War trauma and brain impact

Although much of The Telegraph’s science coverage seems to have gone down the pan recently, they’ve just published a remarkably well balanced and informative article on war trauma and how it is associated with measurable changes in brain structure.

Brain imaging studies have found that people with post-traumatic stress disorder tend to have smaller hippocampi, an area known to be key for emotional memory.

But it’s not clear whether this is a direct consequence of PTSD, or simply that people with smaller hippocampi are more likely to develop the disorder after trauma.

The article does a fantastic job of presenting a balanced look at the causality hypnotheses, and quotes psychiatrist Simon Wessely, known for his research on the psychology, neuroscience and history of combat trauma.

But Prof Wessely has found that the very thing that exposes soldiers to PTSD might also help them deal with it: their job. According to his research at King’s, group cohesion and firm leadership are critical in reducing the impact of psychological distress.

“You have to remember we are talking about professional soldiers who have been highly trained,” he says. “Their training is designed to harden them against the unpleasant nature of war. The military is actually very effective at reducing the risk of PTSD with their training, their professionalism, esprit de corps and morale. War is a stressful business and this all prepares soldiers for that.”

The flip side is that the memories that provoke trauma are not necessarily those of gruesome battles or injuries. “The kind of events that affect them are not simply seeing bad things and coming under fire ‚Äì it is when the rules they have come to expect are somehow broken. It is when errors of omission or commission lead to the feeling they have been let down, or that they have let their comrades down, that mental health problems occur. This is why ‘friendly fire’ incidents are so psychologically damaging ‚Äì it violates the soldiers’ rules of who is supposed to be shooting at them. They will feel anger at those responsible.”

The only bizarre bit is the second to last paragraph where it mentions “new treatment is being developed, drawing on neurolinguistic programming, relaxation techniques and even Eye Movement Desensitisation Therapy”.

It mentions EMDR as if it is something unusual, when it is an increasing well researched evidence-based treatment, and NLP as if it is nothing out-of-the-ordinary, when it is largely pseudoscience that lacks even the most basic empirical support.

Link to ‘How brain scans show the trauma of war’.

6 Comments

  1. Michael MacAskill
    Posted January 29, 2009 at 10:51 am | Permalink

    As an eye movement researcher, I can’t agree with the claim that EMDR is supported by evidence. Oddly, EMDR has remained entirely within the psychotherapeutic community and has never had any noticeable involvement from specialists in the eye movement field. Perhaps as a result, the mechanisms that have been proposed for its (claimed) effects are almost embarrassingly inadequate.
    For example, it is claimed that horizontal eye movements are represented bilaterally and hence “facilitate interaction between the brain’s hemispheres” and this is supported by no apparent effect of vertical eye movements in one study. Unfortunately for the theory, vertical eye movements are also represented bilaterally. The lack of understanding of basic eye movement physiology and behaviour makes the whole area difficult to take seriously.
    This is also shown in the claim that eye movements induce some sort of waking REM state and that “compared to eye fixation, eye movement promoted attentional flexibility and increased preparedness to process metaphorical material”. What this fails to take into account is that active eye movement is the normal state for awake humans. Saccades (fast eye movements) are the most common human behaviour, occurring on average three times a second, or 100-200 000 times a day. Sustained fixation is actually rare and difficult to maintain without an effort of will. Active exploration is the normal mode of the saccadic/attentional/perceptual system. So it doesn’t make sense to compare EMDR to fixation, as our normal and spontaneous rate of saccading is close to maximal anyway. EMDR should only be compared to normal rates and patterns of saccades, and not to artificial conditions like fixation.
    The issue of effectiveness is a separate one. The fact that EMDR enthusiasts have not been able to put forward a credible mechanism based on viable physiology doesn’t mean that EMDR can’t work, of course. There are plenty of things that happen for which we currently have no explanation, which is the joy of science. But I have also yet to see any convincing, controlled, and reputable studies showing that it DOES work. As you showed, research has been done, but it still tends to be based on case reports. These can only provide the motivation and justification for clinical research, not the basis of conclusions. When there are experimental studies, they are generally poorly controlled. I haven’t done a thorough review as EMDR is not my area of interest, so I’d be keen to know if there are definitive studies out there that I’ve missed.
    I think most EMDR practitioners believe passionately and genuinely in its effectiveness. But then for decades psychoanalysis was also seen as a useful treatment until Eysenck finally thought to empirically assess it and showed it to be no more useful than waiting for spontaneous remission.
    Nowadays, psychoanalysis has been relegated to its proper place as an artistic endeavour and is not taken seriously as a scientific approach. Psychotherapy is prone to adopting interventions which have no evidence of efficacy because both the practitioner and the patient have a strong investment in wanting them to succeed. Just as in Eysenck’s day, most psychological conditions have a high spontaneous rate of remission, so improvement will often be ascribed to whatever ‘treatment’ was being followed. My suspicion is that EMDR is simply a highly effective placebo (more effective than the competing placebo employed in studies to date), and one which operates from both sides of the therapeutic partnership.

  2. Posted January 29, 2009 at 12:10 pm | Permalink

    That bizarre bit makes the entire article bizarre.
    It goes to great lengths to explain how PTSD might be caused by changes in the brain, or by changes in cognition. But the only treatments it mentions, describing them as “new”, are not new, do not directly address changes in the brain, and do not directly address changes in cognition.
    I have to agree with Michael MacAskill that EMDR may be effective as a placebo because it operates for the therapist as well as for the patient. My impression is that therapists typically turn to EMDR when the patient needs to explore a horrifying event that the therapist finds difficult to face.
    Ironically, Prof. Wessely’s findings suggest that horrifying events in themselves might not always be relevant.

  3. Posted January 29, 2009 at 1:27 pm | Permalink

    I agree that the mechanism is still unknown, although a recent study has shed some light on it (bottom line: it’s not clear that the eye movements are actually essential):

    http://dx.doi.org/10.1016/j.brat.2008.04.006

    However, the treatment is evidence based. There are a now a number of RCTs which show its effectiveness to be significantly better than placebo and one of the most effective treatments for PTSD and trauma. It is recommended by a recent Cochrane Review:

    http://www.ncbi.nlm.nih.gov/pubmed/17636720

    The fact that this evidence is based on randomised trials discounts the ‘therapist placebo’ hypothesis mentioned above.
    It’s probably also worth mentioning that EMDR probably involves going over the most unpleasant parts of the trauma much more than other forms of psychotherapy, making it potentially more unpleasant for the therapist.

  4. Michael MacAskill
    Posted January 29, 2009 at 9:26 pm | Permalink

    Vaughan, thanks for posting those links.
    Note that randomisation can’t discount placebo effects: only double blinding can do that, which is inherently difficult to achieve when comparing different styles of psychotherapy. Unlike taking one of two apparently identical white pills, both the therapist and client can detect and be influenced by the particular aspects of any given form of psychotherapy. That isn’t a criticism of EMDR studies, it’s a difficulty inherent to the whole field. It makes the gold standard RCTs which are the normal fodder for Cochrane reports to be almost impossible to conduct.
    But my issue is with the proposed eye movement mechanism of the therapy. No doubt there are other aspects which EMDR sessions shares in common with standard cognitive/behavioral techniques which could produce real improvement in many cases. I just don’t see that jiggling your eyes about provides anything additional other than a (possibly quite effective) placebo.

  5. Posted January 30, 2009 at 6:44 pm | Permalink

    While many people think NLP as pseudoscience, I used it with great success while working as an “English Teacher” in Japan for 18 years, 1982 – 2000. At the time English learning was divided into two parts Eikawa (The English Language) and Eigo (English Conversation). Getting a high score on paper-and-pencil Eikawa tests was used in selecting people for advanced education or the better paying jobs: success was achieved through wrote memorization. While the process worked for Eikawa, it failed miserably for Eigo, except where it amounted to once-again, rote memorization which meant that people could enter fictional face-to-face conversation, but couldn’t order a real-life cup of coffee.
    I was introduced to NLP by somebody who said, “Ask them three questions and see which way their eyes move: ‘What’s your favorite color?’ ‘What’s your favorite music?’ What’s your favorite food?’ Then compare the kind of eye motions you get from those who look like they can answer quickly and easily with those who can’t.” I checked it out and found there were indeed significant differences. I bought a book and learned that the three question reference what NLP called modalities: visual, audio, kinesthetic.
    My self-appointed task was to figure out how to induce the eye motions of people who couldn’t answer such questions quickly and easily, to look more like those who could. It took about a year to work it out and became go-to-guy for people who could pass all the low-level paper-and-pencil tests but failed the top level where you had to actually have a conversation.
    I don’t know how NLP would fare with PTSD, but I found it a useful way to dimensionalize the situation.

  6. Posted February 4, 2009 at 7:53 am | Permalink

    Thanks to this unique post Vaughan. That’s why I hated war so much. Once my dream was to be a soldier, thank God I was able to change my mind through my friend at kamja otherwise I’m dead. This is why people need such life-coaching technique including NLP. Probably to some it works and to some not depending how they view things properly. Mind has power to transform man and his future. What a man thinks, so is he. It is a matter of faith that surpasses man’s limitation. Man can both think natural and supernatural. And in every man, there is a vacuum within that when fill can passes all understanding and that is faith that can see mountains and can even move mountains of life.


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