS IS
THEORETICAL, NOT DATA, YOU LOOK
AT THE ACQUISITION OF FEAR AND
THEN THE EXTINCTION OF FEAR.
AND THEN TESTING IT, IT COMES
BACK.
AND FOR THE EARLY INTERVENTIONS,
THE DEBRIEFING LITERATURE IS
EQUIVOCAL AT BEST AND SOME
STUDIES HAVE SHOWN IT CAN CAUSE
HARM.
OBVIOUSLY WE DON'T WANT TO CAUSE
HARM.
AND IT'S REALLY VERY
FRUSTRATING.
I WAS PRESIDENT OF IFSTSS, THE
ENTERGNASH GNAT SOCIETY OF
TRAUMATIC STRESS STUDIES.
THE YEAR OF THE LONDON BOMBINGS,
THE TSUNAMI AND HURRICANE
KATRINA.
MY BROTHER SAID I WAS BAD LUCK
FOR THE WORLD.
OKAY, I'M READY NOT TO BE
PRESIDENT.
BUT INTERNATIONAL TRAUMA
ORGANIZATION.
EVERYBODY WANTED TO HELP.
THERE WERE NO EMPIRICALLY
SUPPORTED TREATMENTS TO DELIVER.
I HAVE MET WITHS AT THE PENTAGON
AND THEY FORM AD LITTLE
SUBCOMMITTEE OF US TO COME UP
WITH RECOMMENDATIONS FOR WHAT TO
DO IN THEATER, WE COULDN'T COME
TO A CONSENSUS.
THERE'S NO DATA ON AN EFFECTIVE
EARLY INTERVENTION.
I REALLY BELIEVE THE BOTTOM OF
MY HEART THERE ARE THINGS WE CAN
DO IN THE IMMEDIATE AFTER MATH
OF TRAUMA THAT CAN HELP AND THAT
CAN HURT.
OBVIOUSLY WE WANT TO FIGURE OUT
WHAT HELPS.
IT MAYBE DIFFERENT FOR DIFFERENT
PEOPLE.
THAT MIGHT BE PART OF IT.
SO AGAIN, TALKING ABOUT THE
ANIMALS, SOME OF THE PROPERTIES
OF EXTINCTION.
WE DON'T THINK THE EXPOSURE
ALONE AN EXTINCTION TRAINING
ERASES THE FEAR MEMORY.
IN THE ANIMAL LITERATURE THEY
SEE THREE INDICES OF THIS,
SPONTANEOUS RECOVERY, IT COMES
BACK WITH TIME.
IT RETURNS WITH THE DELIVERY OF
SHOCK OR AVERSE STIMULUS,
REINSTATEMENT, AND IS EXPRESSED
OUTSIDE OF THE EXTINCTION
CONTEXT SO YOU PUT THEM IN A
DIFFERENT CONTEXT AND THEY CALL
IT RENEWAL WHEN YOU SEE IT
AGAIN.
THE ANIMAL EVIDENCE SUGGESTS
THAT SOME IMMEDIATE EXTENSION
TRAINING CAN RESULT IN THE
DECREASES IN THESE THREE
INDICES.
MY BUDDY MIKE DAVIS IN THE
ANIMAL STUDIES FOUND THAT IF YOU
DID EXTINCTION TRAINING TEN
MINUTES AFTER FEAR CONDITIONING,
IN HIS -- IN THEIR WORDS, I
WOULD NEVER SAY THIS ABOUT
PEOPLE.
THEY SAID IT ERASED ALL THE
INDICES OF FEAR YOU SEE IN
REINSTATEMENT CONTEXT
SPECIFICITY AND SPONTANEOUS
RECOVERY.
THAT IS OPPOSED TO HOW THEY
TYPICALLY DO THE EXTINCTION
TRAINING WHICH IS 72 HOURS
LATER.
I THINK THAT THIS IS TRUE.
I THINK THAT WHAT'S HAPPENED IS
THEY'RE MESSING WITH THE
CONSOLIDATION OF THE FEAR MEMORY
BEFORE IT'S CONSOLIDATED.
AND WE SEE THIS IN OUR TRAUMA
SURVIVORS.
OUR RAPE VICTIM, WHAT HAPPENS IN
THE EMERGENCY ROOM OR WITH THE
POLICE IMMEDIATELY AFTER THE
TACK IS PART OF THEIR NEMRY AS
WELL.
AND -- THEIR MEMORY AS WELL.
SO WHAT WE'RE TRYING TO DO IS
SEE IF WE CAN CHANGE THAT.
SO REMEMBER, REEN STATEMENT IS
IN THE SAME CONTEXT, IT COMES
BACK, WHEN HE DID THE STUDY
FOUND THAT EXTINCTION GIVEN TEN
MINUTES AFTER FEAR CONDITIONING
PREVENTED RELAPSE AFTER STRESS,
WHEREAS EXTINCTION GIVEN 72
HOURS LATER DID NOT.
ALSO FOUND IT IN THE RENEWAL.
THIS IS DIFFERENT CONTEXT.
FOUND THE EXTINCTION GIVEN TEN
MINUTES AFTER THE FEAR
CONDITIONING.
PREVENTED THE RETURN OF FEAR IN
A DIRVE CONTEXT, THE LATER HE
CAN -- IN A DIFFERENT CONTEXT,
THE LATER DISTINCTION 72 HOURS
DID NOT, FOUND IT IN SPONTANEOUS
RECOVERY.
SO WITH THE PASSAGE OF TIME
FOUND AGAIN, EXTINCTION,
TRAINING GIVEN TEN MINUTES AFTER
THE FEAR CONDITIONING.
YOU DIDN'T SEE THE SPONTANEOUS
RECOVERY, WHEREAS THEY DID WHEN
IT WAS 72 HOURS LATER.
SO THIS LED US TO THINK THAT
EXTINCTION TRAINING CONDUCTED
VERY SHORTLY AFTER FEAR
CONDITIONING MAY PREVENT
CONSOLIDATION OF THE ORIGINAL
FEAR MEMORY.
AGAIN, THEY DO IT FEAR
POTENTIATED STARTLE IN RATS.
WE CAN DO IT IN ADULTS.
WE DID IT IN A PRE-CLINICAL
STUDY IN HUMANS, AND WHERE WE
ALSO FOUND THAT THE TEN MINUTES
IN THE LIGHTER YELLOW, THE
EXTINCTION TRAINING AFTER TEN
MINUTES, WE DIDN'T SEE THE
SPONTANEOUSLY COVERRY.
WHEREAS THE EXTINCTION TRAINING
72 HOURS LATE WE DID.
SO WE HAVE DONE IS WE CAN SEE P
IF WE CAN DO THIS IN IMMEDIATE
TRAUMA SURVIVORS TO TRY TO
PREVENT DEVELOPMENT OF PTSD.
IF WE FIGURE PHARMACOLOGICAL
AGENT, LET'S PUT IT IN WATER.
WE PUT FLOWER RIDE IN WATER AND
PREVENT CAVITIES BUT LET'S
FIGURE OUT WHAT WILL WORK AND
FOR WHOM.
WHAT WE DID, IF ANYBODY KNOWS
ATLANTA AND GRADY HOSPITAL, IT'S
A LARGE LEVEL 1 TRAUMA CENTER
INNER CITY HOSPITAL, HAVE TOLL
MY HUSBAND IF I GET SHOT OR
STABBED TAKE ME TO GRADY, AS
SOON AS I'M STABLE GET ME THE
HECK OUT OF THERE, BECAUSE IT'S
A SCARY PLACE BUT A WONFUL PLACE
TOO.
-- WONFUL PLACE TO -- WONDERFUL
PLACE TOO.
IF THEIR MEDICALLY STABLE IF
THEY DIDN'T HAVE A CRITERION A
TRAUMA WE ASSESSED EVERYBODY IN
THE EMERGENCY ROOM AND ONE MONTH
LATER WHEN PTSD COULD BE
DIAGNOSED AND THREE MONTHS LATER
WHEN PTSD IS CHRONIC.
EVERYONE ASSESSED AT THAT POINT
BUT THEY WERE RANDOMLY ASSIGNED
TO RECEIVE THE ASSESSMENT OR
RECEIVE AN EARLY INTERVENTION.
WHAT WE DID FOR EARLY
INTERVENTION IS MODIFICATION OF
PROLONGED IMAGINABLE EXPOSURE.
WE DID ONE SESSION RIGHT THERE
IN THE EMERGENCY ROOM, THEN
BROUGHT THEM BACK A WEEK LATER
FOR A SECOND SESSION AND A WEEK
LATER FOR A THIRD SESSION.
I'M RUNNING SHORT ON TIME.
IT'S A MODIFICATION OF EXPOSURE.
WE HAVE THEM GO BACK IN MIND'S
EYE, DESCRIBE OUTLOUD, WE TAPE
RECORD IT, GIVE THEM THE TAPE TO
LISTEN TO.
WE TALK ABOUT THUGHT THOUGHTS AN
UNHELPFUL THOUGHTS.
WE HELP ANTICIPATE WHERE THEY
MIGHT WANT TO AVOID THAT THEY
REAL IESIC -- REALISTICALLY
THINK IT'S OKAY TO DO AND HELP
THEM TRY NOT TO DO THAT.
WE HAVE NOW JUST COMPLETED THAT
STUDY.
WE ASSESSED -- I KNOW IT'S HARD
TO SEE, ALMOST 9,000 FOLKS.
SO WHAT THAT MEANS IS WE HAD OUR
STAFF COVERING THE EMERGENCY
ROOM SEVEN DAYS A WEEK FROM 7A
TO 7:0 O 0 P.
ANYBODY ADMITTED TO THE TRAUMA
AREA OF THE EMERGENCY ROOM AND
HAD A TRAUMA CODE, THAT'S WHO
WENT INTO THAT 9,000.
SO MOST WERE NOT ELIGIBLE.
I KNOW IT'S HARD TO SEE.
SO 6,000 DIDN'T MEET INCLUSION
CRITERIA.
THEY HAD TO MEET INCLUSION
CRITERIA FOR A TRAW MA. IT HAD
TO HAVE BEEN TRAUMATIC FOR THEM.
ANOTHER 1200 REFUSED TO
PARTICIPATE.
THIS IS AN INNER CITY EMERGENCY
ROOM, BY THE TIME WE GOT PEOPLE
THEY HAD BEEN THERE FOR HOURS,
THEIR THEY WERE TIRED, VERY
OFTEN IF IT HAPPENED IN THE
MIDDLE OF THE NIGHT THEY'RE
READY TO GO HOME.
SO WE ENDED UP RANDOMLY
ASSIGNING 137 TO THE
INTERVENTION OR ASSESSMENT ONLY.
THIS IS JUST TO TELL YOU WHO
THEY ARE.
SO TWO-THIRDS WERE FEMALE.
MOST OF THEM IN THEIR AVERAGE
EARLY 30s.
BETWEEN 75 AND 80% WERE AFRICAN
AMERICAN.
THE TRAUMAS ROUGHLY ABOUT A
THIRD, RAPE ABOUT A THIRD
NON-SEXUAL ASSAULT AND ABOUT A
THIRD MOTOR VEHICLE AND MY
INJURY CONTROL COLLEAGUES TELL
ME IT'S MOTOR VEHICLE CRASH OR
COLLISION, NOT ACCIDENT, THEY
SAY IT'S NOT AN ACCIDENT.
THE TIME THAT WE GOT THEM, THE
MEDIAN IS 6.9 HOURS SO OVER --
HALF THE PEOPLE WE SAW WITHIN 6
OR 7 HOURS OF THE TRAUMATIC
EVENT OCCURRING.
THE MEAN IS 11 TO 12 HOURS.
AND THERE ARE A COUPLE OF
OUTLIERS LATER BUT MOST PEOPLE
WE SAW EARLY ON.
OUR FOLLOW UP RATE, 74% AT FOUR
WEEKS, AN 66% AT 12 WEEKS.
THIS IS THE DATA I KNOW IT'S
HARD TO FOLLOW BUT I HAVE IT
GRAPHICALLY AS WELL.
WHAT YOU NEED TO KEEP IN MIND IS
THERE'S NO BASELINE OF THE PTSD
SCORE.
I DO NOT THINK IT'S VALID TO
ASSESS PTSD WITHIN SIX HOURS OF
TRAUMATIC EVENT.
WHAT WE'RE LOOKING AT FOR PTSD
IS BASICALLY CROSS SECTIONAL
FROM THE RANDOMIZED GROUPS AT
ONE MONTH LATER AN THREE MONTHS
LATER.
PROBABLY EASIER JUST TO SEE T
HERE.
SO THIS IS THE PTSD SYMPTOM
SEVERITY, THE FOLKS WITH THE
INTERVENTION IN BLUE WERE
SIGNIFICANTLY LOWER AT ONE MONTH
AND AT THREE MONTHS THAN THE
FOLK WHOSE DID NOT RECEIVE THE
SER VENGS.
DEPRESSION INVENTORY, THAT WE
DID ASSESS AT BASELINE.
WE DID ASK THEM TO COMPLETE A
BECK DEPRESSION SCORE IN THE
EMERGENCY ROOM AND ONLY GAVE IT
ONE MONTH LATER.
THE FOLK WHOSE GOT THE
INTERVENTION WERE SIGNIFICANTLY
LOWER ON DEPRESSION.
IT'S HARD TO SEE OTHER, THE FOLK
WHOSE DID NOT MEET THE
DIAGNOSIS.
YOU CAN SEE 74% AT WEEK 12 WITH
THE INTERVENTION DID NOT MEET
THE DIAGNOSIS COMPARED TO 53%.
SOME LIKE NUMBERS, SOME LIKE
GRAPHS SO I DID IT IN BOTH.
SO AT WEEK 12 IT WAS
SIGNIFICANTLY FEWER PEOPLE.
WHO RECEIVED THE INTERVENTION
WHO MET PTSD DIAGNOSTIC
CRITERIA.
THIS IS ALSO -- THIS IS AN INNER
CITY POPULATION THAT'S MULTIPLY
TRAUMATIZED.
SO WHEN THEY CAME IN AND AGAIN,
A MONTH LATER, WE ASKED THEM TO
COMPLETE THE PTSD DIAGNOSTIC
SCALE FOR PREVIOUS TRAUMA, NOT
THE INDEX TRAUMA THAT BROUGHT
THEM TO THE EMERGENCY ROOM.
WE WANTED TO TRY TO PARSE OUT O
PRIOR PTSD.
SO BASE LINE THEY WERE SIMILARLY
SYMPTOMATIC WITH PRIOR PTSD, AT
WEEK FOUR, THIS IS NOT
STATISTICALLY SIGNIFICANTLY
DIFFERENT BUT IT'S GOING IN THE
RIGHT DIRECTION.
WE WANT TO MAKE SURE WE'RE NOT
MAKING ANYBODY WORSE.
WE ONLY HAD THREE SESSIONS OF
EXPOSURE THERAPY.
IN A NORMAL COURSE OF EXPOSURE
THERAPY WE WOULD HAVE TIME TO
ADDRESS PRIOR TRAUMAS BUT NOT IN
THREE SESSIONS.
OBVIOUSLY WHAT WE WANT TO BE
ABLE TO DO IS FIGURE OUT WHO
NEEDS IT FOR WHOM AND HOW TO
TRANSPORT IT FOR EXAMPLE, IN
THEATER OR IN MASS DISASTERS OR
CASUALTIES TO BE ABLE TO HAVE
SOMETHING THAT PEOPLE CAN --
>> BRAIN GAME, 600.
VIRTUAL REALITY AND PSYCHOLOGY
ARE USED TO REWIRE THE BRAIN OF
WAR VET JERRY WHO SUFFERS FROM
PTSD SHORT FOR THIS.
WHAT IS POST TRAUMATIC STRESS
DIDS ORER.
>> THAT IS IT.
>> THAT WAS FROM LAST OCTOBER.
SO WE FIGURE WE'RE IN
CONVENTIONAL WISDOM NOW, PTSD
AND VIRTUAL REIAL ON JPTY --
GENERALITY.
THERE ARE LOTS OF FOLKS IN OUR
-- GENERALITY.
-- JE
I FINISHED IN TIME TO ALLOW FEW
QUESTIONS OR COMMENTS OR
DISAGREEMENTS.
HAVE I PUT YOU ALL TO SLEEP?
IT'S AFTERNOON, HUH?
[APPLAUSE]
YES.
WE NEED THE MIC?
OKAY.
(OFF MIC)
>> THANK YOU.
I WANTED TO IN TERMS OF RESEARCH
AND THE POPULATION IS CHANGING
IN A LOT OF METHODS, ALL THE
RESEARCH IS GREAT, AND PTSD HAS
BEEN ON MALE VETERANS AND WE'RE
GOING TO HAVE WOMEN IN
DIFFERENCE ROLES.
I WONDER HOW THAT'S INFORMING
YOUR WORK OR HOW YOU SEE THAT IN
TERMS OF SOME OF YOUR FUTURE
WORK WE HAVE.
I THINK THE AGE CHANGED AS WELL.
SO A DIFFERENT DEMOGRAPHIC IF
TERMS OF VETERAN POPULATION.
>> IT'S AND ALL VOLUNTEER FORCE.
>> IT'S VERY DIFFERENT.
>> SO WHEN THEY FIRST SENT WOMEN
TO IRAQ AN AFGHANISTAN THEY SAID
THEY WESTERN IN COMBAT AND JUST
SUPPORT ROLES.
WHAT'S ONE OF THE BIGGEST ROLE?
DRIVING THE TRUCKS DOWN THE
DESERT HIGHWAY THAT'S WHERE THE
I.E.Ds ARE HITTING.
WOMEN ARE GETTING EXPOSED TO A
LOT.
THIS IS GOING TO BE A SLIGHTLY
POLITICALLY INCORRECT THING TO
SAY.
AND IT'S NOT BASED ON DATA, IT'S
BASED ON MY ON SR.VATION WORKING
WITH FEMALE VETS WHEN WE DID A
BIG STUDY.
IT WAS PAULA (INDISCERNIBLE)
STUDY.
A LOT OF WHAT WE WERE TREATING
WAS PRE-MILITARY TRAUMA.
IT DOESN'T APPLY TO ANYBODY, I
MET A LOT OF FEMALE VETERANS WHO
THEY COME FROM MILITARY
FAMILIES.
THEY ARE PATRIOTIC AND WANT TO
HELP TOO BUT PEOPLE IT CAN OFFER
AN ALTERNATIVE WHEN THEY NEED TO
GET AWAY FROM SOMETHING SO
THERE'S PRE-MILITARY TRAUMA THAT
PRE-DISPOSES SOMEONE TO PTSD
EXPOSED TO ANOTHER TRAUMA.
IN GENERAL WOMEN GET PTSD IN THE
GENERAL POPULATION TWO TO ONE TO
MEN, NOT TRUE IN THE COMBAT
POPULATION, IT'S GETTING MORE
EVENT IN THE COMBAT POPULATION
BUT AGAIN, MEN GETTING EXPOSED
TO MORE SEVERE TRAUMAS, PEOPLE
IN THE CURRENT CONFLICT
SURVIVING INJURIES THEY WOULDN'T
HAVE SURVIVED PREVIOUSLY.
IN GENERAL, I DON'T KNOW THAT WE
KNOW GENDER DIFFERENCES IN THE
RESPONSE TO TREATMENT.
MAINLY BECAUSE STUDIES USE WOMEN
OR PRIMARILY MEN AND WHEN THEY
ARE MIXED THERE'S NOT ENOUGH
DATA, ENOUGH POWER.
IN THE EARLY STUDIES PEOPLE
COMMENTED IT LOOKED LIKE IT
DIDN'T WORK WITH MEN.
BUT THEY DIDN'T HAVE AS MANY
MEN.
SO I GUESS I'M ALL OF THAT IS
USING A LOT OF WORDS TO SAY, I
DON'T THINK I CAN REALLY ANSWER
YOUR QUESTION YET.
WHAT WE WOULD HAVE TO DO IS USE
THREEMS THAT WE KNOW WORK --
TREATMENTS THAT WE KNOW WORK AND
IN GENERAL MOST WORK FOR BOTH
GENDERS.
>> FASCINATING TALK.
THANK YOU SO MUCH.
TO WHAT EXTENT DOES SUBSTANCE
ABUSE COMPLICATE THESE KINDS OF
EFFORTS AT EXTINGUISHING THE
TRAUMATIC MEMORIES?
CAN WE SEPARATE THE TWO OUT AT
ALL?
>> SEASON DRA BLAO AND OTHER
EPIDEMIOLOGISTS AFTER 9/11 IN
MAN AT THAT TIME HAHN FOLLOWED
FOLKS AND FOUND PTSD AN
DECREETION INCREASED OVER TIME.
IF YOU FOLLOW THEM, IT
DECREASED.
THEY ALSO ASSESS SUBSTANCE USE
AN IT INCREASED AND IT NEVER
DECREASED.
IT WAS ALL SUBSTANCE TO PEOPLE
STARTED SMOKING CIGARETTES
AGAIN.
WE SEE WHEN YOU CAN LOOK AT IT
TEMPORALLY, A LOT OF TIMES,
KATHLEEN BRADY AT MUSC HAS SOME
DATA, IT LOOKS LIKE THE TRAUMA
OCCURRED BEFORE THE SUBSTANCE
USE DISORD OAR SO IT LOOKS LIKE
AND SOUNDS LIKE WHEN YOU TALK TO
FOLKS THAT THEY ARE
SELF-MEDICATING.
WE WANT OUR SAMPLE AS REALISTIC
AS POSSIBLE.
PEOPLE CRITICIZE SAYING THAT'S
THE CLEAN PTSD PATIENTS.
I DON'T KNOW WHAT A CLEAN PTSD
PATIENT IS.
I HAVE YET TO MEET THAT PERSON.
AND IN OUR VETERAN POPULATION,
WE WILL ALLOW SUBSTANCE ABUSE
BUT NOT DEPENDENCE.
WITHIN THE ABUSE WE'LL TALK
ABOUT PARAMETERS.
WE DON'T WANT SOMEBODY USING THE
NIGHT BEFORE SESSION BECAUSE WE
DON'T WANT THEM COMING IN HUNG
OVER.
WE DON'T WANT THEM USING THE DAY
qJ0 THE SESSION BECAUSE WE WANT
THEM TO PROCESS AN FEEL WHAT
THEY'RE GOING TO FEEL.
AND SEE THAT IT WILL DECREASE
WITHOUT THE SUBSTANCE.
IF WE DIDN'T TREAT PEOPLE WHO
USE SUBSTANCES EXCESSIVELY WE
WOULDN'T HAVE ANY PTSD PATIENTS
SO WE'RE TRYING TO BE REALISTIC.
I'M ACTUALLY IN THIS TRIAL MORE
WORRIED ABOUT MARIJUANA USE THAN
A LOT OF OTHERS BECAUSE THE
CANNABINOID AND ENDOCANNABINOID
SYSTEM IS SHOWN PARTLY BY ONE OF
MY COLLEAGUES KERRY WRESTER AS
BEING IMPORTANT IN CAN BEING OF
-- IN CONDITIONING FEAR OF
EXTINCTION SO WE ARE A LITTLE
BIT MORE IN TALKING TO PEOPLE
MORE ABOUT NOT USING MARIJUANA
DURING THE STUDY.
IT'S ONLY SIX WEEKS THE
TREATMENT SO KNOCK ON WOOD, WE
HAVE HAD PRETTY GOOD COMPLIANCE.
THERE ARE A FEW PROGRAMS WHERE
THEY TREAT IT TOGETHER.
KATHLEEN BRAY SI AND
(INDISCERNIBLE) TREATING PTSD
SIMULTANEOUSLY WITH GOOD
RESULTS.
ADJUVANTS SEEKING SAFETY
PROGRAM.
>> YOU HAD YOUR HAND UP FIRST
THEN I'LL ASK MY QUESTION.
>> THANK YOU FOR THE TALK.
WONDERING IF YOU COULD SPEAK
ABOUT WHETHER THERE'S ANYTHING
TO BACK UP OR MAYBE YOU HAVE
SOME THOUGHTS ON IT, ABOUT THE
IMAGINABLE THERAPY OR EXPOSURE
THERAPY FOR TRAUMA THAT HAPPENED
LIKE CHILD ABUSE AN ADULTS YOU
MIGHT SEE AS A RESULT OF THAT.
IT'S A DIFFERENT ETIOLOGY.
>> RIGHT.
SO IN THE FIRST STUDY WE DID
WITH EDNA FOA AND MICHAEL WORKED
ON THAT WITH RAPE VICTIMS,
STARTING IN 1986, I CAN'T
REMEMBER THE EXACT NUMBER OF HOW
LONG AGO THE AVERAGE ASSAULT
OCCURRED BUT I SAW SOME PEOPLE
THAT IT WAS OVER 20 YEARS.
FOR THAT THERE HAD TO HAVE BEEN
AN ADULT ASSAULT FOR A NUMBER OF
OUR PATIENTS WE'RE TREATING
CHILDHOOD SEXUAL ABUSE AND
INCEST AND TRAUMATIC EVENTS THAT
OCCURRED 20, 30, 40, 50 YEARS
AGO.
AND HAVE STILL SEEN THE
TREATMENT IS SUCCESSFUL.
SO IT DOESN'T NECESSARILY BODE
BADLY FOR TREATMENT, WHAT IT
DOES, WE'RE TRYING TO DO SOME
RECONSOLIDATION WORK.
MARIE MUNFEELD WHO DID A COOL
KNEW STUDY ON A RECONSOLIDATION
PARADIGM IS EXPLAINING A LOT OF
HOW SOME WORKS AND THAT WHEN
THERE IS INCOMPLETE EXTINCTION,
ONE BECOMES MORE RESISTANT TO
EXTINCTION WHEN YOU TALK
RECONSOLIDATION.
SO THAT'S THE COMPLICATING
FACTOR IN TRAUMAS THAT OCCUR A
LONG TIME AGO.
A LOT OF GUYS WHEN WE TELL THEM
THE EXPOSURE THERAPY, THEY SAY
WHAT DO YOU MEAN ?
I THINK ABOUT IT ALL THE TIME
ANYWAY.
I TRY TO TELL THEM I THINK YOU
THINK ABOUT IT IN WAY NOT
HELPFUL AND WE'RE GOING TO TRY
TO DO IT DIFFERENTLY.
ONE ANALOGY WE USE ALL THE TIME,
THE BOOK OPENS UP, YOU READ A
LINE AND YOU SLAM THE BOOK SHUT.
IT OPENS AGAIN, YOU READ A LINE
AND SLAM THE BOOK SHUT.
THAT KEEPS HAPPENING SO YOU FEEL
LIKE YOU'RE THINKING ABOUT IT
ALL THE TIME BUT T NOT CHANGING
ANYTHING.
WE'RE GOING TO OPEN THE BOOK AND
READ THE WHOLE CHAPTER OVER AND
OVER AND OVER AND OVER UNTIL YOU
CAN MAKE SOME OTHER KIND OF
SENSE OUT OF IT.
AND PUT IT AWAY DEMPLY.
THE SOONER WE CAN TREAT SOMEBODY
THE BETTER CHANCES BECAUSE IS
THERE'S ALSO SO MUCH COMORBIDITY
AND OTHER SEQUELLA OF STUFF WITH
PTSD BUT I'M NOT PESSIMISTIC
ABOUT TREATING PTSD FROM A LONG
AGO PRIOR TRAUMA.
SO AGAIN, LONG ANSWER.
>> THANK YOU FOR A VERY NICE
TALK.
MY NAME IS PAUL GATES.
MY DIRECT FIELDS ARE ON THE
TERMINOLOGY -- THIS MAY HAVE --
MAYBE AN ISSUE OF WHAT YOU'RE
REFERRING TO ABOUT PHENOMENON OF
UNPACK AN REPACKING THE
EXPERIENCE.
AND A LOT OF YOUR TALK WAS ABOUT
POSSIBLE OPPORTUNITIES FOR EARLY
INTERVENTION, THE FACT IT MAY BE
A WINDOW YOU'RE TRYING TO FIND
THAT COULD BE ESSENTIALLY A
THERAPEUTIC WINDOW.
INTERESTINGLY FROM POLICY
PERSPECTIVE, ORGANIZATIONS LIKE
THE AMERICAN RED CROSS AND
DISASTER MENTAL HEALTH
APPROACHES HAVE AS POLICY BEING
CAREFUL TO HAVE CENTRALIZED
OPERATIONS WITH DISASTER VICTIMS
SO THEY DONE HAVE TO RETELL
THEIR STORY OVER AN OVER AGAIN
TO THE SERVICE PROVIDER, TO THE
SOCIAL WORKER, MENTAL HEALTH
WORKER, ET CETERA, BUT TO HAVE
TO TRY TO MAKE IT WHERE THIS CAN
TELL THEIR STORY ONCE AND GET
WHAT THEY NEED.
THERAPY ESSENTIALLY WITH
DISTINCTIONS, YOU HAVE REPEATED
SESSIONS.
WITH EARLY INTERVENTION,
REPEATED SESSIONS OVER TIME, HOW
DO YOU PUT THAT TOGETHER WITH
WITH HOW THE AMERICAN RED CROSS
AND OTHERS ARE DEALING WITH
TRYING TO CUT DOWN ON REPEATED
STORY TELL SOMETHING IS IT
HAVING TO DO WITH UNPACKING BUT
HOW DO YOU REPACK IT?
>> YES.
SO IT'S ACTUALLY A COMPLICATED
QUESTION AND A COMPLICATED
SITUATION AND I DON'T HAVE AN
ANSWER BASED ON DATA.
WHEN I WAS FIRST IN ATLANTA I
JOINED THE LOCAL DISASTER
RESPONSE TEAM, GOT TRAINED, IN
CRITICAL INCIDENT STRESS
DEBRIEFING MAINLY WITH THE IDEA
I WANTED TO DO RESEARCH AND WITH
THE AMERICAN RED CROSS.
I SOON FOUND OUT IT WAS A
PARAMILITARY ORGANIZATION AND
THEY REALLY AREN'T ENCOURAGING
RESEARCH.
WHEN I WENT TO THAT TRAINING,
THEY TYPICALLY DO IT -- WHAT
THAT TRAINER DID WHICH IS
TYPICAL AN EVERYBODY DOES IT
DIFFERENTLY, IN A GROUP FORMAT
AND THEY GO AROUND THE ROOM AND
THEY MAKE EVERYBODY TALK ABOUT
IT.
AND I MADE CLEAR WHAT IF
SOMEBODY DOESN'T WANT TO TALK --
AND THEY SAID NO, EVERYBODY HAS
TO TALK IT IN THAT ROOM.
I DON'T WANT TO THROW OUT THE
BABY WITH THE BATH WATER.
THERE ARE THERAPEUTIC ELEMENTS
IN DEBRIEFING, CRITICAL ELEMENT
STRESS DEBRIEFING.
WE NEED TO FIGURE OUT WHAT'S
RIGHT FOR WHOM.
I TEND TO NOT LIKE TRAUMA WORK
IN GROUPS.
I THINK YOU MAYBE FINE WITH
YOURS AND THEN YOU HEAR WHAT
HAPPENED TO HIM AND YOU THINK OH
MY GOD, THAT COULD HAPPEN TO ME.
I DON'T THINK PEOPLE NEED TO
HEAR THAT, IT'S HARD ENOUGH
DEEPING WITH -- DEALING WITH
YOUR OWN.
SO NOT A FAN OF TRAWKING WORKING
GROUP -- TRAUMA WORKING GROUP.
IT MAYBE THE WRONG DOSE, TOO
SOON OR A DIFFERENT CONTEXT, AND
IT TYPICALLY TENDS TO BE LIKE
YOU SAID, ONE TIME.
THAT'S WHY WE PURPOSEFULLY DID
OURS OVER AND OVER AN OVER AN
OVER.
SO THEY CAN EXPERIENCE HOPEFULLY
EXTINCTION OF THE FEAR.
YOU SAY IT OVER AN OVER AN OVER,
IT CAN TAKE THE Z THEENG OUT AND
THEY CAN LOOK AT IT AND PUT IT
AWAY, IT WILL BE A BAD MEMORY
BUT NOT A PTSD MEMORY.
SO I THINK THE MULTIPLE
RETELLING I THINK IS IMPORTANT
BUT IN A THERAPEUTIC CONTEXT.
(OFF MIC)
>> THE LINE, I DON'T KNOW.
IT WASN'T MORE THAN TEN YEARS
AGO BUT MAYBE HITTING CLOSE TO
TEN YEARS.
I KNOW PEOPLE DO IT DIFFERENTLY
AND I KNOW PEOPLE TOLD ME THAT'S
NOT HOW I DO IT.
SO I THINK THE MULTIPLE -- I
TEND TO THINK THE TELLING WAS
IMPORTANT.
>> THANK YOU VERY MUCH FOR THE
TALK.
WONDERING WHAT KIND OF STUDIES
WERE DONE TO DEVELOP THESE
TREATMENT METHODS?
LIKE THE VIRTUAL REALITY AND ALL
THAT?
THE KIND OF PROFESSIONALS THAT
WHEN INTO IT, WAS IT
PSYCHOLOGIST, PSYCHIATRIST,
BIOTECHNOLOGIST, THE TYPES OF
PEOPLE THAT CAME TOGETHER TO
MAKE THAT, WONDERING WHAT THE
BACK GROWN IS AND ALSO WHETHER
THERE'S RESEARCH BEING DONE
TODAY AND WHAT TYPES THERE ARE.
>> YES, YES, YES AND YES.
WHAT WAS FUN ABOUT THE VIRTUAL
REALITY RESEARCH IS THAT WE HAD
PSYCHOLOGISTS AND PROGRAMMERS
GETTING TOGETHER BRAINSTORMING
AND TALKING.
THE COMPUTER SCIENTIST FROM
GEORGIA TECH BROUGHT HIS
BRILLIANT COMPUTER SCIENCE
GRADUATE STUDENTS TO MY OFFICE
AND I EXPLAINED EXPOSURE
THERAPY, FOR FEAR OF HEIGHTS
FIRST TIME WE DID IT AND I
EXPLAINED WHERE I TAKE SOMEBODY
IN ATLANTA IF THEY HAD A FEAR OF
HEIGHTS AND THEN THEY WENT BACK
AN CREATED THOSE IN VIRTUAL
REALITY.
FOR THE ONE USING DI CYCLE
SERINE, THAT ALSO INVOLVED KERRY
WRESTLER, AN M.D. Ph.D.
PSYCHIATRIST AND OTHER FOLKS.
WE'RE STILL DOING LOTS OF
RESEARCH WITH ALL ASPECTS OF
EVERYTHING THAT YOU SAW.
AND A LOT OF TIMES COMPUTER
PROGRAMMERS WORKING WITH
PSYCHOLOGISTS AND PSYCHIATRISTS
TO COME UP WITH -- EXAMPLE,
COMPUTER SCIENTISTS WHEN WE
FIRST START DODDING SOMETHING,
WHEN WE DID THE VIRTUAL
AIRPLANE, I DIDN'T SHOW YOU THE
COMPUTER SCIENCE THING, WE CAN
CRASH THIS THING, LIKE NO,
LARRY, YOU DON'T UNDERSTAND.
WE WANT TO USE THIS
THERAPEUTICALLY.
SO I THINK THE TEAM APPROACH IS
IMPORTANT.
>> MY NAME IS (INAUDIBLE) A DRPH
STUDENT AT JOHNS HOPKINS.
MY QUESTION IS, WHAT'S NEXT WITH
THE VIRTUAL REALITY?
AFTER YOU'VE DONE STUDIES ON --
IN FAVOR OF EFFICACY OF VIRTUAL
REALITY, WHAT ARE SOME OF THE
POLICY NEXT THINGS TO DO FOR
YOUR STUDY?
>> ONE OF THE NEXT STEPS IS A
STUDY WE'RE DOING NOW THAT I'M
EXCITED ABOUT.
AND IT'S A THREE SITE STUDY,
IT'S LOOKING AT -- SO IT'S TWO
BY TWO FOR THOSE WHO THINK THAT
WAY.
IT'S LOOKING COMPARING VIRTUAL
REALITY EXPOSURE THERAPY TO
PROLONGED IMAGINABLE EXPOSURE
THERAPY WITH OR WITHOUT DECYCLE
SERINE AND WITHOUT LOOKING AT
GENETIC PREDICTORS.
WE'RE LOOKING AT BDNF WHICH HAS
SOME OF THE ALLELES HAVE SHOWN TO BE
INVOLVED IN PEOPLE WHO AND
ANIMAL WHOSE EXTINGUISH TO FEAR
WELL OR NOT, RESISTANT TO
EXTINCTION.
SO THINKING IF YOU HAVE THE
ALLELE WHERE YOU MIGHT BE MORE
RESISTANT TO EXTINCTION, MAYBE
THE VIRTUAL REALITY, A MORE
POTENT STIMULUS, THAIB MA THAT
WILL RESCUE YOU, MAYBE THE
DECYCLE SERINE FACILITATING THAT
WILL RESCUE YOU.
BECAUSE IT'S EXPENSIVE F. YOU
DON'T NEED THE COMPUTER STUFF
DONE USE IT.
TRYING TO FIGURE OUT WHO NEEDS
WHAT KIND OF THERAPY, AND TO
INDIVIDUALIZE AND PERSONALIZE
WHAT PEOPLE GED GET.
I ALSO WANT TO GET AWAY FROM THE
HEADLINE DISPLAY F WE CAN USE A
FLAT SCREEN OR DVD, IF WE
DELIVER IT OVER THE INTERNET,
MAKE IT EASIER AN CHEAPER, I
WOULD LOVE TO GO THAT WAY AND
FIGURE OUT WHO NEEDS WHAT.
>> IN THE TRIALS HOW LONG DOES
THE TREATMENT AFFECT LAST?
HAVE YOU CURED THEM?
OR ARE THEY COMING BACK?
>> IN PSYCHOLOGY I DON'T INTEND
TO USE THE CURE WORD THAT'S A
FOUR LETTER WORD FOR ME.
IN GENERAL IN PTSD AND WITH
EXPOSURE THERAPY, WE SEE MORE
GAINS AT FOLLOW-UP THAN AT POST
TREATMENT.
THAT MAYBE A MEASUREMENT
ARTIFACT BECAUSE THE POST
TREATMENT IF YOU'RE DOING -- SO
WE'RE USING THE REGULAR DSM
DEFINITION WHICH IS FOUR WEEKS.
ONE MONTH THAT. INCLUDES A LOT
OF TIME THEY WERE IN TREATMENT
AND WITH EXPOSURE THERAPY YOU'RE
STIRRING EVERYTHING UP.
(OFF MIC)
>> GENERALLY STILL DOING WELL.
WE THINK THAT WE'RE CREATING
PERMANENT CHANGES IN THE FEAR
STRUCTURE.
AS WE TELL PATIENTS YOU CAN'T
UNDO WHAT YOU HAVE DONE HERE AND
HOW YOU CAN THINK ABOUT IT
DIFFERENTLY AND HOW YOU CAN GO
THERE NOW.
THAT'S NOT TO SAY IF THEY
EXPERIENCE A NEW TRAUMATIC EVENT
THAT THEY WON'T GET PTSD AGAIN
BUT FOR EXAMPLE, WE DID TWO FEAR
OF FLYING STUDIES WITH VIRTUAL
AIRPLANE PRIOR TO 9/11 BECAUSE
YOU CAN'T GET PAST SECURITY NOW
WITHOUT A TICK.
WE FOLLOWED UP THOSE FOLKS AFTER
9/11 TO SEE IF THEIR FEAR OF
FLYING INCREASED AND WE DID A
MATCH CONTROL FOR FRIENDS LIKE
THEM WITHOUT THE FEAR OF FLYING.
THEIR FEAR DIDN'T INCREASE.
THEY CONTINUED TO USE THE COPING
MECHANISMSCH OTHER FOLKS WHO DID
HAVE A FEAR OF FLYING BEFORE
9/11, FEAR OF FLYING INCREASED
BUT NOT THE PATIENTS TREATED.
SO IN GENERAL WE'RE TEACHING
PEOPLE NEW SKILLS AN NEW WAYS TO
DEAL WITH IT.
WE'LL SEE.
YES, SIRCH LAST QUESTION.
(OFF MIC)
>> SO I THINK THE LEARNING FOLKS
TELL YOU THERE IS A LOT OF DATA
THAT MEMORIES ARE CONSOLIDATED
AND THERE'S ANIMAL DATA AND
HUMAN DATA FOR EARLY
INTERVENTION STUDY.
CONVENTIONAL WISDOM IS GET THEM
BEFORE THEY SLEEP.
WE TRIED TO DO THE STUDY IN
FOLKS WHO HADN'T LEFT YET AND
REVIEWER CAME BACK SAYING WE
DONE HAVE THE DATA ABOUT THAT SO
WE'LL LOOK TO SEE IF THAT
INFLUENCE -- BUT IT IS
CONSOLIDATED.
IN SLEEP SO WE WANT TO TRY TO
GET TO THEM EARLIER.
I ALSO DIDN'T SHOW YOU MIKE
DAVIS HAS A LITTLE BIT OF DATA,
NOT PUBLISHED YET WITH THE
DECYCLE SERINE GIVE -- DOING THE
EXTINCTION TRAINING DURING THE
DAY AND THIS IS I THINK IN
ANIMALS AND GIVING THEM THE
DECYCLE SERINE BEFORE THEY SLEEP
AN IT WORKS.
SO I THINK THAT WE DEFINITELY
HAVE EVIDENCE THAT STUFF IS
CONSOLIDATED IN SLEEP.
DREAMS ARE A WHOLE DIFFERENCE
STORY, I GUESS I SHOULD STOP.
YES.
(OFF MIC)
>> SO FOLKS THAT DO AND DON'T
GET PTSD, I THINK IT'S PRETTY
COMPLICATED.
AGAIN, SOME OF MY COLLEAGUES
KERRY WRESTLER AND HIS GROUP
FOUND A GENE BY ENVIRONMENT
INTERACTION.
YOU FIND ON A COUPLE OF GENES
THIS WAS SKBP-5 I THINK.
AND WITH A CERTAIN ALLELE AND
EXPOSURE TO ADVERSITY IN
CHILDHOOD, AND THEN EXPOSURE TO
A TRAUMA AS AN ADULT.
FOLKS GOT PTSD OR NOT SO IT WAS
THE GENE BY THE ENVIRONMENT, BY
THE EXPOSURE IN CHILDHOOD THAT
PREDICTED WITH EXPOSURE IN
ADULTHOOD IF THEY GET PTSD OR
NOT.
SO I THINK IT'S ACTUALLY
COMPLICATED.
IT IS A NATURE, NURTURE THING.
I ALSO DON'T THINK IF YOU JUST
LOOK AT THE FLIP SIDE OF THAT
DATA, AND IF YOU -- YOU CAN CALL
IT RESILIENCE BUT RESILIENCE IS
ALSO MORE THAN THAT.
I THINK RESILIENCE IS NOT JUST
ABSENCE OF PTSD, DENNIS CHARNEY
HAS DONE WORK ON RESILIENCE IN
THE POWs FROM THE HANOI HILL
TON AND IN NAVY SEALS.
AND HE'S ENUMERATED AND OTHER
FOLKS HAVE THINGS THAT THEY
THINK ARE IMPORTANT FOR
RESILIENCE AND I THINK
RESILIENCE, YOU HAVE TO BE
EXPOSED TO ADVERSITY TO DEVELOP
RESILIENCE.
BUT SOME OF THE THINGS HE
IDENTIFIED OF VALUE SYSTEM,
HUMOR, SUPPORT.
SO I THINK IT GETS COMPLICATED.
SO WITH THAT, I SHOULD STOP.
THANK YOU.