By Catherine Dupree
For those who suffer from post-traumatic stress disorder (PTSD), vivid recollections of the horrific events they survived or witnessed — wars, rapes, accidents, injuries, concentration camp internments — often return relentlessly for years, evoking the same fear, helplessness, horror, and consequent anguish that accompanied the initial experience. This creates a disabling cycle that can be difficult, if not impossible, to break.
But encouraging new research suggests that the beta-blocker drug propranolol, by inhibiting the release of certain stress-related hormones, may stop such unwanted memories from being reinforced in our brains. Unlike the creepy device that erases undesirable recalls just like files on a computer in the recent filmEternal Sunshine of the Spotless Mind, propranolol won’t cause PTSD sufferers to forget their ghastly memories, “but it can take out the sting,” says professor of psychiatry Roger K. Pitman.
For a double-blind pilot study published in Biological Psychiatry, Pitman recruited 41 emergency-room patients who had just survived a traumatic event (most were car crashes). Eighteen patients received a 10-day course of oral propranolol; the rest received a placebo. When the patients returned one and three months later for psychometric assessments (like measuring their heart rates while they listened to previously tape-recorded descriptions of the initial event), those who had received propranolol were less likely to show signs of PTSD.
The results are promising for PTSD prevention, which has traditionally been limited to psychological debriefing, a method increasingly regarded as ineffective. And although Pitman is excited about the results, he readily admits propranolol is imperfect, particularly because it exacerbates asthma. (Propranolol, a hypertension drug, is widely marketed as Inderal. It is far from winning approval from the Food and Drug Administration for easing stressful memories.)
The biological reason why we never forget significant experiences involves the amygdala, an almond-shaped portion of the temporal lobe. Highly emotional events stimulate the amygdala to release so-called stress hormones, such as adrenaline, into our hippocampus. These hormones strengthen the recollections, gruesome or lovely, of the events that prompted their release. In PTSD, graphic memories — frequently including flashbacks and nightmares — not only remain intense over time, but are self-perpetuating. Each time a sufferer relives the traumatic experiences, the amygdala re-releases stress hormones into the brain, and consequently reinforces already unwanted memories. But propranolol interferes with the amygdala’s receptors and "takes it off-line," Pitman says. "It blocks the consolidation of memory."
Since the amygdala doesn’t release stress hormones in response to ordinary situations, it’s not surprising we forget where we placed our keys or parked our car. “You are likely to remember in fair detail what you were doing on the morning of September 11, 2001,” says Pitman. “But do you remember what you were doing on the morning of September 10?” This reaction, he maintains, is firmly based in natural selection. “If a primitive hominid decided to take a new route to a watering hole and on her way encountered a crocodile,” he says, “should she fail to remember in the future that a crocodile inhabited that route, she would be more likely to take it again and be eliminated from the gene pool.”
As a society, we place tremendous value on recollection — from court testimonies to cherished reminiscences of childhood — so a drug capable of affecting memory may raise thorny legal and ethical concerns. If, for example, a woman takes propranolol following an assault, is she jeopardizing the validity of future testimony because her memory has been altered? Pitman agrees propranolol could threaten successful prosecutions, but "Medical concerns trump legal concerns," he says. "Would you withhold morphine, which can affect memory, from a mugging victim with broken bones?" He emphasizes that propranolol does not eliminate memories, but allows victims "to maintain a level of memory similar to that of a bystander."
But if propranolol, or drugs like it, become an emergency-room staple, will we soon be tinkering with memories of those experiences that, while painful, serve to define who we are, and teach us valuable lessons? “This is a legitimate ethical concern,” says Pitman. “But it is speculative and I wouldn’t let speculation block the ability to help someone. Most people who have PTSD are so debilitated, they would prefer to have their memories tinkered with.”
If tinkering is to be done, then it must be done quickly. Propranolol must reach the amygdala before a memory has had time to settle in; even 24 hours following trauma may be too late. Pitman has yet to determine the size of “the window of opportunity,” but it will almost certainly be too short for emergency-room doctors to evaluate a patient’s likelihood of developing PTSD (some people, such as those with smaller hippocampi, may be predisposed to the disorder). In other words, if propranolol begins to be routinely prescribed, some percentage of those who receive it may not really need it. “You will have to decide,” Pitman says, “if the damage is worse than the benefit.”
Roger K. Pitman e-mail address:
Source: Harvard Magazine 2004-07