07/01/2016

Looking at the Brain for Hidden War Wounds

34:11 minutes

Conflicts around the world have left too many casualties to count. And while there are many visible war wounds, from missing limbs to scarred flesh, battle also leaves hidden injuries — to the brain.

The Three Soldiers - Vietnam Veteran's Memorial in Washington DC, from Shutterstock
The Three Soldiers – Vietnam Veteran’s Memorial in Washington DC, from Shutterstock

Military doctors are starting to pay more attention to concussions and other traumatic brain injuries on the battlefield, and to the possible role that brain trauma might play in conditions such as PTSD.

Kit Parker is a war veteran who did a combat tour in Afghanistan. He’s also a member of the Wyss Institute for Biologically-Inspired Engineering at Harvard University, and more recently a neurology expert.

“I was talking to a buddy of mine who was wounded,” Parker says. “I got pissed and I decided I’m going to become a neuroscientist because I was going to survive this war with my buddies.”

Parker now studies combat brain injuries, and says the way the US understands war wounds needs to be improved.

“Imagine if you take a young war fighter and you put him out there on a battlefield and you take his brain and you soak it with testosterone, you soak it with cortisol, you soak it with adrenaline, and you put him in a situation where his life is on the line, but that’s not the worst part. The worst part is the moral jeopardy of the the decisions you make every day,” Parker says. “Once you pull them out of that environment, there have been changes to that brain. We don’t know exactly what they are, but I can tell you there are changes to that brain and how they adapt to that non-threat environment is one of the biggest challenges that these young veterans — and older veterans too — face when they come off the battlefield.”

Parker and others are working to better understand the so-called “invisible wounds” of war. He and Jeffrey Lieberman, a professor and chairman of psychiatry at Columbia University College of Physicians and Surgeons, say things are slowly beginning to improve.

“The military and the NFL got religion in sort of the same way at about the same time,” Lieberman says. “There’s a notion, which is understandable but not warranted, that if you can’t see it, it doesn’t exist. And the notion was if there’s no demonstrably physical signs of an injury, traumatic or otherwise, then it’s not real and it’s not having any harmful effect.”

Now the military is beginning to embrace the idea that both physical and psychological trauma can result from combat exposure and exposure to blasts from IEDs.

“How you handle the situation when somebody is near an explosion has totally changed,” says NPR science correspondent Jon Hamilton. “It used to be that chances were they would be just sent back in, say, ‘Kid, you’re fine. Go back in and fight again.’ Now there are rules that require people in combat who have been exposed to an injury or to a blast like that to be pulled out and examined and the assumption is that they may in fact have a physical injury to their brain.”

Parker says new research is showing how blows to the brain produce different types of injury.

“It used to be [thought] that some type of dramatic injury to the brain would kill neurons. But now we realize that smaller mechanical blows, or smaller magnitude mechanical blows — the same thing that causes a concussion — can injure neurons but not necessarily kill them. And what we find is that when these neurons are injured they start to retract, they disconnect from the neural network — the networks of cells that are in the brain that allow you to count your change when you’re at a fast food restaurant or recognize your friend, or to do any type of computation,” Parker says.

Blast injuries, according to Parker, also injure the brain by disrupting blood flow.

“The brain is a very metabolically expensive organ. It eats a lot of energy, and you have a lot of blood flowing up there. And in blast traumatic brain injury, we found that the blood vessels can be damaged. The soldiers are coming back with cerebral basal spasm. That’s something that you don’t customarily see with a football player who’s been concussed,” Parker says.

Research by Daniel Perl, director of the CNRM Neuropathology Core in the Center for Neuroscience and Regenerative Medicine, is beginning to uncover some of these invisible brain injuries sustained in combat. When Perl looked at brain tissue samples taken from soldiers during autopsy, he discovered unique patterns of scarring.

“We found that service members who had been exposed to blasts such as improvised explosive devices — IEDs — showed a very unique and distinct pattern of scarring in the brain, which we believe is related to their exposure to these high explosives. We compared these cases to civilians who have been in things like automobile accidents where there was no blast exposure and they didn’t show this pattern of scarring,” Perlman says. “We’ve been trying to see if we can find this this abnormality with scans and so far they haven’t shown up. It’s one of the reasons why this is referred to as the invisible wound. The scans are really marvelous, but, you know, they have their limitations. And so far we haven’t been able to see these abnormalities on scans.”

While scientists are making headway in uncovering the hidden wounds of war, most agree that there is still a lot of work left to do in preventing such wounds and funding research to diagnose and treat them.

“It’s been late in coming and it’s going too slowly,” Lieberman says. “Individuals who put themselves in harm’s way to defend our nation should be the highest priority of medical research and treatment. And we have a spectrum of injuries that are incurred in the context of combat from TBI [Traumatic Brain Injury] to now this concussive form of injury, where there’s not necessarily the traditional ways of diagnosing it or seeing it, to psychological trauma. And it’s been kind of a reluctant too little too late process to get on top of it. If this was Ebola, if this was Zika, if this was AIDS, we’d have been all over it.”

If you’re concerned that you or someone you know may suffer from PTSD, the following resources should help:

—Elizabeth Shockman (originally published on PRI.org)

Segment Guests

Jon Hamilton

Jon Hamilton is a science correspondent for NPR in Washington, DC.

Kit Parker

Kit Parker  is the Tarr Family Professor of Bioengineering and Applied Physics, head of the Disease Biophysics Group, and a member of the Wyss Institute for Biologically-Inspired Engineering at Harvard University in Cambridge, Massachusetts.

Jeffrey Lieberman

Jeffrey A. Lieberman, MD, is the Lawrence C. Kolb Professor and Chairman of Psychiatry at the Columbia University College of Physicians and Surgeons.

Daniel Perl

Daniel Perl  is director of the CNRM  Neuropathology Core in the Center for Neuroscience and Regenerative Medicine, part of the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

Judith Cohen

Judith Cohen, MD  is a professor of psychiatry at Drexel University College of Medicine, and is the medical director of the  Center for Traumatic Stress in Children and Adolescents at Allegheny Health Network in Pittsburgh, Pennsylvania.

Segment Transcript

IRA FLATOW: This is Science Friday. I’m Ira Flatow. Conflicts around the world have left too many casualties to count. And while there are many visible war wounds– missing limbs, battered flesh– we can also bring hidden injuries to the brain. Just as researchers are starting to pay more attention to the results of repeated head trauma in sports, military doctors are starting to pay more attention to concussions and other traumatic brain injuries on the battlefield. What they have discovered is what we will be talking about for the beginning of the rest of the hour. If you’re a vet who’s experienced head trauma or live with someone who has, we’d like to hear from you. Give us a call. Our number, 844-724-8255, 844-724-TALK. Or you can tweet us @SciFri.

Let me introduce my guest. Jon Hamilton is a Science Correspondent for NPR who has been reporting on military brain research there. Welcome.

JON HAMILTON: Hi. Hi there. Kit Parker is one of the researchers profiled in Jon’s reports. He’s a vet himself, having served two tours in Afghanistan. He’s a Professor of Bioengineering and Applied Physics at Harvard, and a member of the Wyss Institute for Biologically Inspired Engineering. Welcome to Science Friday.

KIT PARKER: Thanks Ira. Thanks for inviting me.

IRA FLATOW: You’re welcome. Jeffrey Lieberman is a Chairman of the Department of Psychiatry at Columbia University College of Physicians and Surgeons, and Director of the New York State Psychiatric Institute. He’s in our New York studios here. Welcome back.

JEFFREY LIEBERMAN: Thanks Ira. Nice to be here.

IRA FLATOW: I just want to say, last time you were here, you were really sort of the catalyst for this. When you were here talking about your book last time, I said to you, what is the most understudied piece of psychiatry. And you said it was PTSD, and it really needed to be studied more. So I’ve been thinking about that since then.

JEFFREY LIEBERMAN: I’m glad I provoked your interest in this follow up program.

IRA FLATOW: It’s actually Jon Hamilton who was doing a series of stories on the military that caught my attention. Jon, what are some of the things the military is doing in this field?

JON HAMILTON: Well they’re doing a couple of things. They have funded a fair amount of research in trying to figure out the sort of biological underpinnings of injuries caused by blasts and in battle. They have also changed, completely, the way they handle these injuries when they occur.

IRA FLATOW: And most people think about war wounds as being mainly physical. You have your bullet wounds, lacerations. Are you saying there has been a shift in the thinking of the military here?

JON HAMILTON: I think there has, yeah. I mean, what has happened is that the military has apparently embraced the idea that yes there can be of course psychological trauma that can affect people who’ve been in combat. But they’re also, especially to these people who have been exposed to blasts from IEDs, that they can actually have a physical injury to their brain. And once they sort of seem to accept that, their feeling about how you handle the situation when somebody is near an explosion has totally changed.

It used to be that chances were they would be just sent back in, say kid you’re fine, go back in, fight again. Now there are rules that require people in combat who have been exposed to an injury or to a blast like that to be pulled out and examined. And the assumption is that they may in fact have a physical injury to their brain.

IRA FLATOW: Kit Parker, you were in combat yourself. How did you come to study brain trauma?

KIT PARKER: Well I was not a– the first one was Afghanistan. I wasn’t a neuroscientist. or I wasn’t even studying traumatic brain injuries. But I did a combat tour in Afghanistan. I started a faculty position at Harvard after that. I was focused on heart disease, mostly pediatric heart disease.

And a friend of my was wounded in Iraq. And after a series of phone calls, it became pretty clear that his treatment was not going well. I had had a little bit of discussion with DARPA, the Defense Advanced Research Projects Agency, about the status of brain injury research after the use of improvised explosive devices increased on the battlefield.

And so one day I was talking to a buddy of mine who was wounded. I got pissed. And I decided to become a neuroscientist if I was going to survive this war my buddy. So I got into it.

IRA FLATOW: Ah, so as simple as that. I’m sure it was a lot tougher road than you’re making it sound to be, to getting to do what you do. Jeffrey Lieberman, what are some of the symptoms of having a traumatic brain injury?

JEFFREY LIEBERMAN: Well first, if I could say that you might be able to say that the military and the NFL got religion in sort of the same way at about the same time. And that is to say that there’s a notion, which is understandable but not warranted, that if you can’t see it, it doesn’t exist. And the notion was that there’s no demonstrably physical signs of an injury, traumatic or otherwise, then it’s not real and it’s not having any harmful effect.

IRA FLATOW: That’s what General Patton, famous slap of the soldier during World War II was, wasn’t it, sort of sort that thing?

JEFFREY LIEBERMAN: Exactly. He called him a coward as a result of his being affected by the psychological trauma of the war. And worse than that was the fact that in the Great War, World War I, where shell shock was first defined, people were shot for cowardice.

But the reality is that concussions in the NFL are now a big thing with chronic traumatic encephalopathy. And the military, in coming to terms with penetrating brain injuries, TBI, traumatic brain injury, and PTSD, posttraumatic stress disorder, are trying to come to grips with the way the most complicated organ in the body can be affected by different types of insults.

IRA FLATOW: So you have to learn how to recognize that.

JEFFREY LIEBERMAN: Exactly.

IRA FLATOW: And why are we learning how to recognize that?

JEFFREY LIEBERMAN: We are, except it’s been late in coming, and it’s going too slowly. Individuals who put themselves in harm’s way to defend our nation should be the highest priority of medical research and treatment. And we have a spectrum of injuries that are incurred in the context of combat, from TBI to now this concussive form of injury where there’s not necessarily the traditional ways of diagnosing it or seeing it, to psychological trauma. And it’s been kind of a reluctant, too little, too late process to get on top of it. If this was Ebola, if this was Zika, if this was AIDS, we’d have been all over it.

IRA FLATOW: And Kit, you’re someone who actually gets down to the cellular level to see what the damages are, aren’t you?

KIT PARKER: Yes I am.

IRA FLATOW: Tell us what you see. What happens in the brain and what happens to the nerves in the cells?

KIT PARKER: So there’s two schools of thought. It used to be that some type of dramatic injury to the brain would kill neurons. But now we realize that much smaller mechanical blows or smaller magnitude mechanical blows to the head, the same thing that causes the concussion, can injured neurons, but doesn’t necessarily kill them. And what we find is that when these neurons are injured, they start to retract. They disconnect from the neural network, the networks of cells that are in the brain that allow you to count your change when you’re at a fast food restaurant or recognize your friend or to do any type of computation that you might do. They sort of disconnect.

And these networks, you see a maladaptive adjustment. They don’t reform. Right now, that that’s the current state of the art. We don’t know how to get them to rewire up so that you can count your change, that you can perform all the tasks that you customarily do.

So any disruption to those neurons– but we also learned from the blast traumatic brain injury, that you can have a disruption to the blood vessels in the brain. The brain’s a very metabolically expense organ. It eats a lot of energy and you have to have a lot of blood flowing up there. In blast traumatic brain injury, we found that those blood vessels could be damaged. The soldiers are coming back with a cerebral vasospam. That’s something that you don’t customarily see with a football player who’s been concussed.

So there was different kinds of traumatic brain injury. And this goes back to years ago, the Center for Disease Control was talking about the epidemic of traumatic brain injury, even before 9/11, because of three point safety belts. And passengers were constrained by a seat belt, but the head would snap back and forth. And your brain would literally smash up against the inside of your skull.

So we had TBIs for a long time. But between the NFL’s retired players and between soldiers on the battlefield, when you start having a 25 kid who’s been concussed 12 different times on the battlefield and he’s starting to have trouble sleeping by the time he’s 30, we have a pretty serious problem on our hands.

I’d like to speak for just a moment to Jeff’s point about too little, too late. One of the challenges we have here is that the National Institute of Health has been very slow to get into the game on traumatic brain injury. And it’s as if they think that any soldier suffering traumatic brain injury is the responsibility of the DoD or the Veteran’s Administration.

And that’s certainly not the case. Veterans are Americans too. The NIH’s mission is to concern themselves with the health care issues that confront Americans. And the NIH has been pretty slow on this.

JEFFREY LIEBERMAN: I couldn’t agree more.

IRA FLATOW: I don’t think many of us understood that. I’m glad you brought that point up.

Jon, how did you end up connecting with Dr. Parker and some of the other researchers you talked to in your reporting? And why them?

JON HAMILTON: I was interested in two things. One, I cover a lot of brain science. And so I was really interested in learning more about– like everybody, I’d been reading all the reports about the amount of traumatic brain injury, the number of concussions happening in Iraq and Afghanistan. And the numbers are pretty staggering. The military itself has estimated more than 300,000 people who fought in those wars ended up with at least one traumatic brain injury. And that’s a lot of people.

So I was very interested in learning more about what was happening. How was that translating into these long term symptoms that people were having, the problems with memory or the problems with thinking, the problems sometimes with emotions and emotional control. So that was one part of it.

At the same time, I was fascinated with doing stories about scientists, looking at why they did the research they did. What compelled them? What was the thing that motivated them? And so with Dr. Parker, it was a combination of this really interesting brain science, and he was really a guy on a mission with a very personal motivation.

IRA FLATOW: Kit Parker, you know, we keep hearing– we’ve done reports on the NFL and the search for the safe helmet. And we keep hearing that there is no such thing as a safe helmet that is going to guarantee you not getting a concussion when you get hit in the head. Is there anything in the military? Is there anything that can be done to help prevent this happening on the battlefield?

KIT PARKER: Well, preventing exposure to blast is probably the biggest thing. Prevention is the big part of it. You’re right, helmets only help so much. But there’s no helmet to put in between the brain and the inside of the skull. And that’s where a lot of the injuries occur.

So we do do a couple of things in the military. We wear a blast dosimeter so we can tell how much the soldier’s been exposed to blasts. So if you’ve been exposed to a really big blast, we can sit you down, we can get to the docs to get treated. We have obviously built various vehicles that are designed to offer protection against blast and a lot less penetrating of shrapnel from blast injuries.

But there’s not a whole lot. We have evolved some clinical protocols that help quite a bit. I mean, if I was going to get a concussion several years ago when I was a member of the Gray Team in 2011, I would’ve much rather been treated in Afghanistan that in the US. And hopefully some of those lessons learned on the battlefield are going to make it to civilian clinics.

IRA FLATOW: Jeffrey Lieberman, are these permanent? I mean, are there permanent changes in the brain that cannot be reversed once these things–

JEFFREY LIEBERMAN: It really depends on the level of severity and the depth of the pathology that Kit was describing before. But I think when you look at insults that occur, whether it’s from an IED explosion, a headbutt on a football field or a soccer player heading a ball, just like trauma in life– being attacked, losing a loved one, being in an earthquake– these things are ubiquitous and they’re going to occur. And you can try and prevent all you want, but you’re never going to stop them.

So in addition to the preventative efforts that Kit was describing, I think the other direction that science needs to go on is to look at how do you promote neural resilience. How do you promote the resilience in the neurotrophic and neurogenetic capacities? So in the future I would think will be protocols to either inoculate before individuals go into theaters of combat or even into athletic competition, or after they do suffer a concussion that could promote neural resilience in the form of either neurotrophic– You had in the segment before the stem cells, which is like 21st century scientific snake oil. But it’s an exaggeration of what actually would be possible in some way.

IRA FLATOW: I’m Ira Flatow. This is Science Friday from PRI, Public Radio International, talking about PTSD with Jon Hamilton, Kit Parker, and Jeffrey Lieberman.

I am surprised to hear– and I’ll ask all of you about– you mentioned the lack of attention paid by the NIH to this disease, thinking well, it’s the Pentagon’s problem. And the Pentagon is– is there a middle ground, or is it going to take a sea change, like we heard with the football players in the NFL, to finally admit there might be a problem?

KIT PARKER: I’d like to speak to that. I’ve only published a few papers on traumatic brain injuries. I’ve gotten into this. And I’ve spent a lot of time traveling the country, speaking to alumni groups from Harvard, trying to raise money for the university. People could care less about the heart research that I do. But anyone who knows someone who’s been concussed is very concerned about the possibility that they might get Alzheimer’s, Parkinson’s disease, or some other type of neural degenerative disease that we can track back to traumatic brain injury. So the public’s interest is there. A lot has been fueled by publications like USA Today, did a fantastic job of keeping this on the front page for a long time.

But it hasn’t got into the Beltway yet. And those lobbyists for patient advocacy groups that suffer from autism and Alzheimer’s, they’ve got that budget at National Institute of Neurological Disorders and Stroke carved up. And it’s a zero sum game. No one’s going to get something unless someone loses something. And so that’s the biggest challenge we face now, I think inside the Beltway in terms of getting funded is a proper advocate.

JON HAMILTON: I think it’s more than a proper advocate, but I completely agree with Kit. To get wonky about this, the federal budget is $4 trillion. The NIH budget is $31 billion dollars. That’s like 0.8%. It’s divided up among the different disease areas and organ systems and populations. And it’s a zero sum game. So if you give more to one, you have to take away from another. And it’s the squeaky wheel that gets the grease when Congress micromanages how the NIH gives money. And if they are going to micromanage, they should be micromanaging for the things that are prioritized in terms of the public interest. And how can you say that something rises above this in priority?

IRA FLATOW: Well you know, talk about veterans has become a big political football this year. In this election, you would think someone would say more about taking care of the vets, you would think.

JEFFREY LIEBERMAN: But Kit I think was correct. First of all, the idea TBI people will get into and believe. When it devolves into concussive effects and PTSD where you can’t see it, you can’t diagnose it–

I had a general who was trying to understand the basis of this increasing suicide and PTSD problem. And I was telling him about the research that we were doing in terms of neurobiology. And he said, well come up with a diagnostic test so we can find out who’s faking it. And the whole thing, the idea of some psychological injury is anathema to military ethos, which is why it took so long to be accepted.

And the responsibly for researching it and treating it was defaulted to VA and DoD, which meant the NIH wasn’t funding it and bringing in maybe the top scientists who otherwise weren’t studying this area of research before. And that needs to be changed.

IRA FLATOW: All right, we’re going to talk about more when we come back. I’m going to take a break, and bring on another guest to talk about PTSD. Our number, 844-724-8255. You can also tweet us @SciFri. Stay with us. We’ll be right back.

You’re listening to Science Friday. I’m Ira Flatow. In case you just joined us, we’re talking about posttraumatic stress disorder in the military and the research or lack of research to understand it completely. We’ve been talking about these injuries, what they do inside the brain. And joining me now is Daniel Perl. He’s Director of the Neuropathology Core in the Center for Neuroscience and Regenerative Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. And he is author of a recent research paper in the journal Lancet Neurology looking at the effects of brain trauma in the military. Welcome to Science Friday.

DANIEL PERL: Thank you. Glad to be here.

IRA FLATOW: Thank you. I understand you looked at samples of brain tissue taken from soldiers during autopsy. And what did you find there?

DANIEL PERL: Well basically we found that the service members who had been exposed to blasts such as improvised explosive devices, IEDs, showed a very unique and distinct pattern of scarring in the brain, which we believe is related to their exposure to these high explosives. We compared these cases to civilians who had been in things like automobile accidents where there was no blast exposure, and they didn’t show this pattern of scarring.

IRA FLATOW: Did these brain abnormalities that you’re seeing show up in scans, without having to do– if you don’t do the autopsy?

DANIEL PERL: We’ve been trying to see if we can find this abnormality with scans. And so far, they haven’t shown up. It’s one of the reasons why this is referred to as the invisible wound. The scans are really marvelous. But they have their limitations. And so far we haven’t been able to see these abnormalities on scans.

IRA FLATOW: So you scanned a living soldier with that and expected to find what– we were talking about before, Dr. Lieberman was saying, you know, the military says we don’t have a definitive way. This would not be a definitive way either to say that?

DANIEL PERL: So far, we have not been able to identify this or diagnose it in the living individuals. But now that we know what we’re looking for, we know what the change looks like. I think we’ll have better ways of devising means by which we can make that diagnosis. But it hasn’t happened yet.

IRA FLATOW: And you can see in the brains that you autopsy, you can see that there has been damage. Is the damage in those areas that would be relevant to PTSD, linked to PTSD?

DANIEL PERL: Yes. I mean, PTSD, it’s a very complex condition. There may be many areas of the brain that are dysfunctional in PTSD. And of course there is the whole psychiatric aspect to it.

But when we look at where these areas of damage have occurred, they do correlate with parts of the brain that have been shown to be dysfunctional in other studies in patients with PTSD.

IRA FLATOW: Let me get to responses from my other responses, Kit and Hamilton here. Let me get–

JON HAMILTON: Can I go ahead?

IRA FLATOW: You can go first, yeah.

JON HAMILTON: I just want to say we have been talking about these injuries as being completely invisible. And I think that’s not quite the case anymore. There are hints, more than hints now, that certain technologies are able to see at least some of the damage that is occurring in the brains of service members who have been exposed to a blast. And for instance, at Washington University in St. Louis, there’s a guy named David Brody who has been doing studies using a technology called diffusion tensor MRI, which is able to look at the connections in the brain. And he has seen abnormalities in those connections in people who have been exposed to a blast. So it’s possible that the technology is coming along now where some of these invisible injuries are becoming visible.

KIT PARKER: Ira, I would like to speak.

IRA FLATOW: Yes, Dr. Parker, go ahead.

KIT PARKER: I’d like to speak to this TBI versus PTSD because this has been pretty controversial for some years. For years, people were thinking that TBI was really just PTSD. And I’ll tell you, imagine this. Imagine that I put someone to sleep. I pulled the amygdala out of their brain and I put it on a table. The amygdala is an emotional center in your brain. And I smash it with a hammer and I put it back inside their brain. And they wake up. And maybe they’re a little sad, maybe they’re depressed. So are you going to say that this person has PTSD, or are you going to say that they have TBI?

And I think that Jon’s point is really important. We can’t see some of these things now. With David’s work out there at Wash U, it’s important to distinguish that there is something called PTSD. There is something called TBI. There can be crosstalk between these two diseases. And we really aren’t quite understanding how to distinguish or treat the two different ones.

But imagine this for PTSD. You take a young war fighter, you put him out there on a battlefield, and you take his brain and you soak it with testosterone. You soak it with cortisol. You soak it with adrenaline. And you put him in a situation where his life is on the line. But that’s not the worst part. The worst part is the moral jeopardy of the decisions that you face every day, of the decisions you make on a battlefield.

Once you pull them out of that environment, there have been changes to that brain. We don’t know exactly what they are, but I can tell you those changes to that brain and how they adapt to that nonthreat environment is one of the biggest challenges that these young veterans– and older veterans too– face when they come off the battlefield. And whether or not that’s PTSD or moral injury or some type of other– those combat stress, we throw everything into the bucket of PTSD. It needs to be a little bit more granular.

IRA FLATOW: Last word Dr. Lieberman.

JEFFREY LIEBERMAN: The notion that these are visible or invisible is an arbitrarily defined one. When Dr. Perl’s article was published in Lancet, there was an article in the New York Times that said what if PTSD is not psychological but is physical. And the reality is that the tools to discern these, whether it’s postmortem or antemortem, are available. But the effort hasn’t been put into doing it.

You were kind enough to have me on when I had written a book previously called Shrinks– The Untold Story of Psychiatry. And if you’d just permit me 10 seconds, I’d just like to read a passage which I think speaks to this issue.

“The brain is the only organ that can suffer what we might call existential disease where its operation is disrupted not by physical injury but by impalpable experience. Every other organ in the body requires physical stimulus to generate illness– toxins, infections, blunt force trauma, strangulation. But only the brain can become ill from incorporeal stimuli such as loneliness, humiliation, betrayal, moral failure, getting fired from a job, abandoned by a spouse, experiencing an IED, watching your best combat buddy eviscerated, watching your child run over by a car, losing your retirement savings to theft. The brain is the interface between the ethereal and the organic where the feelings and memories comprising the ineffable fabric of experience are transmitted into molecular biochemistry.”

IRA FLATOW: All right, that’s going to be the last word, because it’s a very good segue to our next segment about children and neighborhoods coming down with PTSD. I want to thank Daniel Perl and Jon Hamilton, the science correspondent for NPR. You can hear his recent reports about the military and brain research there. Kit Parker, a member of the Wyss Institute for Biologically Inspired Engineering, and Jeffrey Lieberman, the director of New York State Psychiatric Institute, thank you all for taking time to be with us today.

And we will not let go of this image. We will be covering it some more.

We have been talking about the effects of war on the brains of people in combat and the possible, as I say, connection to PTSD. But traumatic events are not limited to the military. Many of the victims are children, victims of an ongoing battle on the street, trauma taking the form of exposure to gun violence in our cities. You have car accidents, physical and sexual abuse.

Joining me now to talk about PTSD in children and how to help them overcome trauma is Judith Cohen. She’s a Professor of Psychiatry at Drexel University College of Medicine and Medical Director of the Center for Traumatic Stress in Children and Adolescents, Allegheny Health Network in Pittsburgh. She’s also a developer of the trauma focused cognitive behavior therapy. Welcome to the program.

JUDITH COHEN: Thank you.

IRA FLATOW: So children out on the street, they’re exposed and vulnerable. How common is PTSD in kids?

JUDITH COHEN: PTSD is very common in children. Your listeners may be surprised to learn that 2/3 of all children experience at least one trauma before they reach adulthood, and a third experience multiple traumas. And of exposed children, about 20% develop significant PTSD symptoms. So that’s a lot of kids.

IRA FLATOW: What are the symptoms and how can parents recognize them?

JUDITH COHEN: Well, that’s another challenge. So the symptoms of PTSD in children are the same as they are in adults. So there, often kids have intrusive memories or intrusive nightmares about the trauma. And that can be difficult because in young children especially, they might have scary thoughts or scary nightmares. And if the parent doesn’t know about the trauma, it can be really difficult for the parent to know. They might have just general scary nightmares. And a lot of kids have nightmares anyway.

And one of the really challenging things is that kids are avoidant, and adults are too when they have PTSD, and they don’t want to talk about or remember the scary thing. So that’s one of the real challenges, recognizing it.

IRA FLATOW: Does that mean that kids growing up in stressful environments like poverty, violent neighborhoods, gun battles between gangs, things like that, are more likely to be affected?

JUDITH COHEN: Yes, sure. Kids who are exposed to community violence are very vulnerable to developing PTSD. And we know that many of the kids in these neighborhoods do develop those difficulties.

IRA FLATOW: Do psychiatrists want to throw drugs at the kids?

JUDITH COHEN: Yes, often they do. And unfortunately we know that there is no evidence that shows that any medication is effective for treating child PTSD. The psychotherapies are much more helpful. But unfortunately medications are very commonly used, even though they are not effective.

IRA FLATOW: Let me go to the phones because they’ve been lit up and we’ve had such a long discussion. It’s been a good one. But let me go to Rockville, Maryland. Patrice, hi. Welcome to Science Friday.

PATRICE: Hi, think you. I am a psychiatric nurse practitioner, and I was working with the Army in a clinic in Germany. And I recently took over a position in an outreach clinic, a nonprofit outpatient clinic where we provide care to all kinds of different people.

But I have noticed that a lot of the clients that we’re seeing, at first I thought it was me seeing TBI everywhere. But now I am realizing that there’s a lot of patients that come in– I realize you’re discussing this on children, but I think it’s a similar situation for a lot of children. But a lot of my patients come in and they too have domestic violence or got into boxing or got hit in the head with a bat on the street during a fight. And I am seeing symptoms that are pretty clear to me as a TBI.

Obviously your discussion right now is more focused on PTSD, and I could address that as well. But it is something that I think people think soldiers have TBIs or PTSD and that a person who was functioning well and is all of the sudden extremely irritable or not themselves, that they’re not getting the full [INAUDIBLE] that they should be getting.

IRA FLATOW: All right. Well Patrice, thanks for calling. We’ll pick that up on Science Friday from PRI, Public Radio International.

Dr. Cohen, what do you think? Do you see patients like that too?

JUDITH COHEN: Well, I see children and adolescents, but certainly we see kids who have had concussions and gotten sports injuries as well. But I think it’s important that we are aware of their trauma history as well. So when children have injuries like that, that we ask about their trauma history as well because it’s important when they have a change or they’re hyperactive or they have difficulties in concentrating, that we take into consideration their past trauma history as well.

IRA FLATOW: Let me go to Stella in Lafayette, California. Hi Stella. Welcome to Science Friday.

STELLA: Hi, how are you Ira.

IRA FLATOW: Fine. Go ahead please.

STELLA: Yeah, I just wanted to bring up a personal history. My mother, who is now 87, suffered tremendous trauma during the Nazi occupation of Greece in 1941 to ’45 when she was 12 to 16. She says her grandfather was executed. Her family village of 30 four story towers in the Mani Peninsula was raided in 1943, and all of the residents, including my mother, were forced from their homes in the dark of night. Their valuables were stolen. All else was burned. And then the stone homes were cannonballed as retribution for resistance actions– really traumatic.

My mother had me at 41, and as a young child, I knew something was off with her. She hoarded newspapers. She ate food out of the garbage, tremendously disturbing to me. But I’m so grateful that I learned of her past in 2012 when she was 83.

I think there’s something about that population, the Greeks, they didn’t want to talk about that time in their history. And it’s a real maybe survival technique. But there’s an alternative, which is the Jewish populations of Eastern Europe, which talk about the Holocaust tremendously. So while I can’t remove the negative, it is very positive and therapeutic to talk about–

IRA FLATOW: Thanks for contribution. That is an interesting story. Just to sum up Dr. Cohen, what kinds of therapy does work for children?

JUDITH COHEN: Yes, and I think Stella’s point is very important, that there are effective treatments. And just as Stella was saying, the difference between effective treatments and usual treatments are just as she was saying, that it’s very important to encourage children to talk about their experiences. And many typical therapists wait until children are ready to talk. And as I was saying, children are often avoidant, and they will not spontaneously talk about it.

And through the federally funded National Child Traumatic Stress Network, effective treatments are available in every state across the country. And these evidence based treatments have three differences from usual treatments. First of all, they provide specific skills to master reminders about the trauma. Secondly, parents or caregivers are actively included. And thirdly, we do help children directly face their fears. We know that facing children’s fears instead of avoiding them or waiting until the child is ready– which often doesn’t happen– and talking about their personal trauma is really important.

IRA FLATOW: Not to interrupt, where can parents go if this is such a niche, so to speak? Where do they find help?

JUDITH COHEN: Well I suggest they go to the National Child Traumatic Stress Network website, nctsn.org. As I said, there are therapists across the country. They can find therapists trained in evidence based treatments in their area. There are websites that provide therapists, For example, the trauma focused cognitive behavioral therapy website, tfcbt.org, has therapists listed by zip code or by state. You can find a trained therapist in your area. Or you can ask your pediatrician if you’re concerned about your child. Your pediatrician can refer you to a therapist who can evaluate your child if you have concerns.

IRA FLATOW: Thank you Dr. Cohen. Judith Cohen, professor of psychiatry at Drexel University College of Medicine, medical director of the Center for Traumatic Stress in Children and Adolescents at Allegheny Health Network in Pittsburgh.

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