PTSD raises risk for obesity in women

Women with PTSD gain weight more rapidly than women without disorder Women with post-traumatic stress disorder (PTSD) gain weight more rapidly and are more likely to be overweight or obese than women without the disorder, find researchers at Columbia University's Mailman School of Public Health and Harvard School of Public Health. It is the first study to look at the relationship between PTSD and obesity over time. Results appear online in JAMA Psychiatry. One in nine women will have PTSD at sometime over the course of their lifetime—twice as often as men. Women are also more likely to experience extreme traumatic events like rape that carry a high risk for the disorder. "PTSD is not just a mental health issue," says study senior author Karestan Koenen, PhD, Mailman School associate professor of Epidemiology. "Along with cardiovascular disease and diabetes, we can now add obesity to the list of known health risks of PTSD." PTSD - Clinical Practice Guideline for Management of Post Traumatic Stress CEU Course "The good news from the study is that it appears that when PTSD symptoms abate, risk of becoming overweight or obese is also significantly reduced," says first author Laura D. Kubzansky, PhD, Professor of Social and Behavioral Sciences at Harvard School of Public Health. However, despite the growing evidence of potential far-reaching problems associated with PTSD, it's estimated that only half of women in the United States with the disorder are ever treated. "Hopefully, wider recognition that PTSD can also influence physical health will improve this statistic, leading to better screening and treatments, including those to prevent obesity," says Dr. Kubzansky. While it's known that women with PTSD have high rates of obesity, it has been unclear whether PTSD was actually driving the weight gain. To explore the issue, the researchers analyzed data collected from 50,504 women, aged 22-44 years, taking part in the Nurses' Health Study II between 1989 and 2009. Participants were asked about the worst trauma they experienced and if they had related post-traumatic stress symptoms. The threshold for PTSD was the persistence of four or more symptoms over a month or longer. Common symptoms include re-experiencing the traumatic event, feeling under threat, social avoidance, and numbness. Normal-weight women who developed PTSD during the study period had 36% increased odds of becoming overweight or obese compared with women who experienced trauma but had no symptoms of PTSD. The higher risk was evident even for women with sub-threshold symptoms levels and remained after adjusting for depression, which has also been proposed as a major risk factor for obesity. In women with PTSD that began prior to the study period, body mass index increased at a more rapid pace than women without PTSD. The observed effect of PTSD on obesity is likely stronger in the general population of women than in nurses, notes Dr. Koenen. "Nurses are great for studies because they report health measures like BMI with a high degree of accuracy. But they are also more health conscious and probably less likely to become obese than most of us, which makes these results more conservative than they would otherwise be." Symptoms of PTSD rather than the trauma itself seemed to be behind the weight gain. "We looked at the women who developed PTSD and compared them to women who experienced trauma but did not develop PTSD. On the whole, before their symptoms emerged, the rate of change in BMI was the same as the women who never experienced trauma or did experience trauma but never developed symptoms," says Dr. Kubzansky. How exactly does PTSD lead to weight gain? The biological pathway is unknown, but scientists have a number of guesses. One is through the over-activation of stress hormones. PTSD may lead to disturbances in functioning of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, each of which are involved in regulating a broad range of body processes, including metabolism. Another is through unhealthy behavior patterns that may be used to cope with stress. Ongoing research is looking at whether PTSD increases women's preference for processed foods and decreases their likelihood of exercising Social Worker Continuing Education ### Co-authors include Pula Bordelois, MPH, and Andrea Roberts, PhD, at Harvard School of Public Health; Hee Jin Jun, DrPH, at the Channing Division of Network Medicine at Brigham and Women's Hospital; Noah Blustone, BA, at Harvard Medical School and Boston University; and Magdalena Cerda, DrPH, at Columbia's Mailman School. The study was supported by grants from the National Institute of Mental Health to Dr. Koenen (MH078928 and MH093612). The authors declare no conflict of interest.

CWRU study finds mending ruptures in client-therapist relationship during PTSD treatment has positive benefits

In order for prolonged exposure therapy, an evidence-based psychotherapy for PTSD, to reach its full potential, any misperceptions or ruptures in trust and communication between therapist and client need fixing, according to a new Case Western Reserve University study. The study, reported in the Journal of Consulting and Clinical Psychology online article, “Patterns of Therapeutic Alliance: Rupture-Repair Episodes in Prolonged Exposure for PTSD,” is among the first to examine how ruptures in the relationship between the therapist and client can damage a patient’s treatment outcome. An alliance rupture may occur when there is a break in the therapist-client bond. For example, ruptures in the therapeutic relationship may occur when therapeutic progress stalls, negative feelings arise between the therapist and client, or when the work in therapy becomes challenging PTSD - Clinical Practice Guideline for Management of Post Traumatic Stress “We want therapists to know that a rupture in the therapeutic relationship isn’t a bad thing, as long as the therapist tends to it,” said Stephanie Keller, one of the study’s researchers and a Case Western Reserve doctoral student in clinical psychology. “However, if the rupture is not repaired, then your patient may not do as well in treatment.” The research study included 116 people who experienced a traumatic event such as childhood sexual or physical abuse, physical assault, or combat exposure, and had a primary diagnosis of PTSD. Participants engaged in a 10-session treatment program called prolonged exposure (PE) therapy. To help therapists chart progress and examine the therapeutic relationship, each client assessed his or her own PTSD symptoms and perception of their relationship with the therapist during treatment. This helped researchers to identify those clients who experience no ruptures in the therapeutic relationship (a stable relationship), clients who experienced a rupture that was subsequently repaired, and those with ruptures that went unrepaired LCSW Continuing Education The first PE session outlined what would happen over the course of treatment to set specific goals. Exposure-based exercises began in the second session, which included exposure to anxiety-provoking situations that served as trauma-reminders and talking about their traumatic experiences. In this sample, 28 percent of patients experiences a repaired rupture and 18 percent experienced a rupture, or dip in the therapeutic relationship, that was never repaired. An unresolved rupture in the therapist-client relationship became a predictor for a poorer outcome in treatment, Keller said. She also said more research is needed to figure out why these alliance ruptures occur and how to best repair them. The research was funded through a National Institute of Mental Health PTSD research project, directed by Norah Feeny, Ph. D. from Case Western Reserve University and Lori A. Zoellner, Ph. D. from the University of Washington. Other researchers contributing to the project were lead investigator and Case Western Reserve alumna AnnaMaria Aguirre McLauglin, and Eric A. Youngstrom, of the University of North Carolina at Chapel Hill.

Couple’s Therapy Appears to Decrease PTSD Symptoms, Improve Relationship

CHICAGO – Among couples in which one partner was diagnosed as having posttraumatic stress disorder (PTSD), participation in disorder-specific couple therapy resulted in decreased PTSD symptom severity and increased patient relationship satisfaction, compared with couples who were placed on a wait list for the therapy, according to a study in the August 15 issue of JAMA, a theme issue on violence and human rights. “There are well-documented associations between PTSD and intimate relationship problems, including relationship distress and aggression, and studies demonstrate that the presence of PTSD symptoms in one partner is associated with caregiver burden and psychological distress in the other partner. Although currently available individual psychotherapies for PTSD produce overall improvements in psychosocial functioning, these improvements are not specifically found in intimate relationship functioning. Moreover, it has been shown that even when patients receive state-of-the-art individual psychotherapy for the disorder, negative interpersonal relations predict worse treatment outcomes,” according to background information in the article. Candice M. Monson, Ph.D., of Ryerson University, Toronto, Canada, and colleagues conducted a study to examine the effect of a cognitive-behavioral conjoint therapy (CBCT) for PTSD, designed to treat PTSD and its symptoms and enhance intimate relationships in couples. The randomized controlled trial, conducted from 2008 to 2012, included heterosexual and same-sex couples (n = 40 couples; n = 80 individuals) in which one partner met criteria for PTSD according to the Clinician-Administered PTSD Scale. Symptoms of PTSD, co-existing conditions, and relationship satisfaction were collected by assessors at the beginning of the study, at mid treatment (median [midpoint], 8 weeks after baseline), and at post-treatment (median, 16 weeks after baseline). An uncontrolled 3-month follow-up was also completed. Couples were randomly assigned to take part in the 15-session cognitive-behavioral conjoint therapy for PTSD protocol immediately (n = 20) or were placed on a wait list for the therapy (n = 20). Clinician-rated PTSD symptom severity was the primary outcome; intimate relationship satisfaction, patient- and partner-rated PTSD symptoms, and co-existing symptoms were secondary outcomes. The researchers found that PTSD symptom severity and patients’ intimate relationship satisfaction were significantly more improved in couple therapy than in the wait-list condition. Also, change ratios (calculated by dividing the change in the CBCT condition from pretreatment to post-treatment by the change in the wait-list condition over this period) indicated that PTSD symptom severity decreased almost 3 times more in CBCT from pretreatment to post-treatment compared with the wait list; and patient-reported relationship satisfaction increased more than 4 times more in CBCT compared with the wait list. The secondary outcomes of depression, general anxiety, and anger expression symptoms also improved more in CBCT relative to the wait list. Treatment effects were maintained at 3-month follow-up. “This randomized controlled trial provides evidence for the efficacy of a couple therapy for the treatment of PTSD and comorbid symptoms, as well as enhancements in intimate relationship satisfaction. These improvements occurred in a sample of couples in which the patients varied with regard to sex, type of trauma experienced, and sexual orientation. The treatment effect size estimates found for PTSD and comorbid symptoms were comparable with or better than effects found for individual psychotherapies for PTSD. In addition, patients reported enhancements in relationship satisfaction consistent with or better than prior trials of couple therapy with distressed couples and stronger than those found for interventions designed to enhance relationship functioning in nondistressed couples,” the authors write. “Cognitive-behavioral conjoint therapy may be used to efficiently address individual and relational dimensions of traumatization and might be indicated for individuals with PTSD who have stable relationships and partners willing to engage in treatment with them.” (JAMA. 2012;308[7]:700-709. Available pre-embargo to the media at http://media.jamanetwork.com) Editor’s Note: This study was supported by a National Institute of Mental Health grant to Dr. Monson. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc. Editorial: Expanding the Boundaries of PTSD Treatment Lisa M. Najavits, Ph.D., of the Veterans Affairs Boston Healthcare System and Boston University School of Medicine, comments in an accompanying editorial on the 2 studies in this issue of JAMA on treating PTSD. “The results of the trials by Mills at al and Monson et al are important scientific attempts to study new options for treatment of PTSD. Overall, comparative studies of PTSD therapies find that they rarely outperform each other in efficacy. Thus, the cost and appeal of treatments to clinicians and patients, their intensity of intervention, and clinical setting and training issues may ultimately be as or more relevant than comparative efficacy in choosing a course of treatment for PTSD. In the current era, there is a focus on short-term treatments (in part an antidote to the overly long psychotherapies of much of the 20th century). However, it is not clear how long treatment needs to be maintained to produce enduring positive outcomes, especially for patients with PTSD and comorbidities and difficult social circumstances. The field of PTSD therapy is still young, and the pursuit of clinically meaningful treatments for all types of patients, like the process of recovery for patients with PTSD, is an ongoing challenge.” (JAMA. 2012;308[7]:714-716. Available pre-embargo to the media at http://media.jamanetwork.com) Editor’s Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of interest and reported receiving royalties from Guilford Press and New Harbinger Press and that she is director of Treatment Innovations, which provides consultation, training, and materials related to psychotherapy lcsw ceus # # #

Healing Trauma’s Invisible Wounds

Mental Health Month Raises Awareness of Trauma and Impact on Children, Families, Communities; New Approaches to Treatment “Healing Trauma’s Invisible Wounds” ALEXANDRIA, Va. (April 23, 2012)—For May is Mental Health Month, Mental Health America is raising awareness of trauma, the devastating impact it has on physical, emotional, and mental well-being, and how therapeutic techniques based in neuroscience can mitigate these effects and create dramatic changes in people’s lives. “As a society, we are just beginning to deal with trauma—bringing it out of the shadows, finding new ways of healing its wounds, and casting off the shame that prevents trauma survivors from seeking help,” said David Shern, Ph.D., president and CEO of Mental Health America. “Most people think that “trauma” refers only to physical trauma that occurs as a result of a car accident or assault. But it’s much more than that.” Trauma includes: ■ Interpersonal violence – such as abuse, rape, domestic violence, and bullying; ■ Social violence — such as war, terrorism, and living under oppressive political regimes; ■ Natural disasters and accidents — such as hurricanes, floods, earthquakes, tornadoes, and auto crashes; ■ Serving in combat; ■ Chronic social stressors – such as racism, sexism, poverty, humiliation and cultural dislocation; ■ Childhood trauma—including physical, emotional and sexual abuse; emotional and physical neglect; a parent who’s an alcoholic or addicted to other drugs; a mother who’s been battered; a family member in prison or diagnosed with mental illness; and a loss of a parent through divorce or abandonment Dr. Shern said trauma has tremendous human and societal costs. Trauma is the leading cause of the death of children in this country. The effect of trauma on productive life years lost exceeds that of any other disease. The economic cost of 50 million injuries in the year 2000, alone, was $406 billion. This includes estimates of $80 billion in medical care costs, and $326 billion in productivity losses. And the predicted cost to the health care system from interpersonal violence and abuse ranges between $333 billion and $750 billion annually, or nearly 17 to 37.5 percent of total health care expenditures. When children or adults respond to traumas with fear, horror and/or helplessness, the extreme stress is toxic to their brains and bodies, and overwhelms their ability to cope, Dr. Shern said. “While many people who experience a traumatic event are able to move on with their lives without lasting negative effects, others may have more difficulty managing their responses to trauma.” Unresolved trauma can manifest in many ways, including anxiety disorders, panic attacks, intrusive memories (flashbacks), obsessive-compulsive behaviors, Post-Traumatic Stress Disorder, addictions, self-injury and a variety of physical symptoms. Trauma increases health-risk behaviors such as overeating, smoking, drinking and risky sex. Trauma survivors can become perpetrators themselves. Dr. Shern said unaddressed trauma can significantly increase the risk of mental and substance use disorders, suicide, chronic physical ailments, as well as premature death. The Adverse Childhood Experiences (ACE) Study, one of the largest investigations ever conducted to assess associations between childhood maltreatment and later-life health and well-being, demonstrated that trauma and other adverse experiences are associated with lifelong problems in behavioral health and general health. Until recently, trauma survivors were largely unrecognized by the formal treatment system. The costs of trauma and its aftermath to victims and society were not well documented. Inadvertently, treatment systems may have frequently re-traumatized individuals and failed to understand the impact of traumatic experiences on general and mental health. But that is changing. Researchers have learned how trauma changes the brain and alters behavior. A movement for trauma-informed care has emerged to ensure that trauma is recognized and treated and that survivors are not re-victimized when they seek care. Complementing these changes are programs to promote healthy development of children and healthy behaviors in families, schools and communities that reduce the likelihood of trauma. “It is critical that these efforts strengthened and we heal the invisible wounds of trauma,” Dr. Shern said. “They are crucial to promoting the healthy development of children and families.” For more than 50 years, Mental Health America and its affiliates around the country have led the observance of May is Mental Health Month by reaching millions of people through the media, local events and screenings. This unified effort includes educational messages about mental health and substance use conditions and the importance of mental health ceus for counselors Mental Health America (www.mentalhealthamerica.net) is the nation’s largest and oldest community-based network dedicated to helping all Americans achieve wellness by living mentally healthier lives. With our more than 300 affiliates across the country, we touch the lives of millions—Advocating for changes in mental health and wellness policy; Educating the public & providing critical information; and delivering urgently needed mental health and wellness Programs and Services.

Rats recall past to make daily decisions

UCSF study offers path for studying learning, decision-making, PTSD UCSF scientists have identified patterns of brain activity in the rat brain that play a role in the formation and recall of memories and decision-making. The discovery, which builds on the team's previous findings, offers a path for studying learning, decision-making and post-traumatic stress syndrome. The researchers previously identified patterns of brain activity in the rat hippocampus, a brain region critical for memory storage. The patterns sometimes represented where an animal was in space, and, at other times, represented fast-motion replays of places the animal had been, but no one knew whether these patterns indicated the process of memory formation and recollection. In the journal Science this week (online May 3, 2012), the UCSF researchers demonstrated that the brain activity is critical for memory formation and recall. Moreover, they showed that the brain patterns through which the rats see rapid replays of past experiences are fundamental to their ability to make decisions. Disturbing those particular brain patterns impaired the animals' ability to learn rules based on memories of things that had happened in the past lsw ceus "We think these memory-replay events are central to understanding how the brain retrieves past experiences and uses them to make decisions," said neuroscientist Loren Frank, PhD, a associate professor of physiology and a member of the Keck Center for Integrative Neuroscience at UCSF, who led the research with Shantanu Jadhav, PhD, a post-doctoral fellow. "They offer insight into how a past experience can have such a profound effect on how we think and feel." The finding gives scientists a new way to investigate fundamental processes like learning and decision-making in animals and in people. It also may help shed light on memory disorders like post-traumatic stress disorder (PTSD), which is characterized by strong, disturbing and uncontrolled memories. WITHOUT LINKS TO THE PAST, RATS FACE INDECISION Seeking to understand how the recall of specific memories in the brain guides our thinking, Frank and his colleagues built a system for detecting the underlying patterns of neuronal activity in rats. They fitted the animals with electrodes and built a system that enabled them to detect a specific pattern, called a sharp-wave ripple, in the hippocampus. Whenever they detected a ripple, they would send a small amount of electricity into another set of electrodes that would immediately interrupt the ripple event, in effect turning off all memory replay activity without otherwise affecting the brain. The UCSF researchers knew that these sharp-wave ripples would be activated when the animals had to make choices about which direction to turn as they wended their way toward their reward: a few drops of sweetened condensed milk. These signals seem to be flashes of memory recall, said Frank, a rat's past knowledge flooding back to inform it on what had happened in the past and where it might go in the future. Squashing the sharp-wave ripples, the UCSF team found, disrupted the recall and subverted the rat's ability to correctly navigate the maze. This shows, said Frank, that the sharp-wave ripples are critical for this type of memory recall. Through these brain waves, the rat reprocesses and replays old experiences in a fleeting instant—lessons from the past essential for shaping their perception of the present. "We think these memory replay events are a fundamental constituent of memory retrieval and play a key role in human perspective and decision-making as well," he said. "These same events have been seen in memory tasks in humans, and now we know they are critical for memory in rats. We think that these fast-forward replays make up the individual elements of our own memories, which jump rapidly from event to event." Next, the team wants to tease out information about how the rats actually use these memory replay events to make decisions and how amplifying or blocking specific replay events will change the way an animal learns and remembers. They also think that these events could be important for understanding memory problems, as when stressful memories intrude into daily life. The article, "Awake Hippocampal Sharp-Wave Ripples Support Spatial Memory" by Shantanu P. Jadhav, Caleb Kemere, P. Walter German and Loren M. Frank is published by Science on May 4, 2012. After that date, the article can be accessed at: http://www.sciencemag.org This work was funded by grants from the Helen Hay Whitney Foundation and the National Institute of Mental Health, a component of the National Institutes of Health. Additional support was provided through a Wheeler Center Fellowship. UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.