Historical approaches to post-combat disorders

The Psychedelic Future of Post-Traumatic Stress Disorder Treatment

Post-traumatic stress disorder (PTSD) is a mental health condition that can occur following exposure to a traumatic experience. An estimated 12 million U.S. adults are presently affected by this disorder. Current treatments include psychological therapies (e.g., exposure-based interventions) and pharmacological treatments (e.g., selective serotonin reuptake inhibitors (SSRIs)). However, a significant proportion of patients receiving standard-of-care therapies for PTSD remain symptomatic, and new approaches for this and other trauma-related mental health conditions are greatly needed. Psychedelic compounds that alter cognition, perception, and mood are currently being examined for their efficacy in treating PTSD despite their current status as Drug Enforcement Administration (DEA)- scheduled substances. Initial clinical trials have demonstrated the potential value of psychedelicassisted therapy to treat PTSD and other psychiatric disorders. In this comprehensive review, we summarize the state of the science of PTSD clinical care, including current treatments and their shortcomings. We review clinical studies of psychedelic interventions to treat PTSD, trauma-related disorders, and common comorbidities. The classic psychedelics psilocybin, lysergic acid diethylamide (LSD), and N,N-dimethyltryptamine (DMT) and DMT-containing ayahuasca, as well as the entactogen 3,4-methylenedioxymethamphetamine (MDMA) and the dissociative anesthetic ketamine, are reviewed. For each drug, we present the history of use, psychological and somatic effects, pharmacology, and safety profile. The rationale and proposed mechanisms for use in treating PTSD and traumarelated disorders are discussed. This review concludes with an in-depth consideration of future directions for the psychiatric applications of psychedelics to maximize therapeutic benefit and minimize risk in individuals and communities impacted by trauma-related conditions.

Moral injury: understanding Swedish veterans who are assessed but not diagnosed with PTSD

This article is based on an interview study of 24 Swedish veterans who experienced deteriorating mental health and increased suffering without meeting the criteria for a PTSD diagnosis. With no clinical answers as to the cause of their deteriorating mental health, they have been thrown into a veteran's health limbo. The analysis was based on an inductive logic. A key finding of the analysis was a kind of deep-seated permanent moral conflict that could be conceptualized as moral injury. Such an injury can give rise to intense guilt, shame, anxiety, anger, dejection, bitterness, identity issues and more. The results section of the article details five different yet for the sample representative cases of moral injury and their implications. The notion of moral injury is linked to Mead's division of the self into an I and me, where me is the socially constructed part of the self that is charged with the morality of a group. Thus, a moral me played a key role in the development of moral injury. The conceptual apparatus illustrates a new way of understanding experiences that can create suffering and negatively impact a veteran's mental health. Future research is encouraged that examines this topic, national designs for addressing moral injury, screening for moral injury, and methods for healing included.

National Guard service members decedent recovery and processing operations during the COVID-19 pandemic in New York City

In Spring 2020, the New York Army and Air National Guard (NYNG) rapidly deployed to New York City (NYC) to assist in the recovery, processing, and transport of COVID-19 decedents. This study reports on a survey conducted by NYNG service members three to six months post-mission (n = 177). Data showed that there was a dose-response relationship between mission stress exposure and decremented mental health, but certain activities were associated with better mental health outcomes. The paper also reviews resources provided by behavioral health personnel to support service members during the mission and lessons learned to inform future decedent recovery missions.

Novel Pharmacological Targets of Post-Traumatic Stress Disorders

Post-traumatic stress disorder (PTSD) is a psychopathological condition with a heterogeneous clinical picture that is complex and challenging to treat. Its multifaceted pathophysiology still remains an unresolved question and certainly contributes to this issue. The pharmacological treatment of PTSD is mainly empirical and centered on the serotonergic system. Since the therapeutic response to prescribed drugs targeting single symptoms is generally inconsistent, there is an urgent need for novel pathogenetic hypotheses, including different mediators and pathways. This paper was conceived as a narrative review with the aim of debating the current pharmacological treatment of PTSD and further highlighting prospective targets for future drugs. The authors accessed some of the main databases of scientific literature available and selected all the papers that fulfilled the purpose of the present work. The results showed that most of the current pharmacological treatments for PTSD are symptom-based and show only partial benefits; this largely reflects the limited knowledge of its neurobiology. Growing, albeit limited, data suggests that the hypothalamic-pituitary-adrenal axis, opioids, glutamate, cannabinoids, oxytocin, neuropeptide Y, and microRNA may play a role in the development of PTSD and could be targeted for novel treatments. Indeed, recent research indicates that examining different pathways might result in the development of novel and more efficient drugs.

Trauma and Remembering: From Neuronal Circuits to Molecules

Individuals with posttraumatic stress disorder (PTSD) experience intrusions of vivid traumatic memories, heightened arousal, and display avoidance behavior. Disorders in identity, emotion regulation, and interpersonal relationships are also common. The cornerstone of PTSD is altered learning, memory, and remembering, regulated by a complex neuronal and molecular network. We propose that the essential feature of successful treatment is the modification of engrams in their unstable state during retrieval. During psychedelic psychotherapy, engrams may show a pronounced instability, which enhances modification. In this narrative review, we outline the clinical characteristics of PTSD, its multifaceted neuroanatomy, and the molecular pathways that regulate memory destabilization and reconsolidation. We propose that psychedelics, acting by serotonin-glutamate interactions, destabilize trauma-related engrams and open the door to change them during psychotherapy.

Elton Mayo and Thomas Henry Reeve Mathewson: the forgotten Australian pioneers of the treatment of patients with shell shock, neurasthenia and nervous breakdown

The contributions of Australians on shell shock are absent from the literature. However, two Australians were pioneers in the treatment of shell shock: George Elton Mayo (1880-1949) and Dr Thomas Henry Reeve Mathewson (1881-1975). They used psychoanalytic approaches to treat psychiatric patients and introduced the psychoanalytic treatment of people who suffered from shell shock. Their 'talking cure' was highly successful and challenged the view that shell shock only occurred in men who were malingering and/or lacking in fortitude. Their work demonstrated that people experiencing mental illness could be treated in the community at a time when they were routinely treated as inpatients. It also exemplified the substantial benefits of combining science with clinical knowledge and skill in psychology and psychiatry.

Post-traumatic stress disorder and mental health assessment of seafarers working on ocean-going vessels during the COVID-19 pandemic

Background

There are increasing concerns about mental health consequences of the COVID-19 pandemic among seafarers. This study aims to assess the effects of the current global health pandemic on life satisfaction and adverse psychological outcomes among seafarers.

Methods

In this cross-sectional study, 470 multinational seafarers working on board ships of two international shipping companies were assessed. Mental health outcomes were assessed by the general anxiety disorder (GAD-7) questionnaire, post-traumatic stress disorder (PTSD-8) questionnaire, and patient health questionnaire (PHQ-9) depressive severity score. Multivariate logistic regression was used to determine the association of demographic and work-related variables with mental health outcomes.

Results

Overall, 439 out of 470 invited seafarers with a mean age of 34.5 (SD: 8.05) years participated in this study (participation rate: 93.4%). The prevalence of anxiety, depressive, and post-traumatic stress symptoms was 12.4, 14.1, and 37.3%, respectively. In the multivariate model, the current vessel’s signing duration was directly associated with the odds of depressive and intrusion symptoms. Moreover, the duration of work per week was inversely associated with hyper-vigilance and avoidance. Also, non-officers, compared to officers, experienced significantly lower anxiety and depressive symptoms, hyper-vigilance, and avoidance.

Conclusion

The present study revealed a high prevalence of mental health problems among seafarers during the COVID-19 pandemic. We recommend that more evidence is generated regarding psychosocial health issues for this vulnerable occupation.

Repetitive Blast Promotes Chronic Aversion to Neutral Cues Encountered in the Peri-Blast Environment

Repetitive mild traumatic brain injury (mTBI) has been called the "signature injury" of military service members in the Iraq and Afghanistan wars and is highly comorbid with post-traumatic stress disorder (PTSD). Correct attribution of adverse blast-induced mTBI and/or PTSD remains challenging. Pre-clinical research using animal models can provide important insight into the mechanisms by which blast produces injury and dysfunction-but only to the degree by which such models reflect the human experience. Avoidance of trauma reminders is a hallmark of PTSD. Here, we sought to understand whether a mouse model of blast reproduces this phenomenon, in addition to blast-induced physical injuries. Drawing on well-established work from the chronic stress and Pavlovian conditioning literature, we hypothesized that even while one is anesthetized during blast exposure, environmental cues encountered in the peri-blast environment could be conditioned to evoke aversion/dysphoria and re-experiencing of traumatic stress. Using a pneumatic shock tube that recapitulates battlefield-relevant open-field blast forces, we provide direct evidence that stress is inherent to repetitive blast exposure, resulting in chronic aversive/dysphoric-like responses to previous blast-paired cues. The results in this report demonstrate that, although both single and repetitive blast exposures produce acute stress responses (weight loss, corticosterone increase), only repetitive blast exposure also results in co-occurring aversive/dysphoric-like stress responses. These results extend appreciation of the highly complex nature of repetitive blast exposure; and lend further support for the potential translational relevance of animal modeling approaches currently used by multiple laboratories aimed at elucidating the mechanisms (both molecular and behavioral) of repetitive blast exposure.

Outside the Military "Bubble": Life After Service for UK Ex-armed Forces Personnel

Military personnel who have seen active service can be affected by their experiences. Much of the literature on the mental and physical health battles faced by men and women who leave the Armed Forces is dominated by research in the United States (US) (1), and is particularly focused on exposure to deployment, combat conditions, and effects on mental health. Research in the United Kingdom (UK) tends to focus on depression or alcohol misuse and the impact these issues have on currently serving personnel. This study aimed to present UK veterans' first-hand experiences related to military service, access to and use of mental healthcare and interventions, and the impact of transition on the military family. Semi-structured interviews explored experiences of 30 participants (27 male, 3 female). Participants ranged in age from 26 to 92 years (M = 53.33), and across multiple war cohorts (from WWII to Iraq and Afghanistan). Data were analyzed using Thematic Analysis and Narrative Analysis. Findings show meaning-making from experiences of transition across veteran cohorts. Main themes were reasons for leaving Armed Forces, life outside the military, and mental health concerns after service. Subordinate themes additionally focused on evaluation of identity and mental health service provision. Future clinical research should include the experiences of UK serving personnel and the effects of pre-and post-military adversity, alongside the impact of deployment experiences. Interventions designed to address transition into life after service are discussed.

Context Processing and the Neurobiology of Post-Traumatic Stress Disorder

Progress in clinical and affective neuroscience is redefining psychiatric illness as symptomatic expression of cellular/molecular dysfunctions in specific brain circuits. Post-traumatic stress disorder (PTSD) has been an exemplar of this progress, with improved understanding of neurobiological systems subserving fear learning, salience detection, and emotion regulation explaining much of its phenomenology and neurobiology. However, many features remain unexplained and a parsimonious model that more fully accounts for symptoms and the core neurobiology remains elusive. Contextual processing is a key modulatory function of hippocampal-prefrontal-thalamic circuitry, allowing organisms to disambiguate cues and derive situation-specific meaning from the world. We propose that dysregulation within this context-processing circuit is at the core of PTSD pathophysiology, accounting for much of its phenomenology and most of its biological findings. Understanding core mechanisms like this, and their underlying neural circuits, will sharpen diagnostic precision and understanding of risk factors, enhancing our ability to develop preventive and "personalized" interventions.

The changing face of posttraumatic stress disorder in modern warfare

OBJECTIVES

This study examined aspects of modern warfare and determined whether they have changed the clinical presentation of posttraumatic stress disorder (PTSD).

CONCLUSIONS

The relationship between PTSD, mild traumatic brain injury, unmanned aerial vehicle operations and women in combat examined. It was concluded that there are significant changes in how contemporary combat veterans may present with PTSD.

Chronic subordinate colony housing paradigm: A mouse model for mechanisms of PTSD vulnerability, targeted prevention, and treatment-2016 Curt Richter Award Paper

There is considerable individual variability in vulnerability for developing posttraumatic stress disorder (PTSD); evidence suggests that this variability is related in part to genetic and environmental factors, including adverse early life experience. Interestingly, recent studies indicate that induction of chronic low-grade inflammation may be a common mechanism underlying gene and environment interactions that increase the risk for development of PTSD symptoms, and, therefore, may be a target for novel interventions for prevention or treatment of PTSD. Development of murine models with face, construct, and predictive validity would provide opportunities to investigate in detail complex genetic, environmental, endocrine, and immunologic factors that determine vulnerability to PTSD-like syndromes, and furthermore may provide mechanistic insight leading to development of novel interventions for both prevention and treatment of PTSD symptoms. Here we describe the potential use of the chronic subordinate colony housing (CSC) paradigm in mice as an adequate animal model for development of a PTSD-like syndrome and describe recent studies that suggest novel interventions for the prevention and treatment of PTSD.

Posttraumatic Stress Disorder and Orofacial Pain

Chronic orofacial pain occurs frequently in patients with posttraumatic stress disorder (PTSD) and at the same time any pathological process involving orofacial area can be reflected in emotional interpretation of pain and can trigger a series of reactions associated with the PTSD group of symptoms in patients with PTSD. Painful stimuli caused in this way may occur after the primary cause ceased, and because of convergence can cause referred pain outside of the anatomical site where the primary injury occurred. Chronic orofacial pain and PTSD are diagnosed on the basis of subjective testimony and this regularly occurs in the context of social interaction between patients, doctors, medical staff or researchers making it difficult to standardize the results and introduces many cultural phenomena.

Neurobehavioral Mechanisms of Traumatic Stress in Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a debilitating psychiatric disorder that develops following trauma exposure. It is characterized by four symptom clusters: intrusion, avoidance, negative alteration in cognitions and mood, and alterations in arousal and reactivity. Several risk factors have been associated with PTSD, including trauma type and severity, gender and sexual orientation, race and ethnicity, cognitive reserve, pretrauma psychopathology, familial psychiatric history, and genetics. Great strides have been made in understanding the neurobiology of PTSD through animal models and human imaging studies. Most of the animal models have face validity, but they have limitations in the generalization to the human model of PTSD. Newer animal models, such as the "CBC" model, have better validity for PTSD, which takes into account the different components of its diagnostic criteria. To date, fear conditioning and fear extinction animal models have provided support for the hypothesis that PTSD is a dysregulation of the processes related to fear regulation and, especially, fear extinction. More research is needed to further understand these processes as they relate not only to PTSD but also to resilience. Further, this research could be instrumental in the development of novel effective treatments for PTSD.

Deployment-related injury and posttraumatic stress disorder in US military personnel

BACKGROUND

The current military conflicts in Iraq and Afghanistan have resulted in the most US casualties since the Vietnam War. Previous research on the association between deployment-related injury and posttraumatic stress disorder (PTSD) has yielded mixed results.

OBJECTIVES

To examine the effect of battle injury (BI) relative to non-battle injury (NBI) on the manifestation of PTSD symptoms in military personnel and to assess the demographic, injury-specific, and pre-injury factors associated with PTSD following a BI.

PATIENTS AND METHODS

A total of 3403 personnel with deployment-related injury (1777 BI and 1626 NBI) were identified from the Expeditionary Medical Encounter Database. Records were electronically matched to Post-Deployment Health Assessment (PDHA) data completed 1-6 months post-injury. The PTSD screening outcome was identified using a four-item screening tool on the PDHA.

RESULTS

Compared to those with NBI, personnel with BI had more severe injuries, reported higher levels of combat exposure, and had higher rates of positive PTSD screen. After adjusting for covariates, personnel with BI were twice as likely to screen positive for PTSD compared to those with NBI (odds ratio [OR], 2.10; 95% confidence interval [CI], 1.60-2.75). In multivariable analysis among battle-injured personnel only, moderate and serious-severe injury (OR, 1.49; 95% CI, 1.12-2.00 and OR, 1.64; 95% CI, 1.01-2.68, respectively), previous mental health diagnosis within 1 year of deployment (OR, 2.69; 95% CI, 1.50-4.81), and previous BI (OR, 1.96; 95% CI, 1.22-3.16) predicted a positive PTSD screen.

CONCLUSIONS

Military personnel with BI have increased odds of positive PTSD screen following combat deployment compared to those with NBI. Post-deployment health questionnaires may benefit from questions that specifically address whether service members experienced an injury during combat.

Managing traumatic brain injury secondary to explosions

Explosions and bombings are the most common deliberate cause of disasters with large numbers of casualties. Despite this fact, disaster medical response training has traditionally focused on the management of injuries following natural disasters and terrorist attacks with biological, chemical, and nuclear agents. The following article is a clinical primer for physicians regarding traumatic brain injury (TBI) caused by explosions and bombings. The history, physics, and treatment of TBI are outlined.

Health of national service veterans: an analysis of a community-based sample using data from the 2007 Adult Psychiatric Morbidity Survey of England

PURPOSE

In the context of increasing concerns for the health of UK armed forces veterans, this study aims to compare the prevalence of current mental, physical and behavioural difficulties in conscripted national service veterans with population controls, and to assess the impact of length of service in the military. The compulsory nature of national service sets these veterans apart from younger veterans.

METHOD

Data are drawn from a nationally representative community-dwelling sample of England. We compared 484 male national service veterans to 301 male non-veterans aged 65+ years.

RESULTS

There were no differences in mental, behavioural or physical outcomes, except that veterans were less likely to have "any mental disorder" than non-veterans (age adjusted OR = 0.56, 95% CI 0.31, 0.99). Longer serving veterans were older but were not different in terms of mental, behavioural or physical outcomes.

CONCLUSIONS

Community-dwelling national service veterans are at no greater risk of current adverse mental, physical or behavioural health than population controls.

Post-traumatic stress disorder: present and future

Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) differ from almost every other psychiatric diagnosis in that they may only be diagnosed with reference to an aetiological event - an external traumatic stressor. ASD occurs immediately after the stressor and is comparatively short-lived, while PTSD is a prolonged abnormal response that may take months to develop. The types of stressor leading to ASD and PTSD are identical and were intended to be tightly defined, involving a perceived threat of death, serious injury or loss of physical integrity. It is useful initially to distinguish ASD and PTSD from adjustment disorders, which are also diagnosed only after an observable life event. An adjustment disorder may be thought of as a gradual and prolonged response to stressful changes in a person's life. The range of stressors precipitating an adjustment disorder is potentially much broader than that precipitating ASD or PTSD, as a threat of death or injury is not needed. Indeed, a 'threat' as such is not needed, as the event may be a loss. Events such as job loss or the breakup of a relationship may lead to an adjustment disorder, as well as threats such as accidents or assaults. The diagnostic criteria for adjustment disorder do not specify what the immediate response, if any, to the precipitating stressor must be.

The Deployment Health Surveillance Program: vision and challenges of health surveillance for Australian military cohorts

The Australian Government has supported the establishment of a Deployment Health Surveillance Program for the Australian Defence Force. Although some health screening mechanisms already exist for Australian Defence Force personnel, until now health data have been used largely for clinical management at an individual level and have not been aggregated to identify trends in health and risk factors in the shorter or longer term. We identify challenges for and potential benefits of health surveillance in the military context, describe features of the Program and progress to date. Retrospective and cross-sectional projects based on deployments to the Near North Area of Influence since 1997 are under way. A planned prospective model of health surveillance for those deploying to the Middle East promises more timely attention to any emerging health problems for military personnel and veterans.

War & military mental health: the US psychiatric response in the 20th century

Involvement in warfare can have dramatic consequences for the mental health and well-being of military personnel. During the 20th century, US military psychiatrists tried to deal with these consequences while contributing to the military goal of preserving manpower and reducing the debilitating impact of psychiatric syndromes by implementing screening programs to detect factors that predispose individuals to mental disorders, providing early intervention strategies for acute war-related syndromes, and treating long-term psychiatric disability after deployment. The success of screening has proven disappointing, the effects of treatment near the front lines are unclear, and the results of treatment for chronic postwar syndromes are mixed. After the Persian Gulf War, a number of military physicians made innovative proposals for a population-based approach, anchored in primary care instead of specialty-based care. This approach appears to hold the most promise for the future.

Managing future Gulf War Syndromes: international lessons and new models of care

After the 1991 Gulf War, veterans of the conflict from the United States, United Kingdom, Canada, Australia and other nations described chronic idiopathic symptoms that became popularly known as 'Gulf War Syndrome'. Nearly 15 years later, some 250 million dollars in United States medical research has failed to confirm a novel war-related syndrome and controversy over the existence and causes of idiopathic physical symptoms has persisted. Wartime exposures implicated as possible causes of subsequent symptoms include oil well fire smoke, infectious diseases, vaccines, chemical and biological warfare agents, depleted uranium munitions and post-traumatic stress disorder. Recent historical analyses have identified controversial idiopathic symptom syndromes associated with nearly every modern war, suggesting that war typically sets into motion interrelated physical, emotional and fiscal consequences for veterans and for society. We anticipate future controversial war syndromes and maintain that a population-based approach to care can mitigate their impact. This paper delineates essential features of the model, describes its public health and scientific underpinnings and details how several countries are trying to implement it. With troops returning from combat in Afghanistan, Iraq and elsewhere, the model is already getting put to the test.