Is science neglecting PTSD patients?
Writers: Viktorija Vaitkeviciute and Eugenia Wong
Editor: Kuldeep Nandra
Artist: Grace Gu
Post-traumatic stress disorder (PTSD) is a disabling condition, resulting in grave consequences if not treated properly. It is the fourth most prevalent psychiatric disorder in the US and around 8% of the global population will receive a diagnosis in their lifetime. The current treatments for PTSD are limited and there is an imperative need for further research. Well-known psychiatric disorders, such as anxiety and depression, seem to attract more attention compared to PTSD. Additionally, as a fallout of the current pandemic, we may see an increase in PTSD cases. It is therefore essential to ask whether enough is being done to tackle this pressing issue and provide support for its victims.
PTSD: what is it?
PTSD is a debilitating psychiatric condition, induced by physical, sexual, or psychological trauma. To be diagnosed with PTSD, an individual should have the following symptoms: avoidance of thoughts and reminders about the trauma, intrusive trauma memories, negative mood and cognition, as well as general hyperarousal (irritability, insomnia, poor concentration).
The main pathophysiological features of PTSD are fear dysregulation and the impairment of brain-mediated fear responses. The easiest way to explain this is through Pavlovian fear conditioning, which is used to study PTSD. The subject is initially given a neutral conditioned stimulus (light, tone, image, etc.), paired with an unconditioned one (shock). A conditioned response forms when the two stimuli are associated: a subject starts having a fear response after the neutral signal as they are expecting the shock to follow it. Healthy people can halt their fear response once the threat is removed. Whereas, PTSD patients continue to feel fear.
Interestingly, stress during childhood can induce epigenetic changes that have an enduring effect on the stress response as an adult. FK506 binding protein 5 (FKBP5) blocks the binding of stress hormones to the glucocorticoid receptor. This binding is essential to induce the stress response and, subsequently, to switch it off. It has been reported that stress during childhood can result in long-lasting demethylation of the FKBP5 gene, which upregulates its expression and impairs stress responses in adulthood. Therefore, epigenetic studies can provide a better understanding of PTSD and help to predict which individuals are more likely to develop it after a trauma.
The current first line of treatment for PTSD is psychotherapy, both trauma-focused and non-trauma-focused. Trauma-focused interventions such as prolonged exposure therapy (PE) aim to abolish the patient’s fear response to the traumatic memory. A study reported that 41-95% of PE participants were no longer diagnosed with PTSD at the end of their treatment. However, effectiveness is significantly limited by dropout rates, which range from 10-38% in randomised clinical trials — this figure is predicted to be higher in community settings. This is likely attributed to avoidance symptoms, which are closely associated with PTSD.
Pharmacological approaches for PTSD are even more limited in efficacy than psychological treatments. Currently, there are only two FDA-approved selective serotonin reuptake inhibitors (SSRIs) for PTSD (sertraline and paroxetine). SSRIs have been shown to relieve PTSD-associated symptoms such as re-experiencing, avoidance, and numbing. However, pharmacologic agents are not universally effective — less than 60% of patients respond to treatment in a clinically relevant manner and only 20-30% fully recover.
Issues with the current approach
With poor accessibility to treatments and ineffective interventions, it is unsurprising that PTSD patients often turn to substance misuse. Substance use disorders are highly comorbid with PTSD. A study examining the relationship between PTSD, childhood trauma and substance use found high rates of lifetime dependence on recreational drugs in the traumatised population: 39% alcohol, 34% cocaine, 6% opiates, and 45% cannabis. This creates an additional issue of drug addiction, which in itself is a major public health challenge and imposes a tremendous socioeconomic burden. Therefore, better, efficacious treatments must be made available to PTSD patients so that they aren’t forced to self-medicate in dangerous ways.
The issues with current treatments involve not only limited options but also a lack of their utilisation. A study reported that only a minority of Iraq and Afghanistan veterans with PTSD completed the recommended mental health sessions offered by the US Department of Veteran Affairs within the first year of their diagnosis. Being less than 25 years old and male was shown to correlate with not completing treatment. This might be due to avoidance, comorbid depression, other priorities (school, employment) and the existing stigma for seeking help. Additionally, it was suggested that living far from treatment facilities also increased the likelihood of non-completion, which could be improved in the future.
Perhaps the key to helping PTSD patients does not just rest in treating them after the fact, but rather identifying and training at-risk individuals. For instance, deployment anxiety reduction training (DART) aims to increase an individual’s resilience to a potentially traumatic stimulus. However, since trauma cannot be predicted in many cases, this is only possible for a subset of the population. Nevertheless, more robust measures need to be implemented to support patients to ensure they are not left out in the cold in the aftermath.
Tackling this disorder is becoming increasingly necessary as the ongoing pandemic might result in a surge of PTSD cases among healthcare workers and the general public. The current situation has significantly affected all of our mental health in ways we would have never thought it could. While ‘self-care’ is becoming a buzzword, just talking about it will not result in real, substantial solutions. Therefore, PTSD research focusing on improving treatment options is essential to provide adequate support for those in need.