PTSD (Post Traumatic Stress Disorder)

Post Traumatic Stress Disorder (PTSD) is diagnosed when a complex set of symptoms develop following a traumatic event. Although the symptoms typically begin within three months of the trauma, the onset can be delayed by years before the diagnostic criteria are met. The lifetime risk in of developing PTSD in the US is 8.7% (6.8%-12.3%) and the twelve-month prevalence in US adults is 3.5%-6%. The clinical presentation of PTSD is individual and variable. Patients experience marked affective, cognitive and behavioral responses to stimuli. In some fear/anxiety based cases, re-experiencing is predominant; in others depression, dysphoria and pessimism is predominant; in others, arousal and reactive symptoms such as rage, combative or fleeing behaviors are predominant; in others, dissociative symptoms are predominant; and many individuals exhibit a combination of theses symptoms.

Examples of the traumatic event can include exposure to war, threatened or actual physical assault, threatened or actual sexual violence, kidnapping, incarceration, natural disasters, car accidents, medical traumas, long term exposure to crisis situations, witnessing such events and learning about such an event affecting a close relative as well as many other possibilities. It is important to note each person has a different tolerance level to trauma.

The traumatic event is subsequently re-experienced in various involuntary ways. Either with recurrent memories that result in emotional arousal or dissociation (flashbacks); or with recurring nightmares with a similar theme to the traumatic experience.

Stimuli or situations associated with the trauma are avoided, and the individual makes an effort to avoid thoughts and memories of the traumatic event (intrusion, negative alteration in mood and cognitions, avoidance and arousal). Negative expectations about life, about people, and negative mood states (depression, fear, horror, anger, guilt, shame) are present. There is a loss of interest or joy in previous pleasurable activities. Patients with PTSD may become enraged easily, may act recklessly with their lives, use alcohol and drugs or become suicidal. They are hyper-vigilant to threats, even those unrelated to the traumatic event and have an increased startle response. Patients with PTSD frequently have difficulty with concentration, focus and with sleep. Some individuals have a sense they are persistently separated from the world around them (numbness, depersonalization, derealization).

PTSD is associated with high levels of social, occupational, physical disability, medical services utilization and high economic costs to society. Even though PTSD is the one psychiatric disorder clearly caused by an external source, it is rarely cured by medications or therapy. Approximately 40% of patients get better naturally within a few years. Medications and therapy (exposure based cognitive behavioral therapy) typically reduce the symptoms but do not induce remission.

PTSD psychiatric comorbidities are high. 16% have one psychiatric comorbidity,
17% have two psychiatric comorbidities and 50% have three or more psychiatric comorbidities. Depression, anxiety and substance abuse are two to four times more prevalent in PTSD. Somatization disorder is 90 times more likely in PTSD.

The neurobiology of PTSD suggests it is a disorder of the fear based circuitry. Specifically, patients with PTSD have decreased activation of the ventromedial prefrontal cortex (vmPFC) when they are exposed to images or sounds related to their traumatic experiences. There appears to be a defect in the extinction (getting rid of the fear response) in patients with PTSD. When they learn to get rid of the fear response, there is increased activity in the medial prefrontal cortex (mPFC) and the anterior cingulate cortex (ACC).

This multisite randomized double blinded controlled study is utilizing deep repetitive transcranial magnetic stimulation(dTMS) to stimulate the mPFC and ACC during exposure to a traumatic script, in order to extinguish the fear response and turn the memory from a traumatic re-experiencing to a simple memory. It uses a special deep TMS coil, the HAC or H-7 coil that specifically targets those regions. Participants will be randomized to either active or placebo (sham) treatment. Patients will receive three treatments a week for four weeks, one treatment in week five and one treatment in week nine. All medical costs will be covered, and $20 gas stipend per visit will be given to patients who comply with the study.

Inclusion Criteria: Ages 22-68 diagnosed with PTSD

Exclusion Criteria:
– Pregnant or Breastfeeding
– Other currently active psychiatric diagnosis other than moderate depression and nicotine dependence
– Seizure history other than from ECT
– Cranial Surgery
– Metal in the head
– Loss of consciousness after head trauma for more than five minutes
– Significant hearing loss
– Suicide attempt in the past year
– Significant Neurological Disorder
– History of previous TMS

Medications Not Allowed During the Study:
Bupropion/Wellbutrin, Clozaril/Clozapine, High Doses of Benzodiazepines (over 3mg Lorazepam)or High Doses of Tricyclics.

PTSD Questionnaire