‘Psychological kevlar’ and the burden of remembering war

I just read a fascinating piece by Clayton Dach, America’s Chemically Modified 21st Century Soldiers, on Alternet. Although there’s a sense in which Mr. Dach jumps to some of the worst possible outcomes when he looks at technology in the pipeline, on the whole, it’s a pretty well thought and concerned-but-not-hysterical account of some of the technology being brought to bear on soldiers, including the possibility of removing humans further from the ‘loop’ in combat decisions. I’m less interested with the latter — the robot warriors angle — not only because I think it’s been done better in science fiction movies, but also because I think it’s simply a more remote technology than some of the pharmaceutical work he discusses.

In particular, I found the discussion of ‘psychological kevlar’ to be interesting for neuroanthropology:

In the U.S., where roughly two-fifths of troops returning from combat deployments are presenting serious mental health problems, PTSD has gone political in form of the Psychological Kevlar Act, which would direct the Secretary of Defense to implement “preventive and early-intervention measures” to protect troops against “stress-related psychopathologies.”

Proponents of the “Psychological Kevlar” approach to PTSD may have found a silver bullet in the form of propranolol, a 50-year-old beta-blocker used on-label to treat high blood pressure, and off-label as a stress-buster for performers and exam-takers. Ongoing psychiatric research has intriguingly suggested that a dose of propranolol, taken soon after a harrowing event, can suppress the victim’s stress response and effectively block the physiological process that makes certain memories intense and intrusive. That the drug is cheap and well tolerated is icing on the cake.

With PTSD so prevalent among soldiers, can it be better treated, even if that means blocking the formation of traumatic memories? Daniel did a piece on PTSD rates in soldiers in April, Invisible Wounds of War, and he discussed a RAND Corporation estimate that treatment of soldiers with PTSD would cost ‘6.2 billion dollars in the first two years after returning from deployment.’ (Daniel also provided links to a number of articles on Iraq and its psychological effects in Wednesday Round Up #7.) The potential to use drugs to stop the development of PTSD, even if it also blocks normal memory formation, raises a number of ethical and moral questions as well as some interesting neuroanthropological ones.


There’s more information on this line of research from an earlier Nature article, Beta-blockers tackle memories of horror, by Jim Giles. Giles discusses research done on the use of Propanolol on civilian populations experiencing traumatic events (like 9/11 or the London bombings), but specifically sites concerns that the drug might be abused by applying it to soldiers. For example, Paul McHugh, a Johns Hopkins University psychiatrist and member of the US President’s Council on Bioethics, warns: “If soldiers did something that ended up with children getting killed, do you want to give them beta-blockers so that they can do it again?… Psychiatrists are once again marching in where angels fear to tread.” 60 Minutes also did a story in 2007 on the experimental use of Propanolol with traumatized individuals, A Pill To Forget?

Propanolol is marketed under a range of names, including a number of AstraZeneca products (Inderal, Avlocardyl, Avlocardyl, Deralin, Dociton, Inderalici, InnoPran XL, Sumial), others by Wyeth, and as a generic. It was once a first-line hypertension drug, but now most sources say that beta-blockers are not considered the treatment of first choice as others tend to work better. Some performers, such as musicians, use propanolol to deal with stage fright, and students have been known to use it to quiet nerves for exams if they are especially likely to anxiety attacks.

Beta-blockers like propanolol block the neurotransmitters involved in laying down memories, especially extremely vivid emotional memories or traumatic memories, the target of most of this research. For example, studies have found that rats who have learned to associate a tone with an electric shock lose their fear of the tone if propranolol is administered after the tone starts. That is, the rats do not demonstrate the normal conditioned response to the stimulus, but they also prove less likely to remember essential information from stressful situations. In another experiment, rats left to swim around in a tank to find an underwater platform that was invisible to them remembered where the platform was when put back in the tank and swam directly to it. That is, unless they were given a beta-blocker which interfered with adrenaline cycles, in which case they were left to wander around again the next time they were placed in the tank until they re-discovered the underwater platform.

The hope of researchers is that propanolol might inhibit PTSD, especially (from the Nature article) ‘panic attacks and flashbacks that are triggered by events associated with memories of the trauma, such as sirens or bangs.’ The President’s Council on Bioethics, in a 2003 report, Beyond Therapy: Biotechnology and the Pursuit of Happiness, discussed the use of ‘memory dampening’ to deal with trauma in general (not specifically in military contexts). The Council reflected on the potential uses but also brought up a number of reservations, including concerns that such use would; 1) discourage us from authentically coping with trauma, 2) tamper with personal identity, 3) demean the genuineness of human life and experience, 4) encourage us to forget memories that we are obligated to keep, and 5) inure us to the pain of others (from Kolber 2006, abstract). Adam Kolber also argues that memory dampening may pit the therapeutic interest of the individual against social interest in reconstructing events: ‘Drugs that dampen traumatic memories may someday test the boundaries between an individual’s right to medically modify his memories and society’s right to stop him from altering valuable evidence.’

Kathleen Logue, a paralegal who had been knocked down in the middle of a Boston street by a bicycle, was asked by a researcher whether or not she thought forgetting would undermine a person’s identity. Logue replied: “A terrible act… Why should you have to live with it every day of your life? It doesn’t erase the fact that it happened. It doesn’t erase your memory of it. It makes it easier to remember and function.” This is another of the key issues for me: how much ‘forgetting’ are we talking about? If it’s just the short circuiting of the psychological processes that produce obsessive revisiting of traumatic memory, but a person still retains some memory of what happened, I don’t really have a problem with this.

The Alternet article points to research done by the US military on the use of these drugs with soldiers, although it’s not clear to me how discriminating their use would be. PTSD seems to arise, not only from horrible events in which one is a passive participant, but also when one is an active agent. The concern is that the drugs will be used, not merely to aid soldiers who are traumatized by violence against them and their colleagues, but also by their own actions: medicating away the pains of conscience, is how the Alternet piece puts it.

I think that this distinction, although very difficult to apply in practice, is at the heart of disagreements about whether these drugs are ethical or moral. Most Westerners, in my opinion, believe that the pain caused by one’s own guilty conscience is one of the few constraints on human barbarity, especially in wartime. We tend to fear those without conscience and worry that certain acts in wartime — torture, war crimes, attacks on civilians — are only prevented by a healthy conscience. Engaging in these acts also allegedly undermines or damages the conscience so that we worry about the chance that a soldier might be unable to return to civilian life, to restore the conscience that restrains violence in everyday life. So one of the causes of disagreement seems to be whether or not the critics or advocates focus on PTSD in circumstances where a soldier is victim of a road-side bombing, a rocket attack, or witnesses a friend killed or if they example we consider is the troubled conscience of a soldier who has engaged in a massacre, seen the effects of his or her own side’s weapons, or been affected by the suffering of civilians. In one set of examples, it’s hard to argue that the individual is responsible, in others, it’s clear that the person to be medicated is guilty on different levels, and in other examples, it’s not really clear who would be considered responsible.

But I’m also not sure propanolol would work on all cases, especially those of the ‘guilty conscience’ variety. In some veterans, it appears that PTSD is at least partially the result of an accumulation of outrage at one’s own actions (or those in which one is forced to participate); would these sorts of processes have the same adrenaline profile as a one-time traumatic event and be susceptible to beta-blockers? That is, if PTSD is caused in some soldiers by the vivid awareness of and discomfort with what they themselves had done, are they to be given propanolol after every encounter with this violence? That is, will a unit be dosed with propanolol when it returns to base every time that the group has seen a dead body, shot near civilian, or see the effects of their own side’s violence? Or would members of the unit be monitored so that, as soon as one of them seemed to be distressed, he or she would be given the drug? That is, is the etiology of PTSD may itself vary in ways that make it more or less treatable with propanolol, and the application of propanolol to what we might call chronic stress PTSD might pose its own problems.

From an ethical perspective, the use of memory dampening drugs by militaries, especially those engaged in actions among civilians (for example, in Iraq), might also make the investigation and prosecution of war crimes, human rights violations, and breaches of the rules of engagement extremely difficult. It’s already extraordinarily difficult to investigate what happened in some fire fights without the soldiers being in a fog of memory-dampening drugs (although some likely self medicate already with traditional memory dampeners, such as alcohol or more common narcotics). Although propanolol might not call wholesale amnesia (it doesn’t), it might make it more difficult to recall dramatic events. Then again, it might make it easier to recall them accurately if they become distorted by stress — I just don’t know.

My attempt to distinguish between ‘PTSD from being victim’ and ‘guilty conscience PTSD,’ a distinction that may not have one shred of support for it (but seems to be assumed in the Alternet piece), would raise virtually impossible practical questions to those medical personnel responsible for administering the treatment. If they were asked to, could they distinguish who needs it because of a traumatic event and who needs it because of a guilty conscience? I can’t imagine that there would be any good way to make this distinction. So even though I might be drawing a difference, I don’t think there’s any way to use that distinction in practice. ‘Stress’ is a pretty broad category, so trying to provide ‘psychological kevlar’ against ‘stress’ might include a number of different phenomena and imply a whole range of preventive mechanisms (like, for example, not going to war in the first place).

On the positive side, stress helps us to learn very quickly. Blocking all the effects of stress is likely to produce a soldier who has a really hard time learning quickly, a tendency that might be severely maladaptive in combat settings.

Finally, one of the other ironies of this discussion is that, after so many wars, forgetting seems to have been one of the few culturally-appropriate coping strategies, and large-scale forgetting did take place. We’ve just had ANZAC Day here in Australia (sort of equivalent to Memorial Day in the US), and one of the things that is constantly discussed is the need to preserve, even to recover memories of the war. Over and over again, we hear about very high functioning veterans of World War II who admit that they returned from war and put it out of their minds, effectively forgetting what happened or at least severely suppressing it. This process seems to be much more difficult for veterans of more recent conflicts, especially Vietnam and Iraq. Some argue that it’s the nature of the public reception upon return, others that it is differences in the nature of the conflict or of their training, that produces the contrasting profiles.

But events like Memorial Day and ANZAC Day, war memorials, and a host of other commemorative practices are specifically about combating forgetfulness, assuring that war will be remembered by society. It’s ironic to me that, at the same time that societies struggle to retain memories of the sacrifices made by servicemen and women, we’re doing research about techniques to suppress their ability to remember war. Couple this with an environment in which many veterans feel ‘forgotten,’ left without sufficient medical care or support when they return from conflict (or are in it, for that matter), and we have a full-blown society-wide ambivalence about memory and forgetting of war.

I’m inherently dubious of violence as a tool for social change, probably because I study violence (in my case, more the sports variety than war), but it seems to me that they battle over how war should be remembered is pretty heated. Although I am excited to hear about the possibility of using propanolol and other drugs to help sufferers of PTSD, I can’t help but think that some of the problems that soldiers experience from remembering war have direct links to the problems our society has with its own memories of war, and those who fight them. The burden of remembering must be greater when one is forced to bear it alone, especially when it is the burden of morally ambivalent action, done on behalf of a society that seems to want to forget what has happened. I suspect that some of the social ambivalence shows up in the symptoms of those who shoulder the burden of fighting war — the soldiers. And I do hope that the military research will also be used in the service of all those who suffer the effects of violence, including the civilians who pay an even higher price than the soldiers.

Acknowledgment:
Graphic by Ben Mills, found in Wikimedia Commons.

References
Kolber, Adam J. 2006. Therapeutic Forgetting: The Legal and Ethical Implications of Memory Dampening. Vanderbilt Law Review 59(5): 1561-1626. Available at SSRN: http://ssrn.com/abstract=887061.

The President’s Council on Bioethics. 2003. Beyond Therapy: Biotechnology and the Pursuit of Happiness. Washington, D.C. (downloadable here)

3 thoughts on “‘Psychological kevlar’ and the burden of remembering war

  1. Dr. Downey, Thank you for an absolutely fascinating piece. I have a few comments, which I’ll preface with two caveats: 1) I have not read the Alternet piece you’re speaking of; and 2) Today is a bit busy, so these comments will be quick and perhaps less thoughtful than the issues you raise deserve.

    But several things strike me here, as someone who is currently studying PTSD among veterans of Iraq and Afghanistan. First of all, the use of propanolol is an intriguing idea. I can’t speak to propanolol itself as I’m not up on the research you write about, but pharmaceuticals have been unusual in the treatment of PTSD for their lack of efficacy. At this time, no drug has yet been proven to be as effective in treating PTSD as some of the cognitive therapies, particularly prolonged exposure and cognitive processing therapy, although several antidepressants and atypical antipsychotics have been approved for use and can be effective in managing symptoms. So it’s interesting to see the move towards using pharmaceuticals in the prevention of PTSD, given that it’s one of the few areas of psychiatry where, as far as treatment goes, therapy has outstripped pharmaceuticals.

    But what strikes me immediately upon reading this is not the moral complexities of forgetting and not-forgetting, although these are notable and important, but the possible impact of this drug on military personnel’s survival in combat. Guilt or horror aside (we’ll get to these in a minute), much of PTSD is the outcome of a physiological response gone awry – a fight or flight reaction in which memories are laid down in a particular way for the express purpose of helping the individual avoid danger in the future. For those with combat PTSD, these responses have often become generalized beyond reason – e.g. the danger of driving with convoys in Iraq becomes conflated with driving on civilian highways back in the States. So a drug that inhibits the laying down of these memories might have implications for how quickly and well soldiers are able to respond to threat in the combat environment. A little PTSD while serving in Iraq can be a good thing. It’s when the response goes overboard that people begin to have problems, or when they return to a non-combat environment where their survival skills are no longer adaptive. There may be no negative impacts to propanolol as it is proposed to be used, but it’s an important question to have answered.

    (As an aside, the effects of drugs on individuals’ responses and laying down of memory during combat also points to questions about anecdotal descriptions of troops using sedatives and stimulants in the field. For myself, I hear a lot about Valium and massive doses of caffeine…anyone have any thoughts about how this might affect acute stress?)

    Second, I spent most of last week at a workshop of miitary and civilian mental health care providers learning the use of prolonged exposure (PE) therapy among active duty military and veterans. PE has a solid body of research demonstrating its effectiveness among civilian PTSD cases, and a growing body of research demonstrating its usefulness with combat PTSD as well. Interestingly, new research will soon be testing its effectiveness with personnel suffering from Acute Stress Disorder during combat deployment – i.e. while the individual is still within 30 days of the trauma and doesn’t yet meet criteria for PTSD, but is at enhanced risk for developing PTSD down the line. It’s a similar approach to the propanolol idea, only using therapy instead of a drug. The anecdotal evidence so far suggests it may be helpful in terms of not only preventing the development of PTSD and enabling the individual to complete his or her deployment (believe it or not, psychiatrists have been consistently observing since World War I that the best way to ensure a case of combat stress gets worse is to remove the individual from their unit in the combat arena), but also in providing some future resilience by teaching individuals how to cope with future trauma exposures. Again, the research isn’t in yet, but it’s another possibility that’s being actively investigated. This, of course, in addition to the other steps the military has been taking in its attempt to support resiliency and prevent PTSD – through their Battlemind training (www.battlemind.org)and through the new Warrior Resiliency Program.

    Third, the question you raise of who gets what “kind” of PTSD is a tricky one. Because PTSD, like any mental disorder (and depending on who you ask), overlaps more often than not with other disorders – depression, substance abuse, personality disorder, etc. Speaking as a non-clinician who has spent a lot of time with PTSD-diagnosed veterans in the past year, I have to say that I’ve come to understand PTSD memories not in terms of victim vs. perpetrator, but much more in terms of the level of anger vs. depression involved. Anger is one of the most toxic problems associated with PTSD, and arises both out of the elevated physiological arousal and out of the sense of a destroyed worldview that many veterans carry around, particularly if they saw too much injustice or atrocity. That said, I’ve had a number of clinicians swear to me recently that, in their experience, if you can deal with the level of anxiety and physiological arousal, the anger naturally goes down too. And I haven’t been able to identify that perpetrators and victims have a manifestly different experience of PTSD – survivor guilt is a common thing, and many times it’s not related to perpetrating violence but to things utterly beyond the individual’s control. The presence of guilt doesn’t require that there be actions about which to feel guilty. Taking it one step further, it has been my experience that those who describe genuinely horrifying violence are not necessarily those who describe guilt and regret. So when it comes to considering how propanolol will affect the moral weight of traumatic memories…it’s difficult to say. Will those who should remember – if remembering one’s violence is a just form of suffering – remember, or will it matter to them? Will those who would be blessed to forget be spared unnecessary emotional pain? I’m not sure, but these seem like questions, and perhaps distinctions, that apply less often than we might suspect.

    I thank you for bringing the propanolol issue to my attention. I’ll look into it further, and I would be interested to hear any further thoughts you have about all this. I have to say – my initial reaction is that it’s too easy, handing out a drug to prevent PTSD. Particularly for the reasons you outline above, as far as who gets it after what experiences and how often. Combat is messy, trauma exposure can be constant, and memories may not prove to be disturbing until years after the fact. But anything that can prevent PTSD and all its suffering would be very welcome, and I look forward to seeing the research.

  2. Dear Erin —

    THANK YOU for significantly improving the quality of this post. I hesitated, at first, before writing because I don’t have specific knowledge of PTSD, but I found myself compelled by the original piece and couldn’t stop thinking about it. Your ‘comment’ deserves to be a post of its own — thanks for building upon what I say and adding so much to the quality of discussion. Your own experience working with PTSD survivors, especially your insights into the presence of anger and depression, sheds a whole new light on the issues.

    And I agree with you that the use of pharmaceuticals to suppress memory formation might severely hamper soldiers’ abilities, including their chances of surviving in a combat theater. Like you, I don’t know about drug use among soldiers already, but it would be interesting to know about self medication using various substances and how it affects soldiers.

    Thanks, and please pass along any more information on the issue that you would like us to post at Neuroanthropology. Greg

  3. Pingback: Encephalon #45 - Life Is Good, Brains Are Better « PodBlack Blog

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