This is our first ever Law and Medicine podcast, presented by Joanna for the Law and Medicine team. This short podcast contains a variety of news, with a strong bias towards medical law an ethics. We hope that you enjoy listening to it, and you will feel to give us feedback on any of the topics we discussed. We have this week a spokesperson nterview with from MIND about their work with individuals and communities.
Download the podcast here L&M Podcast .
Enjoy it!
This blog is supposed to be the informal blog for our Law and Medicine project.
The main teaching website, members-only, can be found here for candidates of the GDL and MRCP exams.
Currently, I am designing an international study on Parkinson’s disease at the moment to be carried out by a clinical nurse in an English NHS Trust and a national institution for cognitive neurology research abroad. This study will not actually be funded by Parkinson’s UK as we have never sought to seek funding from there. In fact, I have nearly two years’ previously on actual patients at the country’s leading centre for neurology, the National Hospital for Neurology, and in their academic unit, the Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, Queen Square. I am therefore very interested in what happens in Parkinson’s Awareness Week.
While I was there I published a paper entitled “Quality of life in Parkinson’s disease: the relative importance of the symptoms.” ((1), Mov Disord. 2008 Jul 30;23(10):1428-34.) I argued that a large literature now exists, which demonstrates that idiopathic Parkinson’s disease has a major negative impact on quality of life (QoL), and that depression and cognitive impairment are among the main predictors of poor QoL: in this condition. In addition to depression and anxiety, the major predictors of QoL were shuffling, difficulty turning, falls, difficulty in dressing, fatigue, confusion, autonomic disturbance particularly urinary incontinence, unpredictable on/off fluctuations, and sensory symptoms such as pain.
Why did I mention this? Just go to any website on Parkinson’s disease and you will find a description of the disease as follows:
What are the symptoms of Parkinson’s Disease?
Motor symptoms of Parkinson’s Disease include tremor, slowness of movement (known as bradykinesia) and stiffness or rigidity of muscles.
Non motor symptoms of Parkinson’s Disease may also be experienced. These include constipation, depression, sleep disturbances and urinary urgency.
Parkinson’s UK is about to launch, “Parkinson’s Awareness Week 19-25 April 2010 Parkinson’s Awareness Week 2010 is all about making sure the voices of people affected by Parkinson’s are heard – loud and clear.” This is of course to be applauded, and it is hoped that public awareness of Parkinson’s disease will improve (it is generally poor at the moment, it is thought). Of course, it belies the fact that this is very much also a “Parkinson’s Society Awareness Week”. At worst, it is a collection of sporadic interviews on sofas of daytime TV, at best it is a discussion of the real problems faced by patients with Parkinson’s disease. Parkinson’s Awareness Week must promote a much better awareness of the diagnosis and treatment of non-motor (non-movement) symptoms in Parkinson’s disease.
I just have a vision of lots of non-scientists and non-medics sitting in a room thinking about what to campaign on. This is a fair question if it includes training more nurses, although it does beg the question why this training is not taking place already in the context of NHS training. And as for research – where exactly is the money to be spent? There are obviously crucial questions to be resolved about the management of Parkinson’s disease, but also some thorny questions on social care and the regulation of new technologies (e.g. deep brain stimulation) exist. I certainly would not wish anyone to be hesitant to donating to the Society during this Parkinson’s Awareness Week. However, it is like the general election – their campaigning must make it clear what their policy is on these issues, and why. Not everyone for example agrees with the idea of free prescription charges. I do agree with free prescriptions, mainly because I am disabled, I suppose.
I genuinely feel that the PD Society has failed adequately to campaign ‘outside of the box’. They should, for example, include campaigning on something which requires reflecting current trends in the literature. Unfortunately, it feels to me as if some people have decided , “Oh yeah – generally raising awareness of Parkinson’s disease”, and in all fairness it is for real PD ‘stakeholders’ to voice their opinions, not the Society or government.
Prior to Parkinson’s Awareness Week, it has long been recognised that the non-motor symptoms (NMS) of Parkinson’s Disease are unfortunately common at all stages of disease (2). There has been an overwhelming consensus now that the NMS of Parkinson’s disease, such as apathy and depression, can predate the traditional motor symptoms and signs of the disease. Chaudhuri and Schapira (3) have warned that such symptoms tend to be under-diagnosed and under-reported, and therefore tend to be under-treated. Apathy itself has attracted in Parkinson’s disease has attracted much interest in the neurological community. Pluck and Marsden (4) argued that apathy in Parkinson’s disease is more likely to be a direct consequence of disease-related physiological changes than a psychological reaction or adaptation to disability (5). The definition of this term in the neurological press has been notoriously difficult. Marin defined apathy as “a lack of motivation not attributable to diminished level of conscience, cognitive impairment or emotional distress” (6).
It is now useful for someone to campaign from any of the world Parkinson’s charities on the fact that these non-motor symptoms sometimes go unlooked for physicians (especially during Parkinson’s Awareness Week). As such, my deep concern is these are not treated in patients with early Parkinson’s disease, but ask any patient or carer they’ll tell you they definitely exist. Apathy and depression, whilst not as visible as stiffness or slowness, can be treated, and it is a tragedy that they are not widely at the current time of writing.
Finally, my inspiration, by the way, for my detailed study of Parkinson’s disease commencing 15 years’ ago at Cambridge was this man by the way. Dustin Hoffman in the brilliant film “Awakenings”. Awakenings is a 1990 drama film based on Oliver Sacks’ 1973 memoir Awakenings. It tells the true story of Oliver Sacks, fictionalized as American Malcolm Sayer and played by Robin Williams who, in 1969, discovers beneficial effects of the then-new drug L-Dopa. He administered it to catatonic patients who survived the 1917-1928 epidemic of encephalitis lethargica. Leonard Lowe (played by Robert De Niro) and the rest of the patients were awakened after decades of catatonic state and have to deal with a new life in a new time.
About 10 years’ ago (I think?), I was really excited when the international research community thought that they had discovered a similar post-infectious antibody after streptoccal infection (the PANDAS antibody). These are indeed exciting times, if patients also become aware of what is happening with the research monies that they have contributed to (7). This would be a good benefit and outcome of Parkinson’s Awareness Week in my considered opinion.
Dr. Shibley Rahman BA (1st.), MA, MB, BChir, PhD (all Cambridge), PRINCE2, LLB, FRSA, MSB
Company Director of Law and Medicine Limited
23 April 2010
References
(1) http://www3.hi.is/~martaj/Verkn%E1m/l%EDfsg%E6%F0i%20parkinsons.pdf
(2) Lo RY, Tanner CM, Albers KB, Leimpeter AD, Fross RD, Bernstein AL, McGuire V, Quesenberry CP, Nelson LM, Van Den Eeden SK. Clinical features in early Parkinson’s diease and survival. Arch Neurol. 2009 Nov;66(11):1353-8
(3) Chaudhuri, KR, Schapira, AH. (2009) Non-motor symptoms of Parkinson’s disease: dopaminergic pathophysiology and treatment. Lancet Neurol. 2009 May;8(5):464-74.
(4) Pluck, GC, Brown, RG. (2002) Apathy in Parkinson’s disease. J Neurol Neurosurg Psychiatry 2;73:636–642.
(5) Dujardin et al. (2009). Apathy may herald cognitive decline and dementia in Parkinson’s disease. Mov Disord 11. [Epub ahead of print]
(6) Marin RS. (1991) Apathy: a neuropsychiatric syndrome. J Neuropsychiatry Clin Neurosci 3l:243-254.
(7) Hollander E, Kim S, Braun A, Simeon D, Zohar J. (2009) Cross-cutting issues and future directions for the OCD spectrum. Psychiatry Res. 170(1):3-6. Epub 2009 Oct 6.
GUEST ARTICLE BY PROF JOHN LOCKE
In U.S. criminal law, necessity may be either a possible justification or an exculpation for breaking the law. America’s abortion debate was ignited again yesterday after a judge was asked to allow the man who killed an abortion doctor in front of 250 people to make a ‘necessity defence’ in court. Judge Warren Wilbert refused to allow the defence to present a plea of necessity, but did allow them to present a case for voluntary manslaughter on the grounds that the defendant sincerely believed that he was committing a crime to prevent a greater evil.
Anti-abortionist Scott Roeder will have been allowed to testify that he believed he was saving unborn children when he gunned down Dr George Tiller in a Kansas church last May, Judge Warren Wilbert ruled yesterday. Roeder, who has confessed to the killing, is charged with first-degree murder in the Kansas trial. But Wilbert recently had decided he would allow the 51-year-old to build a defence calling for the lesser charge of voluntary manslaughter. Kansas law defines voluntary manslaughter as ‘an unreasonable but honest belief’ that there were circumstances to justify deadly force.
Pleading such a case could bring a prison sentence closer to five years, instead of a life term for first-degree murder. Wilbert said that until Roeder’s team decides which evidence it will present, he cannot rule out his proposed defence claim. The prosecution argued this week that such a defence should not be considered because there is no evidence Tiller posed an imminent threat at the time of the killing.
A voluntary manslaughter-based argument would essentially ‘enable a defendant to justify premeditated murder because of an emotionally charged political belief,’ the prosecution wrote.
But the defence hit back , arguing that in Roeder’s mind, there was an imminence of danger because Dr Tiller’s Wichita clinic was performing abortions. ‘It had staff. It had a practitioner. It had a budget. It had clientele. … In the mind of Mr. Roeder, the victim presented a clear danger to unborn children,’ the defence wrote.
While again turning aside the prosecution argument, Wilbert warned that the defence had a difficult task and he would ‘make every effort to try this case as a criminal first-degree murder trial.’ The judge said he would rule on a witness-by-witness, question-by-question basis on whether to allow jurors to hear specific evidence on what Roeder’s beliefs were at the time of the shooting.
The facts of the case are not in dispute. On May 31, Roeder got up from a pew at Wichita’s Reformation Lutheran Church at the start of services and walked to the foyer, where Tiller and a fellow usher were chatting. He put the barrel of a .22-caliber handgun to Tiller’s forehead and pulled the trigger. This recent ruling therefore changed what had been expected to be a simple case – with the defendant’s confession and more than 250 possible witnesses for the prosecution – and galvanized both sides of the abortion debate.
While we wait even longer for the English Law Commission to deliberate on the future of the insanity defence, it is worth noting that events have supersed my last blog. Yesterday, a “devoted husband” who said he killed his wife because he thought she was an intruder has been freed by a judge, who told him he bore no responsibility.
Brian Thomas, 59, admitted killing Christine, 57, in their camper van, but blamed his rare sleep disorder. The judge told the jury to declare Mr Thomas, of Neath, not guilty over the death in Aberporth, Ceredigion in 2008.
The case involved automatism as a cause of ‘insanity’. Automatism is essentially a legal defence, arguing that a person cannot be held responsible for their actions because they had no conscious knowledge of them. It is a legal defense in the sense that the correlates of what is happening in the brain are poorly understood, therefore leaving psychiatrists with some difficulty in providing evidence on it for thecourts.
They drew attention to the fact that the present law derives from a work written in 1797. The current test uses out-of-date language (the accused has to be suffering from ‘a complete alienation of reason’). This terminology cannot be easily understood by persons who have to apply it, such as psychiatric experts or jurors. Clearly, this definition does take into account the rapid advances in cognitive neuroscience, nor in legal academia about the nature of responsibility.
The Scottish Law Commission further argued that the reformed defence should require the presence of a mental disorder suffered by the accused at the time of the alleged offence. The existence (or non-existence) of a mental disorder in a particular case would normally be a matter for expert, psychiatric evidence. The core element of the defence should be that, by reason of a mental disorder at the relevant time, the accused was unable to appreciate the nature or wrongfulness of his or her conduct. Now the hard part! What would the defendant or his lawyer need to prove that this was the case at the time?
The problem is obviously the defendant can be made subject to all sorts of complicated tests. For example, it is known that many legal diagnoses of insanity actually correspond to a diagnosis of psychosis or schizophrenia. However, for such patients, an electroencephalogram or MRI (advanced brain scan) can be normal. And what about proving that the defendant suffers from some abnormality in moral thinking? The group led by Josh Greene at Harvard has only just begun to develop such tests, and to find out how the brain processes moral behaviour. Or could it be a problem with impulse control? Or could it be that the defendant simply has no idea about his own mental state, what the neuropsychiatrists called “anosognosia”?
The upshot is that the law is ripe for reform. People, however, disagree how. One valid view is that the defence of insanity should be simply abolished. Abolition of the defence has been considered in academic literature for some time. Furthermore as a reaction to the Hinckley case in 1982 some states in the USA enacted measures to abolish the insanity defence.
There is now the added issue of how the English law can be reconciled with European law. Article 5(1) of the European Convention of Human Rights provides for a general right to liberty and security of a person and states that no one “shall be deprived of his liberty save in the following cases and in accordance with a procedure prescribed by law.” One of the specified cases is in paragraph (e) of that article which provides for “the lawful detention of persons for the prevention of the spreading of infectious diseases, of persons of unsound mind, alcoholics or drug addicts or vagrant.”
A fascinating legal journey has now begun, and at present the destination is unclear. Watch this space!
After much careful planning (!), we now have a fully functioning Law and Medicine blog.
It is hoped that this will act as a fulcrum to this blog and other activities to promote law and medicine.
Please register using the button in the top right of the home page.
The home page is found here.
The forum you will need is “General law and medicine” news, where, as a user, can you start your own threads.
Talk about what you wish as long as it doesn’t contravene our forum terms and conditions!
The intellectual arena is now all yours. We should especially like to hear details from students of the biosciences, bioethics, ethics, neuroethics or medical law. Keep your eyes peeled in the news for any interesting discussion topics.
If you are a student of medicine or the law, you will also see revision sites for the MRCP and the GDL which we hope are useful in the run-up to the exams. These exams will be taking place shortly in April, May, June and July 2010.
The question about whether young people should be subject to passive smoking (or “second hand smoke” (SHS)) soon resolves an issue of the rights of the child or the responsibilities of the parent. A person may wish to exert autonomy over their desire to have a cigarette, but does his or her child have an overriding right not to be subject of that smoke? As is usual with the law, the judgment crucially deciding upon conflicting interests, and balancing their decisions to make an apt decision. Ethicists have long wondered who exactly confers these rights, how are they defined and on what basis (Hall, 2005)
In fact, it is tempting to believe that UK health policy exists in a total vacuum, when it comes to the outside world. This is in fact not true, because the UK is a signatory to the United Nations Convention on the Rights of the Child (UNCRC). Although UN Conventions do not have ‘the force of law’, countries do report at regular intervals to the relevant UN Committee on their progress in implementation. From a legal point, it is noteworthy that the UNCRC does not have the same force as the Human Rights Act, although it is widely quoted in policy documents (Hagger, 2005). The concept of “rights’” cannot change human behaviour, but it “adds an element of accountability and a legal framework that can be used to make governments wake up to their obligations to make things happen’”. (Hall, 2005)
It is therefore nonetheless encouraging that one of that the UK’s leading lung charities seems to be very serious about children and lung health.
One of their election points, in relation to the British Lung Foundation’s “Children’s Charter”, argues the following:
The BLF therefore believes that parents and carers should be given opportunities to learn how to keep young lungs healthy and that children should have the right to enjoy a smoke free environment both inside and outside of the home.
In some ways, this is reminiscent of the NHS Patient Charter, which had its oft-exhausted list of inherent strengths and weaknesses. Christine Farrell has done a very considerabke review of the NHS Charter process (Farrell, 1999). The weaknesses of the Charter were seen by patients and staff as falling within three categories although staff were much more vocal in their criticisms than patients and carers. The problem areas were categorized into three groups:
1. problems with standards and rights;
(From this point of view, it is worth noting therefore the phrasing of “opportunities to learn how…” is not trivial, given the previous problems in how people understand standards and rights. NHS staff and patients have in the past commented on the lack of clarity and the confusion about what was a “standard’ and what was a “right”. This is an issue much discussed in the literature too (Hogg, 1994; Bynoe, 1996).)
2. difficulties with monitoring;
3. patient expectations raised too high.
Smoking, lung disease and policy
A very recent study has looked in fact at the relationship between childhood environmental tobacco smoke (ETS) exposure and the development of subsequent lung disease (Lovasi et al. 2010) Mechanical stress to alveolar walls, the little units which make up our lungs, may cause progressive damage after an early-life insult such as exposure to environmental tobacco smoke. Childhood ETS exposure was assessed retrospectively as a report of living with one or more regular indoor smokers. Childhood ETS exposure was associated with detectable differences on computed tomography scans of adult lungs of nonsmokers.
Indeed, young children who are exposed to tobacco smoke are in general significantly more likely to develop health problems during childhood and in later life. who are exposed to second-hand smoke (Health Care Commission (2006), ATS (1999). Although parental smoking is the commonest source of ETS exposure to children, children are also unfortunately exposed to ETS in schools, restaurants, public places and public transport vehicles.
Apart from containing thousands of chemicals, the particle size in the ETS is much smaller than the main stream smoke, and therefore has a greater penetrability in the airways of children. Exposure to ETS has been shown to be associated with increased prevalence of upper respiratory tract infections, wheeze, asthma and lower respiratory tract infections. Therefore, arguably, an increased awareness of the harmful effects of ETS on children’s health is warranted for formulating health policy overall (Cheraghi and Salvi, 2009). Furthermore, specifically, environmental tobacco smoke exposure carries a number of risks for the developing lung of the fetus, infant and child. (Wallace, 2009)
Despite the recent campaigns to eliminate smoking and hinder the detrimental effects of passive smoking , actual smoking rates still increase worldwide. Several physiological systems, with the respiratory being the primary, are disrupted by PS and progressively deteriorate through chronic exposures. This is of particular importance in children, given that respiratory complications during childhood can be transferred to adulthood, lead to significantly inferior health profiles. (Metsios, Flouris, and Koutedakis 2009).
SHS exposure is a known cause of disease among non-smokers, contributing to lung cancer, heart disease, and sudden infant death syndrome, as well as other diseases. Yet thousands of children remain unprotected from exposure to SHS in private homes and cars. New initiatives targeting SHS in these spaces have raised ethical questions about imposing constraints on private behaviours (Jarvis and Malone, 2008) In the countries where the smoke free legislation was successfully implemented (Ireland, Italy, Scotland) there is evidence of reduced prevalence of the smoking induced diseases, especially acute coronary attacks (Kemp, 2009).
Summary
One would, arguably, want to follow one’s intuitions and to see a society where children’s lungs are not damaged to the actions of their parents or adults generally. However, the whole issue brings up the added problems of whether second-hand smoke or passive smoking does without doubt cause lung problems (is science infallible?) and, as a country, whether we can do anything other than ‘encourage opportunities’ rather than to ‘enforce rights’. It is not an electoral issue, however, and nor is it likely to become one. It might become, on the other hand, a very campaigning issue for charities such as the British Lung Foundation and the British Heart Foundation.
References
Bynoe, I. (1996), Beyond the Citizen’s Charter. New Directions for Social Rights, Institute for Public Policy Research, London.
Cheraghi, M, Salvi, S. Environmental tobacco smoke (ETS) and respiratory health in children. Eur J Pediatr. 2009 Aug;168(8):897-905. Epub 2009 Mar 20.
Farrell, C. The Patient’s Charter: a tool for quality improvement? International Journal of Health Care Quality Assurance 12/4 [1999] 129-134
Guyer, B, Ma, S, Grason, H, Frick, KD, Perry, DF, Sharkey, A, McIntosh, J. Early childhood health promotion and its life course health consequences. Acad Pediatr. 2009 May-Jun;9(3):142-149.e1-71.
Hall, DMB. Children, rights, and responsibilities. Arch Dis Child 2005;90:171–173. doi: 10.1136/adc.2004.053017
Health Care Commission report, Clearing the Air 2006
Hogg, C. (1994), Working with Users: Beyond the Patient’s Charter, Health Rights, London.
Jarvis, JA, Malone, RE. Children’s secondhand smoke exposure in private homes and cars: an ethical analysis. Am J Public Health. 2008 Dec;98(12):2140-5. Epub 2008 Oct 15.
Kemp, FB. Smoke free policies in Europe. An overview. Pneumologia. 2009 Jul-Sep;58(3):155-8.
Lovasi, GS, Diez Doux AV, Hoffman, EA, Kawut, SM, Jacobs, DR Jnr., Barr, RG. Association of environmental tobacco smoke exposure in childhood with early emphysema in adulthood among nonsmokers: the MESA-lung study. Am J Epidemiol. 2010 Jan 1;171(1):54-62. Epub 2009 Nov 25.
Metselos, GS, Flouris, AD, Koutedakis, Y. Passive smoking, asthma and allergy in children. Inflamm Allergy Drug Targets. 2009 Dec;8(5):348-52.
The American Thoracic Society (1999) Pulmonary rehabilitation, American Journal of Respiratory and Critical Care Medicine
Wallace, J, The respiratory effects of tobacco smoke exposure on the fetus and child. S D Med. 2009;Spec No:11-2.
While damages for mesothelioma following asbestos exposure are well recognized (although sufferers still have to go through many legal hoops to get their damages), proving a case for damages for psychological illness following combat is much harder. Both torts require an agent causing damage due to a breach of duty-of-care (1).
PTSD (Post-Traumatic Stress Disorder) is at the harsh interface of law and medicine. Many argue that the Home Office, the Ministry of Defence and the Criminal Justice System need to get their head round it. Post-traumatic stress disorder (PTSD) may develop after a terrifying ordeal involving physical harm or the threat of physical harm. You do not have to be physically hurt to get PTSD.
War veterans brought PTSD to public attention. However, PTSD can stem from traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes. The majority of people exposed to such events experience some symptoms of distress (sleep problems, jumpiness). Most fully recover in a few weeks or months.
Symptoms of PTSD
PTSD is not often recognized, because mone of us like to talk about upsetting events and feelings. We may not want to admit to having symptoms, because we don’t want to be thought of as weak or mentally unstable. People with PTSD often find it easier to talk about the other problems that go along with it – headache, sleep problems, irritability, depression, tension, substance abuse, family or work-related problems. However, common symptoms may include the following:
Flashbacks, nightmares or night-time terrors
Sufferers may find themselves re-living the event, again and again. This can happen both as a “flashback” in the day, and as nightmares when you are asleep. These can be so realistic that it feels as though you are living through the experience all over again. Such mental visions are vivid, but also accompanied by the emotions and physical sensations of what happened – fear, sweating, smells, sounds, pain. Ordinary things can trigger off flashbacks.
Avoidance and numbing
It can be just too upsetting to re-live your experience over and over again, especially at night time, so many sufferers find it useful to keep their minds busy busy by losing yourself in a hobby, working very hard, or spending your time absorbed in crossword or jigsaw puzzles. It can be a good idea avoid places and people that remind one of the trauma, and try not to talk about it. Some people may deal with the pain of your feelings by trying to feel nothing at all – by becoming emotionally numb; and they find themselves communicating less with other people, who then find it hard to live or work with you.
Other important symptoms
These include:
History of PTSD and the Ministry of Defence
In 2002, a group of 2,000 veterans took legal action against the Ministry of Defence for failing to treat them for combat-related PTSD, and it was only after this court action that the MoD were made responsible to treat troops/veterans for this psychological disorder. The MoD now have established a treatment programme for dealing with the problems of combat-related PTSD for troops/veterans coming out of wars/conflicts – however it is still a matter of intense debate whether this is working.
Iversen and colleagues (Iversen et al., 2009) carried out a study of the prevalence of common psychological illnesses, including PTSD, including the military (2). The authors argued that the mental health of the Armed Forces is an important issue of both academic and public interest. Participants were drawn from a large UK military health study. The authors concluded that the prevalence of PTSD symptoms remains low in the UK military, but reservists are at greater risk of psychiatric injury than regular personnel. With rather similar findings, several Kings College research papers (3) had been previously bee published in 2003. Of 1551 mobilised British Military Personnel (Regular and Reservists) who deployed to Operation, 208 Servicemen fulfilled the diagnostic criteria for Post Traumatic Stress Disorder.
The Ministry of Defence recognises Post Traumatic Stress Disorder (PTSD) as a serious and disabling condition, and that can be treated. Measures are in place to mitigate against PTSD and other stress-related disorders occurring among Service personnel. These include pre-and post-deployment briefing and the availability of counselling both during and after deployments.
Treatment of PTSD
Traditional treatment modalities include:
Often, mainstream government is not the driving force behind change. For example, the charity Mental Health Foundation has done ground-breaking policy research in various areas of mental health, including noticeably the transition of mental illness patients from childhood to adult services. Other charities, such as MIND, have been equally successfully, In the wold of PTSD,
Talking2minds is a UK Registered Charity in England and Wales with a unique process that eradicates the symptoms of PTSD. The process has been developed over the last 6 years with a significant and ongoing input from those that have suffered from PTSD and is results focussed. The charity specialises in treating the symptoms, and uses a system called the Synergy Programme, to allow the client to create rapid and positive changes. In this way, they help clients to quickly regain control of their lives. Synergy is a combination of the following specifically designed for the direct treatment of PTSD. This gives the client an education as to how they think, feel and respond accordingly, teaching them them how to harness their thoughts effectively.
This is an intervention that is used to eradicate the negative emotions that hijack so many PTSD sufferers. Once these are dealt with the client can recall the same memories without the emotional pull that was often debilitating. This is used to get the client to realise the importance of mental and physical relaxation, it teaches the client the benefits associated with relaxed states and gives them the ability to do this themselves, when needed. If results carry on being positive, this could make an impact on the treatment of those individuals who suffer from combat-related PTSD.
Cognitive neuroscience
To find out how the brain processes fear, researchers lesioned brain regions and circuits in laboratory animals. When they lesioned a region called the amygdala, the animals failed to associate a neutral stimulus, like a tone, with a fearful event, like a shock (4). Furthermore, people who had surgery to remove the portion of the temporal lobe that contains the amygdala, a treatment for some forms of epilepsy, had difficulty learning to associate a flash of light with an unpleasant noise. Neurones in the amygdala show electrical and chemical changes that are associated with learning in other parts of the brain. However, unlike some other types of learning, lasting fear memories can be acquired quickly, often after a single experience, and can last a lifetime. These findings suggest that fear is a special type of learning and memory.
Rewriting fearful memories or forgetting them altogether might therefore help conquer fears. In fact, a common therapeutic technique to counsel people with phobias and PTSD is called memory extinction — patients are repeatedly exposed to formerly frightening stimuli in a safe environment, without harmful consequences. However, many people experience relapse after completing therapy. Recent animal research points to more promising techniques to change fear memories. Two research groups have shown that treatments that affect enzymes called kinases are effective in disrupting fearful memories in rats and mice if they are given when the fearful memory is recalled, during a stage of memory called reconsolidation. The idea is that memories are written and rewritten every time we recall them, so modifying the brain’s memory machinery during recall might change a memory for good.
As researchers learn how fear memories are encoded in the brain, and as animal research helps to identify new treatments, there may be new therapeutic options. One new treatment is the antibiotic D-cycloserine. This drug activates receptors in the amygdala that are important in extinction. Studies in rats show that D-cycloserine accelerates extinction of fear memories. In a small clinical study, people with acrophobia (fear of heights) who took D-cycloserine in combination with CBT fared better than those who tried CBT alone. Traumatic events activate the body’s stress response, strengthening and coloring subsequent memory. Some researchers are testing the idea that reducing the body’s emotional response during the reconsolidation of frightening memories might reduce or prevent PTSD.
Drugs called beta blockers are used to treat people with high blood pressure — they stabilize the body’s response to a stressor, preventing the fight-or-flight response. A recent human study showed that, when given during recollection of a frightening memory, the beta blocker propranolol reduced fear but did not affect knowledge of an event. Researchers are currently evaluating propranolol’s ability to prevent PTSD in trauma patients.
Conclusion
More research needs to be done into why certain individuals are at risk of developing PTSD. We may sitting on a clinical iceberg, with many undiagnosed sufferers. However, need to allow a climate which does not deny its existence, and so that governments from all jurisdictions can explain what it is about and encourage treatment, from any source, that makes a real difference from people proudly serving their country.
References
(1) Winfield and Jolowicz on Tort. WVH Rogers. Sweet & Maxwell, 2006
(2) Iversen, AC, Van Straden, L, Hughes, JH, Browne, T, Hall, H, Greenberg, N et al. The prevalence of common mental disorders and PTSD in the UK military: using data from a clinical interview-based study. BMC Psychiatry 2009 Oct 30;9:68.
(3) Hotopf, M, Hull, L. Fear, NT, Browne, T, Horn, O, Iversen, A. et al. The health of UK military personnel who deployed to the 2003 Iraq war: a cohort study. Lancet 2006 May 27;367(9524):1731-41.
(4) The Human Amygdala, Whalen, PS, Phelps, EA. Guilford Press, 2009
