Ecstasy for war trauma: a flashback to earlier treatments

Mother Board has a completely fascinating article on the current ongoing trial testing whether MDMA or ‘ecstasy’ could be useful in treatment combat trauma.

The piece is interesting as much for what it doesn’t say, as for what it does, and for how it ties into the history of psychological treatments for posttraumatic stress disorder or PTSD.

The trial is testing whether MDMA can assist in psychological treatment for the condition, in which a traumatic event leads to a sense of current threat and intrusive sensory impressions that are maintained by a pattern of avoiding reminders.

The most effective tried-and-tested treatments for the condition are types of therapy that are ‘trauma-focused’ that involve, among other things, a mental revisiting of the traumatic memories to ‘take the sting out of their tail’.

But this is exactly what most people who arrive in psychologists’ offices don’t want to do. This makes sense from the perspective of someone who is troubled by these memories and wants to stop thinking about them, but the avoidance actually helps maintain the problem.

This is, in part, because the person never learns to adjust to the anxiety (they don’t habituate in technical terms) and the memories remain as fragmented impressions that don’t fit into a coherent narrative, making them more likely to intrude into the conscious mind.

In other words, most people with PTSD initially arrive for treatment wanting a better form of avoidance because their current methods simply aren’t working. The mental health professional has the unenviable task of explaining that treatment involves exactly the opposite and reliving the event and experiencing the anxiety will be key.

It is so key, in fact, that anti-anxiety drugs like benzodiazapines (e.g. vallium) may reduce the effectiveness of treatment because they dull the experience of stress that the person needs to adjust to.

The MDMA trial is interesting in this regard, because ecstasy is, for many, a remarkably effective anti-anxiety drug.

So how does the drug facilitate the psychotherapy? Here’s the description from the article:

MDMA’s effects typically manifest themselves 30-45 minutes after ingestion, so it doesn’t take long for rhythms to develop in Charleston. Sessions at the clinic oscillate between stretches of silent, inward focus, where the patient is left alone to process his trauma, and unfiltered dialogue with the co-therapists. “It’s a very non-directed approach,” Michael Mithoefer told me. This allows subjects to help steer the flow of their trip. They are as much the pilots of this therapy as their overseers. “Once they get the hang of it,” Mithoefer explained, “sometimes people will talk to us for a while and then say, ‘OK, time to go back inside. I’ll come report when I’m ready.’”

That said, patients understand that if no traumas emerge, the Mithoefer’s must coax them out. But they’ve never had to. The traumas always emerge, and by now there have been over 60 sessions between an initial, smaller Phase 2 study and the present trials. Horrors are bubbling up naturally, patient after patient.

This harks back to a more psychoanalytic or Freudian-inspired idea of trauma and treatment. The goal of the therapy is to understand the inner self while the drug is intended to help us overcome psychological defences that prevent us from seeing things as they really are. In fact, this is a central assumption of the therapy.

This approach is not new. ‘Narcoanalysis’ was used widely in mid-20th Century where a range of drugs, from ether to sodium pentathal, were applied to patients with ‘war neurosis’ for exactly this purpose. Unfortunately, it was unsuccessful and abandoned.

So this is why the MDMA treatment is a gamble. All known effective psychological treatments for PTSD involve not only confronting the memories of what happened to make sense of them, but also re-experiencing the associated anxiety. A treatment with a drug that removes anxiety will, by current predictions, have limited effectiveness.

But this is also why the approach is interesting, because if it is shown to be genuinely effective, we might have to rethink our ideas about PTSD and its treatment.

Link to Mother Board article on the MDMA PTSD trial.

View the original article here

A dark chapter in the history of combat trauma

Neurology has an article that looks back at the dark history of ‘treating’ war trauma with torture during World War I.

During the conflict, ‘war neurosis‘ became a serious problem as thousands of troops where disabled by psychological trauma that often expressed itself as extreme anxiety and seemingly neurological symptoms – something called ‘shell shock’ early on in the conflict

Contrary to appearances, symptoms such as paralysis, blindness and tremors were not due to physical damage to the nervous system but to psychological stress.

These were classic presentations of ‘hysteria’, now diagnosed as conversion disorder, although many in the forces just assumed the affected soldiers were faking and felt they were motivated by cowardice.

Most famously, psychiatrist W.H.R. Rivers pioneered a psychotherapeutic treatment for ‘shell shock’ for British troops, although as there was no standard treatment so different countries and even different hospitals used different methods.

One of the most desperate ‘treatments’ was popularised by neurologists Clovis Vincent and Gustave Roussy, who widely applied it to traumatised French troops during the Great War.

The method involved ordering the traumatised soldier to go back to the front and electrocuting them until they agreed.

Although officially called faradization “torpillage was the term chosen by soldiers receiving the treatment because they likened the electric part of the therapy to being hit by a shell (une torpille).”

At first, faradization was carried out using virtually pain-free currents so that the soldiers would relate the painless nature of the treatment to their comrades. However, Roussy recommended the use of more intense faradization in difficult cases. To begin with, electrodes were placed on the targeted areas and then, if necessary, on more sensitive areas such as the soles of the feet or the scrotum. It was sometimes necessary to incorporate certain complementary measures like disciplinary isolation or a milk diet. Soldiers in the recovery phase performed military exercises under the supervision of officers who had been cured using the same method.

Growing awareness of the cruelty of the ‘treatment’ and an outraged story in a French national newspaper stopped the torpillage technique by the end of the war but it remains a dark chapter in the history of combat trauma management.

Link to Neurology article ‘The “torpillage” neurologists of World War I’

View the original article here

Five minutes past trauma

A new series of ABC Radio National’s All in the Mind has just kicked off with a thoughtful programme about treating traumatised people just after a tragic event.

If you’re not familiar with the contentious area of disaster response, you may be surprised to hear that there is no firm evidence that psychological treatment of just-traumatised people is any more helpful in the long-term than doing absolutely nothing.

This is in contrast to the widely held belief that all disaster victims ‘need’ to see mental health professionals. In fact, studies on psychological treatment in disaster victims have suggested the worrying result that some treatments may actually make matters worse in the long-term for some people.

This was famously found in studies on single session ‘debriefing’ but also less well known is that there is a similar conclusion with regard to multi-session psychological treatment that is aimed to prevent trauma in disaster victims.

To complicate matters, in the studies where the effects are shown to be harmful in the long-term, patients reported feeling better immediately after the sessions.

If you are a psychologist responding to a disaster, grateful and apparently relieved patients are extremely strong personal evidence that you are being helpful, even if in the long-term you might be causing problems.

This makes it very hard for some to accept that they need to question what they are doing.

But there is one over-arching and important point that trauma psychologist Richard Bryant makes in the programme – that, despite some good hints, the evidence is still not firm enough to say for sure whether we are helping, harming or being irrelevant when working with just-traumatised victims.

It must be stressed that this is in contrast to treating people who are still traumatised a long while after an incident and haven’t recovered on their own, where we know psychological treatment is helpful and important.

This issue of All in the Mind is a fantastic discussion of the potential benefits and drawbacks of ‘trauma debriefing’ and immediate psychological treatment and don’t miss some great additional material on the blog.

Link to AITM on ‘The mind in crisis’.
Link to additional material and audio on the AITM Blog.

View the original article here

Post-coma nail trauma

Being in coma could play havoc with your nail care routine.

A 1997 report from the Journal of Neurology, Neurosurgery and Psychiatry notes how discoloured fingernails may be a secondary effect of coma owing to the side-effects of a common medical assessment for consciousness.

The test is nothing more high-tech than giving the finger a hard prod with a pencil to see if there is any reaction to pain, which is a common test on unconscious patients.

In fact, it forms part of the universally used Glasgow Coma Scale. You’ll often hear doctors saying “the patient was admitted with a GCS of…” followed by a number up to 15 which rates how conscious and alert the patient is, depending on their reaction to various prods, pokes and verbal requests.

The brief article reported an unintended side-effect of repeated Glasgow Coma Scale assessments after a patient woke up from coma to find her nails all black and blue.

A 30 year old woman was admitted to hospital with a rapidly progressive decline in level of consciousness and seizures. Neuroimaging studies disclosed thrombus in the superior sagittal sinus, bilateral cerebral venous infarctions, and oedema. She was treated with intravenous heparin and propofol for control of agitation and increased intracranial pressure. She made an excellent recovery.

Three weeks after admission she alerted us to a painless brownish discolouration of many of her fingernails. Bilateral subungual haematomas in different stages of resolution were noted. These lesions had been created by frequent nail bed compression with a pencil to monitor motor response, a common practice of applying noxious pain stimuli in comatose patients admitted to neurological intensive care units.

Obviously, if you’re a Goth, Glasgow Coma Scale evaluations are likely to have much less of an impact on your post-coma nail care routine.

Link to brief JNNP piece on ‘Coma Nails’.

View the original article here