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Military experiment seeks to predict PTSD

U.S. Marine Lance Cpl. Greg Rivers, 20, of Sylvester, Ga., waits to take psychological tests at the Marine Corps Air Ground Combat Center in Twentynine Palms, Calif. on Sept. 29, 2009.

Military experiment seeks to predict PTSD

Some Marine and Army units being tested to detect early signs of stress

TWENTYNINE PALMS, Calif. – Two days before shipping off to war, Marine Pfc. Jesse Sheets sat inside a trailer in the Mojave Desert, his gaze fixed on a computer that flashed a rhythmic pulse of contrasting images.

Smiling kids embracing a soldier. A dog sniffing blood oozing from a corpse. Movie star Cameron Diaz posing sideways in a midriff top. Troops cowering for safety during an ambush.

A doctor tracked his stress levels and counted the number of times he blinked. Electrode wires dangled from his left eye and right pinky finger.

Sheets is part of a military experiment to try to predict who’s most at risk for post-traumatic stress disorder. Understanding underlying triggers might help reduce the burden of those who return psychologically wounded — if they can get early help.

PTSD is a crippling condition that can emerge after a terrifying event — car accident, sexual assault, terrorist attack or combat. It’s thought to affect as many as one in five veterans returning from Afghanistan and Iraq.

Military doctors have been mystified as to why certain warfighters exposed to bombings and bloodshed develop paralyzing stress symptoms while others who witness the same trauma shake it off.

Studies on veterans and civilians point to some clues. Childhood abuse, history of mental illness and severity of trauma seem to raise a person’s risk. Having a social net and a coping strategy appear to offer some protection.

However, none of the factors explored so far are reliable predictors.

“Right now, we can’t determine with certainty who will and who won’t develop PTSD,” said Paula Schnurr, deputy executive director of the Department of Veterans Affairs’ National Center for Posttraumatic Stress Disorder. “Perhaps with better measures, we can get closer.”

Earlier this year, a quarterly publication from the national PTSD center found that studies to date have looked at only “a narrow band of the potential risk and resilience predictors” and that more work beyond surveys was needed.

Urgency to detect early signs
New PTSD studies are using technology to try to get at the answer. Select Marine and Army units are undergoing a battery of physical and mental tests before deployment including genetic testing, brain imaging and stress exams. They are followed in war zones and upon return.

There’s an urgency to detect early signs. Since the 2001 terrorist attacks, more than 1.8 million U.S. troops have fought in Afghanistan or Iraq. The Obama administration is weighing whether to increase forces in Afghanistan where violence has escalated in recent months.

Previously called shell shock, combat fatigue and post-Vietnam syndrome, PTSD was officially recognized as a mental disorder in 1980. Sufferers experience flashbacks, nightmares, sudden outbursts and social withdrawal and are sometimes haunted years after the trauma.

The ongoing wars have given scientists fresh opportunities to follow service members.

One autumn morning, a throng of Marines squeezed into a trailer at the Marine Corps Air Ground Combat Center in Southern California before deploying to Afghanistan. They belonged to the 3rd Battalion, 4th Marine Regiment — nicknamed the “Thundering Third.”

“We’re doing this not to make you better prepared to go do what you have to do in Afghanistan. We’re not doing this to make your health any better,” said Dr. William Nash, a retired Navy psychiatrist and study co-investigator. “We’re doing this so that we can learn more about how to protect Marines from stress injuries like PSTD.”

Nash asked how many have heard of PTSD. A half dozen raised their hands.

Who wants PTSD? “Right, nobody,” he answered rhetorically.

The trailer soon buzzed like a factory, with Marines rotating from one test station to another in an assembly line. They donated blood, urine and saliva samples so researchers can search for genetic biomarkers that might play a role.

Groundbreaking research published last year on adult survivors of child abuse suggests that specific variations of a gene increased their chances of developing PTSD. Scientists believe there may be many other gene variants that contribute to PTSD risk.

Marines also underwent a blink test to gauge their startle response and neuropsychological screening. They filled out questionnaires and were interviewed by psychiatrists with a checklist to diagnose PTSD.

The work is funded by the Marine Corps, Veterans Affairs and Navy Medicine. Last year, about 1,000 Marines were recruited before leaving for Iraq.

This latest batch of 673 Marines who were tested during a two-week period in the fall headed to Afghanistan where they’re sure to see more intense fighting. They will be followed up in the field by Navy corpsmen with special “stress first-aid” training to read early signals.

Researchers recently did six-month follow-up testing on some Marines who returned from Iraq. It will take time to analyze the results, said the study’s lead investigator, Dr. Dewleen Baker of the VA San Diego Healthcare System.

Cmdr. Bryan Schumacher, the 1st Marine Division’s top doctor, said the purpose of studying PTSD triggers is not to bar someone from service. If it turns out that something can be done to prevent it, those vulnerable could get special training to reduce their risk, he said.

Similar research is ongoing 1,300 miles away at the University of Texas at Austin where scientists have collected detailed health data from 178 soldiers from nearby Fort Hood who recently came back from Iraq. The base was the scene of a massacre on Nov. 5 when an Army psychiatrist opened fire, killing 13 people and wounding dozens more.

The shooting has not affected the research, which enrolled first-time deployed soldiers. Unlike the Marines, the soldiers filled out monthly questionnaires online while in combat that tracked their experiences such as whether they saw a roadside bomb go off or knew of a wounded buddy.

Before deployment, soldiers submitted a DNA sample, had an MRI scan of their brain and inhaled carbon dioxide as part of a stress reaction test.

Early results suggest soldiers who reacted more strongly to the CO2 test and who were exposed to more stress in the field showed greater PTSD symptoms, said chief researcher Michael Telch, of UT Austin’s Laboratory for the Study of Anxiety Disorders.

The decision to volunteer in the Marine experiment was personal for Lance Cpl. Jaecob Kyllo. His grandfather fought in Korea and Vietnam and two uncles served in Operation Desert Storm. They spoke less afterward and would get irritated easily.

Kyllo said his uncles were diagnosed with PTSD and suspects his grandfather had it too.

“I’ve seen it before and it’s not the most pleasant thing,” said the 20-year-old from Seattle, who previously served in Iraq.

Melvin Carter, a 27-year-old Marine sergeant who had done three tours in Iraq, noticed buddies who were once laid-back turn angry after coming home. The Oakland, Calif., native copes with stress by laughing and cracking jokes.

Navy corpsman Benjamin Reinhardt was recently trained to look for signs of PTSD in 20 Marines attached to a mortar platoon. He likened his job to a school nurse. Marines confide in him about their innermost struggles. He thinks he can spot when someone is not himself.

“I tend to be reasonably observant with people’s personalities. I can see changes,” said the 21-year-old from upstate New York.

He added: “I hope none of us become PTSD casualties.”

Sheets, a 22-year-old private first class from Newark, Del., has never seen combat before. Before joining the Marines, Sheets dabbled with college and was working a dead-end job hauling trash.

He enlisted after being inspired by a sermon from his pastor. While in infantry school, he met a sergeant who suffered from PTSD. He’s not exactly sure what it is, but has heard horror stories.

“A guy comes home from war and he’s freaking out. He’s beating his wife. He’s drinking. He’s doing everything he can. He’ll go off and he’ll hate the Marine Corps,” Sheets said. “And it’s just like, OK, is that going to be me when I come home?”

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pregnancy

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Whether bipolar pregnant women should stop taking medication depends on each individual case, expert says.

As recently as 10 years ago, doctors advised women with bipolar disorder not to have children. While that thinking is now dated, bipolar women often face tough decisions about how to handle their medication during pregnancy.

Most drugs prescribed for bipolar disorder carry some risk of birth defects, yet women who discontinue medication risk relapsing into a manic or depressive episode; during the postpartum phase the relapse rate is as high as 50 percent to 70 percent, by some estimates.

Even more alarming, bipolar women are 100 times more likely than other women to experience postpartum psychosis, a severe mood disorder that, at its very worst, can result in infanticide.

Sally Martini, 38, started taking lithium after a severe manic episode eight years ago. She eventually switched to other drugs, but in 2007 she stopped her medication altogether when she learned that she was pregnant.

The pregnancy was uneventful. Her daughter, Stella, did arrive six weeks early, but after 21 days in the hospital Stella was finally at home and thriving.

Martini, meanwhile, was falling apart.

“I was extremely hyperactive,” she says. “I was going a million miles an hour.” Everyone had told her, “When the baby sleeps, you sleep” — but she couldn’t rest. While Stella napped, Sally would clean her Jackson, N.J., home yet again, wiping down doorknobs and light switches. She baked blueberry cobbler at 6 a.m. and pulled weeds into the night.

Though she had restarted her meds the day she gave birth to Stella, after a string of sleepless nights several months later Martini finally realized that lithium was the only thing that would bring her back to her senses. And it did.

Yet Martini continued to have doubts that she was strong enough to be a mother. These are doubts that many women with bipolar disorder share.

Say no to drugs?

Meredith, 27, of Dix Hills, N.Y., was diagnosed with bipolar disorder in 2007 and began taking lithium. Two years later, as she was planning her wedding, she took a cocktail of mood stabilizers, antidepressants, and antipsychotics: lithium, Abilify, propranolol (Inderal), and escitalopram (Lexapro).

“I was grateful for the lithium at first,” says Meredith, who did not want her last name used. “But then I was like, ‘There go all my options for having kids.'”

When it was first approved by the FDA in 1970, lithium was believed to cause heart-valve defects in an extremely high percentage of infants born to mothers who were on the drug (about 1 in 50). Decades later, new research has downgraded the risk, to about 1 in 1,000 to 2,000.

Bipolar medications aren’t considered as risky during pregnancy as they once were, but they aren’t exactly harmless either. According to the FDA’s letter-grade system for drug safety during pregnancy, most psychotropic drugs pose a potential risk to the fetus. Studies have found that the anticonvulsants valproic acid (Depakote) and carbemazepine (Tegretol) can cause birth defects ranging from physical deformities to spina bifida, for instance, while some research suggests that another anticonvulsant, lamotrigine, may carry an increased risk of cleft palate.

The risk of birth defects is small, yet the decision to stop taking medication is common, even among women with severe psychiatric illness. In 2008, after she got engaged, and after consulting her psychiatrist, Meredith decided to start tapering off lithium. “I, personally, would like to not be on any medication,” she says, when considering a future pregnancy. “I just don’t want to take any chances.”

Should bipolar women discontinue their medication? According to reproductive psychiatrist Catherine Birndorf, MD, the founding director of the Payne Whitney Women’s Program at New York Presbyterian Hospital, “There’s not just one answer.” The severity of bipolar disorder varies widely from person to person, and for this reason it’s difficult to standardize care for pregnant women with the disorder, Birndorf explains. “Each case must be considered on an individual basis,” she says.

But what many of Bindorf’s patients do not initially realize is that untreated illness — and not just medication — can be risky. According to a 2007 study in the American Journal of Psychiatry, women who discontinued mood stabilizers during pregnancy spent over 40 percent of their pregnancy in an “illness episode.” And research suggests that the effects of maternal depression on the fetus can lead to complications both during and after pregnancy.

Still, many bipolar women believe they have to stop taking all of their medications for the sake of their child — and often psychiatrists or OB/GYNs steer women away from medication, according to Margaret Spinelli, MD, director of the Women’s Program in Psychiatry at Columbia University.

“I hope that women will come to a perinatal psychiatrist to get an evaluation,” says Dr. Spinelli. “Because they can become so ill. And the problem is that if they become really ill during the pregnancy off the medication, it may take a lot more medication to stabilize them.”

Postpartum planning

A complication-free pregnancy with or without medication doesn’t mean a woman is in the clear. For any bipolar mother, the trickiest time is not the pregnancy itself but the postpartum period.

Postpartum difficulties are not limited to bipolar women, of course. Many women experience the crying episodes known as the “baby blues,” and an estimated 10% of women go through a more severe postpartum depression. Women with bipolar disorder are at much higher risk, however; postpartum psychosis — which is believed to be a form of bipolar disorder — occurs in as many as 25 percent to 50 percent of deliveries.

While postpartum psychosis is a serious risk, it’s a risk that can be treated, and often prevented, with medication. It’s extremely important for a woman with bipolar disorder to have a plan in place with her family and her doctors in the event that she does become psychotic, says Spinelli. Due to the high risk of psychosis, bipolar women should “really start medicines at least before they deliver,” she adds.

As the field of perinatal psychiatry grows, many bipolar women are choosing to stay on medications to avoid any chance of postpartum psychosis or manic episodes. “I’d heard so many horror stories of people harming the baby,” says Michele Noll, 38, of Atlanta, who has delivered two healthy babies while taking mood stabilizers.

“I did not have mood swings,” Noll says of her pregnancy and postpartum period. “Nobody even knew I was bipolar.”

Breast-feeding presents another challenge. Even though some medications are safe while nursing, feeding a baby requires waking up often throughout the night. And in people with bipolar disorder, sleep deprivation can trigger a manic episode.

Shanun Carey, 26, of Manchester, N.H., became so manic while breast-feeding that she was “bouncing off the walls,” eventually volunteering to clean her neighbors’ apartments to burn off excess energy. When her daughter was six months old, Carey realized she had to stop breast-feeding to get healthy again; she switched to formula so she could resume her medications and a regular sleep schedule.

Formula isn’t the only solution. Rachael Bender, 31, of Naples, Florida, who writes a blog called My Bipolar Pregnancy, realized that losing sleep would be a huge challenge in trying to breast-feed. But she did want to try, so she and her husband worked out a system when her daughter was an infant.

To save Bender from getting the baby up and back to sleep, her husband slept in the guest room, next to the bassinet, and brought the baby in to Bender when the baby was hungry. “The hardest thing about the whole pregnancy,” Bender says, “was the sleep after she was born.”

The next generation

Martini, who lapsed into depression after the lithium got her mania under control, still struggles with the ups and downs of bipolar disorder. Because she is committed to being a great parent to Stella, she has made what she says is the most difficult decision of her life.

“Absolutely, I will not have another baby,” Martini says, acknowledging that no matter how many times her healthy daughter kisses her, or her husband tells her she’s a wonderful mother, she still has doubts related to her bipolar disorder and the amount of attention it requires. “I want to be the best mother I can be, and if I had two children I’d worry that I was spreading myself too thin,” she says.

Meredith knows that pregnancy will be “a difficult time,” and people have already questioned her decision to have children; a family friend even told her that it would be a “heartache” for her if she did have a child with bipolar disorder. Bipolar disorder does tend to run in families: Studies show that a person is 10 times more likely to develop the disorder if a parent is bipolar.

None of this has swayed Meredith’s desire to be a mother.

“I’m not going to not have a child because I’m afraid they’re going to be bipolar,” says Meredith. “I’ve seen so many wonderful things and I’ve done so many wonderful things, and I plan to do a lot more. My kid will have a better life than a lot of kids out there. This isn’t going to stop me.”

Skin cancer can be inherited: studies

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Skin cancer can be inherited: studies

One found that having an identical twin with melanoma increased a person’s own risk of developing the disease much more than having a fraternal twin with this type of skin cancer. The other found that having a sibling or parent with one of several different types of non-melanoma skin cancer increased risk as well.

Several studies have suggested melanoma and other skin cancers run in families, but it can be difficult to tease out the difference between the influence of genes and environment. In the Australian study, Dr. Sri N. Shekar of the University of Queensland in Brisbane and his colleagues attempted to do so by looking at twin pairs in which at least one sibling had been diagnosed with melanoma.

They searched through thousands of cases of melanoma reported in Queensland and New South Wales and found 125 twin pairs. In four of the 27 identical twin pairs, both had melanoma, while three of the 98 fraternal twin pairs had both been diagnosed with the deadly skin cancer.

Based on these numbers, having an identical twin with melanoma increased a person’s own risk of the disease nearly 10-fold, while melanoma associated with having a non-identical twin with the disease was roughly doubled.

This suggests, the researchers say, that some of the increased melanoma risk can be attributed to genes, in particular interactions between genes. They estimate that genes account for about half of the differences in risk between two people.

In the second study, Dr. Shehnaz K. Hussain of the University of California Los Angeles and colleagues looked at the Swedish Family-Cancer Database to gauge the risk for several types of skin cancer among siblings and children of people diagnosed with these diseases.

They found that people with a sibling or parent diagnosed with some types of skin cancer were more likely to develop skin cancers of various types, not just the ones their relatives had. When tumors occurred at parts of the body more likely to have been exposed to the sun (such as the face, compared to the torso), the familial risk was stronger.

Based on the findings, Hussain and colleagues conclude, a person’s family history can be used to gauge their own skin cancer risk, and genetic studies could be a useful way to identify potential targets for treating or preventing the disease.

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