Resonance Frequency Breathing Biofeedback to Reduce Symptoms of Subthreshold PTSD with an Air Force Special Tactics Operator: A Case Study

Using Wearable Digital Devices to Screen Children for Mental Health Conditions: Ethical Promises and Challenges

In response to a burgeoning pediatric mental health epidemic, recent guidelines have instructed pediatricians to regularly screen their patients for mental health disorders with consistency and standardization. Yet, gold-standard screening surveys to evaluate mental health problems in children typically rely solely on reports given by caregivers, who tend to unintentionally under-report, and in some cases over-report, child symptomology. Digital phenotype screening tools (DPSTs), currently being developed in research settings, may help overcome reporting bias by providing objective measures of physiology and behavior to supplement child mental health screening. Prior to their implementation in pediatric practice, however, the ethical dimensions of DPSTs should be explored. Herein, we consider some promises and challenges of DPSTs under three broad categories: accuracy and bias, privacy, and accessibility and implementation. We find that DPSTs have demonstrated accuracy, may eliminate concerns regarding under- and over-reporting, and may be more accessible than gold-standard surveys. However, we also find that if DPSTs are not responsibly developed and deployed, they may be biased, raise privacy concerns, and be cost-prohibitive. To counteract these potential shortcomings, we identify ways to support the responsible and ethical development of DPSTs for clinical practice to improve mental health screening in children.

Sympathetic nerve blocks for posttraumatic stress disorder: an evidentiary review for future clinical trials

Posttraumatic stress disorder (PTSD) is a chronic disorder resulting from exposure to traumatic events. In recent years, sympathetic nerve blocks have gained interest as an emerging treatment modality for PTSD. They have been shown to reduce autonomic dysfunction associated with PTSD symptoms, particularly in refractory and treatment-resistant patients. However, there is limited evidence regarding the technique's effectiveness in PTSD patients. Therefore, this scoping review was designed to update and summarize the current literature on this topic to inform the design of future clinical trials and studies. Our review of 22 studies (mostly case reports and series) included 1,293 PTSD patients who received sympathetic nerve blocks, primarily military service members and veterans, with a median age of 42.2 years. 0.5% Ropivacaine was the preferred anesthetic, and the right sided stellate ganglion block was the most commonly used technique. Relapse of symptoms was reported commonly, resulting in additional nerve block sessions. Most reported side effects were mild and transient. Despite the encouraging results, we remain cautious in interpreting the benefit of the technique due to the lack of sufficient standardized clinical trial data, heterogeneity in reported results, and the potential for bias in reporting. Future studies should focus on evaluating and addressing the technique's effectiveness, safety, tolerability, and indications.

The Efficacy of the Stellate Ganglion Block as a Treatment Modality for Posttraumatic Stress Disorder Among Active Duty Combat Veterans: A Pilot Program Evaluation

INTRODUCTION

The lifetime prevalence for development of Posttraumatic Stress Disorder (PTSD) among military combat veterans has been estimated to be as high as 17%, or more than double the national average. The stellate ganglion block (SGB) has been proposed as a PTSD treatment modality that may potentially affect positive change in the attitude of a service member (SM) toward mental health treatment, lead to improved clinical outcomes, promote the likelihood of a return to a productive job performance, and decrease the economic burden of PTSD treatment on the Department of Defense.

MATERIALS AND METHODS

A pilot program to determine the efficacy of the SGB was conducted in a single, closed-unit of active duty combat veterans with a statistically high prevalence of PTSD-related symptoms associated with combat deployments. A retrospective project-level program evaluation was completed to assess the effectiveness of the treatment in reducing symptoms, the level of SM acceptance of the procedure, and the SM perceived response to the SGB treatment. The project-level program evaluation methodology was based on the suggestions of the W.K. Kellogg Foundation Evaluation Handbook. The primary design and context of the evaluation was viewed from an outcome evaluation perspective and format, with focus on both individual and system-level outcomes. The outcome evaluation addressed: 1) the measured outcomes and critical findings of the procedure during the pilot, 2) feasibility of and recommendation for replication of the pilot, and 3) the quality improvement potential of the SGB as part of a clinical pathway for the care and treatment of PTSD in SMs.

RESULTS

Program evaluation analysis demonstrated that the SGB exhibited success in both rate and level of response, reduced stigma relative to acceptance of the treatment, and SMs verbalized a high perceived value of the treatment. However, the effect of the procedure was shown to peak and plateau with a regression to baseline at roughly the 3-month timeframe, with a reciprocal decrease in perceived value.

CONCLUSION

The most significant benefit of the SGB appears to be its ability to act as a gateway to treatment and to facilitate active participation and compliance by the SM during its "window" of efficacy. Additional research, including RCTs are required to continue to evaluate its efficacy relative to symptom-specific effectiveness, effectiveness of sequential procedures, and effectiveness when combined with other nonpharmaceutical treatment modalities. Moreover, the application of an accepted medical procedure as a mental health (MH) therapy with marked reduction in stigma, encourages pursuit of additional such treatment methods that reduce stigma and promote active SM participation in PTSD management.

Tackling hyperarousal: an integrative multimodal approach

Introduction: The effectiveness of treatment for PTSD is limited, which is especially true for war veterans, of whom 30-50% do not respond to therapy. Hyperarousal is central to the maintenance of trauma pathology. The mainstream trauma-focused therapies traditionally target the cognitive processing of traumatic experience. In this article, we propose that these therapies may be enhanced by the inclusion of interventions specifically targeting hyperarousal.Method: We review an earlier formulated model of trauma supporting our proposal. This model is based on a theory of trauma that integrates the concept of allostasis with the predictive processing framework. In this view, trauma is considered a maladaptive stress response guided by false inference.Results: The reviewed model is in agreement with the central role of hyperarousal in the maintenance of trauma-induced disorders. It also demonstrates the importance of targeting hyperarousal at the same time as maladaptive cognitions and behaviours associated with trauma. A treatment for PTSD is proposed that combines exposure to trauma-related cues with neurofeedback-mediated regulation of arousal.Conclusions: Our analysis argues for the integration of hyperarousal-targeting interventions into existing therapies. Accordingly, we offer methodological considerations based on the nested hierarchy principle that can guide such integration.