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A traumatic brain injury (TBI) occurs when brain function is altered due to an external blow to the head or body.

 National surveillance data indicates there are approximately 3 million new cases of TBI each year in the United States, and that the incidence of TBI has been increasing since 1995.

 Rates of TBI are increasing in all age groups, but particularly for adults over the age of 65, primarily due to falls.

 According to some estimates, mild traumatic brain injury (mTBI), or concussion, accounts for as many as 75% to 90% of all 

The American College of Rehabilitation Medicine (ACRM) defines mTBI as:

Any period of loss of consciousness (LOC)

Any loss of memory of events immediately before or after the incident

Any alteration in mental state at the time of the incident (ie, feeling dazed or confused)

Focal neurological deficits that may or may not be transient, but the severity does not exceed:

Initial Glasgow Coma Scale (GCS) score of 13-15

Normal brain imaging results (ie, CT, MRI)

Despite current surveillance data, the actual number of mTBIs occurring each year is difficult to measure because many individuals do not seek medical care immediately following injury. Although the military and most athletic organizations (ie, organized school, college, and professional sports teams) provide education, testing, and strict protocols for identifying and managing concussion, many individuals with noncombat or nonsports-related mTBI/concussion do not seek initial treatment. Some may delay seeking medical care for weeks or months until attempts to self-manage symptoms fail; they are encouraged by family, coworkers, etc, to seek care; or their symptoms become problematic.

mTBI/concussion can result in multiple and complex changes in a number of domains, including physical/somatic, cognitive, emotional, and behavioral.

 Physical or somatic complaints following mTBI include 

, nausea, dizziness/balance disturbance, fatigue, poor sleep, noise or light sensitivity, blurred vision, hearing impairment, and numbness/tingling. Frequently reported cognitive complaints include decreased attention/concentration, poor memory, slow information processing speed, difficulty multitasking, impaired judgment, impulsivity, and subtle language difficulties (such as word-finding problems). Emotional and behavioral problems following mTBI can include anxiety, depression, irritability and agitation, increased emotional lability, apathy, and in some instances, aggression.

Although most symptoms associated with mTBI resolve in a relatively short period of time (ie, 2 to 4 weeks), about 10% to 20% of individuals with mTBI experience symptoms beyond 4 weeks. When symptoms persist beyond 4 weeks, a diagnosis of persistent postconcussive symptoms (PPCS) is offered. Risk factors that predict PPCS include female gender, being older than 40 years of age, history of 

, previous psychiatric diagnoses (ie, anxiety, depression), propensity toward somatization, and pending litigation.

Unfortunately, diagnosis is complicated because usual imaging techniques (ie, CT scans) do not readily detect concussion/mTBI, and there is considerable symptom overlap between mTBI and other psychological conditions. For example, light/sound sensitivity, headache, sleep disturbance, dizziness, fatigue, and cognitive problems such as decreased concentration, impaired attention, and poor memory are present in both mTBI and 

 (PTSD). Likewise, symptoms such as depressed mood, apathy, sleep problems (ie, too much/too little), irritability, decreased attention, and poor memory are present in both mTBI and depression.

Given the symptom overlap between mTBI and other psychological/psychiatric conditions, obtaining a thorough event history is extremely important. During the clinical interview, patients should be queried regarding any recent falls, vehicular or sporting accidents, or any other event that could have caused a blow to the head or body. A thorough neuropsychological evaluation can provide information about a patient’s cognitive and psychological functioning, and personality features necessary for differential diagnosis. It can also begin the rehabilitation process by providing education, reassurance, as well as referral for comprehensive therapies to treat cognitive and emotional consequences of mTBI.

Though not widely available, there are now sophisticated imaging studies and blood biomarkers that can detect concussion/mTBI. Diffusion tensor imaging (DTI) can reliably detect microstructural white matter changes that accompany diffuse axonal injury (DAI) produced by rapid acceleration/deceleration injuries.

 Blood biomarker tests can detect brain-derived proteins that are released into the blood stream within minutes to hours following brain injury. Two such biomarkers—glial fibrillary acidic protein (GFAP) and S 100 calcium-binding protein B (S100B)—have been used in clinical studies to diagnose concussion.

Research indicates that effective management of concussion/mTBI includes early identification and treatment.

After a brief, initial period of rest to lessen symptoms and reduce metabolic demands, patients should be encouraged to begin treatment. For most individuals with concussion/mTBI, treatment should be symptom-focused and include education about the injury, provide optimistic expectations about recovery and outcome, provide information about how to manage symptoms (ie, headache, 

, etc), and caution about returning to activities that involve risk of repeat head injury. Normal physical and cognitive activities can resume slowly while monitoring to ensue symptoms do not worsen. For individuals with PPCS, a multidisciplinary approach may be indicated. The core multidisciplinary team may include physician specialties (physiatry, psychiatry, neurology, etc), occupational therapy (to improve activities of daily living and monitor timing for return to work and driving), physical therapy (to manage pain, balance problems, vestibular issues), speech/language pathology (for treatment of cognitive-linguistic deficits), counseling (for mood disturbance, sleep disorders, etc), and case management to coordinate treatment.

Concussion/mTBI is the most common type of brain injury. It can be difficult to diagnose for a variety of reasons, but primarily because the symptoms of concussion/mTBI are similar to the symptoms of other psychiatric conditions such as anxiety, depression, and PTSD. Although symptoms of concussion/mTBI resolve within 2 to 4 weeks, about 20% of patients with concussion/mTBI will experience persistent or worsening symptoms and may require comprehensive, interdisciplinary treatment. Clinicians should u

nderstand the symptom overlap between concussion/mTBI and other psychiatric conditions in order to provide accurate diagnosis and treatment.

is the regional director of clinical services at the Centre for Neuro Skills, which operates post-acute brain injury rehabilitation programs in California and Texas. He is licensed in Texas as a chemical dependency counselor and psychological associate with independent practice. He also holds a clinical appointment at the University of Texas Medical Branch (UTMB) in Galveston in the Department of Rehabilitation Sciences.

1. Menon DK, Schwab D, Wright DW, et al. 

Position statement: definition of traumatic brain injury.

2. Coronado VC, McGuire LC, Sarmiento K, et al. 

Trends on traumatic brain injury in the United States and the public health response: 1995-2009.

3. Albrecht JS, Hirson JM, McCunn M, et al. 

Increased rates of mild traumatic brain injury occurring in older adults in United States emergency departments.

5. American Congress of Rehabilitation Medicine Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group. 

Definition of mild traumatic brain injury.

Essential Brain Injury Guide, 5th edition. 

Brain Injury Association of America; 2019.

Symptoms of concussion and comorbid disorders.

8. Morgan CD, Zuckerman SL, Lee YM, et al. 

Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study.

9. Shenton ME, Hamoda HM, Schneiderman JS, et al. 

A review of magnetic resonance imaging and diffusion tensor imaging findings in mild traumatic brain injury.

Systematic review of clinical studies examining biomarkers of brain injury in athletes after sports-related concussion.

11. Silverberg ND, Iaccarino MA, Panenka WJ, et al. 

Management of concussion and mild traumatic brain injury: a synthesis of practice guidelines.

Understanding the symptom overlap between concussion/mild traumatic brain injury and other psychiatric conditions, such as PTSD and depression, can assist clinicians in differential diagnosis and providing effective treatment.

Differentiating mTBI/Concussion

“Real true, posttraumatic stress disorder [PTSD] is going to have an impact, certainly on the next generation and maybe generations after that,” said Rachel Yehuda, PhD.

Yehuda, in the Educator of the Year Lecture at the 

2022 Annual Psychiatric Times™ World CME Conference

 in San Diego, shared her research on the potential of PTSD being passed genetically through the generations. Studying the Holocaust and 9/11 survivors showed fascinating results.

At a clinic for Holocaust survivors and their families at Mount Sinai School of Medicine, families reported feeling damaged, guilty, anxious, full of morbid grief, and had dysfunctional interpersonal relationships due to fear of loss. Overall, the children of survivors believed that parental Holocaust exposure was involved in their current mental health problems.

Previous research by Yehuda et al showed adult offspring of Holocaust survivors had differential effects of maternal and paternal PTSD in both glucocorticoid receptor sensitivity and vulnerability to psychiatric disorder. With both maternal and paternal PTSD, offspring had lower GR-1F promoter methylation; with just paternal PTSD, offspring had GR-1F promoter hypermethylation.

 Furthermore, Holocaust exposure induced intergenerational effects on FKBP5 methylation; specifically, Holocaust survivors and their adult children showed a nongenotype dependent change in methylation compared to their respective controls.

 This was the first demonstration of an association of preconception parental trauma with epigenetic alterations that is evident in both exposed parent and offspring.

Similar findings resulted from Yehuda’s work on the effects on 9/11. For example, in a post-9/11 program surveilling women who were pregnant, Yehuda and researchers collected salivary cortisol from mothers and babies.

 “What we found is that the mothers that felt PTSD, their cortisol levels were lower, but it’s also lower in babies, which was really wild,” said Yehuda. “But here’s the kicker: Both cortisol levels are lowest in the babies of mothers with PTSD who were exposed in the third trimester.”

This research suggests maternal PTSD may confer additional in utero effects, causing more anxiety for example.

 Trauma exposure during pregnancy directly affects the fetus and fetus germ cells, Yehuda shared.

How does trauma pass down? Yehuda explained that epigenetic changes could survive cell division associated with the formation of sperm and eggs; if the parent is exposed to trauma, their exposure could result in epigenetic changes that may affect their sperm or egg—meaning a single trauma could simultaneously affect multiple generations without direct exposure.

“This is inherited in our DNA,” said Yehuda. “Trauma is inherited.”

The biological remnants of parental experiences in our DNA can affect us in multiple ways, according to Yehuda. They can influence our response to stressors/challenges, make us better able to detect and respond to threats, increase vulnerability to mental health disorders, and increase our attunement to injustice. They are enduring, but not irreversible, Yehuda stressed.

1. Yehuda R, Daskalakis NP, Lehrner A, et al. 

Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring.

2. Yehuda R, Daskalakis NP, Bierer LM, et al. 

Holocaust exposure induced intergenerational effects on FKBP5 methylation.

Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy.

Can we inherit our parents’ trauma? Research points to yes. 

Trauma in Your DNA: Educator of the Year Lecture

Although psychotherapy is first-line treatment for posttraumatic stress disorder (PTSD), there are a few psychopharmacological options that may be useful, Mark B. Hamner, MD, told attendees at the 

Antidepressants are currently considered the mainstay medication for 

, Hamner said, and sertraline and paroxetine are the 2 selective serotonin reuptake inhibitors approved by the FDA for this indication. Hamner is professor of psychiatry and behavioral sciences at the Medical University of South Carolina as well as the director of psychopharmacology research and medical director of the PTSD Clinical Team in the Department of Veterans Affairs Medical Center in Charleston.

Venlafaxine, a serotonin and noradrenaline reuptake inhibitor, has also shown efficacy in clinical trials, he reported. Specifically, in a 6-month placebo-controlled randomized trial (RCT) (N=329), venlafaxine (mean dose = 221.5 mg/day) has been shown to be helpful in reducing re-experiencing and avoidance/numbing; however, it did not seem to address hyperarousal. He also discussed a 12-week RCT of venlafaxine, placebo

 In addition to improvement as measured by Clinician-Administered PTSD Scale (CAPS), investigators found remission in 30.2% of patients on venlafaxine versus 24.3% on sertraline and 19.6% on placebo.

Hamner said other classes of the medications have been discussed for addressing PTSD. Although 

 have been considered, he noted they are not indicated per current treatment guidelines. Mixed data is the name of the game for other classes, according to Hamner. For antipsychotics, for instance, one VA cooperative study of risperidone was negative, while another RCT of quetiapine was positive, he said.

 A current study of hypnotics is in progress, he added. 

Antiadrenergic agents have also seen mixed data. The α1-adrenoreceptor antagonist 

 has also been of interest, Hamner reported, with some efficacy in alleviating nightmares associated with PTSD in military veterans. However, Hamner also reported results of a large RCT VA cooperative study (N=304, 13 sties) in which participants were randomly assigned to receive prazosin or placebo for 26 weeks.

 Investigators failed to find a significant differences between the prazosin group and the placebo group in the mean change from baseline in the CAPS item B2 score, in the mean change in Pittsburgh Sleep Quality Index (PSQI) score, or in the Clinical Global Impression of Change (CGIC) score, he said.

“More studies are needed of medications alone or in combination,” Hamner concluded. He further reminded attendees, “Psychotherapy is an essential, first line treatment for PTSD; evidence-based psychotherapies that are trauma-focused have larger treatment effect sizes than antidepressant medications.”

1. Davidson J, Baldwin D, Stein DJ, et al. Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled trial. 

2. Davidson J, Rothbaum BO, Tucker P, Asnis G, Benattia I, Musgnung JJ. Venlafaxine extended release in posttraumatic stress disorder: a sertraline- and placebo-controlled study [published correction appears in J Clin Psychopharmacol. 2006 Oct;26(5):473. Dosage error in article text]. 

3. VA/DoD Clinical Practice Guidelines: Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017. https://www.healthquality.va.gov/guidelines/MH/ptsd/ Accessed August 18, 2022.

4. Raskind MA, Peskind ER, Chow B, et al. Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans. 

Despite mixed data, there are some psychopharmacological options for treating PTSD.

Exploring Psychopharmacology for PTSD

“Anna” is a 24-year-old Latina single transwoman (male to female) who has struggled with symptoms related to posttraumatic stress disorder (PTSD) for the past 5 years and was recently diagnosed with opioid use disorder (OUD). She is currently being treated with buprenorphine for her OUD and has been referred to you for treatment of her psychiatric symptoms. Her trauma symptoms began following a sexual assault that occurred when she was in her teens.

As a mental health professional, you are acquainted with stigma and how it can impact treatment. Psychiatric patients often experience stigma in the general community, including in health care settings. In this case, you would not be surprised that Anna has experienced stigma related to her PTSD and OUD. She has also been discriminated against because of her race and gender. Unfortunately, this is not an unusual presentation in many clinical settings. Anna’s treatment and recovery program will need to deal directly with these complex issues of stigma and discrimination.

This article will spell out how treatment can be structured around respect for patients and the building of a healthy sense of self-esteem as a central element in the recovery process. This overarching issue will be the central issue that pulls together all the elements of a complex treatment program.

Stigma can be found in any environment and can be directed toward any subgroup. There is an automatic neurobiological brain reaction that leads individuals to distinguish themselves from unfamiliar “others.” This is a protective biologic function that enhances the safety of the core group and generates fear of strangers. This reaction has been localized as a preferential activation of the amygdala—the brain region that generates precognitive reactions of aggression, fear, and anxiety.

 A few hours of CME lectures are unlikely to reverse such deep-seated biologic functions. Many religious and philosophical traditions have recommended a focus on compassion and exercises for placing yourself in the position of the “other,” as remedial techniques. Models for “walking in the shoes of the other” have long been identified as effective techniques for change.

Overcoming the Effects of Stigma in the Clinical Setting

Unfortunately, it is relatively easy to generate stigma and to direct it toward any subgroup that is “different” and easily identified. Reversing such a primal brain function requires significant effort. This may require intensive exposure to new experiences and new information. How can a mental health service design its training program to address this problem? Ronald W. Pies, MD, has 

 that we use our brains “to think and feel our way out of that mindset, and to behave with compassion and decency.”

Getting to know and respect our patients as individuals is at the core of standard psychiatric practice. It is already standard practice to collect a careful longitudinal patient history as the first step in an assessment. Listening techniques that are empathetic, nonjudgmental, and kind are critical, as is getting to know our patients through attention to verbal and nonverbal cues. Writing up a comprehensive history with a dynamic formulation and presenting it to your peers and supervisors should be a central part of any training program. None of this is new, but it requires that clinicians and trainees have the time to both perform these evaluations and provide intensive treatment if needed.

With any patient, treatment must begin with a thorough history and assessment. In this case, it is important to clarify her self-image. How does she see herself? What are her goals? The patient and her clinicians must share a common sense of aspirational goals. Where does she wish to go, and how can we facilitate that process? No matter how grave her current situation, her therapist must be able to recognize her potential for recovery and focus her efforts on goals that will restore her self-esteem. Trabian Shorters has described this process as asset framing.

 This is the beginning of the recovery process.

Most of the typical components of a psychiatric treatment plan can be utilized in these cases. Patients with substance use disorders (SUDs) and cooccurring psychiatric disorders will respond to the same psychopharmacology interventions and psychosocial treatments that are utilized in the general population. With the exception of benzodiazepines, most medications can be safely prescribed to such patients.

 Cognitive behavioral therapy (CBT), contingency management (CM), and motivational interviewing (MI) have also been used effectively in these patients.

 It is important to recognize however that the successful treatment of other psychiatric disorders will not resolve cooccurring SUDs. To achieve effective recovery for both the mental illness and cooccurring SUDs, it is important that specific elements of SUD treatment be integrated into the treatment program for any mental health condition. Fortunately, US Food and Drug Administration (FDA)-approved medications for addiction treatment (methadone, buprenorphine, naltrexone, disulfiram, acamprosate, varenicline, and nicotine replacement therapies) have all been prescribed successfully in this these populations.

Lastly, person-centered language is important in building the relationship with the patient. Even when patients use particular language to describe their experience, researchers, clinicians, and others who interact with or communicate about cooccurring disorders should use neutral person-centered language. This is language that reflects the disorder as only 1 aspect of the patient’s life that does not define who they are. Using nonstigmatizing language in all our conversations is an immediate way to demonstrate care and compassion to those with SUDs and cooccurring psychiatric conditions.

Similarly, mutual-support programs such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and SMART Recovery can be an essential element of recovery.

 It is important, however, to identify specific mutual-support programs that are comfortable welcoming patients with other health mental disorders and individuals in specific racial or gender groups. Clinicians should be aware of which mutual support programs in their area will be comfortable for these patients. Unfortunately, there are some mutual support groups, and individuals within mutual support groups, who are biased against patients with other psychiatric diseases or racial/gender identities. Individuals in the mutual-support community are usually willing to identify which groups are accepting and which groups are more problematic.

 Clinicians should guide patients toward groups that will be affirming for them. Psychiatric patients need to be particularly cautioned to avoid groups that have negative attitudes about the use of medication for psychiatric disorders or SUDs.

Group membership in the treatment setting and in mutual-support programs is absolutely critical for developing positive self-esteem and for building a new positive identity. Similar goals may be reached in individual psychotherapy, but this path to successful recovery may be available free of charge to anyone who is able to identify the appropriate mutual-support program. These aspects of group membership may be as important as, if not more important than, some of the more traditionally recognized elements of addiction recovery groups.

For these reasons, we strongly recommend that patients be referred to mutual-support groups that match their racial and/or gender identities. Such an environment has the best chance for achieving enduring sobriety. Research has shown that participation in mutual-support programs is highly correlated with long-term recovery.

The Clinician’s Role in Reversing Stigma

This leads us back to the question of how stigma can undermine recovery programs for patients with both psychiatric disorders and SUDs. Recovery is driven by hope—both the clinician and the patient must share the view that recovery is possible. Recovery coaches are particularly effective in this role. All involved clinicians must support the patient’s aspirational potential for achievement and success in life. Whenever possible, the clinician should avoid any undue focus on the patient’s failings or negative self-image. Encourage the patient to explore their dreams and aspirations; avoid dwelling on past failures. How can their skills be translated into legitimate and rewarding activities? Always try to reward successes and, when possible, ignore failures.

The clinician’s attitude and language are particularly important. The patient must be treated with respect at all times. Stigmatizing or discriminatory language must be avoided whether it is related to race, gender, psychiatric diagnosis, or substance use.

 Whenever possible, treatment program policy and procedures must avoid degrading or penalizing patients. Limit setting must be realistic and appropriate, yet guided by these affirming principles. If urine toxicology testing is required, the results must be used to guide treatment and identify needed services—never to penalize patients. Discharge from treatment should be the absolute last alternative.

The options for recovery and continued access to needed services are always the most important criteria. Even if a patient’s behavior makes it impossible to retain them in their current treatment situation, every effort should be made to transfer them to an alternative program that can better accommodate their needs.

In the Boston University Medical Center (BUMC) general psychiatry program, we have developed an experience in addiction psychiatry that is designed to provide these opportunities. It has been recognized as a model for reversing stigma and encouraging psychiatry residents to seek out opportunities to treat patients with SUDs and cooccurring mental health problems. All third-year psychiatry residents are assigned to the VA dual-diagnosis outpatient clinic for 20 hours a week for the full year. This continuity clinic is followed by a fourth-year 4 hours per week, with continued rotation in the same setting; the residents are therefore able to follow this group of patients for a potential 2 years of treatment. Typically, treatment begins after an inpatient admission for medical withdrawal treatment; the residents then treat both the SUD and any other cooccurring psychiatric problems for the next 2 years.

As the patients progress in their recovery, the frequency of visits is typically tapered from 2 or 3 a month to once a month in the fourth year. Residents have the opportunity to follow patients through any early relapses and into stable recovery. During the third year, there is a robust didactic curriculum for 2 hours each week. This includes case presentations, patient interviews, a wide range of seminars in SUDs and addiction pharmacotherapy, and introductions to the basics of CBT and MI.

At the end of this experience, the residents not only have become comfortable treating patients with the full range of common outpatient psychiatric disorders—they have also become comfortable working with patients with all the common SUDs including OUD, alcohol use disorder, stimulant use disorder, and cannabis and tobacco use disorders. As they get to know their patients well, the discomfort and stigma that often characterized their first patient contacts has been replaced with caring and often enthusiasm for working with this population. They learn the high level of clinical effectiveness of methadone and buprenorphine and come to appreciate the clinical enthusiasm that characterizes addiction clinicians.

Anna, and many patients like her, can engage and be successful in treatment with psychiatrists and other mental health professionals who demonstrate compassion and recognize their own biases. Stigma impacts the way individuals with cooccurring SUDs and psychiatric disorders engage in the mental health system. As demonstrated by the BUSM general psychiatry residency program, any outpatient psychiatry clinic can be adapted to both successfully treat dual-diagnosis patients and help address the stigma that often characterizes the treatment experiences of these patients.

is a professor of psychiatry at Boston University. 

 is clinical associate professor of psychiatry and pediatrics at Boston University School of Medicine.

Behave: The Biology of Humans at Our Best and Worst

Counteracting the effect of stigma on education for substance use disorders.

3. Pies RW. Are we “hardwired” for hatred? 

. December 6, 2018. Accessed March 10, 2022. 

https://www.psychiatrictimes.com/view/are-we-hardwired-hatred

4. The power of perception. TrabianShorters.com. September 30, 2021. Accessed February 27, 2022. 

www.trabianshorters.com/the-power-of-perception

Treatment of depression in patients with alcohol or other drug dependence: a meta-analysis

Treatment of co-occurring anxiety disorders and substance use disorders

Use of antidepressants in patients with co-occurring depression and substance use disorders

8. Aoun E, McCance-Katz EF. Psychiatric comorbidity. In Renner JA, Levounis P, LaRose AT, eds. 

Office-Based Buprenorphine Treatment of Opioid Use Disorder

 American Psychiatric Association Publishing; 2018:209-235.

9. Friedman PD, Park TW. Psychosocial and supportive treatment. In Renner JA, Levounis P, LaRose AT, eds. 

 American Psychiatric Association Publishing; 2018:145-162.

Choosing appropriate language to reduce the stigma around mental illness and substance use disorders

11. Kelly JF, Hoeppner B, Stout RL, Pagano M. 

Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: a multiple mediator analysis

12. The A.A. member—medications & other drugs. Alcoholics Anonymous. 2018. Accessed March 10, 2022. 

https://www.aa.org/aa-member-medications-and-other-drugs

How to train residents to identify and treat dual diagnosis patients

What is the clinician’s role in reversing stigma for better outcomes?

Impact of Stigma for Patients With Dual Diagnosis

In the midst of Posttraumatic Stress Disorder (PTSD) Awareness Month, it could be said that its culmination is today, PTSD Awareness Day.

Of course, historically, we have been aware of PTSD, but did not call it that. It is described in classic literature, such as the warriors of Homer’s epic Greek poems, the 

. Such descriptions occurred in many ensuing wars under various terms, including “shell shock.”

The Vietnam War was the more recent stimulus for more formal study, along with concomitant research on World War II’s Holocaust and rape victims, resulting in the formal classification of PTSD in our DSM III in 1980. National PTSD Awareness Month was designated by the Senate in 2014, and recognizes the importance of all kinds of trauma.

Early treatment was electric shock, followed by group therapy in the 1950s. More recently, besides various psychotherapies and medications, EMDR and the psychedelics have emerged. There are no antitrauma medications, in contrast to antidepressants, antianxiety, and antipsychotics.

What makes the call for awareness so important is to keep repeating that the emergence of symptoms—such as hyper vigilance, flashbacks, and avoidance—can be delayed for weeks, months, and even years. Triggers that relate to the original trauma can precipitate the emergence of symptoms time and again.

Some feel that there is a pretraumatic stress disorder, such as is emerging in the expectations of future increased climate instability trauma. In our June 15th video “

,” I wondered if we are now a traumatized country beyond individuals. On the other hand, we have to be careful about over-diagnosing it as a too ready faddish explanation for problems.

The good news is that PTSD can be preventable and, even if not, can lead to improvement from the prior baseline in recovery. Most obviously, it can be reduced by the social elimination of life-threatening traumas caused by mankind, as well as the harm done by multiple less severe traumas. Micro trauma also seems to insidiously contribute to burning out.

As our understanding increased, and unique among psychiatric disorders, it seemed possible to end up with posttraumatic growth, strength, and resilience. It takes community support, learning from the experience, and a new positive vision for the future. No one wants the suffering involved in PTSD, but there is some consolation when we can obtain such a positive ending. When trauma cannot be presented, it still has the potential to give way to joy as long as it is not ignored.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

It’s PTSD Awareness Day: Be Aware!

 was onsite for the 2022 American Psychiatric Association (APA) Annual Meeting in New Orleans, Louisiana, covering expert opinions and the latest research on a wide variety of important psychiatric issues. Here are some highlights from our coverage.

“Why is it that people with ADHD can do some specific things that they happen to be really interested in, or where they feel like, if they don’t take care of this 

 want to see happen is going to happen fast?”

Thomas E. Brown, PhD, of the Brown Clinic for ADHD and Related Disorders and the University of California-Riverside School of Medicine shared with 2022 American Psychiatric Association (APA) Annual Meeting attendees that attention-deficit/hyperactivity disorder (ADHD) may appear to be a problem of motivation, or “willpower,” but it is not. 

More Than a Knockout: Structural Brain Effects in MMA Sparring

In a first-of-its-kind study, researchers looked at the effect of practice sparring on possible brain changes in mixed martial arts (MMA) fighters. The results were presented at the 2022 American Psychiatric Association Annual Meeting by study author Aaron I. Esagoff, a medical student at Johns Hopkins University School of Medicine.

Although previous studies have looked at other sports that involve repetitive brain injury, the real risk for MMA fighters occur during practice sessions, explained Esagoff. Fights/matches only happen a few times per year, but individuals can spend hundreds of hours sparring and practicing. MMA is a hybrid combat sport that includes moves from boxing, wrestling, karate, judo, and jujitsu. 

“I think until we really understand the underlying neurobiology of PTSD, we’re stuck with a situation where the patient gets better, but they don’t get well.”

Charles B. Nemeroff, MD, PhD, Matthew P. Nemeroff Endowed Chair and professor in the University of Texas at Austin (UT Austin) Dell Medical School Department of Psychiatry & Behavioral Sciences, discussed the neurobiology of posttraumatic stress disorder (PTSD) at the 2022 American Psychiatric Association Annual Meeting. In the session—moderated by Edmond Hsin T. Pi, MD—Nemeroff described the diagnosis, epidemiology, and pathophysiology of PTSD, along with notable risk factors and some current and emerging treatments for PTSD. 

Leading the Artificial Intelligence Revolution

“Artificial intelligence (AI) is here to stay, and it’s really very important for the psychiatric field to take a leading role in developing it.”

P. Murali Doraiswamy, MBBS, FRCP, of the Duke University School of Medicine discussed some of the latest developments in AI and its current and potential applications for psychiatry at the 2022 American Psychiatric Association (APA) Annual Meeting. He was joined in a panel discussion by Robert M. Califf, MD, MACC, commissioner of food and drugs for the US Food and Drug Administration (FDA), and moderator Samantha Boardman, MD, psychiatrist and author of 

Everyday Vitality: Turning Stress Into Strength

 coverage from the 2022 APA Annual Meeting 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

Catch up on the latest research on ADHD, PTSD, and more with Psychiatric Times.

In Case You Missed It: Highlights From the 2022 APA Annual Meeting

“In a disaster, we naturally tend to pay attention toward the most immediate victims, so people who are impacted physically and with physical injuries and damages,” Gaëlle Rached, MD, MSc, said in a new research presentation at the 2022 American Psychiatric Association Annual Meeting. But what about the family members who live thousands of miles away?

Rached, Research Postdoctoral Fellow at Northwestern University, shared details about the events of August 4, 2020, when the residents of Beirut experienced a massive explosion as a result of improperly stored ammonium nitrate at the port. More than 200 individuals were killed, and many more were injured and left homeless. Although Rached was in the city and saw firsthand the devastation and trauma, she found herself taken aback by the reports from expat friends and colleagues. 

“They heard about the blast from social media, and they tried reaching out to their families, but they weren't able to reach them,” she said. “The lines weren't connecting. They spent hours trying to reach them and thinking and imagining the worst… Can you imagine sitting at home looking at these headlines and wondering what your family is going through? Can you imagine seeing these videos shared over on social media and being stuck abroad due to COVID, not being able to help?”

As she talked with her colleagues about these experiences, she realized that the traumatic experiences were similar, “but somehow a little bit different.”

In general, expatriates are exposed to stressful living conditions, which makes them more susceptible to developing mental health problems, Rached noted. Yet their general mental health is not well studied, and even less is known about such in the context of traumatic events. Thus, Rached and colleagues conducted a 7-month study to examine the impact of the Beirut explosion on expats.

The study consisted of 670 Lebanese citizens or first generation from Lebanese descent who were residing abroad (not in Lebanon) and at least 18 years old. Of that population, 268 experienced the explosion and/or had close family members physically impacted by it. The median age was 31, and the majority (62.2%) were female. Participants came from all over the world, with the highest percentages coming from the United States and France. Study co-authors included Muriel Slim; Dimitri Fiani, MD; Margarita Abi Zeid Daou, MD; and Souraya Torbey, MD.

Participants were screened using the Hopkins Symptoms Checklist and the PTSD Checklist for DSM-5. Preliminary analysis found almost 60% of the 268 who had more personal experience had scores on the PTSD Checklist indicative of PTSD. Furthermore, about 41% of participants screened higher than the threshold for anxiety and depression on the Hopkins Symptom Checklist. Both younger age and female sex were associated with higher scores, even months after the event occurred.

Rached explained their results show expatriates’ mental health are negatively affected by traumatic events in their home countries:

- Regardless of how long the expat has been away from their home country

- Regardless of if they experienced the event or witnessed it firsthand

“My simple message would be that there are 200 million expats around the world right now. Look out for expats in your life—your friends, your coworkers, your colleagues—especially when the country is going through traumatic events,” Rached concluded.

Are you attending the 2022 American Psychiatric Association Annual Meeting? We want to hear your thoughts! Share recaps, reflections, and experiences with us at PTEditor@mmhgroup.com. Be sure to visit us at booth 1852.

Research explored how a traumatic explosion affected individuals around the world. 

New Data Shows Trauma’s Ripple Effects

Charles B. Nemeroff, MD, PhD, Matthew P. Nemeroff Endowed Chair and professor in the University of Texas at Austin (UT Austin) Dell Medical School Department of Psychiatry & Behavioral Sciences, discussed the neurobiology of posttraumatic stress disorder (PTSD) at the 2022 American Psychiatric AssociationAnnual Meeting. In the session—moderated by Edmond Hsin T. Pi, MD—Nemeroff described the diagnosis, epidemiology, and pathophysiology of PTSD, along with notable risk factors and some current and emerging treatments for PTSD.

According to Nemeroff—who is also director of the Institute for Early Life Adversity Research and co-director of the Center for Psychedelic Research & Therapy at UT Austin Dell Medical School—PTSD is the only diagnosis in DSM-5 that is dependent on an external event, and the traditional view is that most individuals who develop PTSD eventually recover from it. However, there are several preexisting conditions and risk/vulnerability factors for PTSD that play a role in its development and course, including female sex; childhood or adolescent trauma exposure; family or personal history of anxiety or mood disorder; stressful life events in the prior and following year; and either panicked reactions (eg, shaking, sweating) or dissociative reactions (eg, tunnel vision, slow motion) at the time of the trauma.

Nemeroff also cited several pathophysiology studies using PTSD as the prototype gene X environment interaction disease, with a special focus on candidate genes such as FKBP5 and CRHR1, which have been shown to be predictive of PTSD development. These, along with preexisting conditions and risk/vulnerability factors for PTSD, are important because “psychiatry needs to focus on identifying people who are at risk for psychiatric disorders and intervening before the breaking point (the first psychotic episode, etc),” he stated.

Nemeroff discussed multiple options for psychosocial and pharmacological PTSD treatments, all with the general goals of reducing core symptoms, improving function and quality of life, strengthening resilience, relieving comorbid disorders, preventing relapse, and providing rehabilitation. For psychosocial treatments, he discussed exposure therapy, anxiety management, desensitization, hypnotherapy, and cognitive behavioral therapy (CBT). He added that CBT is a particularly notable psychosocial treatment, stating that “There’s no doubt that either a cognitive processing therapy or trauma-focused CBT should be a component of the treatment.”

In terms of pharmacological PTSD treatments, Nemeroff cautioned that “PTSD takes much longer to respond to medication than depression. You have to stick with it.” He did, however, discuss the efficacy of selective serotonin reuptake inhibitors (SSRIs) sertraline (Zoloft) and paroxetine (Paxil)—the only 2 drugs approved by the US Food and Drug Administration (FDA) for the treatment of PTSD—as well as 3,4-methyledioxymethamphetamine (MDMA)-assisted therapy. Recent research has highlighted the potential of MDMA-assisted therapy as a potential breakthrough treatment for PTSD. “This is the most exciting finding in the PTSD world,” Nemeroff stated. “I believe there will be a role for MDMA in the treatment of PTSD.”

How can we more effectively help patients with PTSD? Charles B. Nemeroff discusses the diagnosis, epidemiology, and pathophysiology of PTSD, along with current and emerging treatments, at the 2022 APA Annual Meeting.

Understanding the Neurobiology of PTSD

, we worked with experts from multiple areas in psychiatry to bring you thoughtful articles about a wide variety of psychiatric issues, from managing depression in older adults and differences in trauma response to the effects of the COVID-19 pandemic on youth and the growing US mental health crisis. Here are some highlights.

Psychiatric Care in the US: Are We Facing a Crisis?

The experts weighed in on a wide variety of psychiatric issues for the April 2022 issue of Psychiatric Times.

PTSD