Thursday, March 5, 2015

We Can't Erase The Traumatic Memories of First Responders with PTSD, But....

Who Gets PTSD and Why?

Approximately 50-60% of people living in the US report having at least one traumatic event in their lifetime1. These traumatic events usually cause symptoms in the days and weeks that follow. These symptoms might be flashbacks, nightmares, feeling numb and detached from people, and avoidance of trauma reminders. Obviously, people who work as first responders (soldiers, police, paramedics, fire fighters, etc.) are more likely to experience traumatic events and develop Post Traumatic Stress Disorder (PTSD).

Fortunately, for many people these initial PTSD symptoms decline naturally in the 3-6 months following the event. However, research shows that anywhere from 5% to 30% of sufferers will actually develop chronic PTSD.

In the movies, characters who have PTSD (like a soldier home from war) are usually startled by loud sounds, or the director might show jumbled images that are supposed to represent flashbacks to the trauma.

These movie scenes are true and accurate, but come nowhere near the real range of intrusive thoughts and memories that get triggered in those with PTSD

First, there are the more ‘obvious’ memories and thoughts associated with a traumatic event – seeing a dead body and blood, or hearing gunshots. However, it can sometimes be the ‘less obvious’ things that get traumatically remembered - gasoline, smoke, article of clothing, someone’s facial features, or even common smells like cleaning products (accidents and crime scenes need to be cleaned and sanitized at some point).

When getting robbed at gunpoint, someone with PTSD might remember a facial feature of the criminal (“I’ll never forget his teeth and smile”) as much as they remember the gun.

The point is that traumatic events can “burn” memories into the brain that cause unwanted thoughts and images to pop into the person’s head. It also makes them want to avoid things associated with the memory.

Not only does PTSD produce memories that are highly disturbing and intrusive, but it also tends to change the person’s fundamental beliefs. For example, they might have negative beliefs about:

·         Themselves (“I will never be the same person”)
·         Other people (“People are dangerous ”)
·         The world (“Unless you stay alert, this world will eat you alive”)
·         Work activities (“The risk of dying in my job is very high”)
·         Basic activities (“The risk of dying while driving is very high”)

It is this combination of haunting memories and new beliefs that play a large causal role in someone developing PTSD.

 Can We Erase These Memories and Beliefs?

In the past number of years, scientists have been working to develop treatments that would erase traumatic memories. They have had some initial success in studies with rats. For example, one recent study showed that exposing rats to a gas called Xenon appeared to erase their fear memories. This type of research is still in the early stages, and there are no treatments at this time that allow us to erase the traumatic memories of PTSD sufferers.

However, psychological treatments can have large and positive effects for those with PTSD. For example, psychologists have learned a lot about the causes of fear and traumatic memories, based on hundreds (if not thousands) of research studies. They've used this knowledge to develop and hone certain treatments for PTSD.

One of the findings from this research is that we never really erase memories through therapy. During a traumatic event, the brain seems to create a number of very strong connections between fear/trauma and various things present during the trauma (ex: image of a gun, smell of smoke, sound of someone screaming, etc.).

For example, a police officer who witnesses a suicide via gunshot to the head, might develop a whole memory system that links the following things with fear:

·         Guns
·         A type of sweater (similar to the one worn by victim)
·         Blood
·         Certain verbal expression (if the victim said “Life sucks” or “I’m outta here” just before pulling the trigger)
·         A particular facial expression of squeezing eyes closed (victim did this before shooting)

Now, the police officer has intrusive thoughts about the trauma whenever his son squeezes his eyes shut or when he sees someone wearing a certain sweater.

He also is more likely to avoid things like TV shows with violence.

Arguably the best treatment of PTSD is a type of therapy called Cognitive Behavioural Therapy (CBT). This type of therapy requires the therapist to use a procedure called “exposure.”

When psychologists use exposure they have the person face the very things that remind them of the trauma. They look at images, watch videos, smell objects, and hear sounds that cause them to feel anxious.

Sound cruel and unusual? That is sometimes the reaction of some of my clients – “why would I do that when I am trying to forget this stuff?”

We use exposure techniques because we are trying to build a new set of memories – what many professionals call a “safety memory.” Let me explain.

Think about the police office from the previous example. Prior to the trauma, things like guns, sweaters, facial expressions and even blood didn’t bother him. In fact, these things usually don’t cause much fear in most people. This is where we want to return – to having all the things in the “fear/ trauma memory” go back to normal.

The research shows that we do this by using exposure therapy in safe settings (ex: therapists office) and in a particular way that allows new memories to form. Over the course of sessions and repeated exposures to all kinds of feared stimuli, things like the sweater develop new and strong associations with safety and normalcy.

Now, does the old, fear/trauma memory disappear? No, it does not2. What seems to happen is that the new “safety memory” that gets developed in therapy inhibits or prevents the old memory from getting activated. In fact, over time and in certain settings the old memories might get triggered again, even when therapy is successful. This doesn’t mean therapy has failed – in fact, most experienced psychologists anticipate these situations and develop a plan with the client.

In terms of the PTSD beliefs that get developed after the trauma, part of CBT involves working to change these as well to something more healthy and adaptive.

So, for those first responders suffering from PTSD, science has yet to find a treatment that allows us to erase those memories. but there are excellent treatments available that help rewire your memory systems and change beliefs. This allows PTSD sufferers to get rid of those difficult symptoms and finally start to recover.


1. Shipherd & Salters-Pedneault (2008). Attention, memory, intrusive thoughts, and acceptance in PTSD: An update on the empirical literature for clincians. Cognitive and Behavioral Practice, 15, 349-363.

2. Craske et al. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5-27.

Tuesday, March 3, 2015

Why I Don't Like the Term Mental Illness

I have to admit something embarrassing. I am a registered psychologist working in private practice and I don't know what the term mental illness means. Well, on a general level I know that it refers to psychological problems, but I don't know exactly what is meant by the "illness" part.
As far as a I can tell, there are two possibilities. First, illness could be a metaphor. If a writer used a phrase like "terrorism is an illness of society," we would know that the author is using a metaphor because a society cannot literally be sick. It cannot get the flu or have a bacterial infection.
The second potential meaning of illness is literal -- there is actually a disease or sickness that affects the mental functioning of the person.
When we use the term mental illness, what do we mean? Are we using a metaphor, like the mind is not working properly, as if it was ill. Or, do we mean it literally that the brain is in some way sick?
This is not simply an issue of semantics and splitting hairs. There are consequences and implications to the language we use to describe problems, including how we conceptualize or think about the cause of the problem, and how we treat it.
Brain Illness
When people speak of mental illness, it is common to speak of problems with the mind. But according to modern medicine and science, there is no "mind" per se. We have a brain and the neurons of that brain are responsible for our thinking, emotions, behaviour, and so forth. So, whenever we use the term mental illness or speak of the mind being unhealthy, we are really referring to the brain.
We are saying the brain is sick.
Given that the brain is an organ of the body, there are two significant implications of using the term illness to describe psychological problems.
First, there is an implication that the tissue and chemicals that make up the brain are either diseased (ex: virus or bacterial infections) or dysfunctional (the neurons are not firing properly).
Second, and following from the first implication, there is an assumption that medicine can be used to fix the ill brain. We use medicine to fix the other organs in the body, so why not the brain as well?
Hence, the term mental illness seems to lend itself more to the use of medication as an ideal and first line of treatment. And given that psychotropic medications (ex: antidepressants like Prozac) are among the most popular drugs in the world, it is fair to assume that medicine is indeed most people's first line of treatment.
But is the brain sick, and does the medicine fix this sickness?
The Biological Model of Mental Disorders
The treatment of mental illness has a long history of physical approaches, including lobotomy, electroconvulsive therapy, medication, and a variety of other such methods. Success has been variable.
As mentioned, the most popular approach is medication. The idea that medication might work rests on the chemical imbalance theory of mental illness, which proposes that chemicals in the brain are not functioning properly, causing problems like depression and anxiety.
The idea that mental illness, most notably depression, is caused by chemical imbalances is arguably the most widely disseminated theory of mental illness in existence. The theory is described on respectable internet sites, the mainstream media, professional organizations (ex: National Institute of Mental Health), and is used by innumerable health professionals.
The problem is that the research evidence for this theory is simply too weak. The problems with this theory have only really started to hit the mainstream media and the general population in the past five to 10 years. For example, multiple experts, including psychiatrists, have come forward to say that the chemical imbalance theory for depression is simply wrong. There is poor and inconsistent evidence that low serotonin causes depression.
Neuroscience has done a great job of finding correlations between mental disorders and various brain dysfunctions, but to date, no one has found a definitive biological cause for any one mental illness.
What Else Could There Be?
If biology doesn't explain mental health problems, what does (or could)? If thoughts and emotions occur because of neurons firing, then problems with neurons must underlie mental disorders right?
Not at all. Problems can arise when the brain is perfectly intact and operating with all chemicals in balance (whatever that might mean).
Imagine you touch a hot stove top. The pain will immediately force your hand to pull away quickly, which is an example of healthy reflexes.
Following this painful lesson, imagine that the stove has been turned off and you are asked to touch the stove top again. It is not hard to imagine being a little hesitant to touch it, even though you know it is no longer hot.
What is happening here? The brain has learned that the stove can cause pain and damage, and has produced a feeling of anxiety when around stoves as a precaution. This is the mark of a healthy, adaptive brain - one designed through evolution.
Now imagine that a child is bullied repeatedly at school. To prevent further bullying, they stay away from people and become mistrustful. Is this any less adaptive than pulling your hand away from the stove? Both serve to stop pain.
Now imagine that the child grows up and is very wary of other people and feels anxious in social situations. Like the stove example, they are generalizing from one period of time to another, in order to protect themselves.
In this latter example, does the person need to have chemical imbalances in their brain, or any other biological dysfunction to be anxious of other people? You might find that certain areas of the brain "light up" on an MRI when this person is in social situations, but this doesn't mean that dysfunction in these brain regions are causingthe anxiety.
In fact, this person could meet criteria for depression and social anxiety disorder, and yet their brain is in no way dysfunctional or sick. If anything, their brain is operating the way we would expect it given the environmental circumstances, and the priority that evolution puts on self-protection.
Here we have a healthy brain (medically speaking) that is causing problems in the person's interpersonal life.
This person might need therapy to deal with the problem, but the root cause of the problem (bullying, mistrust, and avoidance) could never be solved by medication.
Should we say this person is mentally ill? Is their brain diseased in some measureable way?
Give it some thought. When you use the term mental illness, what do you mean?
Is it just a metaphor?

The Importance of Insuring Mental Health Care

In 2006, a research paper was published in the Canadian Journal of Psychiatry, where the authors argued for greater public access to psychotherapy - specifically Cognitive Behavioural Therapy (CBT). To make their point, the authors did not rely on emotional appeals to compassion or empathy for those in need. Rather, they examined the very thing that directs much of the decision-making in government - the cost.
I have no idea whether any government officials read this paper, but recent changes in mental health benefits for federal employees in Canada suggest someone must be paying attention to the research. As of October 1, 2014, members of the Public Service Health Care Plan will now be reimbursed up to $2000 per year for psychological services.
Given the results of research on the cost-effectiveness of therapy, such an increase should be viewed as an investment.
The Costs
The alarm bells for mental illness having been sounding for some time in public discourse, and the research supports every bit of the hand-wringing. The prevalence of mental illness is fairly high (the 1 in 5 people estimate is likely too low), costs the Canadian economy $14.4 billion annually, and leads to the occupation of more hospital beds than cancer. Let me give a more concrete example of the costs - in 1999/2000, mental illness in Canada accounted for 9,022,382 of days spent in hospital - an average of 45 days per person.
The considerable price tag of mental illness comes at a time when the provincial governments in Canada are having to brainstorm ways of containing unsustainable health care costs.
Which brings us back to the 2006 article examining the cost-effectiveness of CBT.
CBT is now the most popular form of psychotherapy in the Western world, which is due in large part to the tremendous amount of research on its effectiveness. Hundreds of outcome studies have shown that CBT is just as effective as medication for depression and anxiety, and tends to have a lower relapse rate than medication for depression.
In terms of cost-effectiveness, the research shows that CBT is more cost-effective than medication. A major reason for this outcome is due to the fact that patients who use CBT instead of medication make less use of health services following treatment.
For example, patients with clinical depression who receive CBT have been found to relapse around 29% of the time, whereas those who take antidepressants have a relapse rate of 60%. Similarly, panic disorder (PD) tends to respond very well to CBT, but can also be effectively treated with medication. Those who are treated with the medication for PD (ex: imipramine) may have lower costs than CBT after 1 year of treatment, but after two years the cost of medication surpasses therapy. This long-term cost-effectiveness occurs arguably because people who are successfully treated with CBT no longer need treatment (or at least need less ongoing treatment), whereas people prescribed medication continuously require treatment over the years.
Given that CBT is at least as effective as medication and costs less, any effort to increase access to such care seems to be the most fiscally prudent option available to the government, employers and insurance agencies alike.
Moving Forward
Ideally, the increase in benefits to federal employees represents only the beginning of such change across the country. Employers would be wise to make comparable changes to employee insurance packages where possible. Trying to save on premiums and having employees rely solely on medication to manage mental illness is a sub-optimal approach, and likely results in greater long-term costs via sick days and lost productivity.
Increasing insurance benefits increases access to private care, which has become a necessity in Canada. Those wanting psychological treatments must either choose between public care (ex: psychologist in a hospital) or private care (ex: psychologist in private practice). Unfortunately, there tend to be unreasonable wait lists for access to public care (typically one year or longer). Access to a psychologist or counsellor in private practice tends to be much faster, which is ideal when dealing with mental illness. However, private practice can be expensive (it is common for costs in Ontario to be around $200 per hour).
The increase in insurance coverage for private, evidence-based psychological care would pay dividends not only to the patient, but also to the employer, economy and society at large.
The economic and societal costs of mental illness are not going to change on their own - and we can no longer consider therapy to be a luxury.
It is an investment -- in every sense of the word.