The Golden Hours
Shaili Jain, M.D., a top expert on trauma, writes about cutting edge medical interventions that hold the promise of preventing PTSD.
Primary prevention of trauma is not always possible, and PTSD researchers have ventured into the realm of secondary prevention as a result. Secondary prevention intervenes in the window of time after trauma exposure but before the onset of PTSD, an opportunity to strike before it’s too late. This window of time has come to be referred to as the golden hours, a time during which medical intervention could set a pathway toward recovery.
The PTSD literature is flush with enticing leads about the way medications and psychological therapies can be harnessed to prevent the onset of PTSD in those who have survived trauma. Dr. Gustav Schelling, a German physician caring for very sick patients in an intensive care unit (ICU), was used to reports of patients developing PTSD related to their near-death experiences. He observed that patients who were given hydrocortisone as part of the care for their critical illness experienced fewer signs and symptoms of PTSD after they recovered.
Cortisol is known to impair the retrieval of long-term memory, and scientists have hypothesized that hydrocortisone, delivered as a pill or an intravenous treatment, might prevent the onset of PTSD after trauma. Schelling tested his observation in randomized controlled studies and found that hydrocortisone administered during ICU treatment was associated with not only a significant reduction of PTSD symptoms in survivors, but also improvements in their overall health. Another cutting edge approach uses the drug mifepristone, which also impacts cortisol levels, but instead of providing an artificial and temporary boost in levels, it resets the way the body produces cortisol in the first place.
Early work suggests that using opioids on a short-term basis to aggressively reduce pain after physical trauma may help prevent the onset of PTSD related to the same trauma. One such study, published in The New England Journal of Medicine, followed almost 700 combat-injured military personnel serving in Iraq who were given morphine very soon after surviving a severe injury and found they were significantly less likely to develop PTSD. This study yielded encouraging findings, but there is an important caveat: it is doubtful that morphine would be valuable for the prevention of PTSD following severe psychological trauma when the survivor did not sustain painful physical injuries.
Less progress has been made in investigating which psychological therapies might work in the golden hours to prevent PTSD, due in part to the disappointing results that came from the routine use of critical incident stress debriefing (CISD) after traumatic incidents in the 1980s. CISD was designed to take place within hours or days of a traumatic event and typically included all emergency personnel responding to a disaster scene. It consists of a single four-hour session that encourages the group to share their emotional reactions to and experiences of the trauma.
Unfortunately, subsequent studies found that CISD was not only ineffective in preventing PTSD but actually appeared to do more harm than good. Exactly why is unknown, but some explanations point to the timing of CISD being too soon after the trauma and the overly zealous one-size-fits-all approach of including everyone involved. A more tailored “watchful waiting” approach is favored now, in which trauma survivors are identified and educated about how to get help but not required to talk about the incident unless and until they feel a need to do so.
The finding that CISD might harm trauma survivors meant that researchers shied away from testing psychological interventions in the golden hours—that is, until a team led by Dr. Barbara Olasov Rothbaum, a psychologist at Emory University, piloted a modified prolonged exposure (PE) intervention for delivery within hours after a trauma. Distinctly different from debriefing, its aim was to intervene early enough to prevent the consolidation of trauma memories in survivors.
The intervention consisted of three brief sessions that focused on breathing relaxation, exposure exercises, attention to cognitions, and self-care. Those assigned to the modified PE arm of the study reported fewer symptoms of PTSD and depression in the three months following the trauma.
More recently, researchers from the University of Oxford attempted to disrupt memory consolidation in the golden hours by using the computer game Tetris. Engaging in a visually absorbing task soon after surviving trauma could, they hypothesized, distract the brain and prevent it from over-consolidating those early visual memories of trauma.
The team recruited 71 individuals who survived motor vehicle crashes while they were still in the emergency department. Half of them were asked to think about the worst moments of the accident and then were asked to play Tetris for twenty minutes. The other half were asked to write down a log of what they had done since coming to the hospital.
The results, which were published in the journal Molecular Psychiatry, are promising. When compared to the log completers, participants who played Tetris were less likely to report post-trauma intrusive memories and related psychological distress in the week that followed their car accident.
While important concerns will need to be addressed before such golden hour interventions can be implemented into routine practice, the promise of interventions that could prevent the future suffering of so many is hard to ignore.
Adapted excerpt from The Unspeakable Mind: Stories of Trauma and Healing from the Frontlines of PTSD Science by Shaili Jain, M.D. © 2019. Printed with permission from HarperCollins publisher