Posttraumatic Stress Disorder
This article explores the link between emotional trauma and chronic relapsing tick-borne infectious disease affecting the brain. Two case histories are presented. In these cases, posttraumatic stress disorder (PTSD) is associated with increased symptoms of chronic, relapsing, infectious diseases, and there is also greater difficulty recovering from the traumatic event. These cases suggest psychic trauma contributes to the relapse of chronic infectious tick-borne disease, and chronic infectious disease also appears to contribute to the development of stress and posttraumatic stress symptoms. A study of greater numbers in more depth is advised.
Studying the dynamics of stress is an area of great interest in both biology and medicine. It is generally accepted knowledge that individuals under greater stress are more susceptible to the common cold, the flu, a relapse of a herpes simple fever blister, or a number of other acute and chronic infectious diseases. Conversely, chronic illnesses such as chronic Lyme disease can result in increased chronic stress, which may further reduce immunocompetence, deter recovery, and contribute to a vicious cycle of chronic illness, chronic stress, and lack of recovery from this illness.
Current research demonstrates that chronic stress, sleep deprivation, and depression contribute to a decline in immunocompetence and a decline in natural killer cell (NKC) activity. The presence of PTSD is associated with a lower number of lymphocytes and T cells, decreased NKC activity, and a reduction of the total amount of interferon gamma and IL-4. In contrast, antidepressant treatment with fluoxetine (Prozac) has been demonstrated to increase NKC activity in vivo (in a living person). Both fluoxetine and paroxetine (Paxil) have increased NKC activity in vitro. Improvement in immunocompetence in vivo appears, in part, associated with serotonin 1-A receptor activity. Other indirect mechanisms through the autonomic, neuroendocrine, and immune systems may also be significant in vivo.
Much has been written recently about the effect of chronic, relapsing, infectious diseases upon the brain. There are a multitude of journal citations, anecdotal reports on the Internet, and cases in clinical practice of trauma contributing to a relapse of infectious disease symptoms. The traumas involved may be psychic, somatic, or psychic and somatic (i.e., emotional trauma, childbirth, surgery, immunizations, or accidents).
Normally, we can peacefully co-exist with a multitude of microbes within us and in our environment. In a state of severe or chronic stress, there is a shift of allocation of resources towards dealing with the acute stressor at the expense of an immunosuppressive effect, which can result in an increased vulnerability to the pathogenic effect of microbes that might otherwise be non-threatening. This increased vulnerability may trigger a relapse of latent infections, resulting in a progression of symptoms from these infections. The effect of the microbes, plus the body’s response to them, results in the pathological symptoms associated with infectious disease. Although we could focus on many facets of this disease process, this article shall particularly focus upon mental symptoms, or more specifically, symptoms associated with posttraumatic stress disorder (PTSD) and chronic, relapsing, tick-borne diseases.
PTSD is an illness with a complex and puzzling etiology when a traumatic event occurs, some recover with a healthy grief, and a subsequent adaptive process. However, for a number of reasons others are not able to integrate this experience into their lives in an adaptive manner. As a result, patients with PTSD continue to experience symptoms of chronic stress, accompanied by different combinations of re-experiencing of the trauma, avoidance, hypervigilance, and psychic numbing. In a healthy adjustment to a traumatic event there is, instead, a learning process accompanied by a change of the neural architecture and neuro-chemistry of the brain, resulting in a capacity to better differentiate and respond appropriately to specific threats. However, in PTSD the fearfulness and response to the threat lacks adaptive specificity. A dysfunction of the process of learned fear and the learned response to this threat is, therefore, hypothesized as contributing to the pathology of PTSD. A dysregulation of norepinephrine and cortisol are particularly significant in understanding PTSD.
When a chronic, low-grade, relapsing infection affecting the brain is present, brain functioning is impaired through a number of pathophysiological processes. The presence of this impairment at the time of psychic trauma may deter the normal recovery from trauma and contribute to the development of PTSD.
Mrs. A is currently a 37-year-old white female with an interest in outdoor activities. She was previously in good health until a camping trip she took to a South Jersey State Forest seventeen years ago (1981). After this point, her health showed a decline with the gradual progression of a multi-system illness. It appeared there was a more rapid progression of these symptoms in 1985 after her son was born, who was diagnosed as being autistic with developmental delays.
In 1987, a bull’s-eye rash was noted on her right leg. The multi-system illness progressed further after this time. She was seen by a number of physician and was diagnosed with mitral valve prolapse, and possible multiple sclerosis.
Symptoms continued to increase and she was eventually diagnosed with Lyme disease (LD) in 1990 by a physician with experience in the treatment of LD. The diagnosis was confirmed with a positive Lyme ELISA and Lyme Western Blot. There were multiple other positive tests confirming Lyme disease in the course of her illness. In addition, white matter lesions were noted on an MRI of her brain. Over time, the prior lesions improved and new ones appeared. The patient was stabilized in 1992 after antibiotic treatment, including extended courses of IV antibiotics.
In 1994, while in a remission, the patient was in her home and heard an explosion. Reportedly, outside the sky was orange, boulders were flying in the air, and her car was melting and blistering. The patient thought it was a nuclear blast. She embraced her son and husband and said, “I love you. We’ll die. I’ll see you in Heaven.” The walls of her home were burning, glass was cracking, and her skin was burning. At that point, they took the risk of running from their home. As they left the house, it collapsed. The patient and her family survived what was later found to have been a gas main explosion.
After the incident, the patient experienced a number of symptoms associated with a posttraumatic stress disorder (PTSD), including flashbacks of running through fire, seeing the car melt, and telling her son they would die. There was an exaggerated acoustic startle in response to noises and she was distraught that all her possessions were lost in the explosion. There was a return and increase of symptoms associated with LD immediately after the explosion and a Lyme Western Blot both IgM and IgG were positive two weeks after the trauma.
An exam in 1997 demonstrated the following signs and symptoms:
· Attention span symptoms include difficulty with cognitive tracking and sustained attention, impaired ability to allocate attention, impaired attention span when frustrated, and hyperacuity to sound, light, touch, and smell. Memory symptoms include impairments of working memory, working spatial memory, short-term memory, memory encoding, letter reversals, spelling errors, word substitution errors, number reversals, and slowness retrieving words, numbers, names, faces, and geographical memory.
· Processing symptoms include impairments of reading comprehension, auditory comprehension, transposition of laterality, left-right discrimination, capacity for visual imagery, calculation, fluency of speech, fluency of written language, handwriting, and spatial perceptual abilities. There was stuttering, slurred speech, and optic ataxia. Executive functioning symptoms included unfocused concentration, “brain fog,” difficulty prioritizing multiple tasks, difficulty with multiple simultaneous tasks, and decreased abstract reasoning.
· The patient experienced depersonalization, derealization, vivid nightmares, and illusions.
· Mood symptoms included decreased frustration tolerance, sudden abrupt mood swings, and hypervigilance.
· Behavioral symptoms included disinhibition, exaggerated startle reflex, suicidal tendencies, accident proneness, decreased job performance, marital difficulties, compensatory compulsions, dropping objects from her hands, and crying spells.
· Psychiatric syndromes present including depression, panic disorder, and posttraumatic stress disorder (PTSD).
· The patient had insomnia and was not well-rested in the morning. There was anorexia and weight loss. Capacity for pleasure, libido, and social interests were all diminished.
· There were body temperature fluctuations with intolerance to heat and cold, decreased body temperature, low-grade fevers, night sweats, and chills.
· Headaches were in the neck, with sharp shooting pain radiating to the scalp and eyes. In addition, there were TMJ and sinus headaches.
· Eye symptoms included blurred vision, sensitivity to bright light, sensitivity to fluorescent light, floaters, eye pain, double vision, and a lid drop.
· A prior Bell’s palsy and loss of sensation on the side of the face had not re-emerged. However, there was tinnitus, dizziness, vertigo, motion sickness, choking on food, and difficulty swallowing.
· Neurological symptoms Included numbness, tingling, sensory loss, burning, crawling under the skin, stabbing sensations, weakness, tremors, twitching, muscle tightness, muscle discomfort, and an odd sensation that her head felt hollow. The patient fell backwards on Rhomberg testing when her eyes were closed.
· There was pain and tightness of multiple joints. There was periosteal tenderness of the tibias, ribs, iliac crest, sternum, and clavicles. In addition, there was chronic fatigue, muscle tenderness, and tenderness of the
cho strochondal joints.
· There was mitral valve prolapse, a racing pulse, pericarditis, and a heart murmur. Shortness of breath, a sore throat, and swollen glands were present. Upper GI distress, irritable bowel syndrome, and gallstones were also present. There was breast tenderness and irritable bladder. In addition, alcohol intolerance, hair loss, tooth pain, multiple chemical sensitivities, bruising, chronic pain, and an increase in allergies were noted.
Symptoms were noted to have gradually evolved with time, and they were sometimes subtle and variable. The symptoms were increased by stress, they were exacerbated by antibiotic treatments, and they increased in the perimenstrual period.
Laboratory testing demonstrate LUAT – 78, 110, and O on samples collected at two days intervals – Lyme ELISA was positive at l.32. Lyme Western Blot IgM was positive with reactivity of KDa 23-25, 31, 34, 39, 4l, and 58 bands. The patient also tested positive for babesiosis and human granulocytic ehrlichiosis (HGE). The combination of problems from the LD and the explosion resulted in considerable financial distress and difficulty paying for necessary medical care, which further exacerbated symptoms. She has been treated with a combination of antibiotics, psychotropics, and psychotherapy, with a partial response.
Mr. B is currently a 43-year-old white male who may have been infected by tick-borne diseases thirteen years ago and eight years before diagnosis and appropriate treatment. He, like many patients with these complex problems, had been to numerous doctors. The illness also affected his marriage and his occupational adjustment. His prior diagnosis was considered to be asthma, irritable bowel syndrome, colitis, bipolar illness, and personality disorder (NOS). He experienced many of the symptoms that Ms. A. described. Emotional numbing, over-reactivity, hypervigilance, explosive outbursts, and vague somatic symptoms give the impression of PTSD. In describing his temper, this patient stated, “I was in a mind fog. I didn’t know what was right or wrong.” He assaulted his wife and a restraining order was entered. He cut the phone lines to his house, jumped up and down on his wife’s car, and put his foot through her windshield. He was arrested three times and was committed to psychiatric hospitals. The patient expressed the feeling he had no control.
After starting a suicide attempt, he regained some control, drove to a hospital, and was committed to a state hospital, where an internist diagnosed him with Lyme disease and started treatment. Mr. B began to respond, was discharged, and pursued treatment with a doctor who had an extensive reputation in the treatment of Lyme disease. The patient improved. Mr. B developed a close working relationship with this treating physician, who confided to him that he also suffered from Lyme disease. The patient felt his doctor was showing increasing signs of Lyme disease. The State Board of Medical Examiners investigated the doctor. Shortly thereafter, the doctor with whom Mr. B identified committed suicide. The patient then suffered a relapse of symptoms associated with PTSD. He was subsequently diagnosed with babesiosis and HGE and stabilized with penicillin, Probenecid, Biaxin, and Paxil.
After stabilization, his medications were gradually reduced. He was stable for a few years until experiencing a business failure. His symptoms increased with a predominance of psychiatric symptoms. He experienced flashbacks, hypervigilence, avoidance, and depression, and became increasingly isolated and suicidal. He failed to respond to all psychiatric interventions and the suicidal risk factors increased. He was given a shot of 2 grams of Rocephin IM and three hours later, the depression improved and he was no longer suicidal. He had since been stabilized on a combination of psychotropics and antibiotics. There was a recent relapse related to stress from the World Trade Center terrorist attack. He recovered through crisis intervention and treatment with psychotropics.
In the case of Ms. A, it appeared PTSD caused a relapse of a chronic relapsing tick-borne disease. In the case of Mr. B, it appeared a chronic relapsing tick-borne disease resulted in behavioral symptoms, which resulted in a reciprocal intensification of both PTSD and the tick-borne disease. After being stabilized, traumatic events resulted in subsequent relapses of the tick-borne disease.
These cases suggest there is a reciprocal intensification between chronic relapsing tick-borne diseases and PTSD. Treatment of the chronic tick-borne disease with antimicrobial interventions improved both the systemic infection and also the PTSD. In addition, treatment of the PTSD with traditional psychiatric treatments improved both the PTSD and the systemic infection. Further research is needed to study this link in more detail.
Recent terrorist attacks against the U.S. and the civilized world have resulted in traumatic reactions to many. In addition, to this, there is also the stress of adapting to the chronic threat of international terrorism.
In working with patients directly and indirectly affected by the events of 9/11/01, some trends are apparent. Many of those close to the trauma have suffered horror, grief reactions, acute stress reaction, and adjustment reactions, and some have demonstrated the development of PTSD.
Patients with pre-existing psychiatric illness often had an increase of symptoms, most notably anxiety, panic, phobias, paranoia, depression, acoustic startle, and irritability. From similar events, such as the Pearl Harbor attack or the Holocaust, some PTSD patients had increased PTSD symptoms. A significant number with PTSD or other emotional reactions from some other causes had limited improvement, since they felt the general population could better understand and empathize with their emotional difficulties and they felt less isolated. A number of patients with chronic Lyme disease relapsed, especially those who personally witnessed the event or had direct involvement in the trauma. It appears we may see many relapses of patients with chronic Lyme disease in the wake of the September 11, 2001 tragedy. The patients can be treated with a combination of psychotherapy, psychotropic medications that are effective in treating PTSD (i.e., Paxil, Zoloft, Topamax), and antimicrobial approaches.
Contending with the threat of international terrorism is a separate, but related, issue. Terrorism is “the use of force to threaten, to frighten people, and cause them to obey, especially by a government or political group” (Webster’s). Both violence and terrorism are an unfortunate part of human nature. The degree of violence and magnitude of the attack of September 11 is conducive to causing posttraumatic reaction in many, even those far removed from the actual attack. Many patients with chronic tick-borne disease and the physicians who treat them have prior experience and capability in dealing with more subtle forms of terrorist tactics, which are implemented by some to suppress freedom, access and ethics in the health care system, and suppress the adequate recognition and treatment of tick-borne diseases. The best defense against this threat is many of the same treatments used to combat PTSD. This includes understanding the exact nature and extent of threats, well-focused vigilance and response to threats, and approaches that restore and maintain will, resolve, spirit, courage, self-esteem, and unity.
MENTAL HEALTH AND ILLNESS