Post-traumatic stress disorderBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6161 (Published 26 November 2015) Cite this as: BMJ 2015;351:h6161
All rapid responses
This excellent Clinical Review on PTSD (1) asks “Are there emerging options to prevent and treat PTSD?” Dutton and Ashworth (2) suggest a model that permits new therapeutic focus: this applies not only for PTSD, but also for symptoms of stress and traumata that commonly present in General Practice. These symptoms can be disabling without meeting the diagnostic criteria of PTSD. The only neurobiological intervention described here is EMDR, a specialist treatment. We describe a simple intervention for some symptoms that can easily be applied by generalists for patients in the safety level of the Dutton Ashworth “Snakes and Ladders” model (figure 1) .
Observing that feeding babies while gazing at their mothers were extremely calm, led us to consider the importance of the Edinger-Westphal nucleus in the treatment of fear and anger. The E-W nucleus is situated between the IIIrd (occulomotor) and IVth (trochlear) cranial nerve nuclei and has an autonomic function that may go beyond its occular efferents. Our patients have described visceral feelings associated with emotions that may be autonomic in origin.
Fear and anger might be considered protective emotions (flight or fight) in appropriate proportions in the presence of external threats but, when they continue to overwhelm after the event, they become disabling for the patient. In clinical practice we have noted that by teaching patients to locate the body feeling associated with fear or anger, then asking them to concentrate on this visceral sensation while adopting a suitable “baby gaze” to stimulate the contralateral occulomotor and trochlear pathways (looking up and to the right or left), symptoms resolve, typically within 5 minutes. Appropriately instructed patients also report being able to carry out exercises at home, successfully controlling and reducing their troublesome symptoms.
1 BMJ 2015;351:h6161
2 Dutton, PV, Ashworth, AJ. The natural history of recovery from psychological trauma: An observational model. Medical Hypotheses 85 (2015) 588-590
Competing interests: No competing interests
This clear and informative clinical review may alert more GPs to the hidden horrors that often lie, buried for decades beneath the fearful silence that so often follows the abuse of young children. Uncovering those memories in a gentle and non judgmental way will sometimes provide a very therapeutic beginning, to what may become a healing process.
Difficult, in these days of brief consultations.
There is also a large group of people with severe PTSD, whose numbers will surely increase, and whose awareness of, and whose ability to contact, sources of NHS help, is in itself a serious concern.
Many asylum seekers, men and women, have histories of physical, sexual and emotional abuse that challenge the equanimity of a listener.
Are they numbered in thousands, or tens of thousands, in the UK ?
The authors remark “.. some evidence suggests that high levels of social support are perceived as protective.“ The unintended irony of this observation is clear to those who are familiar with the responses that asylum seekers often receive at Home Office interviews, and from Immigration Tribunals.
Support is available to asylum seekers from voluntary groups who work under the umbrella of the Cities of Sanctuary movement, and from NGOs like Freedom from Torture and Medical Justice.
What of treatment in those parts of the UK where these NGOs have no presence, and where the psychiatric service is severely stretched, and talking therapies are difficult to access?
The authors discuss the evidence for different treatment modalities.
As they point out, seldom do more than 50% of sufferers show a sustained improvement.
In these days when the evidence, or perceived lack of it, of clinical trials allows treatments which appear safe and effective when used by bona fide colleagues, to be summarily dismissed by those with closed minds, it still remains the duty of caring doctors to examine any approach that seems to be safe and effective.
We have been seeing about eighty asylum seekers and their families, for homeopathic assessment and treatment. Some have made dramatic recoveries from very dark places. Nearly all have been helped. No one is harmed.
Our experience is anecdotal, but it reflects the experience of many homeopaths in the west, and in developing countries. (1) We suggest to colleagues in primary care who encounter damaged asylum seekers, and other PTSD patients, in areas where psychiatric services are limited, or when there has been a poor response to conventional approaches, that they should consider this option.
1 Trauma. Spectrum ofHomeopathy, No 1/ 2014. Narayana Verlag. ISSN 1869-3091
Competing interests: No competing interests
I appreciate that a CPD article intended for general medical readers has to be brief, as evidence based as possible, and highlight the main points. Readers wishing to broaden their interest in Post Traumatic Stress Disorder (PTSD) may wish to be aware of the possible emerging role of Ketamine in treating PTSD and indeed may wish to be aware that there is an animal study which suggests that Ketamine may have a prophylactic role in preventing the condition from occuring.
Whilst many caveats apply to observational studies, in one observational study investigating the prevalence of PTSD in Operation Iraqi Freedom/Operation Enduring Freedom service members who were treated for burns in a military treatment center it was found that among 119 patients who received ketamine during surgery and 28 who did not the prevalence of PTSD was 27% (32 of 119) versus 46% (13 of 28), respectively - almost a 20% reduction (1).
In a randomized, double-blind, crossover trial comparing ketamine with an active placebo control, midazolam, conducted at a single site involving forty-one patients with chronic PTSD intravenous infusion of ketamine hydrochloride (0.5 mg/kg) was associated with significant and rapid reduction in PTSD symptom severity, compared with midazolam, when assessed 24 hours after infusion (mean difference in Impact of Event Scale–Revised score, 12.7 [95% CI, 2.5-22.8]; P = .02). Greater reduction of PTSD symptoms following treatment with ketamine was evident in both crossover and first-period analyses, and remained significant after adjusting for baseline and 24-hour depressive symptom severity. Ketamine was also associated with reduction in comorbid depressive symptoms and with improvement in overall clinical presentation. Ketamine was generally well tolerated without clinically significant persistent dissociative symptoms.The authors concluded that their study provided the first evidence for rapid reduction in symptom severity following ketamine infusion in patients with chronic PTSD, which if replicated might lead to novel approaches to the pharmacologic treatment of patients with this disabling condition(2).
The role of Ketamine in enhancing stress resilience was tested using a chronic social defeat (SD) stress model, learned helplessness (LH) model and a chronic corticosterone (CORT) model in mice. Mice were administered a single dose of saline or ketamine and then 1 week later were subjected to 2 weeks of SD, LH training, or 3 weeks of CORT. Mice treated with prophylactic ketamine were protected against the deleterious effects of SD in the forced swim test and in the dominant interaction test. The effects were confirmed in the LH and the CORT model. In the LH model, latency to escape was increased following training, and this effect was prevented by ketamine. In the CORT model, a single dose of ketamine blocked stress-induced behavior in the forced swim test, novelty suppressed feeding paradigm, and the sucrose splash test. These authors concluded that ketamine can induce persistent stress resilience and, therefore, may be useful in protecting against stress-induced disorders (3). Furthermore, according to the authors "If this research translates to humans,ketamine could be used as a prophylactic against stress-induced psychiatric disorders, a use of pharmacotherapy not even considered previously” (4).
As one enthusiastic advocate has termed it: Ketamine : the new penicillin of psychiatry (5) and whilst not directly related to PTSD, another has stated that “The rapid therapeutic response of ketamine in treatment-resistant patients is the biggest breakthrough in depression research in a half century”(6)
1. McGhee et al,The Correlation Between Ketamine and Posttraumatic Stress
Disorder in Burned Service Members The Journal of TRAUMA Injury, Infection, and Critical Care 2008;64:S195–S199
2. Feder et al, Efficacy of Intravenous Ketamine for Treatment of Chronic Posttraumatic Stress DisorderA Randomized Clinical Trial JAMA Psychiatry. 2014;71(6):681-688. doi:10.1001/jamapsychiatry.2014.62
3. Brachman RA et al, Ketamine as a Prophylactic Against Stress-Induced Depressive-Like Behavior Biol Psychiatry. 2015 May 4. pii: S0006-3223(15)00360-1. doi: 10.1016/j.biopsych.2015.04.022
4. http://newsroom.cumc.columbia.edu/blog/2015/07/02/could-a-dose-of-ketami... last accessed 26 11 15
5. http://prehospitalmed.com/2015/09/19/ketamine-the-new-penicillin-of-psyc... last accessed 26 11 15
6. http://news.yale.edu/2012/10/04/yale-scientists-explain-how-ketamine-van... last accessed 26 11 15
Competing interests: Over the years I have attended meetings and had lunches/dinners sponsored by a range of pharmaceutical firms and equipment manufacturers. My work on Ketamine is frequently referenced in the book "Ketamine for Depression" written by Dr Stephen J Hyde which is where I first came across accounts of the use of Ketamine in PTSD.