Psychiatrist Thomas Neylan (left), psychologist Shannon McCaslin-Rodrigo, and social worker Gerard Choucroun worked with officers from the Grant Air Force Medical Center to develop the Deployment Anxiety Reduction Training (DART) program, with the aim of stopping post-traumatic stress disorder before it starts.
Post-traumatic stress disorder (PTSD) remains one of the biggest threats to veterans who survive military deployment.
At NCIRE – the Veterans Health Research Institute, based at the UCSF-affiliated San Francisco VA Medical Center (VAMC) – researchers are exploring better ways to get former soldiers with PTSD into treatment and to find more effective treatments for them.
And a new pilot program developed by NCIRE researchers – all of them UCSF faculty-- along with officers from the David Grant Medical Center at Travis Air Force Base, –aims to prevent PTSD from developing in the first place.
The program, called Deployment Anxiety Reduction Training (DART), was a major focus of this year’s annual “Brain at War” symposium, hosted by NCIRE in San Francisco in June. The goal of DART is to tame the initial stress reaction to combat trauma.
Stress is a normal response to combat and other life-threatening situations. But the experience of extreme stress in the immediate aftermath of such a traumatic event may cause it to live on in the mind in especially vivid fashion, and this can elevate the risk for developing PTSD.
DART is being launched as a small pilot program in Afghanistan. The training of combatants will be conducted by medical personnel in battlefield settings. The training involves educating soldiers about how to recognize stress responses they can expect to experience, and teaching them exercises to monitor and control stress. The information and exercises are simple, and the short handbook also is a quick and clear read.
Combatants will be able to complete the training within hours of experiencing a traumatic battlefield event.
Seeds of PTSD Sown by Combat Stress
The threat to mental health posed by battlefield deployment has been highlighted recently by data pointing to rates of suicide in the US military that are higher than in years past. In addition, a record number of US Army combatants are seeking help for mental health issues, according to an Army report issued last month. Unfortunately, mental health issues may persist after the battlefield has been left behind.
Even after deployment ends, experiences of war can lead to long-lasting intrusive memories, avoidance behaviors or emotional numbing, and increased anxiety or emotional arousal, the hallmarks of PTSD.
For instance, some PTSD sufferers may withdraw and have trouble engaging others about everyday civilian concerns. Others may find it very difficult to let down their guard, habitually viewing each new public encounter as a potential threat.
PTSD, especially if unrecognized and untreated, may persist for many years after deployment has ended, diminishing the quality of life and even hastening the development of physical health problems, research now shows.
Behavioral Approach Instead of Medication
The fight-or-flight response has undoubtedly proved useful for survival throughout evolution and to this day. Heightened responses to a stressful event also may prime us to recall the event and respond similarly when a new situation appears similar. However, this response may arise even when there is no comparable threat.
“Brain at War” audience members spoke during a videoconference with Air Force Major Jennifer Hatzfeld, who is implementing DART at a field hospital in Afghanistan. Photo by Roy Kaltschmidt
“The idea is that excessive anxiety right around the time of a traumatic event can consolidate a type of memory called fear conditioning,” says Thomas Neylan, MD, UCSF professor of psychiatry and head of PTSD research at the San Francisco VAMC.
In studies of other traumatizing events, psychological debriefing; – in which the person who has experienced the event talks about it in the immediate aftermath with a trained and sympathetic counselor – is more likely to do harm than good. It’s better not to dwell on the event.
Charles Marmar, MD, a former UCSF and VAMC researcher who now heads the Department of Psychiatry at New York University, earlier worked with collaborators on a French study showing that the drug propranolol administered within 24 hours of a traumatic event may help people to better manage these memories. Propranolol is a heart drug, but it also blocks the action of stress neurotransmitters on the amygdala, a brain structure with a crucial role in fear conditioning and vigilance.
But within the military, taking a drug to manage one’s mental state has the potential to be stigmatizing.
“The idea of giving propranolol to soldiers in the field is not very attractive,” Neylan says. “We want to know if there is a behavioral intervention to achieve the same thing, to cool down the sympathetic nervous system,” the nerve pathways that generate the stress response.
VAMC psychologist Shannon McCaslin-Rodrigo, PhD, explains that the behavioral principals behind DART are simple and have been shown to reduce stress in other contexts. Deep breathing, for instance, has been shown to be effective in quickly managing panic attacks.
“The intervention involves a series of behavioral techniques and should take no more than 60 minutes,” McCaslin-Rodrigo says. Other techniques included in DART are muscle relaxation, which can reduce anxiety, and grounding, which focuses on turning attention away from the internal experience of a traumatizing event.
Adapting to Warrior Culture
Recognition of PTSD as a disorder worthy of medical intervention has not come quickly or easily within the military, where having mental health issues has often been seen as a sign of weakness. Some soldiers may view behaviors that counselors associate with PTSD as simply being normal responses to grossly abnormal circumstances.
As a caregiver who has seen the impact of PTSD on many lives over the years and who also has seen medical intervention help veterans to turn their lives around, Neylan understands that perspective but cannot dismiss the threat or symptoms of PTSD in the same way.
“We need to communicate that PTSD is something that warfighters can reasonably recover from with early treatment while at the same time warning about the possibility for long term negative consequences if it is left untreated,” he says.
DART emphasizes the importance of resilience. Working with Air Force psychologists at the David Grant Medical Center, the VAMC researchers came to realize that concepts such as deep breathing already have been part of “warrior culture” over the years. For example, to steady their aim snipers take a deep a deep breath before firing.
The DART manual frames the exercises in the context of maintaining combat readiness. Undergoing the training is a way of taking active responsibility for one’s own mental as well as physical health within a fighting unit, in which each member is depended upon by others.
The recent “Brain at War” symposium featured a live video conference from Afghanistan with Air Force Major Jennifer Hatzfeld, PhD, RN, whose medical staff already has begun implementing the intervention in a field hospital. Medical technicians in the combat zone will soon begin to conduct the training.
If the pilot proves successful, Neylan says, the hope is that, once they are trained, “Non-medical people will be able to easily teach it to others – it would be like a buddy system.”
In addition, VAMC social worker Gerard Choucroun is developing an online DART module.
Participants at a 2010 “Brain at War” session on strategies for resilience and stress management in the theatre of battle included US Air Force Captain Daniel Michel (speaking at podium); US Army National Guard Major Paul Gonzales (seated on the right); and California National Guard Captain Lance Friis. Photo by Roy Kaltschmidt
PTSD, Resilience and Performance
As director of the VAMC’s PTSD program, Neylan oversees research ranging from biochemical, sleep physiology, and brain imaging studies to novel treatments and new clinical care models that better integrate primary and mental health care. In his own recent research Neylan has been focusing on sleep studies and resilience to stress in the context of performance and preparedness. He is collaborating with Marmar on a controlled clinical trial to study a DART-like intervention in a New York City hospital emergency room. In addition, working with Marmar at NYU, Neylan is studying police officers, their personalities and responses to stress.
“We’re trying to find out if there is a profile that will tell you who is resilient, and who is at greater risk,” Neylan says. It would not be the intent of the police or military to exclude those who might be at greater risk, but rather to make sure they get adequate preparation for the stressful situations they will encounter, according to Neylan.
“For us at the VA this is a new development in our collaboration with the military and with UCSF, because we’re focusing on resilience and cognitive performance, as opposed to disease. We’re trying to prevent disorders from arising,” Neylan says.
SFVAMC “Brain at War” Symposium Highlights Often Subtle, but Common Traumatic Brain Injury
UCSF Science Café, May 20, 2008
PTSD and Heart Disease in Veterans: A Conversation with Beth Cohen
UCSF Science Café, December 19, 2008
Most Iraq and Afghanistan veterans with PTSD did not get enough care, study shows
UCSF News Release, February 9, 2010
Killing in Iraq combat linked with PTSD, alcohol abuse, other problems
UCSF News Release, February 10, 2010
NCIRE – The Veterans Health Research Institute
US Army Health Promotion, Risk Reduction, Suicide Prevention Report 2010