Staff Perspective: Stellate ganglion block for PTSD
As clinicians who veterans and active service members, many of us see residual symptoms following successful treatment. We have patients who have successfully completed exposure treatment who were very capable of rehearsing their traumas and reducing their anxiety, yet some of them continue to show stubborn residual agitation. Their stories have become more coherent as they work through successive exposures, they progress through in vivo experiences, and their functioning improves. Their description sounds like their baseline anxiety level has gone from 3 to 5.
This was the case with treatment with a 28 year old infantry soldier, we had dutifully completed a full course of exposure treatment. He was a hardworking and careful patient that completed almost every homework assignment. Yet despite this he still seemed to carry the hyperarousal symptoms. He would make it through the exposures, staying at the crowded mall for the required amount of time. Yet he had this residual arousal that bothered him and impaired his focus.
Together, we began researching alternative therapies. We began looking into mindfulness based stress reduction which was just beginning to show effectiveness with veterans. I was learning the same time I was teaching and while he was grateful for the progress, he was still nagged by his symptoms. He was leaving the service soon and returning to college. He wanted to make sure he had the same focus he had when he attended college prior to his service.
A couple of weeks into this he called me up out of the blue to tell me he was going to get an experimental procedure done for his symptoms. A Stellate Ganglion Block (SGB).
The Stellate Ganglion
The stellate ganglion is a bundle of nerves in the neck that is the intersection of several systems in the body including sensation and muscle tone in the face and arms. It is also connected with pathways associated with stress and arousal.
Stellate ganglion block is a simple outpatient procedure that involves the injection of a local anesthetic through the front of the neck at the C6 spine level into the bundle of nerves in the neck. Typically a patient will receive 1 or 2 injections with various time intervals between.
Anecdotally, many patients report that the result is dramatic and immediate. Their hyperarousal drops off and I have even heard grand claims of a miracle cure. My brigade surgeon once gloated that “we will be putting the psychologists out of business with this.”
While these results are dramatic. These studies are case studies. We don’t have the randomized, placebo-controlled trials that conclusively establish this as an evidence-based practice. There are also some questions about the mechanism of action. There are several of these studies in progress right now so within the next couple of years we will hear more about it. The very first report from these randomized, placebo-controlled studies (in a brief poster presentation) showed no separation between the placebo and active group. These results are preliminary, however, and don’t represent the complete study.
http://www.painmed.org/2015posters/abstract-126/
The Malaria Connection?
In my very first week in the military, I was taught that disease and illness usually lead to more casualties than combat. The military is always looking for ways to reduce the impact of illness on their service members in order to keep them in the fight. During the civil war, the bloodiest American war, two soldiers died from disease for every one soldier who was killed in combat. In WWII alone there were over 3 Million sick-days due to malaria.
Quinine has been used for close to two centuries to prevent malaria infection. It is an ingredient in Tonic water. Even the name tonic suggests a medicinal origin. The British drank tonic water in tropical areas to prevent Malaria. Its taste was so bitter that soldiers began mixing it with sugar, soda and alcohol birthing classic alcohol mixed drinks.
Quinine and mefloquine have known psychiatric side effects that range from nightmares and depression to actual paranoia and hallucinations. This has led to questions about the interaction of meflaquine with trauma exposure. The Military and DoD have even published warnings advising against mefloquine use in large military deployments where individual providers will not have eyes on each patient.
My SGB patient reported that he noticed a sharp increase in arousal during the two weeks leading up to second deployment. He had previous combat stress symptoms, but was hit dramatically right before his second deployment. As we progressed through therapy, this was something that he always attributed to anticipation of combat. He would also become preoccupied with how his symptoms “turned on” and how he needed to “turn it off.” With reflection I am struck with how closely his “two week” time frame maps on to standard mefloquine prescription prior to deployment.
Many physicians were aware of the concern with this class of medications even before the CDC and military warnings. When I was deployed, I began vomiting daily from the interaction between food and my daily malaria prophalxis (Doxycycline). I was truly miserable and begged my doctor for something else. He was very wary about switching me to mefloquine because of the known psychiatric side effects. He agreed to a short-term trial as long as I agreed to regular monitoring. When I returned a week later without any symptoms we continued the medication for the remainder of my deployment. Others have found that vivid dreams and mood side effects are too uncomfortable.
The interesting twist in the story is that there are studies over 50 years old that used SGB to treat quinine complications.
Future Directions
At this point, mefloquine, PTSD and SGB make for an intriguing story. This treatment remains an interesting direction for more research. The dramatic results in these pilot studies are sure to get people excited and further well-controlled studies may demonstrate its usefulness. Understanding any possible link between quinine medications and psychiatric symptoms could potentially broaden our understanding of what leads a deployed soldier to return with PTSD or why combat PTSD may be different than other forms of PTSD. At this time, it is important to remember that this procedure is still experimental for PTSD.
Michael Jones, Ph.D., is a deployment behavioral health psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He is located at the Madigan Army Medical Center in Tacoma, Washington. He is a veteran of the United States Air Force and received his doctorate in clinical psychology from Brigham Young University in Provo, Utah.
As clinicians who veterans and active service members, many of us see residual symptoms following successful treatment. We have patients who have successfully completed exposure treatment who were very capable of rehearsing their traumas and reducing their anxiety, yet some of them continue to show stubborn residual agitation. Their stories have become more coherent as they work through successive exposures, they progress through in vivo experiences, and their functioning improves. Their description sounds like their baseline anxiety level has gone from 3 to 5.
This was the case with treatment with a 28 year old infantry soldier, we had dutifully completed a full course of exposure treatment. He was a hardworking and careful patient that completed almost every homework assignment. Yet despite this he still seemed to carry the hyperarousal symptoms. He would make it through the exposures, staying at the crowded mall for the required amount of time. Yet he had this residual arousal that bothered him and impaired his focus.
Together, we began researching alternative therapies. We began looking into mindfulness based stress reduction which was just beginning to show effectiveness with veterans. I was learning the same time I was teaching and while he was grateful for the progress, he was still nagged by his symptoms. He was leaving the service soon and returning to college. He wanted to make sure he had the same focus he had when he attended college prior to his service.
A couple of weeks into this he called me up out of the blue to tell me he was going to get an experimental procedure done for his symptoms. A Stellate Ganglion Block (SGB).
The Stellate Ganglion
The stellate ganglion is a bundle of nerves in the neck that is the intersection of several systems in the body including sensation and muscle tone in the face and arms. It is also connected with pathways associated with stress and arousal.
Stellate ganglion block is a simple outpatient procedure that involves the injection of a local anesthetic through the front of the neck at the C6 spine level into the bundle of nerves in the neck. Typically a patient will receive 1 or 2 injections with various time intervals between.
Anecdotally, many patients report that the result is dramatic and immediate. Their hyperarousal drops off and I have even heard grand claims of a miracle cure. My brigade surgeon once gloated that “we will be putting the psychologists out of business with this.”
While these results are dramatic. These studies are case studies. We don’t have the randomized, placebo-controlled trials that conclusively establish this as an evidence-based practice. There are also some questions about the mechanism of action. There are several of these studies in progress right now so within the next couple of years we will hear more about it. The very first report from these randomized, placebo-controlled studies (in a brief poster presentation) showed no separation between the placebo and active group. These results are preliminary, however, and don’t represent the complete study.
http://www.painmed.org/2015posters/abstract-126/
The Malaria Connection?
In my very first week in the military, I was taught that disease and illness usually lead to more casualties than combat. The military is always looking for ways to reduce the impact of illness on their service members in order to keep them in the fight. During the civil war, the bloodiest American war, two soldiers died from disease for every one soldier who was killed in combat. In WWII alone there were over 3 Million sick-days due to malaria.
Quinine has been used for close to two centuries to prevent malaria infection. It is an ingredient in Tonic water. Even the name tonic suggests a medicinal origin. The British drank tonic water in tropical areas to prevent Malaria. Its taste was so bitter that soldiers began mixing it with sugar, soda and alcohol birthing classic alcohol mixed drinks.
Quinine and mefloquine have known psychiatric side effects that range from nightmares and depression to actual paranoia and hallucinations. This has led to questions about the interaction of meflaquine with trauma exposure. The Military and DoD have even published warnings advising against mefloquine use in large military deployments where individual providers will not have eyes on each patient.
My SGB patient reported that he noticed a sharp increase in arousal during the two weeks leading up to second deployment. He had previous combat stress symptoms, but was hit dramatically right before his second deployment. As we progressed through therapy, this was something that he always attributed to anticipation of combat. He would also become preoccupied with how his symptoms “turned on” and how he needed to “turn it off.” With reflection I am struck with how closely his “two week” time frame maps on to standard mefloquine prescription prior to deployment.
Many physicians were aware of the concern with this class of medications even before the CDC and military warnings. When I was deployed, I began vomiting daily from the interaction between food and my daily malaria prophalxis (Doxycycline). I was truly miserable and begged my doctor for something else. He was very wary about switching me to mefloquine because of the known psychiatric side effects. He agreed to a short-term trial as long as I agreed to regular monitoring. When I returned a week later without any symptoms we continued the medication for the remainder of my deployment. Others have found that vivid dreams and mood side effects are too uncomfortable.
The interesting twist in the story is that there are studies over 50 years old that used SGB to treat quinine complications.
Future Directions
At this point, mefloquine, PTSD and SGB make for an intriguing story. This treatment remains an interesting direction for more research. The dramatic results in these pilot studies are sure to get people excited and further well-controlled studies may demonstrate its usefulness. Understanding any possible link between quinine medications and psychiatric symptoms could potentially broaden our understanding of what leads a deployed soldier to return with PTSD or why combat PTSD may be different than other forms of PTSD. At this time, it is important to remember that this procedure is still experimental for PTSD.
Michael Jones, Ph.D., is a deployment behavioral health psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He is located at the Madigan Army Medical Center in Tacoma, Washington. He is a veteran of the United States Air Force and received his doctorate in clinical psychology from Brigham Young University in Provo, Utah.