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

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.