Guest Blogger Dr. David Hellerstein on Trauma and Resilience, Ten Years after 9/11

All New Yorkers have vivid memories of the events of 9/11/2011; and for New York-based health care workers our memories are generally mixed with feelings of frustration and helplessness. We recall how we emptied out hospital beds that day, how we were prepared in emergency rooms and clinics, and how we waited hour after hour—in expectation of a flood of patients that never came.  And we recall how in the ensuing days, weeks, and months, survivors finally entered our offices, clinics and hospitals, seared by memories and nightmares and visions they could not erase.

Patients working on Wall Street, living in Battery Park City or in lower Manhattan, those who were evacuated by boats from apartments located close by the base of the towers, people who happened to be shopping or walking in Lower Manhattan that Tuesday morning, firemen who rushed to the site of the rubble, parents who were scheduled for meetings at Windows on the World restaurant, but had to drop their kids off at school first, people who heard the first impact, and—remembering the prior attack on the WTC—immediately  left the buildings and headed North, people whose apartments were destroyed or cars were crushed or jobs were eliminated…or people who waited in the suburbs for a spouse to return on the MetroNorth commuter train, and finally concluded they would never return.  They all came, looking for help.

We remember equally vividly how many months and years it took for recovery to begin. We worked intensely to enhance the process of recovery, whether through medical treatments or psychotherapy.  All of us, patients and doctors alike, were haunted by the memories of those who never emerged from the rubble, and by the randomness of survival.  And yet we patients and doctors had a unique cameraderie as well—a feeling that we were all in this together, united against a common, though perhaps unseen, enemy.  Surely this helped with recovery, along with the expectation that life would eventually return to normal. 

For neuroscience researchers, the events of 9/11 were a sort of natural experiment, similar to the events of war.  Over the past decade, there has been significant progress in understanding the brain’s responses to trauma and what causes PTSD, and as well as understanding what may help people to recover from such cataclysmic events. It has become abundantly clear that the brain’s fear systems, commonly associated with the center called the amygdala, have incredibly tenacious memories for trauma that are extremely difficult to dislodge.

New research has brought illumination and hope to these issues.  NYU researcher Elizabeth Phelps is doing research on the neurological processes involved in the consolidation of traumatic memories, which indicates that there may be a window of time during which the deposition of such memories can be interrupted. Will this eventually provide a way to prevent PTSD, either by new types of psychotherapy or by the development of new medications that can block the deposition of such memories?

On a broader level, the events of 9/11/2001 have underlined the importance of resilience.  Some survivors of 9/11 quickly returned to their usual level of functioning, yet many others, a decade later, are still haunted by those events.  Resilience, or the ability to survive or even thrive under stress, is being studied as a neuroscience-based process. Researchers such as Avram Caspi have determined that there are genes related to resilience. Other researchers have described behavioral characteristics that are related to higher levels of resilience, such as Charles Nemeroff and Dennis Charney in their book The Peace of Mind Prescription.  (Resilience is one of the 6 key New Neuropsychiatry principles described in my book Heal Your Brain and in my blog at Psychologytoday.com).

Just to mention one key element of resilience: appraisal.  Appraisal means the way in which we interpret events.  If an event is interpreted as a threat, it evokes fear responses, including activation of the amgdala, and a series of physical responses including release of cortisol and stress hormones. Yet if an event is interpreted as a challenge, it evokes a different series of responses, including interest, calm, relaxation, and adaptive coping. And as Nemeroff and Charney note, “The hormones released by an appraisal of challenge include growth factors, insulin, and other compounds that promote cell repair, trigger relaxation responses, and stimulate efficient energy use.”

The components of resilience include:

·      Physical resilience, physical ‘toughening’ and ‘tempering’

·      Psychological resilience “situations are viewed as challenges, not threats”:

·      Activating social networks, including confiding relationships

·      Adequate external supports

·      Challenging one’s self

·      Looking for meaning through involvement

·      Learning

Now, a decade after 9/11/2001, it is possible to have almost a strange nostalgia for that moment, since we live in a world with increasingly huge problems but without clear solutions, in which day-to-day stresses seem to be continually increasing, with worsening financial and political instability, and increased polarization between incompatible world-views.  In attempting to cope with all of these ongoing and much less clearly defined stressors, the question is, what can help?

In my view, resilience is key.

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But I Do Want To Talk

First, Roy wants your opinion about Online Access to Prescription History, so if you haven't chimed in, please do.

This post was inspired by ClinkShrink's post, I Don't Want To Talk, where she discusses mandated debriefing after trauma and what role that might have in either preventing or causing mental illness (Roy: which is what we spent all of podcast #46 talking about).

Disaster Psychiatry is a field that it still defining itself. It's a close-to-home issue for me because Shrink Rap was started as a way for me to deal with some residual angst I had after returning from a couple of weeks in Louisiana where I worked on the Katrina Assistance Project. Roy & Clink got sucked in, but what can I say? At that time, I wrote a piece about my experiences and posted on it's own blog link. I talked a bit about the stuff ClinkShrink discusses-- some history of the Mitchell Model of Critical Incident Stress Debriefing, as well as Sally Satel's paper on how the mental health industry exploited the terrorist attacks of September 11th. You can click HERE to link to my Katrina Reflections.

Since ClinkShrink wants to talk about mandatory debriefing and whether talking about a trauma lessens it's impact and prevents the development of future psychopathology, I'll talk about my own thoughts about the role of psychiatry in the aftermath of a community trauma.You can define community in a big or small way, but I mean a shared experience as opposed to a traumatic act to a single individual .

There are five concerns from a shrink's point of view. There may be more, but these are my random thoughts and it's our blog. Do chime in on the comment section.

• There are people with psychiatric disorders who may no longer have access to treatment-- perhaps because they need to relocate, because their doctor &/or records have been obliterated, their pharmacy closed down-- and they are at risk for a relapse of a pre-existing illness.
  
• There are people who develop psychiatric disorders as a direct result of stress-- it's not unheard of for people to become manic after the death of a relative, to become anxious or depressed, and so if psychiatric symptoms are precipitated without disasters, it's safe to assume they can be precipitated by trauma. Certainly, some of these people may have underlying disorders that would eventually be unmasked anyway.
• There are people who develop psychiatric disorders as a direct result of the specific trauma who may not have ever required the services of the mental health profession if such an event didn't occur. The question here, and the one that ClinkShrink addressed, is whether early interventions to the entire population alter the likelihood that someone will develop a psychiatric illness. Who to target, what to target them with, and if it will matter are all questions to address
  
• There are people who are distressed by an objectively distressing event but who don't (and hopefully won't) develop a psychiatric condition. These people often feel a need to talk and are well-served by friends, family, and religious leaders. The role for psychiatrists here is one that should be taken only if the trauma victim identifies himself as a patient and requests treatment. There seems to be a statement in our society that it's bad to not talk about troubling things-- this is true for some people who feel a need to talk, but it's a blanket statement that often crosses the line into being judgmental.
• Lastly, there is question as to the role mental health professionals should take with disaster workers who go to the aid of the victims. We're back to the Critical Incident Stress Debriefing and I wonder if the issues are different for those who are in the position of being helpers voluntarily (Red Cross workers and assorted humanitarians) versus those who go as a job requirement-- fire fighters and the like. I'm not sure what to say here. Again, this speaks to the issue of interventions to prevent the development of disorder in a population that might remain healthy without intervention.

Ugh, I can't get a picture in. Open all those alligator mouths and yap it up for me.

Roy: Warrantless Brain Scans

This whole search for terrorist collaborators thing is getting a little ridiculous. Tapping into millions of domestic phone calls (and probably blogs and emails and IMs) in the name of terrorism? That's legal?

So, here's my nightmare scenario. If this is legal, the next step is to force functional MRIs on people to determine what they know (about terrorism, of course). The technology is there. Functional MRI (fMRI) measures minute changes in blood flow in the brain, comparing areas to see which ones have more blood flow, and thus are more active. It seems that one must use specific brain areas to make stuff up. This technology is being used for good purposes (eg, controlling chronic pain), but could certainly be applied to darker motives.

Talkleft asked:

"Would the Court view an involuntary brain scan as a nonintrusive gathering of information rather than a search governed by the Fourth Amendment? Would the Court view brain scans as forcing an involuntary disclosure of thoughts prohibited by the Fifth Amendment's requirement that individuals not be made to testify against their will?"

fMRI is not "invasive" in the classical sense. No needles. No tubes. Sorta like going through an airport scanner, but lying down (you can even keep your shoes on). So what's to stop them from using this technology on Gitmo detainees (or on us)?

The chronic pain link above is interesting, BTW. It makes me wonder if real-time fMRI scanning can be used to learn how to better control obsessive thoughts or auditory hallucinations or anxiety.

HIPAA vs. the US Patriot Act

[Posted by ClinkShrink]
In the course of reviewing for my forensic recertification exam I am struck by the dramatic and divergent changes in patient privacy issues since I did my fellowship ten years ago. When I was in training the standard assumption was that psychiatric records were private and that a written release was required from the patient to disclose any information. That was pretty simple. We didn't have to think about electronic medical records, email, faxes, telepsychiatry or many other forms of electronic communication either because they just didn't exist or weren't in common use. Then came HIPAA. Enough said.

The latest and most counter-intuitive twist in patient privacy is now the U.S. Patriot Act. What this means for psychiatrists is that if the government wants your records, you give it to them. Period. And you can't tell your patient. Ever. A request for records under the U.S. Patriot Act comes in the form of a National Security Letter (NSL). According to the Foreign Intelligence Surveillance Act (FISA), an NSL must be approved by a judge of the Foreign Intelligence Surveillance Court. However, there is no requirement for any standard of proof that a national security issue is at risk---no "reasonable suspicion", no "probable cause"---and no mechanism to challenge the letter or appeal the granting of the NSL.

If you receive a National Security Letter you may not tell your patient that you received it or that you have turned their psychiatric records over to government investigators. This gag order is permanent. And the request is not limited to any particular physical location---keep this in mind if you have a home office.

As you struggle every day to interpret and comply with HIPAA regulations, it's ironic to know that the government could suddenly decide to rifle through your home office filing cabinet and there's really nothing you can do about it.

For those of you interested in learning more about the ramifications of NSL's and the Patriot Act on your practice, download the ACLU's pdf file on this issue:

Unpatriotic Acts: The FBI's Power to Rifle Through Your Records and Personal Belongings Without Telling You