Preventing PTSD

According to the U.S. Department of Justice’s Bureau of Justice Statistics, approximately 324,500 Americans were victims of sexual assault or rape in 2021. That equates to a sexual assault or rape every 97 seconds in the U.S. [1]

According to the Department of Defense, as of March 2023, nearly 7,000 U.S. Service personnel and DoD civilians were killed in Iraq, Afghanistan, and the surrounding area in support of military operations following the September 11, 2001 attacks. Another 53,000 were wounded in action. [2]

Rape, sexual assault, and military combat are very powerful drivers of post-traumatic stress disorder (PTSD). Suffering or witnessing violent acts that are intentionally perpetrated on human beings commonly leads to PTSD in its most intractable form. As many as 37 percent of the people who survive such intentionally-inflicted trauma go on to develop the disorder, and of those, 40 percent still have it a year later [3]. Preventing PTSD from taking hold – finding a way to head it off either at the emergency room or among a population of combat survivors – becomes very important.

Back in 2012, a research team from Emory University and the University of Washington collaborated in a review of early interventions to prevent post-traumatic stress disorder (PTSD) [4]. The “early” timeframe generally started in the emergency room after a traumatic experience, but could take place up to a few weeks after the event.

The study reveals some important Don’t Dos – practices that apparently increase the odds that a trauma survivor will develop PTSD:

  • Psychological debriefing. This practice started in World War I when commanders would meet with their men following a major battle to talk about what had happened, recounting the horrors they had just been through. A more modern version is called a “critical incident stress debriefing,” usually conducted 2 to 10 days after the incident and intended to help the trauma survivor cope. The problem is that multiple controlled studies concluded that these psychological debriefings result in higher rates of PTSD.

  • Benzodiazepines (anti-anxiety meds like Xanax or Klonopin). They don’t work to prevent PTSD, and may make things worse.

On the positive side, there were a few interventions that did reduce the odds someone would develop PTSD:

  • Hydrocortisone shot, especially within a few hours of trauma exposure.

  • Psychological interventions that talk about trauma reactions, like sleep problems or angry outbursts (as opposed to talking about the traumatic experience itself). (Though a 2019 review and meta-analysis of 27 studies didn’t find benefit from any of the psychological interventions that were tested.[5])

Other methods were undergoing testing when the 2012 article was published (like ketamine infusion and different types of cognitive behavior therapy), but there was not enough evidence to show if they worked or not. The study did show that intervention earlier – within a few hours of the traumatic experience – was more effective than intervention later.

Guidance for the Battlefield

Given that military combat is so potent in producing lasting PTSD, it’s disappointing that the U.S. Department of Veteran’s Affairs (VA) and Department of Defense (DoD) clinical practice guideline for the management of PTSD has no recommendations for preventing PTSD in trauma-exposed individuals. They did recommend an individual trauma-focused psychotherapy for exposed individuals who were showing symptoms of Acute Stress Disorder, to keep it from turning into PTSD, though. While they acknowledged that hydrocortisone injection had proved to be effective in preventing PTSD in medical settings, they said those results didn’t necessarily apply in non-medical settings (like back on post for the non-injured after an ugly incident) and were concerned about the safety of broadly administering high-dose hydrocortisone shots. [6]

That isn’t the last word on the subject, though. The VA-DOD guideline (2017 version, which includes evidence reviewed through March 2016) is under revision. Plus, the VA and the Icahn School of Medicine at Mount Sinai are currently investigating the use of oral hydrocortisone (a tablet, instead of a shot) to prevent PTSD in people exposed to trauma.  It’s a lot more palatable to think of medics handing out pills to a large company of people who just survived a battlefield attack, rather than putting needles in their arms, and, hopefully, this project will show good results.

Guidance for the Emergency Room

For the survivors who make their way to an emergency room for care, there are a few more options. The International Society for Traumatic Stress Studies (ISTSS) published a review in 2019 that lists the following interventions as having “emerging evidence” that support their use to prevent the development of PTSD symptoms in adults [7]:

  • Group 512 PM. This intervention is based on critical incident stress debriefing. (Caution! Remember the “Don’t Do” from above?) Individuals are asked to provide detailed facts of what happened, their thoughts, reactions and symptoms before being provided with psychoeducation about symptoms and how to deal with them. Group 512 PM is based on that sort of debriefing, but supplemented with cohesion training exercises, like playing games that need team cooperation.

  • Single session Eye Movement Desensitization and Reprocessing (EMDR). Here is a definition of EMDR, from EMDR Institute, Inc., in Watsonville, CA. “EMDR therapy is an eight-phase treatment. After the clinician has determined which memory to target first, he asks the client to hold different aspects of that event or thought in mind and to use his eyes to track the therapist’s hand as it moves back and forth across the client’s field of vision.  As this happens, for reasons believed by a Harvard researcher to be connected with the biological mechanisms involved in Rapid Eye Movement (REM) sleep, internal associations arise and the clients begin to process the memory and disturbing feelings. In successful EMDR therapy, the meaning of painful events is transformed on an emotional level. For instance, a rape victim shifts from feeling horror and self-disgust to holding the firm belief that, ‘I survived it and I am strong.’[8]” So, by mimicking REM sleep, it prompts the brain to process the memory into something more benign. Wow.

  • Brief dyadic therapy. According to the ISTSS document, this is a brief cognitive behavior therapy (CBT)-based session delivered one-on-one with the aim of improving communication and fostering a shared approach to addressing psychological and practical difficulties.

  • Self-guided Internet-based intervention, usually based on CBT.

  • Hydrocortisone shot.

So, there are some promising interventions for preventing the development of PTSD. But they are not universally available to everyone exposed to serious trauma, and for those who do develop the disorder, it can be a long and arduous journey to remission.

References:

[1] Thompson, A., & Tapp, S. N. (2022, September 20). Criminal victimization, 2021. Criminal Victimization. Retrieved March 31, 2023, from https://bjs.ojp.gov/content/pub/pdf/cv21.pdf

[2] U.S. Department of Defense. (2023, March 20). Casualty Status. Casualty. Retrieved March 31, 2023, from https://www.defense.gov/casualty.pdf

[3] Santiago PN, Ursano RJ, Gray CL, Pynoos RS, Spiegel D, et al. (2013) A Systematic Review of PTSD Prevalence and Trajectories in DSM-5 Defined Trauma Exposed Populations: Intentional and Non-Intentional Traumatic Events. PLoS ONE 8(4): e59236.

[4] Kearns, M. C., Ressler, K. J., Zatzick, D., & Rothbaum, B. O. (2012). Early interventions for PTSD: a review. Depression and anxiety, 29(10), 833-842.

[5] Neil P. Roberts, Neil J. Kitchiner, Justin Kenardy, Catrin E. Lewis & Jonathan I. Bisson (2019). Early psychological intervention following recent trauma: A systematic review and meta-analysis. European Journal of Psychotraumatology, 10(1), 1695486, DOI: 10.1080/20008198.2019.1695486.

[6] Management of Post-Traumatic Stress Working Group [Online]. VA/DOD clinical practice guideline for management of post-traumatic stress disorder and acute stress disorder. Washington (DC): Department of Veterans Affairs, Department of Defense; 2017. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf.

[7] International Society of Traumatic Stress Studies (ISTSS) [Online]. (2018, November 26). New ISTSS prevention and treatment guidelines. Retrieved from http://www.istss.org/treating-trauma/new-istss-guidelines.aspx.

[8] Copied from https://www.emdr.com/what-is-emdr/