Alcohol-related aggression: New therapies may result from Ohio State study
Department of Psychiatry and Behavioral Health creating tools to help people build resilience through mind-body practices like mindfulness
Anthony King, PhD, studies the neuroscience behind resiliency and the environmental, psychosocial and physiological factors that influence how we adapt to and manage chronic stress and traumatic incidents. He recently joined The Ohio State University Wexner Medical Center’s Department of Psychiatry and Behavioral Health to build and lead a resilience program.
Like existing resilience programs, Ohio State’s program will focus on the important work of sharing known tools and resources with patients. King also plans to create a clinical and translational research-focused academic program to better understand the psychological and physiological processes that underlie successful adaptation and recovery from adversity and trauma.
The program will continue using powerful scientific approaches like functional magnetic resonance imaging (fMRI) brain scanning; measurements of the autonomic nervous system, stress hormone and immune system; and molecular genomics/epigenomics to understand how trauma and stress affect the brain. It also seeks to understand how therapeutic and resiliency tools like mindfulness and other resiliency approaches affect the brain and the specific mechanisms of how they help people to effectively adapt and cope. Ohio State’s resilience program will improve clinical care and education for patients and providers as its research findings grow.
Goals for the program include:
- Identifying and elucidating resilience factors (environmental, psychosocial, neural function, physiological, genomic) and understanding how they work
- Developing new, empirically supported therapeutic and educational approaches based on optimally engaging the target mechanisms they discover
- Formulating appropriate ways to teach proven coping principles, skills and strategies like mind-body, mindfulness and cognitive behavioral therapy (CBT) techniques to the public
- Building support networks to maintain wellness
- Training providers in empirically supported resiliency approaches
“Stress and trauma are ubiquitous — almost unavoidable,” King says. “Everyone experiences stress, and most people also experience some form of trauma in their lifetime. Yet we also know that some populations and people with some conditions are exposed to much higher levels of chronic stress and much more trauma — in early life and throughout the lifespan.”
For example, childhood adverse experiences (ACEs) and childhood trauma can have profound negative effects on mental health and physical health that remain through adulthood. It is therefore hugely important to understand how stress and trauma affect the brain and the nervous system and lead to increased risk, to be able to develop improved treatments, King says.
Yet we also know some people with even the highest level of stress and trauma can show relative positive outcomes in mental and physical health. The program hopes to understand the psychological and neurobiological processes by which people can “metabolize” and adapt to trauma and adversity, and then use this information to develop interventions to cultivate resilience processes.
“There is a beautiful quote from the Most Reverend Desmond Tutu that we reflect on within our team: ‘There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in,’” King says.
“It’s a fairly simple idea,” King says. “Can we provide approaches to cultivate resiliency for people under high levels of stress now — and people who have been exposed to trauma, ACEs and chronic stress throughout their lives — and help to prevent or ameliorate negative mental health impacts?”
In concept, the effort is something all of us can benefit from, especially given our lives during the COVID-19 pandemic, King says. Resiliency can help anyone exposed to trauma from a variety of sources, such as injuries, a psychiatric condition like post-traumatic stress disorder (PTSD), or the stress of cancer treatments or family relationships.
The idea is to work upstream to bring empirically supported, validated skills or techniques, or forms of therapy or education that can help people remain healthy and manage, King says.
NIH funding to understand neuromechanisms behind mindfulness
Much of the program’s work will focus on understanding resilience and how practicing techniques like mindfulness and other mind-body and psychological approaches, like attachment theory and CBT principles, can impact one’s resiliency.
Simply put, we can think of resilience as one’s ability to adapt to adverse situations, such as extreme or chronic stress or trauma, and manage to have relatively good outcomes even in the face of such adversity.
Some people appear to find ways to keep functioning — mentally and physically — during difficult times and/or to recover from traumatic situations relatively sooner than others. For example, in the first days and weeks following a severe trauma, most people experience many of the symptoms of PTSD. After a month, many people have somehow found a process to recover from the trauma and function relatively normally, yet many people continue to experience these symptoms and are then diagnosed with PTSD.
“It is hugely important not to ‘blame the victims’ of adversity and trauma,” King says. “Or to put the onus on people with PTSD or other psychopathology due to their ‘failing to have enough resilience.’”
It is also important to think of resilience as a process, with many different (and potentially modifiable) inputs, modulators and sub-processes, rather than a hard-wired property that one has or does not have, King says. For example, there is no doubt that genetics plays some role in resilience. King’s own lab has found evidence linking genetic variants in the adrenergic system to resilience, but it appears to be a relatively small role.
Vietnam War-era twin studies estimated genetics accounted for about 30% of the variance in who develops PTSD, whereas more recently, much larger molecular genetic studies found much less variance in PTSD risk (about 5% to 20%) accounted for by genetics.
This means at least 70% to 80% of the variance in who develops PTSD versus who is able to recover has to do with other things — likely things like social support; psychosocial and community factors; one’s lifetime history of trauma exposure (or “trauma load”); one’s childhood experiences, level of income and resources; levels of stress and ongoing adversity; formal education, informal learning and understanding; peer relationships; coping strategies; and maybe even things like mindfulness, perspective taking and worldview.
“We do know that some people are somehow able to ‘beat the odds’ and maintain mental health and well-being even when exposed to severe childhood adversity, chronic stress and/or adult traumas,” King says. “What is their secret? How have they been able to do that?”
King’s research into approaches like mindfulness practice, and how it impacts the brain and treatment for trauma and PTSD, is closely linked to understanding resilience. He explores how our brains respond differently to stress and trauma. He wants to know:
- How does stress affect the brain and nervous system and impact behavior?
- Can we identify the processes involved in “naturalistic” resilience, and can we use these to develop more efficient and effective psychotherapies?
- Might we also use these same principles in interventions or educational programs for stressed and traumatized people to cultivate resilience and prevent psychopathology?
King leads several studies funded by the National Institutes of Health (NIH) to understand how PTSD affects the brain and how effective treatments work.
People with PTSD live with overactive threat signals from their nervous systems that drive changes in sleep, mood, concentration and the ability to maintain good relationships. Different forms of psychotherapy can make a big difference for those with PTSD.
“Trauma exposure” treatments are based on the idea of extinction of conditioned fear learning, and these can be highly effective for patients who stick to it. The treatment can also be arduous for patients and have high refusal and dropout rates.
Various forms of cognitive behavioral therapy have also been shown to improve PTSD symptoms. There is growing evidence that mind-body treatments with mindfulness practice can also help PTSD, and King’s group has performed some of the first clinical trials and the first neuroimaging studies of mindfulness-based approaches for PTSD.
Other forms of psychotherapy, like CBT and psychodynamic therapy, can also include aspects similar to mindfulness, referred to as metacognition, mentalizing, decentering and reflective capacity.
“We don’t know exactly what makes each therapy work, so we need information on the neural mechanisms that lead to targets that can help us become more efficient,” King says.
Each treatment is different, and each may access different neural mechanisms. If so, researchers might be able to design interventions that combine neural mechanisms for maximal efficacy and efficiency. It is also clearly the case that “one size does not fit all” in trauma recovery, and it is likely that some approaches are particularly useful for some people. Knowing how to best match patients with the best treatment is essential in providing personalized medicine in mental health.
One of King’s NIH projects uses a randomized controlled trial (RCT) to compare mindfulness-based cognitive therapy (MBCT) to an older form of therapy called progressive muscular relaxation (PMR). PMR trains patients in relaxation but does not have specific instructions in mindfulness. The study uses fMRI before and after the eight-week treatments to track brain changes in large-scale connectivity networks using cutting-edge analytic techniques to study effects of mindfulness in PTSD patients at the whole-brain level.
Another NIH project is in the “proof of principle” stage. It also uses an RCT with MBCT in PTSD patients to determine if mindfulness treatment leads to an increase in connectivity between two specific brain regions: the posterior cingulate cortex (PCC) — a midline brain structure that is part of the “default mode network” — and the dorsolateral prefrontal cortex (DLPFC) — a frontal lobe area in the central executive network involved in several aspects of higher-order executive function. If this project shows significant results, King could receive an additional three years of NIH funding.
King has done previous clinical Department of Defense-funded neuroscience research in Veterans Affairs (VA) hospitals to study treatments provided to combat veterans living with PTSD. This research includes comparing MBCT to a common form of group talk therapy developed by the VA called present centered therapy. His work shows that mindfulness therapies build greater connectivity in the brain between “midline” brain circuits involved in spontaneous thinking/mind-wandering and the frontal lobe circuits involved in executive function that can control how we respond to aversive thoughts, memories and emotions.
When someone without PTSD is at rest, they tend to engage in spontaneous thinking about innocuous things like the weather, what to make for dinner or plans for an upcoming event. When a person with PTSD is at rest, their spontaneous thoughts tend toward continuous heightened sense of alertness to unseen threats in the environment and often intrusive memories reliving their trauma — either in response to a “trigger” or out of the blue. This is one reason some people with PTSD try to keep themselves continuously busy to avoid getting caught by fearful thoughts and traumatic memories. This pattern can be exhausting and debilitating.
King’s research suggests that the stronger connectivity between the midline and frontal brain networks built through mindfulness training may help calm that PTSD response.
The pilot study was limited to male military veterans and took four years. Now King wants to expand this work to include both sexes, military veterans and first responders or “protector professionals” (like firefighters, police, emergency medical technicians, etc.) who have been exposed to trauma in the course of duty, as well as members of the broader community exposed to interpersonal violence trauma.
Implementing research findings
King wants to use what he learns through research to generate treatment or resilience targets and appropriate training and interventions.
Brain imaging can reveal the active processes that occur in the brain when people are exposed to chronic stress or trauma. Those images, combined with other factors about a person’s response to stress and trauma, can lead to more effective trainings and treatments.
“We know that someone with low income/in poverty likely lives with a number of kinds of measurable chronic stressors, and that can lead to an overreactive brain and nervous system threat responses that drive increased adrenaline, which can lead eventually to the wear-down of the threat response and immune function and physical health issues,” King says.
At the same time, there are many existing treatments known to bring positive benefits and therapy principles that could be introduced to the public. King says efforts are underway to validate those techniques and align them with resilience pathways.
He cites the social emotional learning concepts taught to school students. Children learn about emotions and relationships and find ways to manage their feelings.
Similar learning opportunities can be created for adults exposed to adversity, chronic stress and trauma, King says, to help people manage stressful and traumatic situations and avoid self-medication that can lead to substance abuse.
People can learn to recognize when stress, tension and irritability are reaching high levels and act before the situation weighs them down or they go into depression.
King hopes to create processes that provide resources to others, teach coping skills and offer a variety of social supports.
“If it is true that there is something called resilience, we need to understand how to develop and validate effective forms of training and interventions to cultivate and strengthen that resilience response,” King says. “We want to provide techniques and approaches to the general public or those under high levels of stress.”
Preparing for the future
Ohio State’s strong core of clinical translational researchers in psychiatry lured King away from the University of Michigan. He’s impressed by the level of support, collaboration among colleagues and research directly geared toward understanding clinical conditions like anxiety, depression and PTSD.
In the future, King envisions the possibility of creating emotional regulation tools to help manage stress, trauma or chronic pain, and therapies that can build and maintain resiliency over time.
“Do any of the things that we know are helpful in therapy, can they help with prevention and provide a path to resilience and wellness, even in the face of various forms of adversity?” King asks.
For example, King says that we know mindfulness used in mindfulness-based cognitive therapy does help decrease depression relapse. Now he wants to find out — academically, clinically and scientifically — if we can train people for the future and give them tools they can use.
This concept can also play into a better understanding of social determinants of health, especially among those living in poverty. King wants to understand how exposure to chronic stress from noise, overcrowding, pollution or racial discrimination impact the brain and mind, and ways to ameliorate those negative effects.
“We will be stressed, and we will experience adversity,” King says. “We have interventions that I do believe build resilience. We can get there with a focus on wellness and helping people find the best ways for them to cope with adversity and stress in chronic forms or trauma.”
