How Does Trauma Impact Mental Health?
Approximately 7.7 million American adults are diagnosed with posttraumatic stress disorder (PTSD) each year. A growing concern within both civilian and military populations, researchers are working hard to uncover the mysteries behind this trauma-related illness. Based on an interview that Edstrom conducted with Dr. Terri deRoon-Cassini, Assistant Professor in the Department of Surgery, Division of Trauma & Critical Care at the Medical College of Wisconsin, this article addresses the causes and symptoms of PTSD as well as effective treatment protocols derived from animal research. deRoon-Cassini, who has a Ph.D. in clinical psychology, sees inpatients and outpatients who struggle with distress after trauma and also conducts research on the biopsychosocial aspects of psychopathology and resilience following trauma, including military and civilian injury. Although no longer directly involved in animal research, Dr. deRoon-Cassini provides valuable insight on its relevance to PTSD.
Stress. Nobody can escape it. But some of us are burdened with more than our fair share. Our ability to cope with stress is determined by a myriad of things – from the strength of our support system down to the way our brains are wired. For some individuals, dealing with stress is a daily struggle. But when does stress become anxiety?
When the everyday stressors of work, family, school, etc. activate a person’s stress level to the point it affects day-to-day functioning, a state of constant anxiety can become their new baseline. For working professionals, a new stressful job could create a level of anxiety not previously experienced, leading to panic attacks and more. Feelings of anxiousness, negative thought patterns, excessive worry and fear can accompany the person day and night. This type of perpetuating stress is often situational and not tied to a traumatic event. Although sometimes overwhelming to the point of physical debilitation, stress and anxiety alone cannot cause a much more serious illness known as posttraumatic stress disorder (PTSD).
In February, Jill underwent surgery to remove her right kidney and right adrenal gland, surrounding tissue, fat and lymph nodes. It was a success. The first part of her battle was over, but there was still more cancer to fight.
WHAT CAUSES PTSD?
PTSD is an anxiety disorder that can arise after a person experiences or witnesses a life-threatening event. Examples include military combat exposure, child sexual or physical abuse, terrorist attack, sexual/physical assault, car accident, shooting, natural disaster or industrial accident. "In order for a PTSD diagnosis to be made, a person must have experienced some type of trauma," says Terri deRoon-Cassini, PhD, Assistant Professor in the Department of Surgery, Division of Trauma and Critical Care at the Medical College of Wisconsin. "The culmination of stress cannot lead to PTSD."
It’s estimated that 60 percent of American men and 50 percent of American women endure at least one traumatic event in their lifetime. Not everyone who experiences trauma develops PTSD, however. "The majority of people handle trauma really well," notes deRoon-Cassini. "In fact, some even report a better life functioning after the traumatic event. Something inside them has changed, and the life-threatening nature of the trauma prompts them to reprioritize their life."
Assaultive traumas are more likely to produce PTSD due to the infliction of intentional harm by another human being, unlike an incident in which no one was to blame. Studies show that more than 90 percent of women who’ve been a victim of sexual assault acquire PTSD. Only 20 percent of people who experience trauma other than sexual assault are susceptible to developing PTSD.
The intensity and duration of the trauma, if someone you were close to died, if you were hurt, your proximity to the event, your reaction to the event including whether or not you thought you were going to die, the level of control you felt over events and the amount of help and support you received afterwards can all play a role in a person’s vulnerability to PTSD. Someone who has undergone recent, stressful life changes, experienced a life-threatening event or trauma at another time in their life, has another mental health problem or family members with mental health problems, or has little support from family and friends runs a higher risk for developing PTSD.
WHAT ARE THE WARNING SIGNS?
Most people who experience a traumatic event undergo a variety of emotions in the weeks that follow, but oftentimes these feelings dissipate without medical intervention. Fear, anxiety, sadness, depression, guilt, anger and irritability are normal stress reactions. However, if these symptoms last longer than three months, cause extreme agony, or disrupt a person’s work or home life, they should seek help. "The sooner a person can be evaluated for PTSD, the better," says deRoon-Cassini. "Early intervention is important to prevent PTSD from advancing to a chronic stage."
Signs and symptoms that a person may be suffering from PTSD fall into four categories: 1) nightmares/flashbacks, 2) avoidance, 3) hyper-arousal, 4) numbness. A common symptom of PTSD is to re-experience or re-live the traumatic event. Memories of the trauma can return at any time and any place. Nightmares and flashbacks may be triggered by a certain sound, sight or person, and may even cause someone to feel the same fear and horror they did when the event actually occurred.
PTSD sufferers are also likely to avoid places, situations, people or things that spark memories of the trauma. For example, a car crash victim or veteran whose military convoy was bombed might avoid driving. A person who lives through a natural disaster may decide to move because they no longer feel safe. Someone who was injured amongst a large group of people may avoid crowds.
A person with PTSD may always be on the lookout for danger. They’re easily startled and may experience other hyper-arousal symptoms including fast breathing, increased heart rate, irritability, trouble sleeping, restlessness, and sweatiness. Panic attacks can also occur in tandem with PTSD when a person encounters a situation that reminds them of the trauma.
PTSD can make it difficult for a person to express their feelings or experience emotions. This numbness can affect how the person relates to other people and can negatively impact their relationships. They may lose interest in activities once enjoyed, like spending time with family and friends. Alcohol or drug use and employment problems often occur alongside PTSD as a person battles with feeling responsible for what happened or feeling guilty because others were injured or killed and they survived.
PTSD can also upset a person’s physical health and well-being if left untreated. Chronic stress has the power to impact other bodily processes and has been associated with impaired immune functioning, chronic pain syndromes, gastrointestinal illness, respiratory disease and cancer. "There’s a whole field devoted to looking at the negative health outcomes of PTSD," shares deRoon-Cassini, "including very interesting research around childhood trauma and how it affects adult health." deRoon-Cassini says this research is pertinent to animals as well. "You can induce different diseases in those that have experienced trauma and those that have not, and see if they process the disease differently."
ANIMAL RESEARCH HELPS PTSD PATIENTS
With one of the largest rat populations in the country, the Medical College of Wisconsin currently has many exciting research projects underway, including studies on PTSD. "Animal research is very relatable to PTSD," says deRoon-Cassini. "The understanding or etiology of PTSD is something called fear conditioning. A previously neutral stimulus becomes conditioned during the trauma to produce a fear response. Many behaviors that animals exhibit mimic a PTSD response in humans."
deRoon-Cassini relates it to someone walking across the street and getting struck by a yellow cab. Prior to the accident, if this person saw a yellow cab, they didn’t fear it; it didn’t create an autonomic arousal response. Whereas now when they’re walking down the street and see a yellow cab, they experience that autonomic arousal which elicits the anxiety. "That’s the whole premise behind many of the treatments for PTSD and the basic mechanisms of the disorder. This philosophy can also be applied to an animal model."
In order to study trauma, researchers must first elicit a fear response in the animal. Typically, this is done in one of two ways. In a predator fear paradigm, you present a rat or mouse with the pheromones of a cat or put them in close proximity to a cat to evoke that fear response, while also placing them in contact with other stimulus of this natural, fearful animal. Since rats do not like water, an underwater maze is another tool that may be used to elicit a fear response. Researchers can then study the behavioral response of the animals, as well as pharmacological changes since the administration of certain drugs can alter the animal’s reaction. These behavioral studies are useful for determining appropriate treatment options in humans.
"In animal studies, you can apply the PTSD paradigm to special knock-out gene rats to see how they respond," says deRoon-Cassini. "You can study the impact of particular genes or you can modify certain chemicals in the body before trauma occurs in the animal model, and then study how that animal responds. That’s the huge benefit of the animal literature into translational aspects of PTSD research."
deRoon-Cassini goes on to say that PTSD research has become very sophisticated – studying the comorbidity of PTSD with other factors, such as PTSD and substance abuse in the animal model; traumatic brain injury and PTSD in military personnel – understanding the mechanism of both and how they overlap; and the co-occurrence of PTSD with other disorders.
Risk understanding of PTSD is also important. What’s going on before the trauma to make someone susceptible? How do we build up someone’s resilience before they’re traumatized to prevent them from experiencing PTSD later? An example of this is resiliency training being done in the military.
BEHAVIORAL THERAPY PROVEN MOST EFFECTIVE TREATMENT
PTSD is a very treatable illness, especially when symptoms are addressed promptly. "A cognitive behavioral therapy (CBT) approach to treatment is the most effective line of defense against PTSD," says deRoon-Cassini. "Evaluating how our thoughts and behaviors affect our emotions is a key component of this process. When we change how we think about and behave towards those emotions, we can prevent the cycle of anxiety from perpetuating."
Exposure-based treatment is also essential. "If someone was attacked in a parking structure and now they avoid all parking structures, they’re learning the only way to not feel anxious is to never go in a parking garage," says deRoon-Cassini. "Clearly, that could interfere with someone’s life." A gradual exposure to the situations, places and reminders of the trauma help the PTSD patient produce that anxiety response. "Although anxiety accelerates quickly, it reaches a peak and within minutes, goes away. Fortunately, our bodies are not meant for that really intense anxiety to remain high."
During behavioral exposure, the person must wait out the situation until their anxiety starts to decrease. Then they realize it’s doable – they can enter a parking structure without something bad happening. The anxiety response that leads to fearful thoughts like, ‘This is going to happen to me again’ becomes tolerable. The basis for treatment is exposing someone to this fear response until it extinguishes to the point that they can tell their story and stop avoiding things they began fearing after the trauma.
Referred to as imaginal exposure, the other piece of exposure-based intervention for PTSD involves talking about the event in a very prescribed way. Although often painful at first, when people avoid discussing the incident, it only impedes the emotional processing of the trauma. By talking about it over and over, people realize it’s a memory just like any other memory, and it doesn’t have to control their lives.
"Talking about the trauma is very helpful," confirms deRoon-Cassini. She compares it to a volcano explosion. "If a person keeps stuffing an event back inside that they refuse to talk about, eventually they’re going to explode. This also happens to working professionals who are under a lot of pressure, but don’t necessarily have PTSD. The pressure is bigger than the sum of its parts. You’re holding on so tight suppressing those emotions that it becomes this big thing you fear talking about. When you learn to address it, you realize it’s not as bad as you once thought."
A treatment protocol that employs both CBT and pharmacologic intervention in combination can be quite effective for certain people, especially those who do not respond to behavioral therapy alone. "The goal of pharmacologic intervention is not to have someone on medication all their lives," notes deRoon-Cassini. "People can be placed on a therapeutic dose of Selective Serotonin Reuptake Inhibitors (SSRIs) to raise serotonin levels in the brain, which eventually changes someone to the point where they can get off the meds, and that change is everlasting." However, people solely on SSRIs have a higher chance of symptom relapse than those who have been through cognitive behavioral therapy deRoon-Cassini says.
Even someone with chronic PTSD can benefit greatly from treatment. Cognitive behavioral therapy has also proven highly effective for people suffering from panic attacks. And for the person with increased anxiety, both pharmacologic and psychological interventions can vastly improve his or her life.
SQUASHING STIGMAS AND CHANGING PERCEPTIONS
The negativity surrounding mental illness sometimes prevents people from requesting the help they need. "One of the best things our department here has done is to bring on a psychologist," says deRoon-Cassini. "Trauma surgeons are the first people patients see. They work very hard saving lives and ensuring people have the best quality of life after a trauma. Part of that is their psychological recovery. The biggest disruptor to quality of life after a trauma is the development of PTSD."
If a patient returns for suture removal and tells their trauma surgeon that they’re having nightmares, the surgeon asks deRoon-Cassini to talk with them. "It lets a patient know this is what happens to people after a trauma – their reaction is normal. It’s not mental health and then everything else," says deRoon-Cassini. "We treat you as a whole person, and we understand that your entire body, including your mind, is going to respond to the trauma. There are ways to deal with this, and people need to realize it’s okay to get help."
Vocalizing symptoms is substantially lessening the stigma associated with mental illness. Across the country, psychologists are being embedded in medical clinics, and health psychology divisions are now often consulted by other specialties. "Our heads are not separate from the rest of our bodies," deRoon-Cassini says. "The recognition, acceptance and adoption of our mental health as a part of our physical health is the best way to reduce the stigma of mental illness."
IS THERE A CURE FOR PTSD?
The goal of PTSD treatment is to reduce symptoms to a point where they no longer interfere with someone’s life – to well below clinical levels or even down to zero. "It depends on an individual’s acceptance of what’s manageable in their lives," says deRoon-Cassini. Cognitive behavioral therapy teaches positive learned behaviors that a patient continues to utilize even after treatment has ended. Therefore, if a car crash victim has another close call six months later and experiences an anxiety response, they know that to curb it, they must get back in their car and keep driving.
Some people even experience posttraumatic growth, which is defined as positive psychological change after a period of "suffering." With a greater appreciation for life, this person is capable of maintaining deeper interpersonal relationships, achieving more fulfilling life goals, having more personal strength and recognizing new life possibilities.
"There is real benefit in seeing someone who went through a horrible traumatic experience and learning how they turned their life around," says deRoon-Cassini. "You start to see there’s purpose behind the suffering and that maybe you can help others. That’s a huge transformation."
Both animal and human research focuses on individualizing treatments so people respond to intervention better. It can also indicate who is going to respond to which particular treatment the best. "It’s starting to look like there’s different neurocircuitry in the brain that makes someone more susceptible to responding to behavioral intervention better than another, as well as research to suggest that pharmacological intervention, or a combination of the two, is ideal for others," concludes deRoon-Cassini. "I think this is the exciting place where animal research on PTSD can continue to inform human research on individualized treatments and identification of at-risk people."
If you or a loved one has PTSD, there are many helpful resources available. Visit www.ptsd.va.gov/public/index.asp for more information.
1. National Institute of Mental Health. "The Numbers Count: Mental Disorders in America." http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml.
2. "Understanding PTSD." A Guide Created by the National Center for PTSD, U.S. Department of Veterans Affairs.
3. Dr. deRoon-Cassini, Assistant Professor, Department of Surgery, Division of Trauma and Critical Care, Medical College of Wisconsin. Personal Interview. August 2013.
Research Facility Caters To Its Animals’ Water Requirements
Dr. Badru Moloo, Director of the Animal Resource Centre at University Health Network (UHN) – discusses the unique decision to supply both chlorinated and acidified water through a single automated watering system in two facilities at UHN. This "dual" system, functioning well since its installation in 2007, offers tremendous benefits to both animals and humans at this research facility. The UHN poster, "Dual Automatic Watering System In A Multi-Species Research Facility" was also referenced for this piece.
Prior to installing your Edstrom automated watering system, how did you provide drinking water to your animals? What prompted you to explore switching to an automated watering system?
We have multiple sites and were using mostly water bottles. However, with the expanding populations it became operationally obvious that we needed to switch to a more efficient and cost-effective watering method.
How important was high quality water to your decision in choosing an automated watering system?
Water is one of the top five housing factors that mouse users consider when setting up their studies. The consistent microbiological quality, palatability and reliability of the water that an Edstrom automated watering system produces are important features for the lab animals housed at our facilities.
Which Edstrom automated animal watering system do you have?
We have both. The recirculating system is in one rodent facility that’s home to 14,000 mouse cages. Then we have a flushing system in buildings that house multiple species – this is our dual system featuring both chlorination and acidification.
How long was the process of choosing the appropriate system for your facility and then implementing that system?
While the design and engineering criteria were finalized within a period of several weeks, the internal financial discussions required a few months to negotiate. To our satisfaction, all the installations were completed and validated within the assigned schedule.
How many types of species do you manage? We currently have ten different species of animals at our facilities, including ferrets, pigs and other large-animal models. Mice are the primary species used in biomedical research here, and currently there are 20,000 mice cages connected to the automated watering system.
Why did you choose both acidified and chlorinated drinking water for your animals?
We chose to design a dual system so that we could accommodate both large-animal and mouse models without restricting room usage, as we disinfect the water differently depending on the species. Acidified water is preferred for certain mouse models, such as transgenic, induced mutant, immunodeficient and mouse/human hybrids as these strains are susceptible to oral cavity infections. Acidified water helps combat this by reducing bucal and gastrointestinal colonization of Pseudomonas aeruginosa and other gram-negative bacteria.
How difficult has it been to operate and maintain a "dual" automated watering system that delivers both acidified and chlorinated water? What special considerations did you have to make?
We have not found this system difficult to operate or maintain. We have an SOP that outlines the conditions that need to be altered (temperature, humidity, housing, etc.), and switching the water source is on the checklist. By taking these steps, we ensure optimal standards of animal health and animal well-being are met consistently.
This system requires a few extra pieces of equipment, such as two central proportioner stations – one to control each type of water we’re supplying – acidified or chlorinated and a dual piping system to distribute water from each station. Every animal room contains a drop line for both acidified and chlorinated water at the pressure reducing station (PRS), making it easy to switch between the two depending on the animal species inhabiting the room at the time (pictured left). All of our large-animal models receive chlorinated RO water while the mice drink from the acidified line. After making the switch from one system to the other, we must perform manual flushes through the pressure reducing station before animals begin drinking.
What benefits have you experienced as a result of using a combined acidifying and chlorinating system?
The design of the room and the dual watering system have decreased overall operational costs. Automated watering has provided substantial cost savings and a reduction in labor throughout the vivarium. We’ve realized even more advantages by using a dual watering system, which allows maximum flexibility in changing rooms for different animal species – since we have the ability to provide either acidified or chlorinated water in each animal holding room.
We can fully maximize vivarium space because we have the flexibility within each room to utilize the preferred sanitization method for each species. Furthermore, we feel this dual system has enabled us to successfully meet the changing research needs within our facility.
Would you choose this watering system again?
Yes, and in fact, we already have as we are in the process of finalizing the installation of a similar dual system in a new vivarium.
Making The Safest Animal Watering System Even Safer – With FloSense™
FLOSENSE™ PRECISELY MONITORS WATER FLOW DOWN TO THE RACK LEVEL
Monitoring water flow within a flushing automated animal drinking watering system – even on a small scale – is now an easy task. Offering precise flow detection, the new Edstrom FloSense™ unit monitors water flow on an individual mouse rack, alarming if there is an abnormal constant flow of 0.5 mL per minute (or greater) detected. FloSense brings monitoring down to the rack level for more accurate diagnoses of abnormal water flow conditions – telling you specifically in which room, and on which rack, the flow condition is occurring. By providing invaluable early detection at the drinking source, FloSense brings peace of mind to researchers, technicians and vets.
SENSITIVITY TO 1/10TH OF A TEASPOON
Due to the product’s exact 0.5 mL-per-minute sensitivity – equal to 1/10th of a teaspoon – FloSense features a programmable alarm delay. Based on the rack’s mouse population, it prevents normal drinking activities from creating a false alarm condition. Therefore, if an alarm time delay is set for 40 minutes, a constant water flow of 0.5 mL or greater would need to occur for 40 consecutive minutes in order to trigger an alarm.
Equipped with intelligent alarming technology, FloSense’s escalating alarm feature recognizes when flow greater than 0.5 mL is observed, which will cause the unit to alarm in a shorter time frame. Depending on how quickly water is flowing, FloSense can alarm in as fast as 10 minutes. By installing an optional solenoid, FloSense can even shut off water to the rack if abnormal flow occurs, providing an added safety measure. When FloSense is connected with Edstrom Watchdog® or Pulse™, the system will notify key personnel of alarms via callout or email. Watchdog and Pulse will report flow alarms and can log when the event began, acknowledgement of the alarm, and when the abnormal flow condition stopped. The FloSense unit also includes a visual indicator (red LED) to signify alarms onsite.
FloSense is universally compatible with all cage rack manufacturers. Housed in an ABS chemical- and water-resistant plastic case, FloSense is mounted on the room distribution piping near the rack it is to monitor. Easy to operate, FloSense can be installed on a new or existing flushing automated watering system without making any modifications to the room distribution piping. Improving upon the safest technology in animal watering, FloSense isolates flow conditions to a specific rack, helping you pinpoint the exact location of an abnormal flow situation well in advance, to offer an added layer of protection for animals and research.
Q: I have a rodent rack with Edstrom drinking valves. One is a replacement valve, which has a gray center. All of my other drinking valves have a red center. Is there a difference between the valves as they look identical?
A:The Edstrom drinking valves’ design and manufacturing processes continue to be refined for improved function, but form and fit remain the same. The color difference of the shield in the center of the valve around the stem is an indication of year of manufacture. The red center indicates these valves were manufactured during the year 2007. The gray center shield indicates this valve was manufactured in 2008. In addition to the color indicator, Edstrom drinking valves are also laser engraved with the month, day and year of manufacture.