© Sipa Press/Rex FeaturesBenzodiazepines may not be the answer for soldiers suffering stress from the horrors of war
The US Department of Veterans Affairs says it will consider this and other studies when preparing new guidelines on treatments for post-traumatic stress disorder (PTSD). If their results are strong enough, it may recommend withholding sedatives in the aftermath of traumatic events. The findings are also throwing up new possibilities for preventing PTSD.
PTSD arises after a person has had a traumatic experience: symptoms include involuntary, often debilitating, flashbacks of the experience, which can keep happening for years. Not everyone develops it, though, and it seems that what happens directly after the event, as the brain lays down the memory, helps determine whether they do.
Benzodiazepines, a class of sedative that includes diazepam (Valium), are prescribed following a traumatic event because they reduce anxiety and aid sleep. However, some studies have suggested that they may hamper long-term recovery.
For example, a 2002 study of 22 volunteers who had experienced traumas such as traffic accidents found that those given a benzodiazepine for the following seven nights showed slightly more symptoms of PTSD six weeks later compared with those given a placebo.
To investigate further, Joseph Zohar and colleagues at Ben-Gurion University of the Negev in Beer Sheva, Israel, put rats in a confined space with well-soiled cat litter - a highly stressful experience used to gain insights into PTSD. Some were given the benzodiazepine alprazolam, while others were left untreated.
Despite a short-term reduction in anxiety, 30 days later the treated rats displayed more PTSD-like symptoms, such as freezing in response to unused cat litter, increased anxiety and less time exploring a maze, something they usually enjoy. As well as this, treated rats had lower blood levels of corticosterone, the rat equivalent of the human stress hormone cortisol, compared with untreated rats (European Neuropsychopharmacology, vol 19, p 283).
Cortisol release is part of the natural response to stress in people, and activation of the brain receptors it binds to is known to be involved in the consolidation of traumatic memories. Zohar suggests that alprazolam interferes with the rats' ability to consolidate memories, leading to PTSD-like symptoms. He says that something similar may happen in traumatised people who are given benzodiazepines. He presented the findings at the 22nd European College of Neuropsychopharmacology congress in Istanbul, Turkey, last week.
Areih Shalev of the Hadassah University Medical Center in Ein-Karem, Israel, who studies benzodiazepines and trauma recovery, suggests another way that sedatives may exacerbate PTSD - by interfering with the brain's ability to learn.
In order to avoid flashbacks, Shalev says, the brain needs to learn that stimuli reminiscent of a particular trauma, such as sounds and smells, are not always dangerous. As cortisol is known to be involved in learning in animals and people, benzodiazepines may interfere with this process.
However, David Nutt of Imperial College London warns that we still don't know whether Zohar's findings can be directly applied to people. "I'm not sure we can say [giving benzodiazepines] is wrong yet," he says.
Fight stress with stress
Perverse as it seems, boosting levels of a stress hormone might be just the thing to deal with trauma.
In the wake of a traumatic event, lowered levels of cortisol, caused by taking some sedatives, may raise the risk of post-traumatic stress disorder (see main story). So does boosting cortisol reduce the risk?
In one study, Joseph Zohar and colleagues at Ben-Gurion University of the Negev in Beer Sheva, Israel, found that rats injected with extra corticosterone, the rat equivalent of cortisol, following a traumatic event were less likely to develop PTSD-like symptoms (Biological Psychiatry, vol 64, p708). "Intervention in the 'golden hours' [after trauma] might be a key element," says Zohar. He is now investigating whether injecting cortisol within 6 hours of a trauma can prevent PTSD in people.
Meanwhile Gustav Schelling of Ludwig Maximilian University in Munich, Germany, has shown that people who underwent major surgery were less likely to develop PTSD if injected with cortisol while recovering (Annals of the New York Academy of Sciences, vol 1071, p 46). However, he warns that these people were suffering from physical as well as mental trauma, so while promising, the results may not apply to all cases of PTSD.
That the words "emotions" and "feelings" are entirely absent from this article reveals an unwillingness in science to acknowledge the humanness of humans, and science's refusal to accept any treatment that is not entirely "logical," quantifiable," "rational," or from within their control. Emotion work done with a competent facilitator as soon as possible after a traumatic event will reduce the lingering effects of stress and trauma.
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