A Battle of Nerves

By Sol Lee

This post was written as part of a class assignment from students who took a neuroethics course with Dr. Rommelfanger in Paris of Summer 2016.

Sol Lee studies Neuroscience and Behavioral Biology at Emory University. As a pre-med student, he is enthusiastic about primary care and global health concerns. Sol is currently doing research on glutamate receptors in Parkinson’s Disease in the Smith Lab.

Absolutely preposterous. This was the response of British doctors in 1916 as they declared heresy to Frederick Mott’s proposal: that post-traumatic stress disorder (PTSD) coincides with an abnormal physical alteration of the brain. PTSD is caused by traumatic events or extreme stressors such as war, personal assaults, and car accidents. Symptoms include negative changes in feelings or beliefs, constantly feeling jittery or alert, having difficulty sleeping or concentrating, and experiencing flashbacks. Physicians and scientists at that time, and until recently, believed that PTSD simply meant emotional trauma. After one hundred years, however, new research suggests that Mott may have been right.

In a New York Times article [1], Robert Worth expands on current PTSD research and details its close ties with explosive blasts experienced during war. For years, explosive blasts were thought to have similar effects as concussions, and blast-related injuries were treated as such. Neuropathologist Daniel Perl, however, realized that blast-injured brains and brains of PTSD patients display tangible patterns of dust-like scarring, which are quite different from the tau buildup in concussed brains.

For some, this news generates a sigh of relief. It may ease one’s mind to realize that symptoms of PTSD are associated with a neurological wound, as opposed to a purely psychological one. It may also help to ameliorate the stigma against PTSD, as some veterans may not want to admit to an invisible psychological disorder. For others, such as the military, this news means that more time, energy, and money must be invested into exploring biological correlates of PTSD. In the past, military authorities refused to treat PTSD because they believed PTSD to be a retreat from war. In more than a few morbid instances, blast-injured and rattled soldiers who fled from battle were sentenced to death by firing squad. PTSD is now regarded more seriously and psychological treatments have been pursued, but redefining PTSD and the toll of war on the brain and body in a biological context means looking at this age-old disorder with a fresh perspective.

Ethical gray areas emerge with any kind of new research, and this issue is no different. For example, if a person with PTSD commits a crime, how will this research affect the legal outcome against the defendant? Will neuroimaging scans demonstrating neurological abnormalities in patients with PTSD be accepted as evidence in court? Because juries are prone to be biased towards scientific evidence, the legislative system should be careful in implementing biological evidence of PTSD until further research is done. At this point in time, scientists do not know whether neurological scarring in PTSD is only caused by PTSD and to what degree the biological correlates of PTSD accurately reflect the state of the illness in a patient. This evidence may be more likely to convince juries to mitigate sentences even more so than the fact that a person is a veteran, but the issue of implementing this kind of evidence lies not only with people’s interpretation of the science, but also with the accuracy of the currently underdeveloped science behind PTSD. Because the logistical, social, and legal ramifications of PTSD have been shaped around beliefs that PTSD is a mostly psychological disorder, new research that suggests otherwise will challenge existing standards and regulations for treating PTSD.

Soldier from the US Army, image courtesy of Wikipedia

Such data has already impacted the way we think about and treat PTSD. PTSD is being treated more seriously as an illness, and the military has given credence to ongoing research on neurological injuries by requiring soldiers to wear gauges that register possible concussions and brain injuries that could contribute to PTSD and also register other brain injury related sequelae, like memory loss and mood changes. This implementation, however, imposes a series of questions. What about soldiers who want to continue fighting despite potential brain injury? Is it ethical to pull soldiers out of a crucial operation? Against their will? Currently, a team has developed a checklist to identify concussed soldiers, but six versions of the checklist had to be created because so many soldiers were memorizing the correct answers in order to stay on the battlefield [1].

For soldiers who do need it, however, medical help should be available. Studies have shown that health care reforms of the 1990s have greatly improved the quality of treatment and efficiency of the Veterans Health Administration [2], but care must be taken to ensure that new policies and treatments are properly implemented into the existing system. This is important to note as trauma not only affects soldiers, but also victims of sexual abuse and auto accidents. Perl’s research focused on PTSD caused by blasts, but developmental, physical, and experiential trauma can be innately unique and demand distinct treatment methods. Trauma is also known to affect adolescents with developing brains differently than adults with mature brains. Perl’s research does not prove anything conclusive on its own, but highlights the fact that our current understanding of PTSD is still in its infancy.

More research must be done to confirm and add to the knowledge that we have on PTSD. Moving forward, we must not forget that PTSD does have a psychological component, and that there is no denying the success of psychotherapy for PTSD [3]. This is crucial to note because just as some may find solace in the physical aspect of PTSD, others may feel even more helpless and doomed by a seemingly irreversible biological disorder. These victims must not forget, however, that there is a silver lining: neuroplasticity is real, and experiences change the brain. Neural pathways are continuously changing and can and improve with new experiences [4]. Research on biological correlates of PTSD should continue and should complement, not compete with, existing treatment methods.

Change can be difficult, especially when there are boundless implications and ramifications to this issue of PTSD. However, this is exactly why we must continue seeking progress on this issue. Researchers estimate that over 24 million people have PTSD at any given moment. They also estimate that the real number may be much higher, as soldiers may be too proud to report a wound that they don’t consider to be ‘real.’ In order to properly set the tone for the future of PTSD, one of the most crucial steps is to be personally aware and to educate others about the importance of PTSD research and the need to reduce stigma against mental disorders. As the public becomes more aware of the comprehensive effects of PTSD, more research and better treatment methods will be pursued and developed. Better helmets and expanded veteran care are a good start, but they should just be the beginning of a nationwide reexamination of trauma. As we study the brain and discover more and more fuzzy lines between physical and emotional injuries, we must carefully consider the naivety with which we once viewed PTSD and retain a humility about the limits (and future horizons) of our current understanding of mental illness.

References

1. Worth, R. F. (2016). What if PTSD is More Physical than Psychological? The New York Times, June 10. Available at: http://www.nytimes.com/2016/06/12/magazine/what-if-ptsd-is-more-physical-than-psychological.html

2. Oliver, A. (2007). The Veterans Health Administration: An American Success Story? The Milbank Quarterly 2007;85(1):5-35. doi:10.1111/j.1468-0009.2007.00475.x.

3. Tran, K., K. Moulton, N. Santesso, and D. Rabb. 2016. Cognitive Processing Therapy for Post-Traumatic Stress Disorder: A Systematic Review and Meta-Analysis [Internet]. CADTH Health Technology Assessments.

4. Bryck, R. L., & Fisher, P. A. (2012). Training the Brain: Practical Applications of Neural Plasticity From the Intersection of Cognitive Neuroscience, Developmental Psychology, and Prevention Science. The American Psychologist, 67(2), 87–100. http://doi.org/10.1037/a0024657

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Lee, Sol. (2016). A Battle of Nerves. The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2016/08/a-battle-of-nerves.html