PTSD Research at Fort Bragg: Prediction and Prevention
A National Center for PTSD Fact Sheet
Charles A. (Andy) Morgan III, M.D., is Director of the Stress and Resilience
Laboratory within the Clinical Neurosciences Division in West Haven, CT. He
and his staff have been engaged for a number of years in groundbreaking research
with active-duty military personnel at the John F. Kennedy Special Warfare Center
and School at Fort Bragg, NC. They are studying trainees under stress in an
effort to better understand the development of PTSD. His work may point the
way not only to more effective treatments but also to possible preventive measures.
Janet Bailey interviewed Dr. Morgan about his work in August 2002.
How did you get involved in PTSD research with active-duty military
personnel?
When I first joined the National Center for PTSD in 1989, we were working
with combat veterans of the Vietnam War and later with veterans of the Gulf
War. The data that were coming out of the early biological and psychological
studies suggested that people with PTSD exhibited a number of differences
compared to people without PTSD. There were differences in their physiology-for
instance, in their startle response (how jumpy they were) to sounds when we
showed them reminders of war stress. We also noted differences in certain kinds
of mental symptoms such as dissociation-for instance, colors appearing brighter
or events seeming to move in slow motion. And we found differences in levels of
certain chemicals that are known to play a critical role in how the brain
responds to stress.
What concerned me at the time was that the majority of our research was
based on retrospective data. We were assessing PTSD patients in the present and
making assumptions about what had happened in the past, which was sometimes
decades ago. We really didn't know whether the differences in biology,
physiology, and psychology that we documented were the result of having PTSD or
whether those differences in fact predated the traumatic exposure. If the
latter were true, then perhaps these differences are actually risk factors that
make some people more or less susceptible to developing the illness.
For instance, one might wonder why PTSD patients have differences in startle
response. Well, it may be that some people have an exaggerated startle response
to begin with, and those people have a heightened sensitivity to stimuli
resulting in the situation where trauma has a more severe impact on them. If
that's true, then this might be something you can measure ahead of time to
identify groups at higher risk for developing PTSD.
So you wanted to study people before they experienced trauma.
That's right. I decided I wanted to do prospective, not retrospective,
studies*, but it would be just about impossible to do that with PTSD research.
We would have to start with a group of healthy people, hope that they get
traumatized equally, assess them within the same time frame, and then follow
them over time to see who gets PTSD. This certainly wasn't going to work! So I
thought, "What organization routinely puts healthy people in harm's way?" The military.
I started contacting military bases around the country and eventually got a
call from Col. Gary Greenfeld, who was the Psychological Applications Director
at Fort Bragg. He had been an enlisted soldier in Vietnam, then got a
psychology degree from Johns Hopkins, and later got back into the military to
develop a program for Special Forces teams. He asked, "Do you think there is a
profile of people who are stress-hardy versus stress-vulnerable? We want the best
people we can have, and if there's a way to identify people who might not do
well under stress, we'd like to know that."
So it seemed that he and I wanted to study the two sides of the same
coin.
The Military Survival School at Fort Bragg provides training in how to
survive in the desert or avoid captivity and, if captured, how to avoid being
exploited by the enemy. It's a very rigorous program that includes both
classroom training and exposure to a mock POW camp where trainees, after being
captured, are held for a few days.
But is this really the same as experiencing stress in the real world?
Surprisingly, yes, it is. We measured trainees' psychological symptoms
before and after the training as well as physical symptoms like hormone levels
and heart rate. We found that trainees report extremely high levels of
dissociative responses-even higher than in people under the influence of
hallucinogenic drugs. We also found that elevations in the stress hormone
cortisol and reductions in testosterone were some of the most dramatic we have
ever seen. After only eight hours, for instance, testosterone levels of the men
were lower than levels we see in many women.
What else have you found with your research?
One of the most significant findings was with a peptide called "Neuropeptide
Y." It is a substance that, in addition to many other actions, works on the
prefrontal cortex of the brain and helps you stay focused on a task even under
stress. We found that the Special Forces trainees-the Green Berets-produced significantly
more NPY than the Rangers and Marines who were going through the same training.
Twenty-four hours after completing the training, the Green Beret trainees were
back to baseline levels of NPY while the others were significantly depleted. In
fact, there was a direct positive relationship between the amount of NPY and
performance in the training. There also was a clear, negative relationship
between performance scores and the number of dissociative symptoms reported by
the trainees and [a negative relationship] between NPY and dissociation. In other words, the less NPY soldiers had,
the more they dissociated, and the more they dissociated, the worse they did in
their training.
We were very excited by these results!
They suggest that at least some of the physiological factors predate the
development of PTSD, that people who release high levels of NPY under stress
stay mentally focused. They don't have as many symptoms of dissociation, and at
the end they bounce right back to where they started. Others, those that
produce less NPY, performed very poorly in the training and looked a lot more
anxious and frazzled at the end.
Then we looked at their trauma histories to see whether a history of
childhood trauma or child abuse predicted differences when they went through
training. Interestingly, those in the Green Beret units tended to have endured
more child abuse but did better under stress. Trainees from the Rangers and
Marines with a history of child abuse had more trouble during training. They
didn't produce as much NPY, they dissociated a lot, and they didn't perform as
well.
This of course raises a key question:
Did the Green Beret trainees come that way, or was there something in
their previous training in the military that helped them perform better under
stress? We're going to be looking into this question by studying the selection
program this fall. By measuring NPY and other factors, will we be able to
predict who the Army is going to select for the Green Beret training?
What are the implications of all this for veterans and others who suffer
from PTSD? Do you see your work leading to better treatments?
We've been able to replicate our findings about NPY and psychological
responses to stress at two Navy sites in both women and men and in the Combat
Dive School in Key West. We can now argue convincingly that NPY, or drugs that
work like NPY, act as anti-anxiety or anti-stress agents. At this point, we
need to figure out how to develop these agents so we can use them with people
who suffer from PTSD. There may come a time when replenishing NPY is a normal
procedure when a person comes back from a stressful situation, in the same way
that you would feed him if he had been malnourished.
Of course, the real benefit would be in prevention. For instance, a low
level of NPY may be a marker that helps us identify which people may be more
vulnerable to developing PTSD. We could put people on a treadmill for 20
minutes and measure their levels of NPY, along with other things. It would be
like an insurance company doing statistical analysis to determine who is a good
risk.
We've also developed a little paper-and-pencil test called an "experiences
questionnaire," which asks mostly about dissociative symptoms. Over the years,
we have administered it to over 2,000 people before they began the Military
Survival School, and we consistently find that people who score high on the
test don't make it through the training. If you just screened those people out
at the beginning, it would save the Army millions of dollars.
Have your findings changed the selection of or methods for dealing with
active-duty personnel?
One of our goals certainly is to develop cost effective methods of weeding
out people who shouldn't be there and selecting the ones that should. But the
Army doesn't like the idea that someone might be prevented from doing something
he or she really wants to do. Also, the military has historically been
reluctant to give too much attention to psychological problems, so there has
been some institutional resistance.
Why is that?
As far back as World War I, studies of what was then called "shell shock"
have shown that if people are given a way out of a difficult situation, they
will take it. The British sent their soldiers back to England for treatment,
and the soldiers almost never came back to the front. The French decided they
couldn't afford that, so they treated their people right at the front lines,
and they had a much better rate of success.
Many people will keep working as long as they think there is nothing wrong with them-that is, as long as they
don't identify themselves as ill. The military trains their medics to identify
symptoms and to recognize when to send people for some downtime. But the medics
have to be careful that they don't send the message to a person that he not
only feels bad but also is useless, because then it can destroy that person's
sense of confidence. We doctors can sometimes communicate a picture that makes
a person feel weak and vulnerable if we're too quick to diagnose an illness.
Interestingly, the people who go through Special Forces training all say, at
the end, that it was the best training experience of their lives. The people
who don't do so well are the individuals who leave without completing the
training. They carry away a sense of failure. They think, "Not only was I
scared, but I failed too." You know, one of the best predictors of PTSD is the
subjective view the person has of the traumatic experience, the story he carries
around in his head, and his sense of self-efficacy.
When I'm on the military post or Navy base, I meet soldiers and sailors who
have seen and done incredibly stressful things and who are, psychologically,
amazingly healthy in spite of it. They go home from work just like the rest of
us, they have great families, and they love their jobs. They say, "I jump out
of airplanes, and it's the greatest job in the world." Those of us who work with patients in a
clinical setting sometimes forget that most people who are exposed to trauma or
stress won't have a problem. They may have thoughts and reactions, but they
won't develop a mental disorder.
What's next in your research?
Our research with the Military Survival School trainees is longitudinal;
we're hoping to follow these individuals over time and to find out who shows
symptoms later in life. We also want to continue to study healthy people under
conditions of stress. Some of my colleagues have a hard time accepting the idea
that we should be studying a disorder before people have actually contracted
it. But, this is the best way to understand what may be helpful in primary or
secondary prevention, how to treat healthy people before they become unhealthy.
We are also using the Survival School as a venue for studying how accurate
eyewitness accounts are of highly stressful events. Studies have shown that
people who have PTSD sometimes change their report of events over time. They
aren't lying, but their memories change. We've studied people after
interrogation and have found that the higher stress the interrogation, the
worse the subjects' ability to recognize their interrogators. We think this
data will help us better understand the memory problems noted in people with
PTSD.
I'm also trying to establish a biological studies site at Fort Bragg. With
a permanent site, we could do ongoing work, studying healthy people during high
stress events and following them over time. Military installations like Fort
Bragg and other bases allow researchers to control for the trauma people are
experiencing, which gives us an excellent model for studying stress and its
effects. I think this is the best way for us to learn about preventing PTSD
and developing better treatments.
Related Fact Sheets
Coping with traumatic stress
Discussion of behaviors that are helpful for coping with traumatic stress reactions
Treatment of veterans
General treatment considerations and care returning soldiers from the Iraq
War
Veterans returning
from war
The returning veteran of the iraq war: Background issues and assessment guidelines
War-related stress
War zone related stress reactions: What veterans need to know
|
