Brain is an Incredibly Complex

Introduction

The brain is an incredibly complex organ that is vital to our survival and its analysis spearheads a greater understanding of disease and degradation. These disorders are a growing issue in developed countries and the leading cause of disability in the U.S. (20) Mental health disorders can have an enormous impact on the quality of life and one's wellbeing. One of these disorders, post-traumatic stress disorder (PTSD), develops after exposure to a traumatic event and is characterized by prolonged and/or delayed stress and anxiety responses as well as an overactive fight/flight response, at times without triggering stimuli. PTSD is known to adversely affect numerous biological systems, including, the immune, cellular, endocrine, neural signaling, neurochemical, and metabolic processes. (2) It is also associated with an adverse impact on daily life, as well as, emotional and mental complications that can be chronically disabling. PTSD is the result of multiple interactions between genetics and environmental influences. These interactions are important in informing our understanding of risk and resilience to trauma. (3)

Because PTSD is complex, a new innovation such as a wellness platform supported by the peer model may be beneficial in improving the quality of life and supporting individuals fighting this disease. Biology and Etiology of PTSD Since it was first recognized in 1980 in the Diagnostic and Statistical Manual of Mental Disorders (DSM), PTSD was only depicted in psychological terms in the clinical field. PTSD was defined as an anxiety disorder, but now is categorized under the Trauma and Stress Related Disorders in the DSM V. Currently, it is defined as a blend of intrusive thoughts from the traumatic event, hyperarousal, avoidant behaviors, dissociation, and detachment. (1) The criteria of diagnosis have changed through the years as accumulated research and new findings have developed. Under criterion D, through the experience of patients and clinicians, people may experience pervasive negative emotions, in addition to, self-conscious and internal-directed emotions such as shame (1). Through fMRI neuroimaging, one study revealed that women with PTSD associated a greater number of negative words with themselves than women without PTSD. (8)

Technology has substantiated the observed psychological elements of the disorder such as shame and guilt. For example, in various clinical settings therapists have found through experience that their clients experienced feelings of internalized guilt and shame. Furthermore, it has been established that this is a fear-based anxiety disorder, but this study has demonstrated the pervasive negative thoughts and expectations about oneself and negative thoughts of others. (8) The use of fMRI scans provided an opportunity to compare negative emotions about oneself such as guilt or shame with people who have been diagnosed with PTSD to those who have not. Through the years, the psychological elements of the disorder have been established through neurobiological and neurochemical underpinnings furthering the explanation of the broad picture and complexity of this mental disorder (2).

Research has hypothesized multiple neurobiological systems that are affected, including the hypothalamic-pituitary adrenal axis (HPA), neurocircuitry between the limbic system and frontal cortex, and neurochemistry of the brain. (3). Structural and functional abnormalities have consistently revealed a general imbalance between the frontal lobe, amygdala, hippocampus, and anterior cingulate cortex activation in PTSD (2). Imbalances lie within distinct neural systems, namely, systems implicated in the acquisition, expression, and inhibition of fear and anxiety. The amygdala is vastly involved in emotional processing and regulation of fear processing.

This structure serves as a connecting hub of neural circuits implicated in PTSD (13) Scientists have discovered how PTSD has hijacked the neurocircuitry of the limbic and frontal cortex of the brain. Focused genetic research described a polymorphism in the serotonin transporter. The short allele has been demonstrated to be less efficient than the long allele and is associated with the decoupling of the circuit between the prefrontal cortex and the amygdala. This short circuit between the prefrontal cortex and amygdala, is responsible for the extinction of fear conditioning. (12) This leads to a hyperarousal state which precipitates a cascade of events such as increased heart rate or increased blood pressure and cortisol levels causing potential long-term damage to the body. Another pathophysiological model was led by Yehuda where it was proposed that PTSD may involve an HPA axis that is characterized by enhanced sensitivity feedback inhibition. (22) Tightly controlling cortisol secretion and responding aggressively to acute rises in cortisol levels, the neuroendocrine system may serve to buffer vulnerable neuronal structures such as the hippocampus. (22)

This could explain why there are research studies showing that patients who have PTSD had a lower level of cortisol in their system. (21) Studies have also demonstrated the correlation between PTSD and the onset of specific immunoendocrine-related diseases. For instance, down regulated glucocorticoid system may result in elevations in leukocyte and other immune inflammatory activities. (20) This could lead to autoimmune disorders and cardiovascular disease. Trauma contains a strong underlying factor in developing PTSD; shame and symptoms of the disease such as nightmares, hyperarousal and fear lead to stress on the body.

Chronic stress associated with PTSD could be associated with an increase allostatic load, which can lead to an increase in susceptibility to illness. (21) Chronic stress has a detrimental effect on the body causing a cascade of events leading to diseases such as cardiovascular, diabetes, or various other inflammatory pathologies. Individuals diagnosed with PTSD experience significant functional impairment including increased risk for unemployment, isolation, and difficulty sleeping. (3) Referring back to the pathology and neurobiology of the disease, symptoms include tachycardia, increased blood pressure, and hyperactive adrenal glands due to being in a constant hyperarousal state, which can cause havoc to the body. (11) Furthermore, psychiatric comorbidity is notably more common among women presenting PTSD, which could lead to an increased morbidity, disability, and mortality. (20)

Individuals diagnosed with PTSD experience a significant burden emotionally, psychologically, and biologically, but what is the impact within populations and communities? The occurrence of PTSD is monitored in the United States through various epidemiological surveys and methods. Epidemiology Through numerous epidemiological surveys in the United States, scientists have been able to approximate the risks and prevalence of PTSD. Life time prevalence of PTSD in the general population ranges between 6.4%-7.8% (9) Rates are much higher among military veterans with 20% of combat-exposed veterans meeting criteria for PTSD during their lifetime (20). Women are more at risk for PTSD than men once trauma has occurred, and the underlying explanation is still unknown. (9) More specifically in regards to trauma exposure, women who have experienced rape or violence have an increased risk and higher rate for PTSD and psychiatric disorder (9). National representative data speak volumes in the prevalence of PTSD, substance use, depression, and psychiatric comorbidity diagnoses among women reporting forcible rape.

In the National Comorbidity Study that consisted of a representative sample of 5,877 men and women, rape and sexual molestation were the most frequently identified traumas associated with lifetime PTSD for both men and women. Nearly half of women who had a history of rape, developed PTSD at some point in their lifetimes (9). Another study by the National Women's Study, represented 4,008 women confirmed these findings from NCS. NWS reported that the lifetime prevalence of PTSD among victims of rape was 32%. (4) Finally, psychiatric comorbidity is notably common among women presenting PTSD. For example, nearly half of women diagnosed with lifetime PTSD also reported a lifetime diagnosis of depression. (6). According to the National Intimate Partner and Sexual Violence Survey 2010 Summary Report developed by the CDC, the lifetime cost of rape per victim is $122,461. Annually, rape costs the U.S. more than any other crime. An estimated 127 billion followed by 93 billion for assault. Eighty-one percent of women report significant short or long-term impacts such as PTSD, depression or anxiety.

Integrating the statistics on violence and mental health expounds that health and social factors such as equality is inextricably related to one another. These statistics and epidemiological statistics capture a gruesome depiction of the public health burden that this nation is facing. In order to find preventative solutions to this crisis, an interdisciplinary approach is crucial. Increased efforts to develop treatments along with new models of researching genetic predisposition and studying the neurobiology of PTSD in diverse SES populations could provide new strategies to support communities at higher risk. Additional studies regarding epidemiological assessment of trauma related diagnoses are necessary to better understand the public health burden from trauma exposure (7). Current Treatments and Innovation The complex nature and unknown factors of PTSD requires creativity and innovation to address the insidious disposition of this disease. Although, there has been pioneering research with great headway behind this disorder, further advancement of finding how DNA and the environment interact to manifest this disease will provide a better understanding regarding the etiology of PTSD. This will provide new specific targeted treatments with short and long-term efficacy that could follow or develop. (14)

Cognitive Behavioral Therapy and antidepressant medications have been the primary treatment for PTSD, but research demonstrates that not all PTSD patients respond the same way to treatment. (14) Like many other mental disorders, there are disorder- and population- related risks, resilience, comorbidity, and iatro genic variables that can influence neuropsycho logical performance. (14) If we can identify these risk and protective factors, we may be able to develop and implement interventions that prevent the on set of PTSD. We must exploit this knowledge to utilize improved treatments for communities at risk. The theoretical research needs to also translate practically and integrate into the lives of people living with the disease. Acquiring knowledge and understanding of the disease is an important component. Furthermore, there are a vast range of factors inherent to the assessment of PTSD such as: mental health policies, access to health care, cultural awareness, and help seeking behaviors. In addition to these factors, underreporting of crimes and stigma can result in research bias and misinformed information.

Cognitive Behavioral Therapy has been successful, but access to health care and poverty are barriers to treatment. Healing can start in the doctor's office but recovery is a process that involves numerous social determinants such as education, relationships, social services, and medication. SAMSHA illustrates on their website the 8 dimensions of wellness: emotional, environmental, physical, financial, intellectual, spiritual, occupational, and social. Having a team of trained personal trainers, nutritionists, therapists, while cultivating their own natural support systems could make a huge impact on patients' overall quality of life. Research has demonstrated the substantial benefits of using exercise as an adjunct treatment modality for depression, anxiety, PTSD, and substance-related disorders (18). In addition to the improvement for mood disorders; exercise can be beneficial for your physical health reducing risks for cardiovascular disease and diabetes. Furthermore, literature has suggested that exercise can improve the health of your brain and nervous system through increasing your brain-derived neurotrophic factor (BDNF). BDNF is critical for fear extinction, a critical component in overcoming symptoms of PTSD (19).

Cognitive Behavioral Therapy along with medication are important in treatment; there are limited medications that treat PTSD. Patients with mental disorders often struggle with medication adherence due to forgetfulness or not feeling that they need to take their medication. It is important to consider alternative or adjunct treatments such as the integrated wellness platform that consists of various programs that could support individuals who have PTSD or a comorbid condition. The mission of the program is to build a strong community through movement, food, and relationships. The objective is to combat mental health issues while shattering the stigmas that accompany mental health and trauma in underserved areas. The program will provide access to a free health platform that will offer fitness, nutrition, education, counseling, and other various health programs that the community needs.

These programs will promote independence and long-term support focusing on individual strengths, natural support systems, and additive goal planning. Taking a trauma informed and person-centered approach is integral for recovery, and making choices that would work for each individual will be unique when factoring in mental health disorders. Developing a wellness platform requires an abundant amount of funding. Financial barriers to fund these programs could be resolved by creating a two-phase model: the first phase is a mobile health platform and eventually, if the program is successful, a brick and mortar wellness center for trauma would be developed. In the first phase, a van will be able to transport various services to the community. Professional counselors, life coaches (peers), nutritionists, and fitness instructors would drive to various domestic violence shelters or clients' homes to provide supportive services that could be integrated into client's daily lives. In addition, offering access to programs that can be transported to the underserved communities would provide a unique approach and niche in the market in meeting the needs of the underserved populations. The distinctive mobile programming will aid in incorporating what they have learned into their individual lives.

If the program is successful, this could provide momentum for funding towards the second phase, a wellness center for trauma. The program will assess the community needs and be modified for improvements into the fabric of the intervention programs. A peer model system is a newly innovative approach to increase the efficacy of the wellness program. This cost effective approach requires fewer health professionals who will supervise and train the peers to implement the program. A peer is someone who had a similar mental health disorder or experience, and is part of a multidisciplinary professional team supporting clients in need. A peer to peer model more easily establishes trust with a client then a therapeutic modality because the it minimizes the power dynamic and creates a distinct relationship. Through sharing their recovery journey, a peer is able to empower the client to be successful in their own journey. Peers can become trained by professionals on receiving certification and also run various wellness groups such as nutrition, stress reduction, or yoga classes. They can work alongside the counselors to champion and empower the clients with PTSD in their recovery.

Their own life experiences can provide clients with a unique avenue by demonstrating a sense of hope to people who are in various stages of recovery. Various literatures have indicated the potential benefits of a peer model approach with different populations. (15,16,17) Results through interviews of clients who collaborated with a peer were mostly positive. Interviews illustrated that this model supported building trusting relationships through sharing lived experience, providing hope for the future by observing someone who experienced a mental health disorder, challenging stigmas, engaging with the community and removing barriers to engagement with others. (15) Comparison group studies have found fewer rehospitalizations, and a community-based peer support system among veterans found significant improvement in recovery and empowerment. (17)

Finally, a before and after study on older adults with depression found that having peer support is a unique avenue of building trust through shared experience, empathy, and guidance to recovery. (16) This unique approach could provide another potential viable treatment that could have multiple benefits, including shattering stigmas of mental health disorders. PTSD is a multifaceted disease which will require a multidisciplinary team and creative approaches. Expanding research interventions may improve underserved populations regarding trauma while pinpointing the interventions could impact the communities in a positive way. The results have potential to further new innovations and solutions to empowering and increasing the quality of life of populations with PTSD.

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