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Advancements in PTSD Treatment 

The treatment of posttraumatic stress disorder (PTSD) among active duty military personnel has come a long way in the last two decades (Peterson, Young-McCaughan et al., 2021). Trauma-focused therapies such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have now become the gold standard for treating veteran and active duty populations with PTSD. Recent clinical trials have shown that 50-70% of service members gain clinically significant improvement in PTSD symptoms (Peterson, Niles et al., 2021). Despite these significant advancements, both CPT and PE are often associated with high dropout rates, limited tolerability, and temporary symptom exacerbation during treatment. 
In the realm of pharmacologic treatment options for PTSD, recent literature indicates significant promise with the use of stellate ganglion blocks (SGB; Summers & Nevin, 2017). SGBs involve the injection of a local anesthetic around the stellate ganglion at the base of the neck and are thought to minimize PTSD symptoms by temporarily blocking sympathetic arousal and physical reactivity associated with reminders of traumatic events. 
Given that PE deliberately and systematically encourages patients to approach feared trauma reminders, often leading to poor tolerability and high dropout rates, SGBs may significantly improve treatment outcomes with PE. It’s reasonable to suggest that by blocking or inhibiting physiological activation, SGBs may reduce patient discomfort, thereby helping them to confront trauma reminders and learn more adaptive responses. 

Can we improve treatment tolerability in trauma-focused therapies?

We hypothesized that by combining an SGB with massed PE, more than 50% of patients would have a clinically significant reduction in symptoms defined as a >10-point reduction on the PTSD Checklist for DSM-5 (PCL-5) and would no longer meet the diagnostic criteria for PTSD based on the Clinician Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2018). Massed PE consists of daily 90-minute PE sessions over the course of two weeks and is considered non-inferior to the typical spaced PE therapy delivered once or twice weekly over several months. 
Twelve active duty military personnel were enrolled in our nonrandomized pilot trial, 11 (91.7%) of whom completed the treatment protocol. A single SGB was given between sessions 1 and 2 to ensure that it was provided after the treatment rationale but prior to beginning exposure therapy. The primary outcome measures were the CAPS-5 and the PCL-5 administered at baseline and 1 and 3 months following completion of treatment. 
By the end of treatment, 90.9% of participants had a clinically significant decrease on the PCL-5. At 1-month follow-up, 80% maintained the decreased PCL-5 score and 50% of participants no longer met diagnostic criteria for PTSD based on the CAPS-5. At the 3-month follow-up, 88.9% of participants had a clinically significant decrease in PCL-5 score and 87.5% of participants no longer met the criteria for the diagnosis. 
To put these results into perspective, a previous study by Rae Olmsted et al. (2020) found that SGB as monotherapy led to a 13-point reduction on the PCL-5. Similarly, a study by Foa et al. (2018) found that massed PE as monotherapy led to a 14-point reduction of symptoms on the PCL-5. Our pilot trial, combining SGB and massed PE, resulted in a 32-point reduction. 

Should we re-consider combined medication and psychotherapy treatments?

In the past, use of medications for the reduction of arousal were found to limit the efficacy of cognitive-behavioral therapies for anxiety disorders (Otto et al., 2010). It has also been suggested that emotional activation is necessary for successful exposure-based cognitive-behavioral therapy (Foa & Kozak, 1986). In contrast to these concerns, the combination of SGB and massed PE resulted in low dropout rates and large reductions in PTSD symptoms. By reducing psychophysiological reactivity, the SGB may have helped participants remain in the exposures longer, engage more deeply with trauma memories, and have greater opportunities for healthy learning and recovery. 
The investigators for the pilot trial recently received notification of Department of Defense funding for a study to determine if the results can be replicated within a well-controlled randomized clinical trial of massed PE combined with either an active or sham SGB. If the pilot results can be replicated, then the rapid reduction in PTSD symptoms associated with this dual treatment approach may prove particularly beneficial for the U.S. military, whose members have limited time available to complete PTSD treatment programs while simultaneously maintaining mission readiness.

Target Article

Peterson, A. L., Straud, C. L., Young-McCaughan, S., McCallin, J. P., Hoch, M., Roux, N. P. III, Koch, L., Lara-Ruiz, J., Roache, J. D., Hein, J. M., & Blount, T. H., for the STRONG STAR Consortium. (in press). Combining a stellate ganglion block with prolonged exposure for posttraumatic stress disorder: A nonrandomized clinical trial. Journal of Traumatic Stress. https://doi.10.1002/jts.22873 

Discussion Questions

  • Would increasing frequency of Prolonged Exposure sessions (i.e., daily versus weekly) improve treatment outcomes or completion rates?
  • What are some reasons in which dropout rates are high in therapy modalities such as Prolonged Exposure and Cognitive Processing Therapy?
  • How do medications or procedures, like Stellate Ganglion Blocks, improve treatment outcomes for PTSD when combined with trauma-focused therapies?
  • Is sympathetic activation necessary during trauma exposure for improvement in PTSD symptoms?

About the Authors

Jennifer M. Hein, MD
, is a U.S. Army Captain and military physician with four years of time in active duty service. She is currently completing her third year of psychiatry residency training at Carl R. Darnall Army Medical Center, Ft. Hood, TX, and received her medical degree from the University of California, Riverside in 2018.
Alan L. Peterson, PhD
, is a professor in the Department of Psychiatry and Behavioral Sciences at The University of Texas Health Science Center at San Antonio, a professor in the Department of Psychology at the University of Texas at San Antonio, and the Director of the STRONG STAR Consortium. Dr. Peterson is a board-certified clinical health psychologist who served 21 years of active duty with the U.S. Air Force, including three post-9/11 deployments, retiring as a lieutenant colonel in 2005. He has clinical and research expertise in the areas of behavioral medicine, psychological trauma, and resiliency.

References Cited

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. https://doi.org/10.1037/0033-2909.99.1.20

Foa, E. B., McLean, C. P., Zang, Y., Rosenfield, D., Yadin, E., Yarvis, J. S., Mintz, J., Young-McCaughan, S., Borah, E. V., Dondanville, K. A., Fina, B. A., Hall-Clark, B. N., Lichner, T., Litz, B. T., Roache, J., Wright, E. C., & Peterson, A. L., for the STRONG STAR Consortium. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. JAMA: Journal of the American Medical Association, 319(4), 354–364. https://doi.org/10.1001/jama.2017.21242

Lipov, E. G., Navaie, M., Brown, P. R., Hickey, A. H., Stedje-Larsen, E. T., & McLay, R. N. (2013). Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: A case report and systematic literature review. Military Medicine, 178(2), e260–e264. https://doi.org/10.7205/MILMED-D-12-00290.

Otto, M. W., McHugh, R. K., & Kantak, K. M. (2010). Combined pharmacotherapy and cognitive-behavioral therapy for anxiety disorders: Medication effects, glucocorticoids, and attenuated treatment outcomes. Clinical Psychology: Science and Practice, 17(2), 91–103. https://doi.org/10.1111/j.1468-2850.2010.01198.x

Peterson, A. L., Niles, B. L., Young-McCaughan, S., & Keane, T. M. (2021). Assessment and treatment of combat-related posttraumatic stress disorder: Results from STRONG STAR and the Consortium to Alleviate PTSD. In N. Gorbunov (Ed.), Military Medicine. InTech Open. https://doi.org/10.5772/intechopen.96323

Peterson, A. L., Young-McCaughan, S., Roache, J. D., Mintz, J., Litz, B. T., Williamson, D. E., Resick, P. A., Foa, E. B., McGeary, D. D., Dondanville, K. A., Taylor, D. J., Wachen, J. S., Fox, P. T., Bryan, C. J., McLean, C. P., Pruiksma, K. E., Yarvis, J. S., Niles, B. L., Abdallah, C. G., ... Keane, T. M., for the STRONG STAR Consortium and the Consortium to Alleviate PTSD. (2021). STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations. Contemporary Clinical Trials, 110, 106583. https://doi.org/10.1016/j.cct.2021.106583

Rae Olmsted, K. L., Bartoszek, M., Mulvaney, S., McLean, B., Turabi, A., Young, R., Kim, E., Vandermaas-Peeler, R., Morgan, J. K., Constantinescu, O., Kane, S., Nguyen, C., Hirsch, S., Munoz, B., Wallace, D., Croxford, J., Lynch, J. H., White, R., & Walters, B. B. (2020). Effect of stellate ganglion block treatment on posttraumatic stress disorder symptoms: A randomized clinical trial. JAMA Psychiatry, 77(2), 130–138. https://doi.org/10.1001/jamapsychiatry.2019.3474

Schnurr, P. P., Chard, K. M., Ruzek, J. I., Chow, B. K., Resick, P. A., Foa, E. B., Marx, B. P., Friedman, M. J., Bovin, M. J., Caudle, K. L., Castillo, D., Curry, K. T., Hollifield, M., Huang, G. D., Chee, C. L., Astin, M. C., Dickstein, B., Renner, K., Clancy, C. P., Collie, C., … Shih, M. C. (2022). Comparison of Prolonged Exposure vs Cognitive Processing Therapy for Treatment of Posttraumatic Stress Disorder Among US Veterans: A Randomized Clinical Trial. JAMA network open, 5(1), e2136921. https://doi.org/10.1001/jamanetworkopen.2021.36921

Summers, M. R., & Nevin, R. L. (2017). Stellate ganglion block in the treatment of posttraumatic stress disorder: A review of historical and recent literature. Pain Practice, 17(4), 546–553. https://doi.org/10.1111/papr.12503