Labs for PTSD?

[whopper]

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http://www.cnn.com/2010/TECH/01/23/brain.scanners.wired/index.html?hpt=T2

 

[cleareyedguy]

The imaging stuff is definitely cutting edge and cool.

There is still a certain amount of uncertainty about how best to treat and prevent PTSD. In a lot of situations, it's my view that CBT gets credit for being "definitive" since that group first started using replicable studies using manuals, and other acronym therapies (DBT, TFP) were a little late to the research game but are likely to be as or more effective for certain types of patients.

A different sort of lab is "virtual reality" treatments that are springing up around the country. Here's one (http://www.weillcornell.org/joanndifede/index.html) though there are others as well.

 

[kugel]

http://www.cnn.com/2010/TECH/01/23/brain.scanners.wired/index.html?hpt=T2

A MEG scan can diagnose PTSD. So what?

I'm a little lost on why this technology would be helpful in diagnosing PTSD. Is it hard to diagnose in the office? Is it really better to wait weeks or months for a scan? Isn't this kind of like running viral cultures on everyone who has the Common Cold?

I can certainly see how this may lead to information about the anatomy and neurophysiology of PTSD, and therefore could lead to improved treatments over time, but I just don't see the utility of using it for diagnosis.

If, however, it becomes a reliable way to diagnose PTSD in complicated, co-morbid patients, or to differentiate PTSD from exaggerated symptoms and flat-out malingering, then it might be useful. However, I have this suspicion that even malingering PTSD symptoms for a long time (long enough to get through the VA system to the point where brass ring of permanent disability and lifetime service connected benefits are on the table) may well change neurophysiology in the direction of actual PTSD to the point that the scans become "inconclusive." After all, wouldn't thinking about having a syndrome, acting like you have the syndrome, forcing yourself to believe the syndrome in order to act like you have it, all be likely to have an effect on the neurophysiology in such a way that it begins to mimic the scans of people with "real" PTSD?

Once this research gets a little further along, I'd be really interested to see if it can accurately differentiate PTSD from other disorders in people who claim PTSD and report the full complement of symptoms from a combat situation which never took place (as documented by indisputable records of when/where the veteran was stationed and clear inaccuracies in the vets story). It's clear to me that some of these poor men and women really believe they were in/near a Viet Nam battle, even though their service record shows they could not possibly have been in-country at the time of that battle.
My own opinion (scans or not) is this:
They served. They're suffering. They get my full attention.
Whether or not the story is real or whether I think it's PTSD or schizophrenia or delusional disorder or personality disorder.

But how this will all shake out regarding various types of scans will be interesting.

 

[HMSPSYCH]

This is very interesting and I hope it works out. But while the sensitivity was high, 72/74, the specifcificity was on the low side- 31/250 healthy subjects were positive for PTSD. I'm glad the authors will follow up with a higher powered study.

 

[whopper]

I'm a little lost on why this technology would be helpful in diagnosing PTSD. Is it hard to diagnose in the office?

Here's my take on why it's important.

1-There's plenty of malingerers. Ever hear of the story of the survivor's quilt? The VAs across America gave out brochures to vets asking them if they had survivor's "quilt" due to a spelling error in the brochure.

Within days, VA hospitals had several vets showing up wearing quilts and demanding benefits. (This is a true story).

2-With the new advancements, it could be possible for the military and law enforcement institutions to see who would be susceptible to them.

3-PTSD scanning can be used as evidence in rape or other violent crimes as evidence. If the victim suffered from PTSD as a result of rape, and there's a scan, this adds evidence that the act was not consensual. As many of you may know, it is sometimes difficult to prove rape and distinguish it from consensual sex, especially in the case of rough sex.

 

[kugel]

Here's my take on why it's important.

1-There's plenty of malingerers. Ever hear of the story of the survivor's quilt? The VAs across America gave out brochures to vets asking them if they had survivor's "quilt" due to a spelling error in the brochure.

Within days, VA hospitals had several vets showing up wearing quilts and demanding benefits. (This is a true story).

2-With the new advancements, it could be possible for the military and law enforcement institutions to see who would be susceptible to them.

3-PTSD scanning can be used as evidence in rape or other violent crimes as evidence. If the victim suffered from PTSD as a result of rape, and there's a scan, this adds evidence that the act was not consensual. As many of you may know, it is sometimes difficult to prove rape and distinguish it from consensual sex, especially in the case of rough sex.

re: #1 - I love that. Absolutely classic. Know any place I can read a report on that?

re: #2 - that's a long leap from being able to diagnose the disorder. If the research goes in that direction, I'll be glad. But for the reasons I stated above, I doubt it.

re: #3 - I doubt that will ever work reliably because when we believe things that are incorrect (for any of many different reasons), our brain/body functions also "lie." And I don't think there's really any serious debate anymore about whether false memories do exist.

Every time a new technology about brains has come along, someone has claimed that it can be used to determine moral content (make no mistake, that's a big part of what diagnosing "lying" is about), likelihood/ability to lie, cognitive/performance/intellectual abilities. None of them have ever really worked out terribly well. Penn & Teller did a great episode of their Showtime series "Bull****" about lie detectors and the inherent problems in any such attempt. Like most any law enforcement activity - they basically only keep decent people from succumbing to the temptation to lie/cheat/steal.

Those who truly do not care about others and those who have vicious, malicious intent do not function in the same way, and so will not react the same way when attempting to "detect" a lie, and "normal" people will sometimes react neurophysiologically as if they were lying when they weren't. If you look at videotapes of people who were convinced to give a false confession, they certainly seemed to believe the confession at the time they gave it. It is the very fact that such people CARE about whether they might have hurt someone, and think it's important to uncover that if it did happen, that makes them susceptible to coercion/confusion/manipulation in a long, arduous interrogation. People who are antisocial or inherently vile are NOT interested in "getting to the truth" whether they are guilty or not.

Just my ramblings. Take it all with a grain of salt. I might decide tomorrow that even I don't believe it completely.

 

[Regnvejr]

...I'm a little lost on why this technology would be helpful in diagnosing PTSD. Is it hard to diagnose in the office? Is it really better to wait weeks or months for a scan? Isn't this kind of like running viral cultures on everyone who has the Common Cold?

I can certainly see how this may lead to information about the anatomy and neurophysiology of PTSD, and therefore could lead to improved treatments over time, but I just don't see the utility of using it for diagnosis. ....

And it may be another tool for insurance companies to deny coverage. Scan not conclusive, so we deny his diagnosis of PTSD.

I treat plenty of PTSD patients and I'm sure any good clinician certainly can diagnose and treat it without scans.

I see very little clinical benefit and potential huge insurance problems and cost with this.

 

[kugel]

And it may be another tool for insurance companies to deny coverage. Scan not conclusive, so we deny his diagnosis of PTSD.

I treat plenty of PTSD patients and I'm sure any good clinician certainly can diagnose and treat it without scans.

I see very little clinical benefit and potential huge insurance problems and cost with this.

I entirely missed that one. Thanks.
This is a problem with all healthcare advancements. If given the opportunity, a corporation that profits by wagering that they will not have to pay back to a client will always looks for ways to avoid paying. That is their nature.
We have to guard against it, but we obviously can't delay, dismiss, ignore advancements because those with profit motives might abuse them.

 

[OldPsychDoc]

Heard the NPR piece on this, and it was clear from the interview that the researchers were not at all promoting this for any clinical utility, but as a research tool. As usual, it is the media attempting to communicate this stuff to people with an 8th grade understanding of the world (even on NPR!) that hype this as a "diagnostic breakthrough".

 

[whopper]

Absolutely classic. Know any place I can read a report on that?

I don't know of any articles, but this incident is taught in the AAPL review course. It was mentioned by Phil Resnick a few times in his lectures on malingering.

I did find this...
http://www.malingering-faking.com/Faking-Injury.html

blished estimates of malingering rates following personal injury vary from 1% to over 50%39 . Following the Vietnam War, the government printed flyers to help veterans recognize characteristic symptoms and prompt them to apply for deserved benefits. Among the symptoms of PTSD intended to be listed was "survivor's guilt." However, a printing error in one region resulted a number of veterans showing up to file their claims carrying their "survivor's quilt." Some veterans claiming PTSD have been found to never have been in combat, or in some cases, never even in the armed services40 .

An attending of mine told me after the flyer went out, a few days later he had a long line of vets all wearing quilts and demanding benefits at the VA where he used to work. He knew many of them well and knew they did not have PTSD.

I agree with all your concerns criticizing labs. I do, however, also believe it can advance the field in a positive direction. Any new development in any field always has the Prometheus problem---it can lead to good as well as bad things.

 

[kugel]

I do, however, also believe it can advance the field in a positive direction. Any new development in any field always has the Prometheus problem---it can lead to good as well as bad things.

We agree completely on this.

 

[PsyDGrrrl]

Perhaps, too, it could be used to see changes in the brain with therapy (psychotherapy and/or meds) to see if the treatment is "working" (for lack of a better word).

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