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Center for the Study of Traumatic Stress 2008 Annual Report Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. 1. REPORT DATE 3. DATES COVERED 2008 2. REPORT TYPE 00-00-2008 to 00-00-2008 4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER Center for the Study of Traumatic Stress 2008 Annual Report 5b. GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 6. AUTHOR(S) 5d. PROJECT NUMBER 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATION Center for the Study of Traumatic Stress (CSTS), , , , REPORT NUMBER 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSOR/MONITOR’S ACRONYM(S) 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF 18. NUMBER 19a. NAME OF ABSTRACT OF PAGES RESPONSIBLE PERSON a. REPORT b. ABSTRACT c. THIS PAGE Same as 28 unclassified unclassified unclassified Report (SAR) Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18 The Center for the Study of Traumatic Stress has uniquely bridged the fields of disaster and military psychiatry. Our work integrates principles of disaster preparedness, response and recovery to foster individual, community, organizational and public health. Acknowledgements The Center for the Study of Traumatic Stress (CSTS) would like to acknowledge and thank each of these organizations for their continued support, guidance, and leadership throughout the past year. ■■ Uniformed Services University of the Health Sciences ■■ Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury ■■ The Henry M. Jackson Foundation for the Advancement of Military Medicine ■■ The National Center for PTSD ■■ Deployment Health Clinical Center ■■ Army Community Service ■■ CSTS Scientific Advisory Board ! Director’s Message 1 Message from the Director Dear Colleagues and Friends, amongst military families in times of war. The Center with its collaborative networks is at the This Annual Report marks our Center’s forefront in examining the neuroscience of post- completion of 20 years of dedicated service to traumatic stress disorder in the human brain Uniformed Services University of the Health and to have confirmed its findings in animal Sciences, the Department of Defense, and our models. Through the Center’s cutting edge nation in advancing trauma knowledge and research, understanding of community variables trauma-informed care. The Center for the that contribute to resilience and recovery in the Study of Traumatic Stress (CSTS) continues to face of disaster and the neuroscience of post- grow and expand its research, education and traumatic stress disorder are closer to our grasp. consultation in the domains of disaster psychiatry, the neuroscience of traumatic stress, This year the Center became a component center understanding and support of first responders, of the Defense Centers of Excellence (DCoE) and care of our nation’s soldiers, sailors, air- for Psychological Health and Traumatic Brain man and marines who experience high stress Injury institutionalizing the Center as the lead- operations on behalf of national security. ing academic arm and source of knowledge around traumatic stress. The Center continues Through domestic disasters that endanger civil- to focus on the horizon and to identify new ian communities and engage the support of our and critical issues for the science and care of military, the Center has uniquely bridged the those exposed to war, traumatic events and fields of disaster and military psychiatry. Our disasters. We invite you to read about our work integrates principles of disaster prepared- work in more depth in the following pages. ness, response and recovery to foster individual, community, organizational and public health. Robert J. Ursano, M.D. Professor and Chairman The Center has been and continues to be a pio- Department of Psychiatry neer in generating and disseminating knowledge Uniformed Services University to mitigate the impact of disaster and trauma Director, Center for the Study exposure. Through the Center’s involvement and of Traumatic Stress leadership with renowned disaster experts, the arsenal of early intervention for disaster now The Center for the Study of Traumatic Stress (CSTS) continues to grow and includes Psychological First Aid. The Center was expand its research, education and consultation in the domains of disaster the first to inform the Department of Defense and the nation about stress exposure to the dead psychiatry, the neuroscience of traumatic stress, understanding and support of and body recovery essential in the aftermath of first responders, and care of our nation’s soldiers, sailors, airman and marines serious trauma. Center scientists were the first to identify trends of escalation in child neglect who experience high stress operations on behalf of national security. 2 About CSTS The Center for the Study of Traumatic Stress Overview As part of the USU Department of Psychiatry, “Disasters are a prominent part of our history the Center conducts translational research and will be a part of our future. From gene to in neuroscience examining the neurobiology protein, cell to organ, and individual to group, of brain structure using animal and human the complexity of human responses to disaster models to inform prevention of and treatments trauma is profound. Understanding both indi- for serious stress disorders such as posttrau- vidual and community mental health responses matic stress disorder (PTSD). PTSD is a sig- to disasters is critical to developing and planning nature illness of our nation’s war on terrorism, for post disaster interventions across the biologi- and a serious mental disorder affecting many cal, psychological, and sociocultural levels.” individuals exposed to trauma in the civilian population. Center scientists provide consulta- —Robert J. Ursano, MD tion to military leadership and the military Textbook of Disaster Psychiatry, 2007 healthcare system around the impact and treatment of traumatic stress and the stress and The Center for the Study of Traumatic Stress health consequences of deployment and com- (CSTS) is one of the nation’s oldest and most bat injury on service members, their families highly regarded, academic-based organizations and children. This work fosters psychological dedicated to advancing trauma-informed knowl- health and strength in the military community. edge, leadership and methodologies. The Center’s work addresses a wide scope of trauma exposure A unique aspect and contribution of the Center from the consequences of combat, operations is the bridging of military and disaster psychia- other than war, terrorism, natural and human- try and the integration of disaster mental health made disasters, and public health threats. CSTS and public health. In applying the principles is a part of our nation’s federal medical school, and practices for dealing with individuals and groups exposed to extreme environments in PTSD is a signature illness of our nation’s war on terrorism, and a serious mental the military, the Center has generated and disorder affecting many individuals exposed to trauma in the civilian population. disseminated its subject matter expertise to inform disaster preparedness, response and Uniformed Services University (USU), and its recovery principles and practices across a wide Department of Psychiatry, as well as a partnering range of traumatic events and populations. center of the newly established Defense Centers Today and into the future, the Center is uniquely of Excellence (DCoE) for Psychological Health positioned to respond to DoD mission rel- and Traumatic Brain Injury. These affiliations evant activities and issues, especially those of represent the Center’s history, mission and future the DCoE, as well as to educate regional and directions as a major contributor to our coun- national stakeholders in government, industry, try’s understanding of the impact of trauma and healthcare, public health, and academia on miti- the advancement of trauma-informed care. About CSTS 3 gating the effects of disaster and trauma in the In response to the events of 9/11, CSTS was in- civilian community to foster human continu- strumental in educating leadership at the federal, ity and community and national resilience. state and local level about individual and community responses to terrorism. This knowledge History drew upon the Center’s early work in the psycho- The Center was established in 1987, as a center logical and behavioral implications of exposure of excellence for responding to the long-term to WMD. The Center expanded its research to concerns of the Department of Defense over encompass workplace preparedness for terrorism In response to the the substantial health risks resulting from the and disaster, and provided consultation to the traumatic impact of: 1) the possibility, or actual U.S. Senate, the U.S. House of Representatives, events of 9/11, CSTS was use, of weapons of mass destruction (WMD) the U.S. Department of State, the U.S. Depart- instrumental in educating during combat, acts of terrorism or hostage ment of Transportation, a number of Fortune 100 events; 2) combat, peacemaking, peacekeep- corporations, and numerous government leaders. leadership at the federal, ing, and operations other than war; 3) natural The Center’s Director, Robert J. Ursano, M.D., state and local level about disasters such as hurricanes, tornadoes, or was part of an Institute of Medicine committee floods; and, 4) more common stress produc- that authored an influential report and publica- individual and community ing events such as physical assaults and motor tion, Preparing for the Psychological Consequences responses to terrorism. vehicle, shipboard, or airplane accidents in of Terrorism. This book recommended the inte- both the uniformed and civilian communities. gration of disaster response principles into the public health arena with significant implications Prior to Desert Storm, the Center pioneered around medical and healthcare preparedness research on exposure to WMD through its and response to large-scale disasters includ- work in Air Force simulation exercises dealing public health threats such as a pandemic. ing with chemical and biological terrorism. This early work generated an unprecedented body of research, including a database that currently consists of more than 20,000 articles on the psychological, social and behavioral manifestations of exposure to traumatic events. These inferences include mental health responses ranging from resilience to psychiatric illness such as post-traumatic stress disorder, acute stress disorder, and depression. In the 1990s the Center made major contributions to the newly emerging field of disaster mental health and psychiatry. The Center published a landmark book, one of the most scholarly and comprehensive of its time, Indi- vidual and Community Responses to Trauma and Disaster. This book and the Center’s work on the effects of trauma on first responders helped shape the landscape of disaster and trauma research, education and consultation. 4 About CSTS Since the start of the war on terrorism, the Health and Traumatic Brain Injury, the Center Center has generated and disseminated knowl- is positioned to contribute to the improved edge on the effects of deployment and combat on psychological health and strength of the military soldiers, sailors, airmen and marines and their community through its cutting edge research families. The Center has galvanized nationally in neuroscience and as a knowledge center for renowned academics and medical leadership as the psychological implications of combat and well as its own subject matter experts to contrib- service to our nation. The Center’s Director, ute to new areas of trauma need, such as the im- Robert J. Ursano, M.D., Professor and Chairman pact of combat injury on military healthcare pro- of USU Department of Psychiatry, is internation- viders, service members, their families and chil- ally regarded for his academic contributions in dren. The Center has also mobilized its existing the fields of trauma prevention and care, and resources to examine the prevalence of deploy- his leadership in bridging the principles and ment-related family violence, child maltreatment practice of military and disaster psychiatry and neglect that has escalated in the military to strengthen our nation’s health and public community since the start of the war on terror. health planning and response to local, regional and national disasters and traumatic events. The Center is positioned Concomitant with the Center’s advances and to contribute to the involvement in military psychiatry, the Center The Center: published in 2007 a landmark book, Textbook psychological health and ■■ Develops and carries out research programs of Disaster Psychiatry. This project, the first strength of the military to extend our knowledge of the medical book to focus specifically on disaster psychiatry, community as a knowledge brought together Center colleagues in trauma and psychiatric consequences of war, center for the psychological and disaster from around the globe to provide deployment, trauma, disaster and terrorism, implications of combat a comprehensive review of the psychological, including weapons of mass destruction. and service to our nation. biological and social responses to disaster. ■■ Educates and trains health care providers, leaders, individuals and public and private Now a component center of the Defense Cen- agencies on how to prevent, mitigate and ters of Excellence (DCoE) on Psychological respond to the negative consequences of war, deployment, traumatic events, disasters, and terrorism. ■■ Consults with private and government agencies on medical care of trauma victims, their families and communities, and their recovery following traumatic events, disasters and terrorism. ■■ Maintains an archive on medical literature related to the health consequences of traumatic events, disasters and terrorism of individuals, families, organizations, and communities. ■■ Provides opportunities for post-doctoral training of medical scientists to respond to and research the health consequences of trauma, disaster, and terrorism. About CSTS 5 CSTS Organizational Structure The Center funds the majority of its research Approximately forty scientists represent- through extramural grants and funding from ing multiple disciplines staff the CSTS. These a wide range of organizations. The Director of disciplines include psychiatry, military and the Center, Robert J. Ursano, M.D., has overall disaster psychiatry, social and organizational responsibility for Center function, science and psychology, neuroscience, research design and fiscal activities. Six Associate Directors oversee statistics, social work, risk communication and the Center’s Scientific Research; Public Education public health communication. The Center grows and Preparedness; Health Care System Education; its activities through cross-disciplinary research, Child and Family Program; Consultation and CSTS disciplines include teamwork and collaborations to respond rapidly Military Psychiatry; Homeland Security Stud- psychiatry, military and to research and education needs. The Center ies; and, Information Systems and Operations. provides real-time consultation (consulta- disaster psychiatry, The Center moved its major location in 2007 from tion at the time of or immediately following the National Naval Medical Center to the North social and organizational a traumatic event) and just-in-time educa- Campus of USUHS located on Rockledge Drive tion (knowledge dissemination at the time of psychology, neuroscience, in Bethesda, Maryland. Neuroscience laboratories a traumatic incident in the form of electronic are located on the main campus of USUHS. The research design and fact sheets) for critical events that face DoD and CSTS has a Scientific Advisory Board composed the Nation. The Center has been involved in statistics, social work, risk of distinguished scientists and national and inter- nearly every large scale disaster the nation has national trauma experts who provide their coun- communication and public faced in the past 25 years, through its educa- sel and perspective to the Center (see page 21). tion, research and consultation activities. health communication. 6 Neuroscience and Neurobiology Research in Neuroscience and Neurobiology “We directly apply our basic research in neu- Center of Excellence (DCoE) for Psychological roscience and neurobiology to inform clinical Health and Traumatic Brain Injury, the Cen- interventions for posttraumatic stress disorder ter’s research in neuroscience and neurobiol- diagnosis and treatment. The Center’s trans- ogy is focused on solving issues of health and lational research model — from bench to performance to optimize the psychological bedside to bench — helps us respond to those health and resilience of the military com- on the battlefield, as well as those exposed munity and the public health of our nation. to natural and human made disasters rang- Stress, especially the extreme stress of traumatic ing from automobile accidents to terrorism.” events encountered in combat, can permanently —He Li, MD, PhD alter brain neurobiology. Posttraumatic stress Associate Professor disorder (PTSD) represents a serious, poten- USU Department of Psychiatry tially disabling and highly prevalent health consequence of deployment to Iraq and Af- The Center conducts pioneering, translational ghanistan since the start of the war on terrorism. research in neuroscience that addresses the Pharmacological prevention and treatment of brain related prevention, onset and recovery stress-related disorders such as posttraumatic elements of the neurobiology of trauma- re- stress disorder (PTSD) is a topic of significant lated exposures. As part of the Department medical interest. The Center’s neuroscientific of Psychiatry of our nation’s military medical research from July 2007 through July 2008 school, and a partnering center of the Defense has made major contributions in this arena. Building upon numerous years of prior research, Center neuroscientists have discovered two new critical paths in the neurobiology of posttraumatic stress disorder (PTSD). These discoveries may lead to new treatments and diagnostic tools for PTSD. The CSTS and its collaborators, using new neurobiologic methodologies have identified the important function of a new gene and protein (p11) and a cellular component (the mitochondria) in PTSD. The studies represent collaborations of CSTS scientists and leading academic and research institutions including the National Center for PTSD of the Department of Veterans Affairs, Stanley Medical Research Institute, National Institute of Mental Health, Yale University and the George Washington Neuroscience and Neurobiology 7 University School of Medicine. The collabo- for understanding and treating PTSD: 1) the rators work together as the Traumatic Stress level of p11 may be a biomarker for diagnos- Brain Study Group (TSBSG), a unique scientific ing PTSD, as well as for differentiating PTSD initiative with access to the world’s first and from depression; 2) the identification of three only Brain Bank that collects and examines glucocorticoid receptor-binding sites suggests a post-mortem brain tissue of PTSD patients. therapeutic target for development of clinical interventions to block or alter p11 levels for PTSD The first study (Zhang et al., 2008) identified prevention and treatment; and, 3) the presence a potential biomarker for PTSD, a protein and of p11 in tissue and therefore blood may lead to its associated gene known as p11. This finding PTSD screening and monitoring for purposes has significant implications for posttraumatic of disease prediction, diagnosis, and prognosis. stress disorder (PTSD) diagnosis and treatment since it was discovered in both animal In another area of work, two important research models and human PTSD brain tissue. Biomark- projects involving Center scientists Dr. H Li and ers are increasingly used to diagnose diseases L Zhang are being carried out in collaboration a promptly and accurately, to identify individuals with George Washington University and have at high-risk for certain diseases and to fol- resulted in the submission of two patent applica- low the course of treatment. In the absence of tions. The Su et al. study (2008) identified PTSD- PFC area 46 clinical biomarkers for PTSD, diagnosis has specific gene targets with implications for PTSD b bcmleiinesnsice dadle, psmyeminsddpaitaongmtn oson.s Theodne lasyne t dhs/yeom ra splseteftosm sumsn tearnreeta ooteftfd e nin dThale gtiesec nstteiuosd nuy,s diwniaaggs h ntuhomes ifisa,nr ps tpr etoovs ete-nxmtaimoonrit neamen dm b tirrtaoeiacnth mtoisnesndutre.i - mRNA (p11/beta actin) --12345 * thousands of affected individuals (military and from individuals diagnosed with PTSD. Mito- p11 0 Control PTSD civilian), thus disrupting the quality of their chondria are the principal energy source of cells lives and the lives of their families and children. that convert nutrients into energy. Mitochondrial p11 mRNA expression in postmor- dysfunctions are increasingly recognized as tem PFC is significantly increased in The Zhang et al. study was the first to use human possible key components in stress related mental patients with PTSD compared to age- post-mortem brain tissue from individuals who disorders. The molecular markers associated and sex-matched controls. (a) A per- had PTSD. Researchers discovered that p11 (a with mitochondrial functions underlying the spective of the human brain to locate protein present in all individuals) decreased pathogenesis of PTSD are poorly understood. area 46 in the prefrontal cortex (PFC). in patients with depression, a condition often Lack of such detailed knowledge greatly ham- (b) P11 mRNA in PFC (area 46) is co-morbid with PTSD, but the new findings pers the development of effective therapeutic significantly greater in PTSD patients from CSTS scientists indicated it is increased approaches to prevent as well as to treat PTSD. at postmortem compared to age-and in patients with PTSD. CSTS scientists further sex –matched controls (n=6 per discovered a possible molecular mechanism Using a 3rd generation mitochondria gene group, 2 cases died of suicide and 4 that could explain the increase of p11 in PTSD chip containing 1,159 genes, researchers ex- died of other causes in PTSD group). and the decrease of p11 in depression. Using amined gene changes in the brain tissue of six Data are shown as means +/- SEM, state of the art techniques of molecular biol- post mortem PTSD patients against a control *p<0.05 (control vs PTSD) and have ogy, they found that three glucocorticoid (stress group of six well matched post mortem control been analyzed by the student’s t test. hormones) receptor-binding sites reside in the subjects without PTSD. Results revealed specific human p11 gene. These sites may regulate p11 gene expression patterns that distinguished the gene expression and p11 levels via their interac- PTSD patients from the control subjects. These tion with stress hormones in PTSD patients. gene changes could serve as a biomarker for PTSD diagnosis as well as a therapeutic target This research area has significant implications