New treatments bring hope for combat-stress patients

By: JOE BECK - Staff Writer | Monday, January 1, 2007 9:35 PM PST ∞

NORTH COUNTY -- Mental health professionals who treat combat veterans suffering from stress and trauma say they are entering 2007 with growing optimism about new, sometimes controversial treatments that show promise in controlling or eliminating psychological damage from battlefield experiences.

The hopefulness springs from a combination of therapists' personal observations and a growing body of scientific research. The new treatments use a variety of resources that range from technology borrowed from video games to a pill, still in the experimental stage, that until now had been used only to treat high blood pressure.

Jeffrey Matloff, program director of the post-traumatic stress disorder clinical team at the Veterans Administration Medical Center in San Diego, said the mental health profession has made dramatic strides in treating post-traumatic stress disorder among veterans since the American Psychiatric Association classified it as a diagnosable mental disorder in 1980.

"There are new things out there that I've been impressed with," Matloff said. "In 27 years of the diagnosis, there's a lot more clinical experience and research that we can bring to bear with problems related to PTSD."

The breakthroughs have come at a time when mounting casualties and multiple deployments are imposing greater emotional and mental strain on members of the military in Afghanistan and Iraq. A recent Veterans Administration study showed a tenfold increase in Iraq and Afghanistan war veterans who had sought treatment for symptoms linked to combat stress in the previous 18 months, a trend affecting one-third of veterans.

About 30 percent of those sent to war zones experience post-traumatic stress disorder and an additional 20 percent to 25 percent suffer from partial post-traumatic stress disorder at some point in their lives, according to the National Center for Post-Traumatic Stress Disorder.

The center's Web site says that civilians who have been subjected to rape, childhood neglect or abuse, threats with a weapon and physical attack are also vulnerable to post-traumatic stress disorder.

'Exposure therapy' making waves

Many of the new techniques fall under a category of treatment that mental health professionals call "exposure therapy," which involves having the patient repeatedly relive a frightening experience under controlled conditions to help him or her through the trauma.

One example of exposure therapy -- using computer game graphics and software to simulate three-dimensional combat environments in Iraq -- appeared among the exhibits at a recent seminar at Naval Medical Center San Diego on new strategies for treating physical and mental injuries among combat veterans.

The exhibitor, Virtual Reality Medical Center of San Diego, has been included in a $4 million project funded by the Office of Naval Research. The goal of the project is to demonstrate whether virtual-reality therapy qualifies as a "best practices" treatment for post-traumatic stress disorder, according to the seminar's program.

The purpose of the therapy is to help clients gain control of their anxiety by exposing them to controlled levels of stress through the virtual-reality equipment. The entire treatment lasts 8 to 12 sessions, most of which are 45 to 50 minutes, according to the Virtual Reality Medical Center's Web site.

"I'm waiting to see what happens with their data, but intuitively it makes a lot of sense," Matloff said. "With repeated exposure to a traumatic event, anxiety, fear anger may dissipate."

Eye Movement Desensitization and Reprocessing, which some researchers have cited as another example of exposure therapy, has been gaining steady acceptance over the last 10 years. In 2004, the treatment received the highest level of recommendation from the Department of Defense and Department of Veterans Affairs for the treatment of combat-related mental trauma.

The treatment involves an eight-step process that typically spans four 90-minute sessions. Part of the process requires the therapist to instruct the client to focus on an image, negative thought or body sensation while shifting his eyes back and forth following the therapist's fingers as they move across the client's field of vision for 20 or 30 seconds.

Mixed reviews for alternative therapies

Carole Herbster, a San Marcos psychologist, said she thought eye-movement therapy was "totally weird and didn't pay a bit of attention to it" at first, but persuaded herself to try it when she was having trouble helping a sexual abuse victim with traditional treatments. Now Herbster counts herself as a convert.

"It's incredibly useful for a wide variety of traumas," Herbster said. She said her clients who have been helped by eye-movement therapy include people suffering from their experiences in combat, vehicle accidents and the 9/11 terrorist attacks.

Herbster said eye-movement therapy eliminated symptoms caused by traumatic experiences in all but one of her clients. The Web site of the Eye Movement Desensitization and Reprocessing Institute cites three studies published in scientific journals that show the therapy eliminating post-traumatic stress in 77 percent to 90 percent of civilian clients.

Some mental health professionals continue to doubt the scientific validity of eye-movement therapy, however. The institute's Web site says some critics persist in calling the therapy "pseudoscience." Matloff of the VA center said he stopped using eye-movement therapy after he tried it on three patients. It failed with all three.

"They actually said they preferred going back to other types of treatment," he said.

Another controversy has begun over the use of propranolol, an experimental drug that is years away from gaining official approval.

Propranolol has been used for decades in treating high blood pressure and is now igniting interest as a fast, effective, easy treatment for dissolving the harmful emotional effects from memories that cause post-traumatic stress disorder. The excitement stems from a 2002 study that showed patients admitted to a hospital emergency room, most of them car accident victims, displayed significantly fewer symptoms of post-traumatic stress disorder than another group of patients who did not receive propranolol.

The study, conducted by Dr. Roger Pitman, a professor of psychiatry at the Harvard Medical School, impressed Army officials enough that they have chosen Pitman for a grant that will be used to study the effects of propranolol on military veterans suffering from post-traumatic stress disorder this summer.

In a telephone interview, Pitman said he expects the study to run three years and include 50 veterans from the Boston area.

Researchers study pill

Pitman said he hoped that patients yearning for a pill that can cure post-traumatic stress disorder will not jump to hasty conclusions.

"We haven't really proven anything yet, and it's important that the public should know about the negative as well as the positive information," Pitman said.

"It's just research at this point," he added.

Pitman's Army study will differ from his emergency room study by using patients who have already been diagnosed with post-traumatic stress disorder, a condition that usually cannot be diagnosed until months after a traumatic event. The emergency room patients in his first study received propranolol within a few hours of their traumatic experience, thus limiting the study to learning whether propranolol worked as a preventative medication.

Dr. Murray Stein, a psychiatrist at UC San Diego, conducted a study among emergency room patients that bore similarities to Pitman's first study. Stein said he found "no benefit" to using propranolol to prevent post-traumatic stress disorder among the 45 patients he studied.

"It's not definitive and conclusive, but it's enough that we decided not to pursue it further," Stein said of propranolol.

Others who have studied Pitman's work warn that drugs with the potential to alter human memories raise serious long-term social and moral predicaments. The President's Council in Bioethics issued a report in 2003 declaring that harsh, painful memories are necessary, up to a point, in maintaining a conscience that fully understands the difference between right and wrong.

In one passage, the report warned that the possibility of using propranolol and other drugs to tamper with memories "has already elicited considerable public interest in and concern about their potential uses in non-clinical settings: to prepare a soldier to kill (or kill again) on the battlefield; to dull the sting of one's own shameful acts; to allow a criminal to numb the memory of his or her victims."

Matloff said lingering uncertainties about the effectiveness and the ethics of the new treatments make it unlikely that any single approach will come to be regarded as superior to all others in treating post-traumatic stress disorder.

"There are, basically, some treatments that are going to be effective with some people and some will be more effective with others. What we really need to do is assess people to find out what treatment works best for each person," he said.

-- Contact staff writer Joe Beck at (760) 740-3516 or jbeck@nctimes.com.

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