Cognitive Science and Trauma - Essay Example

Cognitive Science and Trauma I. Introduction Cognitive science has been recognized as an interdisciplinary study of the mind or intelligence. It includes many other areas of study such as psychology, neuroscience, computer science, and many other specialties. The broad reach of cognitive science includes the study of post traumatic stress disorder (PTSD). The interdisciplinary study of PTSD has resulted in many new, and interesting, findings. A collaborative effort has allowed practitioners treat those with PTSD in a manner that takes into consideration the many factors that a non-collaborative effort may not focus on. A collaborative study of PTSD may include recognizing risk factors that could predispose the development of PTSD in a specific segment of society. If risk factors are identified there is a good chance that by eliminating the risk factors (intervention) the prevalence of PTSD in that segment of society may be reduced. PTSD affects several segments of society. Traditionally PTSD has been associated with soldiers returning from battle. These soldiers have been identified in the past as having ‘shell shock’ or ‘battle fatigue’. They are now identified as having PTSD. It is well recognized that PTSD is not limited to soldiers returning from battle. The PTSD diagnosis is shared by school shooting victims, survivors of hurricanes (most recently Katrina and Rita), car accident victims, victims of rape, and those exposed to abuse and neglect as children or as adults. Those exposed to violent crimes (murders or torture) are at risk as well. Emergency services personnel, such as paramedics and police officers, have been identified as ‘at risk’ for developing PTSD. The interdisciplinary approach to identifying and treating PTSD begins with understanding how PTSD affects perception and the neural events that take place. Treating PTSD effectively may include a combination of medication and cognitive therapy. Studies have shown that PTSD can be prevented but prevention requires prior knowledge that a traumatic event will occur. Those most at risk for developing PTSD can be identified (soldiers, for example). Being able to pre-identify those most at risk for developing PTSD leaves us with moral and ethical dilemmas. Is it ethical to send to combat those most at risk for developing PTSD? Is there a drug that could prevent damage to the brain? These, and other questions, will be addressed in this paper. There are differing schools of thought on what type of treatment works best for those diagnosed with PTSD. Cognitive Behavioral Therapy (CBT) is the number one treatment for PTSD at this time. Most with PTSD are treated with medications and CBT to address their symptoms. II. Risk Factors For Developing PTSD Many would argue that there are risk factors associated with developing PTSD. Some are well known and some are controversial. Well known risk factors include prior exposure to trauma, and a preexisting mental health diagnosis. Other factors include amount of support provided to the individual after a traumatic event. A controversial risk factor for developing PTSD is lower intelligence. Researchers used Vietnam veterans as study subjects to look for any factors that would separate those who suffered from PTSD from those who do not. They found that those with lower intelligence before combat exposure were more likely to develop PTSD than those with higher intelligence before combat. Although their finding is intriguing it is not absolute. This study was published in the April 1988 APA Journal of Consulting and Clinical Psychology and concluded that subjects with higher intelligence were less likely to develop PTSD symptoms because they had better cognitive resources to develop coping skills (McNally, 1998). The author of the study insists that intelligence not be blamed for the development of PTSD but it may be a risk factor. Unless caused by some other factor, pre-combat intelligence and post-combat intelligence are about the same. McNally points out that lower intelligence does not cause PTSD. PTSD is caused by traumatic events. Lower intelligence just makes someone more at risk for developing PTSD. Another factor that may predispose an individual to develop PTSD is the function of the amygdala located in the brain. The amygdala is part of the limbic system. It is associated with expression of emotions such as fear. It is believed associated with autonomic responses such as increased heart rate, startle response, and increased blood pressure. These are behaviors associated with PTSD that are also associated with changes in brain function. The body’s response to trauma is to release stress hormones. When an individual is exposed to repeated trauma the body goes into a state of hyperarousal. This is when the symptoms of PTSD appear. These symptoms include numbing, sleep disturbances, flashbacks, outbursts, etc... Each individual with PTSD shows his/her own symptomology but, generally speaking, PTSD shows itself in the form of an anxiety disorder. Specific mental health disorders are believed to put someone at higher risk of developing PTSD. These include low self esteem, borderline personality disorder, and dependent personality disorder. These are not causes of PTSD but are believed to make a person more prone to developing PTSD if exposed to trauma. Risk factors mixed with traumatic events are the cause of PTSD. Traumatic events can be witnessed or experienced. Watching someone being killed, wounded, or exposure to bloody body parts in combat can cause PTSD. School shootings, rape, car accidents, and childhood abuse and neglect can all cause PTSD. Natural disasters such as Hurricane Katrina and the Tsunami that hit Southeast Asia can cause PTSD. Interestingly, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) has added a second criterion to the PTSD diagnosis. The new criterion requires that the trauma be viewed with "intense fear, helplessness, or horror" (criterion A2) (Korn, 2001). III. Treatments That Help Resolve PTSD There are many potential treatments for a patient newly diagnosed with PTSD. They include cognitive behavioral therapy (CBT), exposure therapy, stress inoculation therapy, eye movement desensitization reprocessing (EMDR), dialectical behavioral therapy (DBT), and hypnosis. Treatment with medication is sometimes indicated for depression and anxiety disorders associated with PTSD. Most cases of PTSD are treated with a combination of medication and Cognitive Behavior Therapy (CBT). Neither treatment seems to help alone but the combination has worked well. CBT focuses on dysfunctional thinking and behavior and is normally done on a one to one basis. CBT is also effective in group therapy. Group therapy offers the patient the opportunity to meet, and get to know, others diagnosed with PTSD. EMDR is a fairly new treatment that requires therapists to undergo special training before using it with patients. It involves eye tracking while visualizing a traumatic event. “The developer of EMDR, psychologist Dr. Francine Shapiro, proposes the idea that EMDR facilitates the accessing and processing of traumatic memories to bring these to an adaptive resolution” (Shapiro, 2001). The goal of EMDR is to improve overall functioning of the individual. Dialectical Behavioral Therapy (DBT) “is a comprehensive cognitive-behavioral treatment for complex, difficult-to-treat mental disorders, specifically designed to treat chronically suicidal individuals, and multi-disordered individuals with borderline personality disorder (BPD)”(OQP VA/DOD Clinical Guidelines, 2007). Research shows that women respond differently than men to therapy. The prevalence of PTSD is higher with women than men (9.7% compared to 3.6% of men). Women respond well to prolonged CBT. Women who were given ‘present centered’ therapy were less likely than their counterparts in ‘prolonged exposure’ therapy to achieve remission (JAMA, 2007). The goal of any program for women is remission. According to the Department of Veterans Affairs Hospital, White River Junction (VT) “practice guidelines for PTSD recommend prolonged exposure and other CBT but the treatments are not widely used” (JAMA, 2007). The most recent trend in cognitive research related to PTSD seems like a throwback to the past. Researchers believe that they can teach a subject to forget the memories of the trauma to achieve remission. This is controversial because years ago patients were encouraged ‘to forget about it’ and get on with their lives. Veterans have been trying to ‘forget’ ever since their return from war. The high alcohol and drug use among veterans is a testament to that. The number of Vietnam veterans that still require PTSD treatment and medication are a proof that it is not easy to forget. Although the study conducted at University of Colorado at Boulder showed that cognitive control can be achieved by study participants the study did not include those with PTSD or others exposed to trauma. Dr. Thomas Neylan of the San Francisco Veterans Affairs Medical Center is quick to respond to the University of Colorado study: “training in memory suppression is not the goal of treatment of many disorders. Effective treatment (in PTSD) is to promote a new form of learning” (Mishra, 2007). The idea of therapeutic forgetting isn’t going away though. Some argue that a drug, such as propranolol (blocks the action of stress hormones that etch memories in the brain) should be administered immediately after a traumatic event to avoid PTSD (Stein, 2004). It is the ‘forgetting’ idea that is disturbing. Medication has its role in the treatment of PTSD but ‘forgetting’ is very controversial. John Gabrielli, a neuroscientist at Massachusetts Institute of Technology (MIT) adds that “the memory has to come back a bit before you can suppress it”(Singer, 2007). This is more in line with CBT or DBT. Drugs do play a big part in the recovery and remission of PTSD. Sometimes a drugs efficacy is discovered when it is used as a primary treatment. Such is the case with prazosin. This drug is primarily used to treat high blood pressure and prostate enlargement. A side effect of this medication is that it blocks the steroid hormones called glucocorticoids. The Department of Veterans Affairs in Portland Oregon found that elevated levels of these steroids cause nerve branch atrophy and death in the hippocampus. From a cognitive point of view this is an important finding. Corticosteroids are not good for the cognitive functioning of the brain. A worrisome thought is that just one high exposure to corticosteroids can cause brain damage. A placebo controlled study was conducted at the VA Puget Sound Health Care System. This study showed that the drug prazosin decreased the symptoms of PTSD in combat veterans (Raskind, 2003). This study was published in the February 2003 American Journal of Psychiatry. The most notable effects of prazosin are the decrease in nightmares, sleep disturbances, and overall lowering of PTSD symptoms. Prazosin is now a frequently prescribed drug, in the VA Health Care System, for psychiatric disorders. The National Institute of Mental Health (NIMH) published a study involving blocking of enzymes in the brain that had a positive effect on the memory of adverse events. The study conducted using rats showed that the enzyme called PKMzeta could be linked to long term memory of traumatic events. Withholding, or blocking, this enzyme had the affect of erasing memory of an adverse event in rats (NIMH, 2007). The idea behind the study is that it may be possible to selectively erase traumatic memories associated with PTSD by blocking PKMzeta in humans. This study by Todd Sactor, MD, and his colleagues, of New York Downstate Medical Center was reported their study in the August 2007 issue of Science. “Last year, Sacktor and colleagues showed that PKMzeta is required for a process underlying initial formation of long-term spatial memory. Blocking this enzyme in the hippocampus, a memory hub, erased rats’ conditioned fear of spaces associated with getting shocked. But little was known about the enzyme’s role in the cortex, where most memories are thought to be stored long-term.” (Shema, Sacktor and Dudai, 2007) IV. Ethical Dilemmas For those diagnosed with PTSD it is most probably comforting to know that research continues in the causes, effects, and treatment of this disorder. But, with study comes ethical dilemmas. For example, if it is known that low intelligence is a leading factor in the development of PTSD in combat veterans is it ethical to recruit, train, and send into battle those with low intelligence? If eliminating those with low intelligence what would be the cut off intelligence score? Should the armed forces be limited to recruiting those with average, or above average intelligence? With the troubles that the armed forces are having recruiting those eligible to serve a further limiting factor could cause big problems. The armed forces currently provide waivers for age, criminal record, and lack of a high school diploma. Will the armed forces add low intelligence to the waiverable requirements? Will the armed forces require low intelligence soldiers to sign a release to go into battle (I acknowledge that I am at high risk for PTSD but choose to go into combat anyway)? And, is it ethical to ask a soldier that question if his IQ shows he may not understand the consequences of signing the release. Other factors that lead to ethical dilemmas are medications. If it is know that prazosin and the enzyme PKMzeta can help prevent PTSD should they be available to those at high risk for developing PTSD? How about providing propranolol to those at high risk of brain damage caused by traumatic events? Should prazosin and PKMzeta be provided to children in high risk environments, to soldiers before battle, or to those in the path of a hurricane? If prevention is good medicine than why are we not using these medications in the prevention of PTSD now? How much research is enough to prove the eficacy of a drug? Those who have known high risk factors for developing PTSD (such as borderline personality disorder, low self esteem, and dependent personality disorder) should be screened for PTSD and treated appropriately if found to have PTSD. V. Conclusion and Recommendations Cognitive science offers an interdisciplinary study opportunity to those who want to take a closer look at the causes, effects, and treatment options for PTSD. The study of PTSD includes identifying risk factors, treatment options, and prevention steps. It is well known that PTSD is not limited to those returning from battle but includes those subjected to child abuse and neglect, car accidents, national disasters, and victims of violent crimes. Some segments of society are more prone to developing PTSD. Those most susceptible include soldiers, those with lower intelligence, low income or below the poverty line, and those with a preexisting mental health diagnosis. Finally, those who care for the general population are also at high risk of developing PTSD. This includes emergency service personnel and police officers. Determining whether or no a person has PTSD is not dependent on the person having a risk factor. Certainly, knowing that a person has been identified as being in a high risk category can help a provider to determine whether or not a person has PTSD. PTSD is trauma dependent. The only way to develop PTSD is to be exposed to a traumatic event or multiple events. This does not mean that everyone who is exposed to trauma develops PTSD. High intelligence and the ability to develop coping skills lower the chances that an individual will develop PTSD. Low intelligence predisposes someone to develop PTSD. It is believed that those with low intelligence develop PTSD because they do not have the ability to develop coping skills like their high intelligence counterparts. It must be noted that PTSD is not limited to those with low intelligence. It only makes one more vulnerable to developing PTSD. PTSD is diagnosed in average to high level of intelligence individuals. Studies have shown that medication plays a role in treating PTSD. Patients with PTSD are treated with a range of medications most often prescribed for anxiety disorders. Medications are prescribed to alleviate the symptoms of PTSD. The usage of the drug prazosin is very promising as the drug has been proven to reduce nightmares, sleep disturbances, and overall PTSD symptoms. Prazosin acts to block steroid hormones such as glucocorticoids that can cause nerve branch atrophy and death in the hippocampus. Other drugs are promising in the treatment of PTSD. Although controversial, the drug propranolol helps the brain ‘forget’ traumatic events. This drug seems to block the action of stress hormones that etch memories in the brain. This drug is still being studied. Another promising treatment for PTSD is blocking the PKMzeta enzyme. Studies have shown that blocking this drug from the hippocampus has the affect of erasing memory of an adverse event. PKMzeta is still being studied using rats. As with any condition studied over time controversy surrounding the diagnosis and treatment of PTSD exists. The big ethical question is to what extent can PTSD be prevented and should medications be provided to those at high risk for developing PTSD before they experience trauma (such as soldiers going into combat). Most traumatic events are not predictable (car accidents, violent crimes) but those that are predictable should be eliminated or the person that will be exposed to the trauma could possibly be pretreated with drugs such as prozosin, propranolol, or drug that would block the PKMzeta enzyme. Because of the prevalence of PTSD, studies should continue and should include examining medications, therapies (such as DBT and CBT), and preventions. The best study group available would be soldiers. A study of this group should include measuring IQ quotients prior to deployment to a war zone and upon return from the war zone. The focus of the study should be on infantry soldiers and marines (those most likely to be exposed to traumatic events). This group should be prescreened for high risk factors such as a mental health diagnosis or a prior exposure to traumatic events. Future studies should include the use of medications that prevent brain damage by high levels of steroids (prazosin), medications that help the memory ‘forget’ (propranolol), and medications that block the PKMzetz enzyme prior to entering the war zone. Works Cited: Bruce Bridgeman, "Perception", in AccessScience@McGraw-Hill, http://www.accessscience.com DOI 10.1036/1097-8542.YB990690 Doyere V, Debiec J, Monfils MH, Schafe GE, LeDoux JE. Synapse-specific reconsolidation of distinct fear memories in the lateral amygdala. Nat Neurosci. 2007 Apr;10(4):414-6. 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(1998)American Psychological Association. "Lower Intelligence May Be Risk Factor For Posttraumatic Stress Disorder (PTSD)." ScienceDaily 27 March 1998. 24 November 2007 http://www.sciencedaily.com/releases/1998/03/980327073956.htm OQP VA/DOD Clinical Guidelines, 2007. Retrieved November 24, 2007 from http://www.oqp.med.va.gov/cpg/cpg.htm Pastalkova E, Serrano P, Pinkhasova D, Wallace E, Fenton AA, Sacktor TC. Storage of spatial information by the maintenance mechanism of LTP. Science. 2006 Aug 25;313(5790):1141-4. PMID: 16931766 Raskind, Murry. (2003). Prazosin Reduces Symptoms of Post Traumatic Stress. VA Puget Sound Health Care System. Feb. 2003 Journal of Psychiatry. Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing, Basic Principles, Protocols and Procedures. (2nd ed.). New York: The Guilford Press. Shema R, Sacktor TC, Dudai Y. Rapid erasure of long-term memory associations in the cortex by an inhibitor of PKMzeta. Science. 2007 Aug 17;317(5840):951-3. PMID: 17702943 Singer, Emily. (2007). “Erasing Memories”. Technology Review Published by MIT. Retrieved November 25, 2007 From http://www.technologyreview.com/printer_friendly_article.aspx?id=19045 Stein, Rob. (2004). “Is Every Memory Worth Keeping? Controversy Over Pills to Reduce Mental Trauma.” Washington Post October 19, 2004. Retrieved November 25, 2007 from http://nootropics.com/memory/erasers.html Read More