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Post-Traumatic Stress Disorder (PTSD) ranks
third in United States veterans seeking psychiatric care through the Veterans
Health Administration (VHA). Approximately 30% of the entire veteran population
currently utilizes VA services leaving 70% to find care in the private sector
or to go without care at all. The presence of PTSD among veterans is estimated
at 35-40%. Unfortunately, current evidence-based treatment rates of
remediation, including medication, are low, thereby necessitating the need for
the development of more effective interventions. The challenge to the mental
health service provider is to stay informed related to emerging treatments that
offer the promise of alleviating PTSD symptomology. This article seeks to
accomplish that objective. New innovative interventions are rapidly emerging,
including Reconsolidation Enhancement by Stimulation of Emotional Triggers
(RESET therapy) and Stellate Ganglion Block (SGB). SGB is alleged to inhibit
connections between sensitized regions of the cerebral cortex and the
peripheral sympathetic nervous system. RESET therapy is perceived to alter
aberrant neuronal circuitry in PTSD sensitized regions of the brain through a
unique sound, thereby resetting the altered circuitry back to a pre-trauma
state. Both interventions offer a biologically-based approach to PTSD
treatment. Psychologists and other adequately trained mental health
professionals provide RESET therapy. Skilled anesthesiologists or
interventional pain management physicians provide SGB. Both approaches serve to
de-stigmatize the varied myths associated with PTSD. However, psychologists and
other trained mental health providers are in a vital position to be able to
implement a remedial intervention rapidly and non-invasively.
Keywords: Post-traumatic
stress disorder, Memory reconsolidation, Transformative treatment, Binaural
beat, Stellate ganglion block
INTRODUCTION
As practicing psychologists
trained over three decades ranging from the late 1960s to the early 90s, the
authors have great empathy for the practicing mental health practitioner of the
twenty-first century. The next generation of practitioners has assumed the
mantle of responsibility for the timely and effective treatment of
trauma-related disorders. The mental health profession is placed under immense
pressure to deliver results quickly, safely and economically that meet the
prevailing standard of care. The mental health client/patient of the 21st
century has been saturated with pharmaceutical ads leading them to expect rapid
relief within a brief period of time or within a handful of therapy sessions.
The current
state-of-affairs in empirical and academic research on PTSD interventions
presents the mental health clinician with bewilderment and little guidance as
to which treatments are the most effective, tolerable, and cost-effective. The
partisan and even acrimonious controversy between proponents vs. opponents of
various theoretical/empirical camps is evidenced in some of the critical and meta-analytic published
reviews of varied
The
introduction of the practitioner to a promising and innovative recent treatment
intervention called Reconsolidation Enhancement by Stimulation of Emotional
Triggers (RESET therapy) is a primary objective of this article. The
psychologist/clinician commands the front line related to applying breakthrough
treatments that lead to the resolution and remediation of trauma-effects.
Within this context, the authors commit to the relief of trauma-associated suffering
to the fullest extent possible and further, to transform the afflicted
individual to full potential and above all, to do no harm.
Shifting now to
the issue of PTSD, the authors find that there is little remaining question
that post-traumatic stress disorder (PTSD) is much more than a psychological
problem, even though the current diagnosis of the condition is based solely on
the presence of behavioral and psychological symptoms. Historically, the
rendering of a mental diagnosis has fallen within the domain of the
psychologist and psychiatrist.
PTSD AS A
NEUROINFLAMMATORY CONDITION
Increasingly,
cumulative evidence has identified associations between the immune and
inflammatory systems and PTSD [1]. For those mental health practitioners who
wish to maintain their involvement in this expanding perspective, it will
require their ongoing awareness regarding the contribution that neuroscience is
making related to clinical practice.
It is known
that PTSD produces elevated rates of pro-inflammatory markers. Additionally, it
is also thought to contribute to both the pathogenesis and pathophysiology of
the ailment [2]. This reality becomes the challenge facing the mental health
practitioner who has traditionally approached the issue primarily from a
psychodynamic or cognitively-based point of view.
Acceptance of
the above association provides support for the perspective that PTSD is more
than a psychological problem but rather is a systemic disorder. The emergence
of chronic medical conditions among those living with PTSD, as compared to
those without it, has led to the exploration of a mechanistic link between PTSD
and other comorbid conditions, such as cardiovascular disease (CVD). An
emerging body of evidence reveals that an immunological balance skewed toward a
low-grade pro-inflammatory state (exists) in PTSD. It remains to be elucidated
if inflammation precedes the onset of PTSD, identifying a vulnerable
population, or rather ensures the onset of PTSD. Lastly, it is unclear how the
time from index event, duration, and severity of PTSD symptoms might affect a
potential relationship to inflammation. Other confounders include heterogeneity
and chronicity of events leading to PTSD (war, childhood trauma, sexual
assault, etc.) as well as temporal proximity to precipitating events [3].
The above
awareness lays the foundation for the psychologist and other mental health
providers increasing involvement as a source of first referral, rather than an
option of last resort.
STATE OF CURRENT TREATMENT INTERVENTIONS
A 2018 consensus
statement of the PTSD psychopharmacology working group advises that “there
seems to be no visible horizon for advancements in medications that treat
symptoms or enhance outcomes in persons with a diagnosis of PTSD” [4]. A
follow-up letter by another group of researchers [5] comments that “With only
50% of veterans seeking care and a 40% recovery rate, current strategies will
effectively reach no more than 20% of all veterans who need PTSD treatment.” In
other words, psychologists are in an ideal position to rapidly implement a
non-invasive remedial treatment following validation of the studied treatment
approach. Furthermore, the intervention has applicability across a broad range
of issues other than PTSD, such as sleep disorders, depression, anxiety, etc.
Numerous
challenges have ensued about the efficacy of psychological treatments for PTSD.
Clarity about the underlying mechanisms of action of the varied procedures,
including ‘Gold Standard’ interventions, remains weak [6]. A classic
meta-analysis published in the Journal of the American Medical Association
rigorously explored studies of traumatized veterans treated with Prolonged
Exposure (PE) and Cognitive Processing Therapy (CPT), versus non-exposure
control interventions, such as meditation or waiting list controls. In the
analysis, an average of 60% of PE and CPT patients ‘outperformed’ waiting list
and treatment-as-usual controls demonstrating a 10 to 12-point average score
decrease on the Clinician-Administered PTSD Scale (CAPS) interview [7].
The ‘clinical
significance’ of the above finding, however, is debatable when one considers
that sixty-six percent of the participating veterans continued to meet
diagnostic criteria for PTSD following the interventions. PE and CPT were
deemed ‘marginally’ superior to non-exposure-based trauma interventions (e.g.,
mindfulness/meditation). Steenkamp et al. [7] make mention of the
disproportionately high dropout rates in PE and CPT, but reasons for premature
termination were not explored in any depth.
Hoge [8] noted
that, among veterans who begin PTSD treatment with psychotherapy or medication,
a high percentage drop out, commonly 20% to 40% in randomized clinical trials
(RCTs) but considerably higher in routine practice. The rate of recovery of 60%
to 80% among treatment completers declines to around 40% when non-completers
are accounted for. Surveys of perceived barriers to veterans seeking treatment
for PTSD include the weeks to months required to access care, possible
medication side effects, and associated comorbidities [9]. There remains an
intense need for rapid, remedial, and transformative approaches to successfully
transition our veterans with PTSD back into the mainstream of civilian life. It
is proposed that the psychologist can play a key role in bringing
transformative therapies into the mainstream of practice, not only for the
veteran but for the broader community.
STELLATE GANGLION
BLOCK (SGB)
Suddenly, bursting out on an 11/06/19 Sunday evening [10], an amazing story about remedial hope for veterans suffering from Posttraumatic Stress Disorder was noted. The featured segment focused on an outpatient
medical procedure referred to as a Stellate Ganglion Block. This procedure
involves the delivery of an analgesic injection under fluoroscopy to a special
bundle of neurons positioned to the right of the spine. The precise location is
between cervical C6 and vertebrae C7 called the Right Stellate Ganglion.
Interestingly only about 80% of humans possess this special bundle.
As professed by former combat veterans in the
60 min segment that have not responded to a myriad of medications as well as
varied forms of psychotherapy for PTSD, dramatic changes ensued following the
SGB procedure. These included comments such as, “felt a huge difference-
RECONSOLIDATION
ENHANCEMENT BY STIMULATION OF EMOTIONAL TRIGGERS (RESET THERAPY)
Paradoxically, comments of this type are also
reported in another little-known experimental procedure called RESET therapy
such as, “it was instantaneous; I have never slept so well in my life. It
sounds too good to be true, I know. Believe me, when I first heard about it,
you have no idea how skeptical I was…I was asked to compare the intensity from
when we first started to how I was at the end of it and honestly, I said that
it went from a 10 to a 1…I still do not really understand how this happened,
but with one treatment, my wife says I am a changed man. I asked her what she
meant and she said, when you came home you have become that boy, I fell in love
with 25 years ago. I can feel the change in me now. I laugh again. I enjoy life
and I love my wife. Since my
treatment, I had been able to sleep 8 hrs. a night like I used to with no flashbacks, no nightmares and no survivor’s remorse.
Also, since my treatment, I have lost 20 pounds, have more energy and I have
come to enjoy life.”
Another
participant noted that, “although I am a practitioner of EMDR, and
neurofeedback as well, these methods were unsuccessful in making headway with
this particular disturbing memory. When doctor tuned into the resonant
frequency, it was like an accelerator being pushed down on a motorcycle zooming
out from 0-60 mph in 1 s. The target lit up like a ball of fire, and my
sympathetic nervous system engaged (huffing and puffing for breath, heart
racing, sweating, cringing/squirming, tensing and bracing my muscles). While
this was happening, a curious visualization came to my mind involving a mending
of my trauma. My breathing slowed and in what seemed like only moments later,
doctor stopped the sound.
As evident in
the above two testimonials, vastly differing, non-invasive, non-verbal
transformative treatment was utilized, which seemingly has similar after-effects
to the invasive Stellate Ganglion Block procedure.
The RESET Therapy procedure uses a non-invasive
special binaural sound to temporarily unlock a part of the brain (hippocampus)
where trauma memories are stored. The transformative treatment is based on the
postulation that PTSD symptomology is sustained because of the memory factor,
not necessarily the trauma experience itself.
Consequently, the intent in this article is to compare the two procedures (RESET therapy vs. Stellate Ganglion Block) about efficacy, as well as similarities and differences in purported mechanisms of action. It is perceived that this effort is related to the overall objective of identifying a rapid remedial intervention that can begin to alter the ‘epidemic’ referred to in the above noted 60 Minute segment. Furthermore, for those colleagues who treat family issues, the authors have found that those close to the PTSD-afflicted individual may be exposed to the effects of ‘secondary traumatization.’ Thus, the residuals of trauma may impact the family system in the form of a contagious disease that negatively impacts spousal relationships, parenthood involvement, and aggressive expression within the household [11].
RESET THERAPY
The core
principles of RESET therapy are based upon three pillars of emerging
neuro-scientific knowledge. The first column began with the work of Nader, et al., [12] who
noted that “New memories are initially labile and sensitive to disruption
before being consolidated into stable long-term memories.” In other words, each
time a fear memory is reactivated, it is restored anew (reconsolidated)
principally in the amygdala and hippocampus regions of the brain. Theoretically,
it is perceived that these parts are equivalent to a locked storage vault for
long-term traumatic memories. Following this profound discovery, the quest has
been to find an efficient therapeutic key to open the vault in order to
selectively modify a trauma memory in a way that neutralizes it. Ongoing
efforts to weaken or alter retrieved trauma memories in PTSD continue at
present [13].
The second support column is based on psychologist Dr. Frank Lawlis’ [14] development of binaural beats
later understood through research efforts to be an effective ‘key’ to unlock the
hippocampal-based trauma storage vault [14,15]. Using the Bio acoustical
Utilization Device developed by Lawlis [14] as part of a protocol called RESET
Therapy (Reconsolidation Enhancement through Stimulation
of Emotional Triggers) [15], was able to alter the CAPS-5 scores in eight
combat veterans dramatically. The veteran volunteers in their study had
previously served in Vietnam, Desert Storm, and the Iraq/Afghanistan
conflicts. After receiving four treatment sessions of RESET Therapy, wherein
the average administration time of binaural sound was for a 15 to 20 min
period, the most dramatic resultant changes were noted in the CAPS-5 data (Figure 1).
Lindenfeld et
al. [15] reported that as a group, participants evidenced sharp reductions in
CAPS-5 total score, with group score at pre-treatment averaging 61.3 (SD=13.5),
reducing to a mean score of 15.5 post-treatment (SD 14.3). The difference
represents an average reduction of 55.8 points on an 80-point scale. Sample
median scores agreed well with the mean scores. All but one of the veterans in
the group no longer qualified for the diagnosis of PTSD, according to the
CAPS-5 criteria. The level of t-test significance for CAPS-5 pretreatment to
post treatment score reductions for the sample veterans was: p=0.00025. Lindenfeld
et al. [15] found large CAPS-5 score reductions with RESET therapy contrasts
with the earlier referenced [7] average drop of 10 to 12 points on the CAPS in
their meta-analytic study of ‘gold standard’ treatments.
RESET therapy
is based on the premise that trauma-induced circuitry in the brain is aberrant
(trauma has its own special fixed frequency, different from one’s normal
(pre-trauma) operative emotional frequency range. This aberrant frequency can
be identified operationally by carefully tuning the base frequency component of
a binaural sound that resonates with the selected trauma frequency (resonant
frequency). The veteran is carefully instructed to ‘tune in’ to the trauma
experience purely on a sensory basis. No talk (i.e., no disclosure of traumatic
theme or content) is involved in the actual process.
Once the
resonant (trauma) frequency is identified (delivered via a pulsed tone to the
right ear via headphones), the optimal frequency level in the left ear is
determined. The patient is asked to identify the moment when a calming or
fading (of the experienced bodily sensations) occurs, as the therapist slowly
adjusts a disruptor dial in the left ear comprised of both the resonant
frequency plus an (added) offset frequency ranging from 0 to 20 Hz.
The difference
between the resonant frequency (right ear) and disrupter frequency plus offset
(left ear) creates a binaural beat key. The unique sound creates in the patient
a subjective awareness of a third tone heard only by the patient’s brain,
comprising the absolute difference in frequency (Hz) between the frequencies
being delivered to the left and right ears. This binaural beat, ideally in the
theta range (difference of 4 to 8 Hz between ears) effectively unlocks the emotional
component of the trauma memory from the declarative component of the long-term
trauma memory and rapidly re-associates the trauma memory with calming (reduced
arousal) rather than fear or horror (high arousal).
Lindenfeld et al. [15] report to have observed this remedial
process (fear de-conditioning vs. reconsolidation-interference) to be
accomplished in as little as 5 min, evidenced by a significant distress (e.g.
SUDS rating) reduction and patient report that the memory is no longer as
disturbing as before. They follow up an initial 5-minute exposure trial with
one-to-three additional exposure sessions, each lasting 15-20 min (involving
pairing of binaural beat via headphones with the patient focusing upon
sensory/somatic aspects of the trauma) [16].
The third and
final column is based on a perspective that PTSD is a systemic disturbance that
creates a neuroinflammatory state which induces comorbid conditions. Current
studies implicate conditions of this type such as, “obesity, smoking disorders,
diabetes, and in particular cardiovascular disease (CVD)” [3]. A general
expectation is that “comorbidity is the rule and not the exception among
veterans with posttraumatic stress disorder [17]. As discussed earlier, this
appears to be fertile grounds for the practicing psychologist to offer
much-needed services to those who are afflicted through the impact of chronic
stress, which manifests in varied ways.
A link between
sleep disturbance, respiratory illness, and PTSD has been noted in a recent
article [17]. The comorbid level of chronic PTSD and addictive disorders is
estimated to range from 26% to 60% [18]. It is proposed that many patients
utilize substance to self-medicate from the trauma effects. The presence of
both conditions is associated with worse clinical consequences than either
disorder alone [19].
Approximately
half of the individuals with post-traumatic stress disorder (PTSD) also suffer
from major depressive disorder (MDD) [20]. Among Israeli veterans 4-6 years
following exposure to war trauma, the major depressive disorder diagnosis was
found to be the most prevalent PTSD comorbid condition (95% lifetime, 50%
current) [21]. Finally, the triadic co-occurrence of posttraumatic stress
disorder, chronic pain and traumatic brain injury (TBI) has been associated
with adverse outcomes.
Multiple
regression analyses demonstrated that: (1) race, chronic pain with PTSD,
alcohol abuse and MDD significantly predicted suicidal ideation; (2) pain
interference, chronic pain with TBI, chronic pain with PTSD, chronic pain with
TBI+PTSD, drug abuse and MDD significantly predicted violent impulses; and (3)
pain interference was a more critical predictor of suicidal and violent
ideation than pain intensity [22]. The psychologist may also contribute to pain
diminishment both by altering earlier-referenced neuronal circuitry involved in
sustaining trauma effects and by targeting the involved pain circuitry in its
own right.
RECONSOLIDATION ENHANCEMENT BY STIMULATION OF
EMOTIONAL TRIGGERS FORMAL STUDIES
The first published journal article regarding RESET therapy article by Lindenfeld et al. [15] appeared in the New Mind Journal in 2019, describing pilot study findings in eight combat
veterans (two female participants) representing three eras, including Vietnam,
Desert Storm and Iraq/Afghanistan [15]. The potential participants were
required to undergo a diagnostic interview, provide a copy of their DD-214, as
well as providing photocopies of medical records involving past PTSD diagnosis
or treatment. The authors mention the later inclusion of the Adverse Childhood
Experiences (ACE) questionnaire [23] to differentiate simple-PTSD from complex
(C-PTSD). It was noted that persons with complex PTSD tend to require a greater
number of sessions than those with simple PTSD.
Lindenfeld et al. [15] described their dependent measures as follows. Following acceptance
into the study, each volunteer underwent a state-of-the-art bio psychosocial
assessment with an independent psychometrician who was blinded to the nature
and purpose of the study. The measures administered included the CAPS-5, as
well as other psychological and neuropsychological measures. Participants each
underwent a pre-treatment qEEG (quantitative EEG) in which they were fitted
with an electrocap and assessed in an eyes-closed default condition and a
trigger (activate the target) condition. EEG signal was acquired via a 19
channel J&J Engineering (Poulsbo, WA) I-330 C2+ amplifier, with
modifications from the Mind-Brain Training Institute, running Physiolab USE3
software.
EEG recording
of the default condition (resting state) involved maintaining stillness with
eyes closed for 5 to 10 min. The second recording, referred to as the
‘activation’ or ‘trigger state,’ directed the veteran to focus his/her
conscious awareness and attention upon bodily sensations and subjective
experiences associated with the traumatic event. Though not necessarily
intended for clinical practice, pretreatment and post treatment qEEG
measurement were acquired in the ‘activate the target’ condition to provide an
analog of a condition utilized during RESET therapy itself.
During the
treatment phase, the veteran met with the Principal Investigator, a licensed
Ph.D. Clinical Psychologist and Diplomate, for an average of four treatment
sessions. Initially, the theoretic model underlying RESET Therapy was briefly
explained. The researchers asked veterans to reserve judgment and assume a
stance of skepticism about the procedure until they were convinced for
themselves that something had changed that was beneficial in altering the
quality of their lives.
The procedure
was provided for five minutes in the initial exposure trial. A Subjective Units
of Disturbance Scale (SUDS) was administered, based on a 0 to 10-point
subjective scale rating, with 0 being neutral or no emotional distress and 10
representing the highest level of emotional distress or disturbance
experienced. The objective of this step was to determine if the frequency of
the selected binaural sound resonated with the predicted trauma-circuitry in the
brain and if this resulted in an alteration in the experienced PTSD
symptomology.
Seven of the
eight veterans required four treatment sessions, with one attaining full
remission of symptoms following three treatments. Within one month of the last
session, the veterans were rescheduled for their psychometric evaluation as
well as their post-treatment qEEG. The recorded qEEG material was inspected for
artifacts and then uploaded into the New Mind Expert QEEG system database. The
New Mind database was selected by the investigators because its population
norms derived from a large sample of normal persons as well as subsamples of
individuals with clinical histories of various conditions. Also, a discriminant
function analysis derived via Neuroguide software [24] provided a second level
of normative comparison (with a database more sensitive to traumatic brain
injury). The discriminant function analyses suggested that it was highly
probable, statistically, that half of the sample (4 of the 8 participants) had also
sustained a comorbid mild to moderate Traumatic Brain Injury (TBI).
About the diagnostic status of the
participants, Lindenfeld et al. [15] report in their
pilot study that all eight veterans met DSM-V diagnostic criteria for
Post-Traumatic Stress Disorder on the CAPS-V interview at pretreatment;
however, post-treatment, seven of the eight no longer met DSM-V diagnostic
criteria for PTSD. One combat veteran marginally met PTSD criteria at
post-treatment, yet reported substantial symptom reduction. What was especially
remarkable about the findings was that all 4 of the individuals with a probable
comorbid mild to moderate Traumatic Brain Injury (TBI) pretreatment indicator
experienced substantial reductions in PTSD symptoms.
Lindenfeld et al. [15] reported that the
dramatic CAPS-5 score reductions were accompanied by
less dramatic, yet objectively-determined, improvement at a brain activation
level. 75% of the veterans showed a movement toward ‘normalization’ of the
qEEG, suggesting a rebalancing towards a healthier, more stable and balanced,
cortical activation status. The primary limitations of the study were (1) its
small sample size; and (2) lack of inclusion of a sham-treatment (equivalent
non-therapeutic form of auditory-stimulation), control condition and random
assignment to treatment conditions.
Positive
aspects of the study included: (1) the psychometrician being blinded to study
purpose and QEEG psychologist diplomat being blinded to results of
pre-treatment data, to minimize confirmatory bias. For example, psychometrician
who administered the CAPS-V interview reportedly had been hired independently
to do assessments and was unaware of key aspects of the study. Likewise, the
qEEG diplomat who acquired the pretreatment and post-treatment brain map (raw)
data reportedly was not able to discern (because raw data signal was involved)
subtle quantitative variations in the EEG raw data as it was being recorded
across sessions. Relatedly, the EEG raw data were handled by a third
knowledgeable clinician who artifact the data files and then uploaded them into
the New Mind Expert qEEG database to generate topographic reports, and to
compare pre and post maps for a percentage of normalization of the maps
following treatment.
The authors
concluded that refinements in methodology were needed in future studies,
including larger sample size, the inclusion of a sham-treatment control
condition, random assignment to treatment condition, the inclusion of
non-symptom behavioral/attitudinal measures of change, and inclusion of
collateral rating measures (psychometrically-validated ratings by a
knowledgeable observer). Their preliminary findings were provocative,
demonstrating the potential therapeutic power (and cost-effectiveness) of this
transformative innovation.
A case study of
a veteran with PTSD who had been court-ordered to treatment (related to a
domestic battery charge) was recently reported by Lindenfeld et al. [15] in the
neurofeedback journal, NeuroRegulation, published by the International Society
for Neurofeedback and Research. The authors’ portent that PTSD is a systemic
neuro-inflammatory state that disinhibits impulse control, including verbal as
well as physical outbursts of anger and rage in afflicted individuals. The
consequent cortical neuronal network in PTSD is conceptualized as having
shifted from a ‘top-down’ to a ‘bottom-up’ state, prioritizing survival
mechanisms over higher levels of complex functioning.
In their
aforementioned preliminary studies using RESET therapy, Lindenfeld and
colleagues characterize the unique features that make it attractive to the
mental health clinician including:
·
Its rapidity
in remediating trauma symptoms
·
Its minimal
invasiveness from the perspective of the patient
·
The use of
non-verbal, exposure-based methodology, which averts a fundamental problem
inherent in exposure-based therapies
·
Avoidance of
cumulative (secondary) exposure to the psychologically-toxic effects of trauma
From this
perspective, PTSD is viewed as analogous to a contagious disease, initiated in
the afflicted individual by a persistent sympathetic (fight, flight, or freeze)
autonomic nervous system response. A cogent case is made that there is no
singular qEEG ‘signature’ for PTSD, given that the neuroinflammatory process is
variable within and across individuals. They advise consideration of the
instigating vs. mitigating contributory factors and circumstances over time.
One could argue the same state-of-affairs holds about current explanatory
models of the underlying bio psychosocial ‘mechanisms of action’ of the PTSD
condition.
It would appear
that psychopharmacology has reached its limit in trying to address
trauma-induced issues through psychotropic medication management. The same
conclusion is evident for traditional talk-based therapies. Researchers have
noted that psychological trauma involves dysfunctionality of areas of the brain
that cannot be accessed or remediated through verbal means alone. No amount of
talk therapy can access or remediate the speechless horror or terror often
relived in the form of flashbacks and nightmares. At least three brain networks
have been implicated in PTSD, including the Default Mode Network (DMN),
Salience Network and Central Executive Control (CEC) Network, with their mutual
activation or inhibition patterns being made dysfunctional by the disorder.
Advances in the treatment of psychological trauma have been made in
transformative interventions which beneficially alter the memory
reconsolidation process.
These
transformative therapies, which require a willingness to ‘think outside of the
box’ on the part of the clinician, are based on neuroscientific breakthroughs
previously unavailable. The paradigm shift is from a largely cognitive and
behavioral foundation to that of a bio psychosocial and neuronal network focus. Lindenfeld et al. [15]
note that the RESET therapy method spares the practitioner
from exposure to raw limbic system material emoted by the patient. Despite the
therapist’s efforts to limit its impact, it may affect the practitioner at
subconscious levels.
The cumulative
development of secondary trauma-related symptoms and other subtle negative
perceptual/attitudinal shifts have been found to influence the emotional and
physical well-being of the therapist. The long-term effect of shielding from
this emotionally toxic contact permits the empathic psychologist to maintain
his/her well-being, optimistic outlook, effectiveness and efficiency throughout
a full career. Additionally, the resetting of aberrant neuronal networks has
the capability of truly re-establishing neurobiological homeostasis in the
afflicted patient.
The case study
involving RESET therapy [1] merits further description. The authors detail the
treatment of a court-involved combat veteran who was charged with Intimate
Partner Violence. While in the military, he was involved in eighty-four months
of combat engagement over his 32 years of active service. His vivid report of
traumatic experiences while in service was provided to clarify the extent of
the trauma he incurred. Within the context of RESET therapy, the traumatic
material is typically not discussed, as the intervention is non-verbally based
(reducing avoidance and shame in actively and privately confronting the
memories on the part of the patient). Included were pre-treatment and
post-treatment measures indicating dramatic positive changes, such as
statistically and clinically significant CAPS-5 score reductions. The
participant’s CAPS-5 score of 58 was indicative of the presence of PTSD. This
elevated score was later reduced to 5 following three RESET therapy treatment
sessions, which is largely unheard of in trauma treatment.
On the Personal
Assessment of Intimacy in Relationship scale (PAIR), results revealed a shift
from an isolative and underlying state of anger and intimacy-avoidance to one
of sociability, engagement, and increased capacity to engage in reciprocal
intimacy. Given that batterer intervention programs commonly use psych educational
weekly group intervention that spans 6 months or longer, yet have been
criticized empirically as lacking more than modest effectiveness, perhaps
consideration of concurrent or alternative cost-effective and efficient
interventions is warranted.
It is at this
point that a shift in focus is appropriate to the medical intervention of
Stellate Ganglion Block, which has been gaining increased media attention and
interest. As with the prior review of RESET therapy, startling similarities are
noted in immediate results that are obtained through both interventions. SGB’s
transformative changes in active duty personnel with PTSD are likewise fertile
grounds for hypothesizing the existence of neuronal network(s) that contributes
to sustaining PTSD symptomology. While the SGB practitioner maintains that the
treatment is not permanent, permanent symptom remediation is reportedly
possible through the RESET intervention. The intensive ongoing SGB research may
provide us with further support that will enhance our understanding of the
underlying mechanism of action of both interventions.
STELLATE GANGLION BLOCK
The Stellate
Ganglion Block (SGB) is a brief outpatient medical procedure, performed by
highly skilled anesthesiologists or interventional pain-management physicians.
The intervention has been used to treat various disorders, including complex
regional pain syndrome, hot flashes, migraines, facial pain, and upper
extremity pain. The stellate ganglion is part of the sympathetic nervous
system, which is found in a cluster of nerve cell bodies located between the C6
and C7 vertebrae. Injection of a local anesthetic to the stellate ganglion is
thought to inhibit sympathetic nerve impulses to the head, neck and upper
extremities.
The specific
mechanism of action by which SGB may mitigate PTSD symptoms remains
incompletely understood. A proposed explanation for the prolonged effectiveness
of SGB on PTSD has been rendered. It is now believed that the targeted
application of a local anesthetic to the stellate ganglion leads to an
immediate and dramatic reduction in the level of sympathetic nerve
activation/innervation. A resulting decrease in sympathetic (nerve) dendritic
sprouting and brain norepinephrine levels is postulated to result from this
intervention [25].
Ropivacaine or
bupivacaine, 7 ccs of 0.5% solution, are the most common anesthetic types and
dosages used in SGB. The use of image-guidance techniques is advised to avoid
potentially serious adverse effects of inaccurate needle placement to the
anatomy surrounding the stellate ganglion. Procedures such as ultrasound,
fluoroscopy, or computed tomography are recommended to help visualize the
injection area. SGB performance also requires the availability of continuous
vital sign-monitoring technology and resuscitative equipment and personnel, to
monitor and respond to changes in respiration and circulation that may occur as
a result of unintentional intravascular injections [26].
The stellate ganglion is involved in the sympathetic ‘fight and flight’ neural/adrenal response network and, tends to be chronically hyper activated in conditions such as PTSD. As chronicled by CBS 60 Minutes, within minutes of the first injection by an anesthesiologist or interventional pain management physician, two military veterans described an experience of being liberated from the chronic hyper arousal of PTSD and sensing a normal level of arousal for the first time since their pre-military service.
RECENT STELLATE GANGLION BLOCK STUDIES FOR PTSD
A series of
case studies referenced by Hanling et al. [27] was utilized to treat 27 PTSD
involved veterans, with the results found to be very promising. Consequently,
the procedure received widespread attention following the publication of a case
series of 166 Special Forces active military veterans who elected to receive
the procedure at Walter Reed Medical Center. These participants were assessed
with a PTSD checklist (PCL) the day before the procedure, one week following
and at three months and six months post-procedure. The authors reported a
success rate of 70%, defined as a sustained reduction of 10 or more points on
the PCL [28].
However, when
the procedure was subjected to tighter experimental control, the outcome was
quite different. A study conducted at San Diego Naval Hospital randomly
assigned 41 military veterans with PTSD to an active treatment condition (SGB)
versus a sham treatment condition (placebo injection of saline). The
participants and the assessors were blinded to the purpose of the study. The
researchers reportedly replicated the procedures described in the preceding
Mulvaney et al.’s study [28] concerning the injection site and dosage of the
analgesics provided.
Participants in
the sham treatment group were allowed to cross over to the treatment group, and
participants who met criteria for PTSD were allowed to receive a second SBG
treatment. While symptoms (PTSD, depression, anxiety) improved across time in
both groups, there were no statistically significant differences between the
active and control conditions, thereby failing to replicate the findings of the
earlier studies [29].
Calling for
caution and continued research [27] cited an example of a 53 year old veteran
with a 10+ year history of PTSD who upon receiving his first injection
(placebo), reported a sense of wellness and a lifting of anxiety to where he
felt the best he had in over a decade. After the second injection (SBG), the
veteran noted, “similar but less dramatic results.” Feeling well enough to take
a trip with his family for several weeks, he suffered a significant relapse of
symptoms over the course of a day, but indicated that he would be willing to
undergo the procedure again multiple times if he could attain the same level of
improvement he had experienced with the first two injections [27].
Lipov [30], an
anesthesiologist/researcher, involved in many of the earlier studies, critiqued
differences between the Mulvaney et al. [26] and Hanling et al’s [27] outcomes,
based primarily on methodological grounds [29]. The experimental group was
roughly twice the size of the control group, hence a lack of equivalent group
sizes. Lipov [30] contends that procedures used in the RCT differed from those
of earlier studies regarding the exact site of injection, noting that a much
lower dose of the active analgesic medication was used in the Hanling et al.
study [29].
There were
qualitative differences, as well, between the populations of military veterans
under study. In the Walter Reed study, the participants were active duty
Special Forces, whose group norm was to deny PTSD symptoms. However, upon
learning of the magical results experienced by others, some of these
individuals may have initially over reported symptoms to qualify for
eligibility for the study and, then minimized symptoms following the study to
be deemed fit to return to duty ASAP.
Alternatively,
in the San Diego Naval Hospital Study, many participants were characterized as
‘part-timers’ who were close to discharge, and who were applying for
service-connected benefits for PTSD, and hence may have had a vested interest
in maintaining higher levels of symptoms before and after treatment. Neither
study provided sufficient focus upon treatment dropouts or non-responders, nor
was potential side effects given sufficient emphasis [25,27,30].
Reviewing the
research from the perspective of the Department of Veterans Affairs, Peterson
et al. [25] found that SGB might have an inhibitory effect upon neural
connections between the peripheral sympathetic nervous system and the central
sympathetic nervous system, thought to be persistently hyper activated in PTSD.
Potential benefits of SGB include the elimination of negative stigma associated
with seeking treatment by labeling it as a biological intervention to manage
symptoms. Other claims are that it offers rapid near-immediate symptom relief
and improved compliance because it does not require daily or weekly
administration.
The above
researchers suggest that until a more conclusive investigation has been
conducted demonstrating safety and efficacy, there is not sufficient evidence
for widespread clinical use of the procedure. Nevertheless, the intervention
may be viewed as an initial treatment or bridge that allows sufficient
reduction of hyper arousal to permit involvement in other evidence-based
interventions. Whether or not VA will opt to invest in experimental research on
the utility of PTSD, versus other promising interventions (e.g.
stimulation-based) remains an open question at this point. U.S. Army Medical
Research is currently funding a three-year, $2 million single-blinded placebo
control study of SGB involving 242 active duty personnel diagnosed with PTSD.
The study began late in 2015 and formal publications of the results are
expected by summer or late 2019.
FUNCTIONAL NEUROANATOMY
In this
section, similarities between RESET therapy and SGB are compared to seek a
commonality between the two approaches that independently appear to produce a
significant diminishment of hyper arousal in the PTSD-afflicted individual.
Supportive evidence concerning neuroanatomical links between auditory
stimulation and limbic-system-mediated emotional responding is present from
several lines of investigation [31]. A review of the effects of music and its
impact on the neurochemical systems related to stress and arousal; the immune
system, reward, motivation and pleasure as well as social affiliation was
provided by Chanda and Levitin [32].
The auditory
steady-state evoked potential (SSEP) in the scalp electroencephalogram (EEG) is
“an evoked neural potential that follows the [frequency] envelope of a complex
stimulus. It is evoked by the periodic modulation or turning on and off, of a
tone [clicking]” [33]. Reports of the functional neuroanatomy underlying the
auditory SSEP supported the contention by Lindenfeld et al. [34] that “through
the acoustical pathway we can directly modulate neural activity in the
amygdalohippocampal circuit during memory retrieval and reconsolidation.”
Investigations
of auditory fear conditioning have shown that auditory stimulation, fear, the
medial geniculate nucleus of the thalamus and the basolateral complex of the
amygdala are intertwined [35-37]. These kinds of interactions are most likely
the behavioral and neuro-anatomical basis for the clinically-observed success
of RESET therapy as well as the stellate ganglion block. Alternative
investigations of deep brain stimulation (DBS) in humans have revealed that it
is capable of changing emotional behaviors. This effect may be analogous to
auditory stimulation [38,39].
Sufficient
evidence exists supporting the presence of neuroanatomical links between
auditory stimulation and emotional responding. Additionally, evidence
implicates the amygdala in memory reconsolidation and fear conditioning. Now,
consider this statement concerning SGB.
Better
understanding of sympathetic neuroanatomy via anatomical labeling techniques is
starting to support explanations of the extensive effects of SGB for treatment
of hot flashes, PTSD and neuropathic pain. In the course of mapping the
sympathetic nervous system to the related regions of the cerebral cortex, Wampold
[6] used pseudo rabies virus injections to identify connections of the stellate
ganglion. Pseudorabies virus allows identification of neural pathway
connections that are 2-3 synapses from the point of injection of the virus.
Early labeling was found in the hypothalamus and central nucleus of the
amygdala. With slightly longer time, labeling was found in the lateral,
basolateral and medial amygdalae. After 6-8 days, injections of the stellate
ganglion produced extensive trans-neuronal labeling in the infralimbic, insular
and ventromedial temporal cortical regions [40].
Using
additional information from other sources, Lipov et al. [40] proposed the
following, evidence-based hypothesis: We believe that CRPS (chronic regional pain
syndrome), hot flashes and PTSD are centrally-mediated, where a relevant insult
leads to increase in NGF levels, which starts a cascade that leads to
sympathetic sprouting, which further increases brain norepinephrine, which
finally leads to the clinical conditions described in this article. Reversal of
this cascade occurs by application of the local anesthetic to the stellate
ganglion, which reduces NGF, which reduces sympathetic sprouting, leading to
the reduction of the brain norepinephrine, which finally results in resolution
of symptoms of CRPS, hot flashes and PTSD. This hypothesis provides a plausible
explanation for the prolonged effect of the local anesthetic markedly beyond
the length of the half-life expected by the pharmacokinetics of the local
anesthetic [40].
A primary focus
on the proposed feedback mediated by the 2nd and 3rd
order connections from the stellate ganglion of the sympathetic nervous system
(SNS) to the amygdala appears to be a common link to both procedures. Lanteaume
et al. [41] noted that “our findings provide major evidence of a link between
emotional affect, facial expressions, sympathetic activity and amygdala
stimulations in humans”. Narayanan et al. [36] concluded that the
reconsolidation of remote contextual fear memory includes changes in
theta-frequency interactions between the lateral amygdala and hippocampal area
CA1.
An additional
investigation of the amygdala showed that it encodes, stores, and retrieves
episodic-autobiographical memories (EAM). Markowitsch et al. [42] provided
extensive evidence that the “amygdala’s main function is to charge cues so that
mnemonic events of a specific emotional significance can be successfully
searched within the appropriate neural networks and reactivated”.
The amygdala
mediates activation of the SNS, which is involved in the reconsolidation of
remote contextual fear memory. Furthermore, it supports the search for mnemonic
events of a specific emotional significance within appropriate neural nets,
leading to their re-activation. Applying the Lipov’s [40] hypothesis to these
characteristics of the amygdala, one may conclude that positive feedback from
the stellate ganglion of the SNS, via 2nd and 3rd order
neurons may enhance these functions to a significant degree. Thus, SGB may act to
block positive feedback, thus lessening or preventing the involuntary
re-activation of unwanted, fear-associated memories that occur in PTSD.
Conversely, there is a parasympathetic nervous system (PNS) neuromodulation
therapy used in humans that provides some context for the idea that SGB may
calm a positive feedback loop associated with PTSD symptoms through vagal nerve
stimulation (VNS).
VNS uses
intermittent stimulation of the left vagus nerve in the neck to reduce the
frequency and intensity of [epileptic] seizures. [The] mechanism of action of
VNS remains uncertain, but stimulation does not induce grossly visible
alterations in the human EEG. Recent studies suggest that metabolic activation
of certain thalamic, brainstem and limbic structures may be important in
mediating the effect of VNS. Depletion of norepinephrine in the locus coeruleus
attenuates the anti-seizure effect of VNS [43].
In theory,
afferent VNS elevates norepinephrine release in the locus coeruleus (LC). The
LC has widespread effects in the brain, spinal cord, and autonomic nervous
system (ANS). At one time, the LC was thought to be a major player in a diffuse
ascending reticular activating system (ARAS). Now we understand that the LC has
many specific functions in the brain [44,45]. Stimulation of the LC causes
adrenergic inhibition of preganglionic parasympathetic ganglia. It also causes,
among many other effects:
·
Release of the
excitatory neurotransmitter noradrenaline in the neocortex,
·
Excitation of
anxiety responses mediated by adrenergic neurons in the amygdala,
·
Possible
declarative memory enhancement mediated by adrenergic neurons in the
hippocampus,
·
Stress
responses by the ANS mediated by adrenergic neurons in the paraventricular
nucleus of the hypothalamus.
The effects of
VNS are likely to enhance symptoms of PTSD, with this certainly being an
untoward side-effect in patients with intractable epilepsy. However, from these
observations, it may be surmised at the most basic contextual level that, if
parasympathetic influences (i.e., VNS) on the amygdala may enhance PTSD
symptoms, then SNS influences (i.e., SGB) may have the opposite effect (Table 1).
A brief
examination of functional neuroanatomy suggests that parallel neuromodulatory
mediations of auditory stimulation and SGB are available for the treatment of
PTSD. Neuroanatomical links are present between auditory stimulation and
limbic-system-mediated emotional responding. The amygdala has been implicated
in memory reconsolidation and fear conditioning.
Evidence
supports a proposed feedback connection from the stellate ganglion via 2nd
and 3rd order connections to the amygdala. The effects of this
sympathetic SGB connection may be compared and contrasted with parasympathetic
VNS neuromodulation, which has the potential to exacerbate PTSD. Whether
PTSD-related neuromodulation occurs via auditory stimulation, SGB or VNS,
questions remain: At what neurobiological level(s) are the effects manifested
and how long do they last?
SBG is an invasive
medical procedure, intended for management of PTSD hyper arousal symptoms over
time. In some ways, it is similar to a steroidal epidural procedure for chronic
pain, which reduces inflammation temporarily. The consequent physical pain
relief may last for weeks to months before a repeat procedure is needed. As
noted earlier, any intervention targeting areas close to the spine and major
arteries and veins may involve risks of adverse effects.
The SGB
procedure is still considered to be experimental and has not been studied well
enough to determine cumulative effects upon efficacy (e.g. improved efficacy
after several injections) or whether the neural circuitry may begin to
habituate to the effects over time, rendering it less effective in potency or duration.
SGB does not permanently alter the characteristics (e.g. dominant or resonant
frequency and amplitude) of the neuron network of PTSD, which postulates a
rebalancing of sympathetic (e.g. reticular activating system, amygdala, limbic
system, cingulate cortex, prefrontal cortex, hemispheric asymmetries) and
parasympathetic (limbic, vagal) circuitry.
In contrast,
while RESET therapy is also considered experimental, it appears to produce a
reboot of the involved neuronal network, leading to the rebalance of the
sympathetic and parasympathetic systems, as evidenced in qEEG pre and
post-treatment findings. Practically speaking, this means that the long-term
effects of exposure to a neuroinflammatory state alter back to a pre-trauma
level. Through this transformative change, later difficulties such as delayed
onset PTSD are minimized. From the psychologist’s perspective, the patient is
now fully available for therapeutic involvement. Previously, the patient was
operating from an emotionally and instinctively based ‘protect and defend’
mode, referred to as a ‘bottom-up.’ With a successful transformative
experience, higher level abilities attain inhibitory control over subcortical
emotional processes, once again.
RESET therapy
is a minimally invasive procedure. Like SBG, immediate positive effects have
been reported, at least episodically, after an initial 5 min exposure trial.
The method involves the accurate identification and pairing of the binaural
beat with the patient’s directed attentional focus upon physiological/sensory
experiences/changes elicited via recall/reactivation of the traumatic memory.
Lasting, permanent reductions in PTSD symptoms to subclinical levels have
reportedly been demonstrated via preliminary prospective research within one to
four sessions of RESET therapy, although controlled studies have not yet been
conducted to include a sham control (placebo control) group and blinded
research design. The permanent symptom changes facilitated by RESET therapy are
associated with significant shifts toward normalization of qEEG patterns.
Topographical brain mapping suggests reorganizational activity occurring at the
cortical level involved in normalizing asymmetry and cortical activation
patterns, which is consistent with our tenets of a neuronal model of PTSD.
SGB requires a
high level of trust in the clinician administering the procedure because of the
risk of infrequent but potentially very serious complications. In contrast, the
RESET therapy practitioner reportedly encourages an initial stance of healthy
skepticism on the part of the veteran until the patient is convinced that
significant symptom relief has occurred. Furthermore, the difference in
potential cost over time is dramatically different between RESET therapy and
SGB. SGB costs have been estimated to be lower than conventional PTSD
therapies, i.e., $2,000 for two SGB injections vs. a range of $6,000 to $30,000
for other conventional psychological and psychiatric interventions [25]. Two
SGB injections may be expected to last at least six months (based on the large
N studies to date) to perhaps a year. The expectation is that once the
beneficial effects eventually wear off, the series of two injections will need
to be repeated, perhaps on an annual basis.
RESET therapy in uncomplicated (simple) PTSD cases, requires a typical expectation of one to four outpatient treatment sessions, each costing $150, which could potentially eradicate uncomplicated PTSD. Side effects have temporary and minimal effects including lightheadedness, mild headache, mild jitteriness or post-adrenalin symptoms, fatigue. By contrast, the estimate for aversive effects with SGB, while quite low, is reported at 0.002 for risk of death or damaging physical consequences. Also, as described earlier, only 80% of humans are estimated to have the stellate ganglion available for the procedure, thus leaving one in five without the SGB intervention possibility.
It appears that
initial training and certification of licensed mental health practitioners in
the RESET therapy method and acquisition of the commercially available
technology are significantly lower in time and costs than that required of
other bio psychosocial interventions. Moreover, rather than repeat
administrations of SGBs, veterans with treatment-resistant PTSD can be issued
their portable treatment device (BAUD unit) with instructions about how to tune
the unit to address PTSD-related issues as well as other mental health-related
issues, including anxiety, depression, anger and chronic pain. In rural areas,
they may also be followed via telecommunications by a skilled and
properly-trained psychologist practitioner.
SGB seemingly
appeals to active military personnel because it allows a quick temporary fix to
allow the soldier to return to his/her unit rapidly. After military discharge,
however, the role of SBG is less clear-cut. It may appeal to the younger
veteran in distress who needs a quick fix (rapid re-stabilization) and who is
unwilling or unable to engage in the more difficult emotional work of tackling
the root causes of PTSD, as currently available.
Veterans with
PTSD who have navigated the VA system have usually experienced partial
measures, such as being provided with medications that may somewhat reduce
arousal, but not sufficiently effective to address the central issues of
intrusive material, insomnia, hyper-vigilance and avoidance. With their PTSD,
at best, partially-treated, many of these veterans remain unable to function at
their previous level in civilian society and begin the game of the VA benefits
process, which rewards sickness rather than health. RESET Therapy could play a
pivotal early intervention role when active duty veterans first enter the VA
system.
Since RESET is
a non-verbal treatment, patients are not required to disclose their traumatic
experiences [1,15]. The sole directed focus is upon sensory awareness during
brief exposure sessions, involving the presentation of individually-attuned
binaural beats (co-awareness of bodily sensations and the pulsed,
individually-attuned sound. By aggressively and effectively targeting PTSD
early on with effective measures, such as RESET therapy, the pattern of
ineffective treatment leading to pursuit and maintenance of disability can be
effectively disrupted, improving lives and resulting in tremendous savings and
reinvestment in new technologies to combat challenging healthcare-related
issues by the Federal Government.
SUMMARY
The authors
compared and contrasted two fascinating and rapidly transformative
interventions for Post-traumatic Stress Disorder that initially appear to
demonstrate high levels of success with minimal treatment complications, side
effects or treatment dropouts. One noteworthy treatment that has been the focus
of increased attention by the media is an outpatient medical procedure called
Stellate Ganglion Block, delivered by skilled anesthesiologists or
interventional pain management physicians.
The second
transformative intervention is a little-known auditory stimulation-based, brief
exposure intervention called Reconsolidation Enhancement through Stimulation of
Emotional Triggers (RESET therapy) provided by psychologists and other trained
mental-health professionals. Stellate ganglion blocks have been used for many
decades to address varied medically-based, pain-related conditions. Similarly,
auditory stimulation has been used therapeutically in numerous applications
other than PTSD. It has only been the past decade that the two approaches have
been applied successfully for the treatment of post-traumatic stress disorder.
As earlier
described, SGB is a brief, precisely targeted procedure that potentially
provides a dramatic reduction of sympathetic nervous system arousal within one
or two treatments. It is newly-intended for emotional pain relief, as opposed
to its previously targeted use for chronic pain. The intervention is labeled as
not being a cure for PTSD, which is expected to recur once the therapeutic
effects of the injection have worn off. There is an apparent absence of new
learning or permanent neural reorganization with the SGB procedure. Rather,
there is a temporary inhibition and quieting of a persistently hyper activated
autonomic nervous system.
Bearing aspects
of similarity to SGB, RESET therapy is brief and precisely targeted. There is
no verbal disclosure by the patient of the traumatic memory. The patient is
initially prepared for the procedure by the treating psychologist by being
alerted that he/she will likely experience rapid and intense shifts in arousal
in response to changes in auditory frequency stimulation. The ‘tuning in’
process is designed to identify the resonant trauma frequency, and the
corresponding optimal offset setting, producing a binaural beat ideally in the
theta range (activating the parasympathetic nervous system), which is central
to the potential success or failure of the intervention. An initial five-minute
exposure trial (pairing focus upon sensory experiences associated with the
recall of the trauma with the continuous binaural beat delivered via
headphones) provides a preliminary indication as to whether or not the derived
settings successfully altered hyper arousal associated with trauma recall.
RESET therapy
is hypothesized to interfere with the reconsolidation of the traumatic memory
by leaving the explicit (declarative) aspect intact while altering the
subjective (implicit) emotional valence aspect of the memory. It is
hypothesized that the temporary success of the Stellate Ganglion Block
procedure confirms a hypothesis of PTSD being a systemic disorder, rather than
solely a psychologically-based condition. RESET therapy purportedly rebalances
the sympathetic and parasympathetic nervous systems by inducing changes in
patterns of activation and deactivation involving aspects of the neural
networks that are involved in fear of learning, including neural feedback
loops.
With successful
intervention, normative hemispheric asymmetries and blood flow patterns are
re-established; over activation reduces in the right hemisphere and
under-activation in the left hemisphere reverse. The prefrontal lobe regions
normalize their activation patterns and the previously overactive right and
central parietal and bilateral occipital areas become stabilized. In other
words, cortical activity reboots back to normal premorbid levels of activation.
Unanswered
questions remain regarding long-term use of SGB. For example, does SGB have a
cumulative effect whereby a series of injections works additively to facilitate
optimal results over time? Alternatively, do the neurons in the Stellate
Ganglion Block begin to habituate to the procedure over time, with symptom
relief becoming progressively lesser in degree and duration? Does using an
artificial means of inhibiting the brain’s sympathetic nervous system over time
have any deleterious effect upon the brain’s neuroplastic capacity to
self-regulate and self-organize? All of these are currently unanswered
questions.
The smaller
number of formal studies of RESET Therapy, including both of the [1,15]
studies, has shown dramatic, positive, rapid and seemingly lasting non-invasive
results. However, follow-up evaluations have not occurred due to lack of
funding. All studies to date were conducted on a pro-bono basis. A prevalent
hope is that researchers in the future can obtain adequate funding to finance
studies using improved methodologies such as a larger sample size, random
assignment to either active treatment or sham treatment control. Inclusion in
the latter group would need to include subsequent crossover so that those in
the control group subsequently receive the benefit of RESET therapy. Finally,
in any unbiased treatment study, there needs to be adequate blinding of
participants and assessors/raters.
As clinicians
who have worked with veterans, the authors dare to dream that someday,
somewhere close to a base of a distant military operation, a trained corpsman
with psychological supervision, adequately trained in RESET therapy, will
immediately address a service member’s adverse reaction to a traumatic
experience. To take this dream a step further, within the VA system, early
intervention via a transformative treatment such as RESET or SGB can achieve
rapid relief, potentially reducing the need for later costly specialty
treatment, inpatient psychiatric hospitalizations or referral to specialized
PTSD programs.
Furthermore, in
complex PTSD cases, the veteran can be issued his or her treatment unit with
RESET training provided by his/her treating psychologist. Supervised
telecommunication can enhance self-applied efforts through the provision of
supervision at needed transition points. Through procedures such as these, the
PTSD intervention can be destigmatized and reframed as a biologic intervention
designed to rebalance the nervous system rather than referring to it as an
illness.
Theoretically, early implementation of a transformative treatment for PTSD could increase medical compliance, improve life satisfaction for veterans and their families, and reduce the financial burden upon the Federal Government for the perpetual care of trauma-altered veterans. In theory, this would allow an increased number of veterans to have treatment available rapidly and effectively. Given the heartbreaking failure of current evidence-based treatments to adequately treat PTSD (only about 40% of cases seeking treatment receive it and of those individuals, only about 60% get some symptom relief), we dare to dream of a future where these dismal percentages significantly alter. Our dream includes a major shift in the unacceptably high suicide rates among veterans.
When hope
replaces despair, when healthy passion replaces apathy, when engagement
replaces withdrawal and isolation, self-destructive ideation becomes a distant
and fleeting past thought, rather than a perceived solution to unbearable and
inescapable life experiences. As psychologists, we expect that our colleagues
in other healthcare disciplines will quickly accept and utilize transformative
therapeutic approaches such as SBG and RESET, once these approaches have been
deemed to have sufficiently met the rigors of scientific inquiry through multiple
research inquiries. The advent of transformative treatment as an emerging
therapeutic approach is upon us. Will we, as independent psychology
practitioners, rise to the impending challenges thrust upon us or will we
continue to opt for the status quo?
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