A Transpersonal Approach to PTSD

Patrick Marius Koga, MD, MPH UC Davis School of Medicine & VIRTIS CAMFT March 19, 2010

Transpersonal?
How could a transpersonal approach have any relevance to such a personal experience?

Time course of reactions

Traumatic event

Acute stress reaction first 48 hours

Acute stress disorder up to 4 weeks

Acute PTSD 4-12 weeks

Chronic PTSD 12 weeks +

Summary and timing of interventions

This model assumes traumatic event or cluster of events. Refugee populations may have not had prolonged and repeated exposure to traumatic events. This will affect the timings of interventions below but NOT their sequencing.

CLINICAL

T R A U M A E V E N T

Treatment of acute stress reaction 4-6 weeks

Treatment of PTSD 6 months -60yrs

TIME
3mths-Several Yrs Community interventions -Education - Network formation

NON CLINICAL

Pre-Trauma Preventative strategies Training (emergency services) Briefing Pre-torture Preparation (special Groups SAS etc.)

2wks 6 months Selective responses to high risk group -selective debriefing - Repeat debriefing - Continuing psychological first aid
24 hrs-2 wks Early general responses Psychological first aid debriefing

Assessment
Cognitive Formulation Ready for treatment Therapy boundaries

NO
Support Monitor

Trauma story

EMDR

IMAGERY

EMDR

Cognitive therapy Normalisation, Vulnerability, Responsibility, Appraisal of trauma, Survival Behaviour, Avoidance

Behavioral Therapy

Drugs
SSRIs tricyclics, Carbamazepine

Dreams, Nightmares Flashbacks

Anxiety Reduction Exposure Activity schedules Stress Inoculation training

Relapse Prevention

Follow - up

PTSD in 3 reality constructs

1. Brain & Ego: personal reality= external locus of control, vulnerable 2. Cultural identity: personal reality= external locus of control, vulnerable to trangenerational trauma 2. Religion/Spirituality &Virtual Reality (VR): transpersonal realities= internal locus of control, invulnerable Mixing the three in todays global world of high tech war: opportunities and threats

(-)

Cortisol is released in

relation to stressor severity. An important role of cortisol in stress is to contain other biological stress responses

Post-Traumatic Stress Disorder (PTSD)

Bremner hypothesized that hippocampal damage represents the anatomical basis for the psychological effects of stress. (mind-body perspective)

Data from MRI studies showed an 8% reduction of left hippocampal volume in Vietnam vets and similar decreases in the right sides of physically and sexually abused women.

100 billion neurons 100 trillion glial cells

LeDoux, Scientific American, 1994

11

The Neurophysiology of PTSD

Cortex
PFC
Sensory Thalamus

Amygdala

TWO PATHWAYS OF FEAR

When the brain receives a sensory stimulus indicating a danger, it is routed first to the thalamus. From there, the information is sent out over two parallel pathways: 1. the thalamo-amygdalic pathway (low road) 2. the thalamo-cortico-amygdalic pathway ( high road).

Thalamo-cortico-amygdalic pathway

The high road

The low road

Thalamo-amygdalo-fugal pathway

FEAR

VINE?

SNAKE?

The Low Road

conveys a fast, rough impression of the situation, because it is a sub-cortical pathway in which no cognition is involved. this activates the amygdala which, through its central nucleus, generates emotional responses before any perceptual integration has even occurred and before the mind can form a complete representation of the stimulus.

VINE

Phew! Vine

SNAKE!

SNAKE!

Fear

 the information that has travelled via the high road and been processed in the cortex reaches the amygdala and tells it whether or not the stimulus represents a real threat. To provide this assessment, various levels of cortical processing are required.

20

levels of cortical processing

the perceived object is processed by the primary sensory cortex. Then the unimodal associative cortex provides the amygdala with a representation of the object. the polymodal associative cortex conceptualizes the object and also informs the amygdala about it. This elaborate representation of the object is then compared with the contents of explicit memory in the hippocampus, which also communicates closely with the amygdala.

The hippocampus
supports the explicit memory required to learn about the dangerousness of an object or situation. especially sensitive to the encoding of the context associated with an aversive experience. not only can a stimulus become a source of conditioned fear, but so can all the objects surrounding it and the situation or location in which it occurs.

The parallel operation

of our explicit (hippocampal) and implicit (amygdalic) memory systems explains why we do not remember traumas experienced very early in our lives. Hippocampus is still immature, while the amygdala is already able to record unconscious memories. Early childhood traumas can disturb the mental and behavioral functions of adults by mechanisms that they cannot access consciously.

SNAKE!

Fear

No Threat

No Danger

Pre-Trauma Processing of ordinary stimulus

Threat!!

Danger!!

Post-Trauma Processing of ordinary stimulus

Trauma produces an anatomical change in the brain

Post-trauma fear network in Amygdala

Post-trauma fear network in Amygdala

A landscape of fear-inducing cues

Integrated Narrative

Neurobiology of Non-Traumatic Memory

LTP builds the neural networks that create new memories

LTP LTP LTP

Hippocampus

Neurobiology of Traumatic Memory

Trauma interferes with LTP functioning

LTP LTP LTP

Results in loss & fragmentation of memories

Hippocampus

Neurobiology of Traumatic Memory

Failure of Extinction in PTSD

Extinction: Decrease in conditioned response

due to nonreinforcement

PTSD:
Inability to extinguish conditioned fear responses

Inability to distinguish between dangerous and safe situations

33

Battlemind: Dys-coordination of Threat Response & Dissociation

Medial Prefrontal Cortex Anterior Cingulate Cortex +

PFC bypass

Sights Sounds

_
dissociation

AMYGDALA +

+ _
Hippocampus

Thalamus

Smells Coordinated Response

34

PTSD Treatment Consensus Panel

(2000)

SSRIs most appropriate first-line medication treatment for PTSD

Exposure therapy most appropriate psychotherapy for PTSD

Journal of Clinical Psychiatry. 61 Suppl 5:60-6, 2000.

Emotional Processing Steps: Basis for Exposure Therapy

1. Fear memories are stored as a fear structure
Fear structure = stimuli + meaning + responses Accessing the fear memory allows for fear structure change

2. Access
Imaginal In-vivo Virtual

3. Change
Cognitive re-framing Habituation, re-appraisal, and mastery

Gestalt: the empty chair technique

Problems with Imaginal Exposure

Many patients are unwilling or unable to effectively visualize the traumatic event Avoidance of reminders of the trauma is inherent in PTSD Inability to emotionally engage (in imagination) is a predictor for negative treatment outcomes (Jaycox, Foa, & Morral, 1998).
Risk of flooding and flashbacks

Virtual Reality and PTSD

A computer generated, immersive (or wide field), multi-sensory information program which tracks a user in real time.

Virtual reality exposure therapy (VRET)

is an altered form of behavioral therapy and may be a possible alternative to standard in vivo exposure.
Virtual reality integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse patients in a computer-generated virtual environment.

VR headsets
small TV screen for each eye slightly different angles 3D effect

inside VR
scenes projected on walls realistic 3-D environment real controls; moving within the world
other people interactive

Engages
the senses sight:
visual realism, 3D effects: shadows, etc.,

sound:
surround sound, subseat woofers etc.

touch:
haptic and force feedback

the body realistic devices movement in the environment interaction and control of objects, rapid feedback

A HMD exposure therapy simulation that uses digital assets from Full Spectrum Warrior.
The object of the simulation is to allow the patient to create personal narratives about real-life traumatic events that foster psychic

integration rather than the dissociation of PTSD. Some versions of the simulation use a motion platform and/or scent release device.

Virtual Classroom
Albert Skip Rizzo ADHD Children

Telemedicine
Rehabilitation and training in virtual environments for amputees, spinal injury patients, the blind, and the developmentally disabled.

VR - PTSD
Virtual Vietnam Emory University World Trade Center Weill Cornell Medical Center/U of Wash Terrorist Bus Bombing - U. of Haifa/U of Wash Motor Vehicle Accidents Univ. of Buffalo

Virtual Angola

U. of Lusfona de Humanidades e

Tecnologias, Lisbon

Virtual Iraq USC Institute for Creative Technologies Virtual Baghdad Virtual Reality Medical Centers

Virtual Vietnam

Emory University

Virtual World Trade Center

Cornell and the University of Washington

Virtual Bus Bombing

Tamar Weiss, University of Haifa

Virtual Iraq

Combat PTSD VR Elements

Multiple scenario settings Selectable user perspective options Create library of trigger stimuli Create a highly usable Wizard of OZ clinician interface Options: Integrate scent and vibration Integrate physiological recording into clinician interface Major Goal: customize VR exposure based on client experience

Multiple Scenario Settings

City Scenes Small Rural Villages Building Interiors Convoys & Checkpoints Desert Base Desert Highway

Selectable User Perspective Options

Walking Alone Walking with One Person Flocking Patrol HUMVEE Interior View HUMVEE Convoy Helicopter Interior View

HUMVEE Convoy

Helicopter Interior View

Wizard of Oz type clinical interface

Tool for placing patient in a virtual environment similar to that in which traumatic events occurred Customize the therapy experience to the patients experience Therapist retains control of environment intensity Systematic delivery of trigger stimuli

Wizard of OZ Clinician Interface

Scenario and settings
Location, Time of Day, Weather, etc.

User perspective
Alone, Patrol, HUMVEE, Helicopter, etc.

Real-time physiologic display Trigger stimuli

Optional Scent and Vibration Integration

Nasal puffer Scent library includes regular gunpowder, military gunpowder, burning rubber, trash, Iraqi spices, radiator fluid, etc. Vibration platform Heat source

Optional Physiologic Monitoring

Therapist display shows clients field of vision Physiologic monitoring used to assist with anxiety modulation training and monitoring therapeutic habituation

Monitoring and Patient Controller

Current Clinical Uses of VR

(VRMC in San Diego, West LA, Palo Alto)
Anxiety Disorders, including PTSD, phobias, and panic Anger management Stress inoculation training Peak performance training Leadership training Pain Addictions Autism Classroom ADHD TBI/Stroke cognitive rehabilitation Physical rehabilitation

Potential Future Military Use of PTSD VR Technology

Integrate VR combat exposure as part of a comprehensive program to assess fitness for duty Stress inoculation training Reintegration screening using VR PTSD with physiological recording to check for physiological reactivity Post-combat reintegration training for military members at risk
This could provide a treatment pathway with less perceived stigma given younger military personnels familiarity with digital gaming More attractive intervention than traditional talk therapy

Transpersonal Reframing or Bypassing?

No evil?
We are not merely human beings having a spiritual experience; we are spiritual beings having a human experience Teilhard de Chardin

Meditation
sustained and deliberate concentration suggesting frontal attentional network activation. functional neuro-imaging (fMRI) demonstrate DL activation meditation may represent mixed transient hypofrontal state wherein the attentional structures are well activated, but other frontal structures are purposefully without content. If psychiatrist Mark Epsteins understanding of the ego as the self concept, the actual internal representation of ones self (Epstein, 1993, p.123), then selective activation and deactivation of the DL and VM would produce a profound state of consciously aware egolessness.

Neurophysiological Impacts of Spirituality

Hypofrontality Deafferentation of the orientation association area (OAA) Overload of the working memory with subsequent shut down Shut down of the cognitive, declarative mind; experience of pure awareness

OAA Deafferentation or 12 steps towards a unitive experience

1) the decision to clear ones mind of thoughts, emotions, sensory inputs, etc. starts in the brains Right attention association area, the seat of willed attention 2) the attention area via thalamus , blocks the informational flow of the hippocampus 3) this neural blockage affects many brain structures inclosing the orientation association area ( OAA) which becomes increasingly deafferented (deprived of input) 4) together with the hippocampus, the OAA tries harder and harder to reduces the ascending neural flow 5) Bursts of build-up, blocked out neural energetic impulses bounce back downward towards the hypothalamus (roles in both calming and arousal).

Contd
6) the reverberant circuit bounces back via the limbic system back into OAA. 7) OAA registers calming impulses and relays them back down for further more laps 8) meanwhile the meditatorss continuing intention to clear up the mind keeps on building up this reverberating circuit. 9) this bombardment produces in hypothalamus a maximum calming effect 10) the electric spillover triggers a maximum arousal effect

Contd
11) the mind is overwhelmed by simultaneous calming and arousal responses and the OAA is forced by the sudden surge to operate at its maximum rate, overloads and shuts down. Deafferentation is complete. 12) the impacts on attention area: a) RT orientation area lacks the info need for a sense of space in which to orient the self b) LFT orientation area lacks the info needed for a subjective sense of self. RESULT: collapse of subjective selfs boundaries. Oneness. A unitive experience with potential for selftransformation.

Research Questions
If both VR and Spiritual Experiences (SE) can provide a safe inner (virtual) space for ones witness consciousness, then why not try using SE for re-exposure to traumatic memories? Compare & contrast outcomes and costeffectiveness Inform policies

God Helmet
Dr. Michael A. Persinger a magnetic field pattern stimulates "microseizures" in the temporal lobes of the brain which, in turn, produces "spiritual" and "supernatural" experiences the sense of a presence in the room, an out-of-body experience, bizarre distortion of body parts, and even religious feelings.

 may dehumanize soldiers & civilians via gradual desensitization (inoculation) to combat & killing stress. dissociation depersonalization, derealization, brainwashing/programming , fanaticism . Risk of training cyborg soldiers, suicide bombers, Talibanization of future armies in local and global conflicts.
International ethical guidelines? Enforceability?

Risks & Misuses of Culture, SEs and VRET

Veteran, Immigrant, & Refugee Trauma Institute of Sacramento (VIRTIS)

1. 2. 3. 4. 5. Provide therapeutic services Prevent secondary traumatization of families Conduct research with UC Davis Medical School Educate & train professionals & families Network with other stakeholders

www.virtis-ptsd.org

email address
pmkoga@ucdavis.edu