From Breakthroughs, 2010
A soldier returns home from battle and commits suicide. A prisoner of war broken under torture suffers humiliation and guilt. The survivor of a terrorist attack succumbs to paralyzing depression.
Post-traumatic stress disorder (PTSD) is our era’s name for a problem that, in various guises, is probably as old as human existence. Yuval Neria, Ph.D., who directs the Trauma and PTSD Program of Columbia University and the New York State Psychiatric Institute, and Alina Suris, Ph.D., clinical director of trauma services at the VA Medical Center in Dallas, are among the NARSAD-funded researchers who are pitting 21st-century science against the psychological toll of trauma. Their research is redefining what PTSD is — how it relates to and can incite other disorders — and how to treat it.
His own experience of combat propelled Neria on a quest “to understand the long-term mental health impact of exposure to trauma and its psychosocial and biological determinants.” As a 21-year-old officer in the Israeli army during the 1973 Yom Kippur War, he saw his entire company wiped out and was himself injured in battle. Later, as a psychologist in a country that since its founding has been a living laboratory of loss and trauma, he treated numerous survivors of the Holocaust and of Israel’s recurrent wars and exposure to terrorism. More recently, he woked with New Yorkers traumatized by the terrorist attack of 9/11.
In Dallas, meanwhile, Suris’ clinical interest in the mental health impact of war led to a 2005 NARSAD grant for a pilot study of a hormone-based treatment designed to disrupt and eradicate the terrifying memories, nightmares and flashbacks that characterize PTSD. She is now conducting larger trials with PTSD-affected survivors of combat in Iraq and Afghanistan. She is also finishing the first funded trial examining the efficacy of a psychotherapy called cognitive processing therapy for men and women with PTSD from military sexual trauma.
Neria and 9/11: PTSD and beyond
In a fateful turn of events, Neria was on sabbatical from Tel Aviv University on Sept. 11, 2001, when the World Trade Center was attacked. Seeking his expertise, Columbia University asked him to help set up a trauma center to study the effects on survivors. In 2003 he received a NARSAD grant to examine 9/11 trauma exposure and its relation to PTSD and depression. Collaborating with him was epidemiologist and NARSAD Distinguished Investigator Myrna Weissman, a leader in depression studies.
The initial study for which Neria received a Klerman Award honorable mention revealed that a significant proportion of those in the sample, drawn from hospitalized primary-care patients, continued to have PTSD and co-existing mental disorders many months after 9/11. Not surprisingly, the rate of major depressive disorder was higher in those with PTSD (63.6 percent). It was also higher than the rate in 9/11 survivors in the general community. Neria believes this reflects the particular nature of his sample population, mainly poor, Latino female immigrants with little education, and with continuous exposure to trauma over the life span. Such populations tend to suffer disproportionately from disasters, especially if displaced from their homelands and traditional supports.
The NARSAD study led to expanded funding from the National Institute of Mental Health, allowing Neria “to examine the relationships between different degrees of trauma exposure, social support, acculturation, medical co-morbidity and a wide range of psychiatric problems.” His cumulative results have demonstrated that the effects of trauma are not limited to PTSD, but can evoke depression, generalized anxiety disorder, bipolar disorder and even schizophrenia. They also led to the identification of a phenomenon Neria calls complicated grief arising from the combined effect of trauma and loss.
Over the years, Neria has been drawn by the question of what factors affect an individual’s ability to be resilient, and to cope effectively with overwhelming stress. “I spent a lot of time interviewing Israeli prisoners of war who had broken down in captivity, trying to understand what brings someone to that point. It was fascinating to learn that for almost all of them what was worst was not so much the physical pain but rather the mental torture, the humiliation, shame and guilt, feeling that they had failed everyone.”
Neria’s current focus is looking for brain-based biological markers for PTSD, both for diagnosis and treatment response. He is particularly intrigued by the potential of functional MRI, which allows scientists to look at the response of the live brain to different experiences. Because PTSD symptoms are shown to be mediated by the brain’s fear circuitry, he says, understanding their function “is potentially key to clarifying the question of why some people are able to extinguish traumatic memories and to recover from PTSD, while others are not.”
Alina Suris: cortisol and memory
"You’re traveling across Baghdad in a convoy of eight Humvees. The convoy slows and stops. You are told that a teenager ran in front of the convoy and exploded a bomb attached to his chest. Your heart pounds, your breathing quickens, and you feel a knot form in your stomach. You hear a series of explosions. Civilians are running. You grit your teeth as you shoot at an assailant sitting in front of a house. You feel hot all over, realizing your Humvee was the only one not hit. You are one of only nine survivors."
This memory was recorded by a soldier asked to describe his worst experience in combat. Hearing it read back to him is enough to raise a physiological response. Personal trauma scripts like this are used in a program of exposure therapy designed to promote what PTSD researchers call memory extinction, which, as Suris explains, involves learning new emotional associations to override the traumatic memories.
The stress hormone cortisol is significantly altered in PTSD patients, and may underlie their difficulties in extinguishing traumatic memories. Following studies that showed glucocorticoids (of which cortisol is the human form) reduced “freezing” behavior in fear-conditioned rats, Suris received NARSAD funding for a trial with a small group of combat veterans with PTSD. The target was a cluster of symptoms called avoidance behaviors, which are thought to be the most characteristic and predictive of PTSD.
The trial, which combined one cortisol administration with a 30-second exposure to the trauma script, appeared to achieve memory extinction, but the effect was transient. In her current study, supported by the VA, Suris will be testing 88 men with four successive treatments, once a week over four weeks. “Our thought,” she says, “is that if we can do it more than once the effect may be more stable.”
Initially, Suris had intended to limit the trial to male subjects because women’s cortisol levels vary with their menstrual cycle. But, she says, “we’re seeing so many women coming back from Iraq and Afghanistan with PTSD that we’ve decided to do a pilot study with just 10 women to see how their cortisol levels impact treatment.” Women vets, Suris says, have symptoms that may be combat-related or may be the result of sexual trauma. “Research indicates that for women who’ve had exposure to both, rape is more predictive of PTSD than combat.”
Suris often finds a co-morbid diagnosis of PTSD and depression in women vets. The difference with similar findings in male vets — and between women sexually assaulted in the military vs. those attacked in civilian life — is that military women often must continue working alongside their assailant. Among the female vets she has been observing, Suris says around 80 percent have both PTSD and depression, and both are predictive of suicide ideation. “But preliminary data analyses in this sample indicate that it’s not the PTSD that’s driving suicidal ideation and acting out, it’s the depression.”
In the intervention study that Suris is just completing, the primary goal is to test the effectiveness of cognitive processing therapy. CPT is a form of cognitive behavior therapy (see p. 3) often effective in civilians. “But the experience of sexual trauma while on active duty is inherently different from civilian rape and assault,” Suris explains. “The results of this study will provide a better understanding of how and if civilian treatments for PTSD need to be adapted for veterans.”