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The Influence of mTBI on
Autonomic Dysregulation in
Combat Veterans with PTSD
James L Spira, PhD, MPH, ABPP
Brenda Wiederhold, PhD, MBA
Kristy Center, MA
Jenifer Murphy, MA
Robert McLay, MD; PhD
Dennis Wood, PhD
Mark Wiederhold, MD, PhD
Prevalence
(Terri Tanielian, RAND Report, April, 2008):
• Since October 2001, approximately 1.64 million U.S. troops have
deployed to support operations in Afghanistan and Iraq.
• Approximately 18.5 percent of U.S. service members who have
returned from Afghanistan and Iraq currently have post-traumatic
stress disorder or depression (303,000); and 19.5 percent report
experiencing a traumatic brain injury during deployment (320,000).
• Roughly half of those who need treatment for these conditions seek
it, but only slightly more than half who receive treatment get
minimally adequate care. (25%)
• Improving access to high-quality care (i.e., treatment supported by
scientific evidence) can be cost-effective and improve recovery
rates.
Prevalence
Tanielian, 2008
Prevalence
• The mental health of soldiers deteriorates with
more combat and repeated tours:
– 12% screen positive for mental health problems on
first deployment, 19% on second deployment, and
27% on third or fourth deployment
– Of veterans returning from Afghanistan, 5% of those
with low combat experience, 11% of those with
medium experience, and 27% of those with high
experience screen positive for acute stress disorder.
(Time Magazine, June 16, 2008)
Prevalence in Combat Veterans
• The violent guerrilla tactics used by
insurgents in Iraq will take a considerable
toll on the mental health of troops,
resulting in a lifetime of disability payments
for many of those who return from war,
U.S. Secretary of Veterans Affairs Anthony
Principi (September 23, 2004).
Prevalence and Time Course
• Kessler et al. (1995) found that one-third of the respondents
with an index episode of PTSD failed to recover even after
many years.
• Breslau et al. (1998) found the median time to the remission
of PTSD was 25 months.
• PRIGERSON et al. (2001) found that although the risk of
PTSD symptoms lasting longer than 2 years was
significantly greater among men with combat trauma
compared with men reporting other traumas as their most
disturbing life event.
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB (1995) Posttraumatic Stress
Disorder in the National Comorbidity Survey. Arch Gen Psychiatry 52:1048-1060.
Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P (1998)
Trauma and Posttraumatic Stress Disorder in the Community: The 1996 Detroit Area
Survey of Trauma. Arch Gen Psychiatry 55:626-632
PRIGERSON, HG; MACIEJEWSKI, PK; ROSENHECK, RA (2001). Combat Trauma: Trauma with
Highest Risk of Delayed Onset and Unresolved Posttraumatic Stress Disorder Symptoms,
Unemployment, and Abuse Among Men. J Nervous and Mental Disease 189(2); 99-108
Types of PTSD
– Acute Stress Disorder
• Mix of hyperarousal and dissociative Sx 0-1mo
– Acute PTSD
• 1-3 mo
– Chronic PTSD
• 3 mo +
– Delayed PTSD
• Of a recent event, delayed onset
• Of an earlier event, brought on by a recent event
– Simple Acute vs Complex Chronic vs Complex Acute
• Single event, mild predictors
• Historical traumatic events, chronic sequelae
• Complex Acute (co-morbid acute Dx: blast victims w/mTBI)
Consensus Panel on PTSD
• Ballenger JC. Davidson JR. Lecrubier Y. Nutt DJ. Foa EB. Kessler
RC. McFarlane AC. Shalev AY.
• Title: Consensus statement on posttraumatic stress disorder from
the International Consensus Group on Depression and Anxiety.
[Review] [15 refs]
• Source: Journal of Clinical Psychiatry. 61 Suppl 5:60-6, 2000.
• EVIDENCE: The consensus statement is based on the 6 review
articles that are published in this supplement and the scientific
literature relevant to the issues reviewed in these articles.
• CONCLUSION: Selective serotonin reuptake inhibitors are generally
the most appropriate choice of first-line medication for PTSD, and
effective therapy should be continued for 12 months or longer. The
most appropriate psychotherapy is exposure therapy, and it
should be continued for 6 months, with follow-up therapy as needed.
Experiential Therapies: Exposure
• In the 1980’s, Terence Keane and colleagues found that
exposure therapy was effective in treating the PTSD symptoms
of Vietnam War veterans.
• In the 90s, research by Edna Foa and her colleagues showed
that exposure therapy was perhaps the most effective Tx for
reducing PTSD symptoms of rape victims, including persistent
fear. Improvements were seen immediately after exposure
therapy, and sustained during a three-month follow-up.
•
•
•
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Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). The treatment of posttraumatic stress
disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of
Consulting and Clinical Psychology, 59, 715-723.
Foa, E. B., Meadows, E. A. (1997). Psychosocial treatments for posttraumatic stress disorder: A critical review.
Annual Review of Psychology, 48, 449-480.
Keane, T. M. & Kaloupek, D. G. (1982). Imaginal flooding in the treatment of a posttraumatic stress disorder.
Journal of Consulting and Clinical Psychology, 50, 138-140.
Keane, T. M., Fairbank, J. A., Caddell, J. M., & Zimering, R. T. (1989). Implosive (flooding) therapy reduced
symptoms of PTSD in Vietnam combat veterans. Behavior Therapy, 20, 245-260
Types of Exposure Therapy
1) Flooding-type
– Based on classical conditioning,
– advocated by Foa, Rothbaum, and others
– patients directly confront fears in order to
activate and maintain high arousal
– Theory states that once arousal subsides,
memories will no longer be associated with
high arousal
– Generalized effects occur through lack of
PTSD causing problems
Types of Exposure Therapy
2) Desensitization-type
– Based upon arousal control
– Advocated by Jacobson and others
– Patients learn to minimize arousal (PMR) while
progressively confronting an increased hierarchy of
fears
– Theory states that fear content will be reassociated
with reduced arousal, eliminating symptoms and
avoidant behavior.
– Generalized effects occur through ability to have
reduced arousal in the face of previous fear producing
stimuli
Types of Exposure Therapy
3) Arousal Control
– Based upon autonomic control and attentional retraining
– CBT-based theory
– Patients learn to control autonomic arousal and focus
more fully in the moment while confronting as much
arousal as they can manage, and exert control over
– Theory states that gaining active control over fears will
reduce irrational and automatic responses and improve
coping strategies
– Generalized effects occur through ability to control
cognitive and physical reactions to whatever arousing
stimuli occur, PTSD related or otherwise.
Arousal Control
– Autonomic Control
• Through biofeedback or other self-regulatory skill development
– Attentional retraining
• Attention is enhanced processing:
– Whatever you attend to, you enhance
» (worry, pain, noise, arousal / breath, warmth, work)
• Your brain/body support what you attend to:
– H-P-A axis
» (ANS activation; PAG relay; Limbic arousal; frontal
interpretation – for SNS or PSNS)
• If you can address a problem, then do so, otherwise focus
on neutral or positive sensations or activity
– Meditation helps reduce background “noise” and enhance
foregrounded signal
» ZEN MEDITATION (signal emphasis)
» VIPASSANA MEDITATION (noise reduction)
Virtual Reality Facilitated Exposure Tx
• We utilized a Virtual Iraq (developed by
VRMC) with a variety of combat-related
scenarios to control exposure variables
• Therapists could control the degree of
exposure with choice of scenario (to fit
patient’s experience) and increasing level
of stimuli within each scenario (sounds,
violence, etc)
• Patients wore headgear and earphones,
and were able to move about their
environments with the use of a joystick
Virtual Reality Facilitated Exposure Tx
• Patients were first taught to control their autonomic
arousal and attend more fully in the moment
• Once achieved (after the first or second session, and
with homework practice), they applied these skills in VR
• Patients were continually physiologically monitored
(HRV, SC, Respiration)
• Arousal was observed, allowed to increase to specified
parameters, and then patients were asked to decrease
their arousal and focus in the moment without reactivity
until arousal decreased sufficiently.
• This was repeated continually until patients no longer
became significantly aroused during sessions or outside
of sessions
Study of PTSD with co-morbid mTBI
• Theory 1: (Hogue et al) – mTBI does not have
substantial psychological disability (or at least, it is
difficult to assess) beyond that found in PTSD.
Therefore, there should be no difference between PTSD
patients with and without mTBI on autonomic
dysregulation, assuming PCL-m is similar.
• Theory 2: The dysregulation seen in TBI (and
characterized by PCS) is significantly different than that
seen in PTSD (cognitive and emotional disinhibition,
sleep, fear reactions, etc). Therefore, PTSD pts with and
without mTBI will show differences in autonomic
dysregulation.
Study Design
• Sample: 37 Navy and Marine combat
veterans of OIF/OEF
• 19 had significant blast exposure, with
increasing levels of effect from feeling
dazed and confused to memory loss
• 37 patients were assessed for skin
conductance at baseline
• 9 patients were assessed for skin
conductance at post-treatment follow-up
Study Design
• Three conditions were assessed at Study
Baseline and Follow-up:
– 5” Rest (sit quietly as we make sure the
equipment is working)
– 5” Stress Recall (what are the most troubling
thoughts and feelings you have associated
with your combat experience?)
– 5” Recuperation (put those thoughts out of
your mind and rest as comfortably as you
can)
Study Results - Baseline
• Repeated measures ANOVA revealed that patients at
baseline became aroused with stress recall, but were
unable to reduce arousal during the recovery phase
(p<.0001), with arousal in fact continuing to increase
during the recovery phase (p<.007).
• A Blast Exposure x Condition at time 1 indicated that the
increase in SC scores during recovery was found for
PTSD patients exposed to blast, but not for non-blast
exposed PTSD patients (p<.05).
• Further, regression analysis revealed that the more
effects of blast (exposure, dazed and confused, memory
loss) the greater the autonomic dysregulation (SC and
HRV), and the less likely to be able to recover, compared
to those with no blast exposure (p<.01).
For all
patients at
baseline:
- There
was less
autonomic
control
over
stress
recall and
recovery
at time
one than
at time two
Study Results – Post-treatment
• This difference between PTSD with and without mTBI was
not found following the Arousal Control Virtual Reality
Assisted Graded Exposure Therapy (VRGET), indicating
that this type of treatment was successful in training
patients with combat PTSD in autonomic control in the
face of a stress recall, and facilitating the ability to reduce
arousal following stress.
•
Further, cumulative blast score was directly correlated
with SC recovery at time 1 (Spearman’s rho=.448; p<.05)
indicating poor pre-treatment recovery of SC, yet this was
not found at time 2 (r=.281, p<.542), indicating that blast
no longer had an influence on SC recovery following
VRGET treatment.
Study Results – Pre-Post Analysis
• Repeated measures Condition (baseline, stress
recall, and recovery) x Time (pre post intervention
for all pt types) ANOVA (N=9) revealed:
– 1) a significant difference for Condition (F=9.06; p<.017;
Partial Eta Squared =.531 with observed power of .751),
– 2) a significant difference for Time (F=5.97; p<.04; Partial
Eta Squared = .427 with observed power of .574)
– 3) a Condition x Time interaction (F=13.12; p<.007; Partial
Eta Squared = .622 with an observed power of .887).
– This shows that there was a statistical and clinical
significant difference in response to stress recall and
recovery over time for subjects with PTSD
Study Results – Pre-Post Analysis
• Subsequent analysis showed that even though patients
had no change in baseline SC over time, patients had
significantly greater control over reactivity during stress
recall and recuperation than they did at Baseline
• Patients at time-2 had 57% greater recovery than they
did at Baseline.
• A simple regression demonstrated that cumulative blast
score predicts baseline SC, stress recall SC, and
recovery SC levels (p<.05 at time 1), but only predicts
SC baseline at time 2, not stress or recovery.
• Hence, while blast patients may continue to have higher
baseline SC values, they have learned how to control
their autonomic reactivity following treatment.
At Baseline:
Blast exposed
patients were
not significantly
different from
non-blast
exposed
patients at
Time 1 or at
Time 2
(i.e. no blast x
time
interaction)
For Stress
Recall:
Blast exposed
patients were
significantly
different from
non-blast
exposed
patients at
Time 1, but
not at Time 2
(i.e. significant
blast x time
interaction)
For Recovery:
Blast exposed
patients were
significantly
different from
non-blast
exposed
patients at Time
1, but not at
Time 2
(i.e. significant
blast x time
interaction)
Results – PCL-M scores
• PCL-M scores decreased significantly from pre
to post treatment (p<.001) for all patients
• There was no correlation between physiological
arousal and any other PCL-M subscale or total
score.
– This may indicate that objective physiological arousal
is not always associated with conscious cognitive
arousal (especially in an active duty combatant
population – ‘How are you feeling?’ -> “I’m fine, sir”).
Conclusions
• These findings support Theory 2
– Even though PCL was similar for PTSD
patients with and without mTBI, they differed
in terms of autonomic reactivity to stress recall
and ability to recuperate, demonstrating the
dysregulation expected in TBI patients beyond
that for PTSD alone.
Conclusions
– PTSD patients with blast exposure had higher
arousal during stress recall, and still higher
arousal during recovery at pre-treatment
assessment, indicating the importance of
considering blast in treatment planning for
patients with PTSD.
– That this distinction disappeared after
treatment further suggests that Arousal
Control VRGET is an appropriate and
effective treatment for patients with PTSD with
or without mTBI.