What is SGB?

What is SGB?

PTSD: A Lay of the Land

To understand how an injection can be beneficial to individuals living with Posttraumatic Stress Disorder (PTSD), we must first understand a little about the anatomy of PTSD.

When a person experiences a traumatic event, they were rendered unable to prevent the event. (The importance of being rendered unable and/or ineffective in PTSD is covered in Dr. van der Kolk’s book, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma.) Simultaneously, the limbic system in the brain activates (i.e., the part of the brain responsible for emotions and memories – to include the fight-flight-freeze response), which results in a variety of physiological changes.

When a person is chronically living with PTSD, their limbic system (and its responses) is hyperactive and hypersensitive. In other words, it’s like running a car at 8,000 rpm and like having a car that jolts to 100 mph with the slightest tap on the accelerator. Once you’ve lived through and have been unable to prevent a traumatic event, your brain may conclude that it has to be hyper-alert and ready to roll at any minute.

Living with a hyperactive and hypersensitive limbic system can keep people on edge, make them irritable, and impact various organ systems in the body. Dr. Henrie describes these limbic system changes as akin to having a threat management radar set on hypersensitive: “The threat-management radar of the average person is set at a specificity level to immediately detect clear and overt threat – like the radar-equivalent of a missile. A person with PTSD, however, has the sensitivity of their threat-management radar turned up as high as it will go. They’re no longer just detecting missiles. They’re detecting mosquitos.” (Read more at: http://www.desertwise.com/the-invisible-creep-of-ptsd/)

Many traditional psychotherapies for PTSD overlook the importance of limbic system alterations in PTSD. Some therapists may tell you to challenge your thoughts or beliefs. Others may flood you with memories of your trauma in an attempt to desensitize you to traumatic content. And so on. But how is a person supposed to live with high doses of adrenaline coursing through their body on a routine basis? And how could anyone expect them to function optimally with those contingencies?

This is the very problem that SGB targets. Effective SGB injections calm the limbic system – attempting to return it to normative functioning, so the individual with PTSD is more comfortable and more in control of their responses to both stress and surprise. This also enables the individual to more fully participate in psychotherapy, which can then focus on improved functioning in relationships, healthier self-concepts, and adaptability across a variety of settings.

For additional information on the physiology and output of PTSD, we encourage you to check out our free handouts:

 

 

 

 

What is the stellate ganglion?

 

Anatomical structure/location of the stellate ganglion

Stellate ganglion’s relation to sympathetic nervous system (fight or flight)

  • “The sympathetic nervous system directs the body’s rapid involuntary response to dangerous or stressful situations. A flash flood of hormones boosts the body’s alertness and heart rate, sending extra blood to the muscles. Breathing quickens, delivering fresh oxygen to the brain, and an infusion of glucose is shot into the bloodstream for a quick energy boost. This response occurs so quickly that people often don’t realize it’s taken place, according to Harvard Medical School. For instance, a person may jump from the path of a falling tree before they fully register that it’s toppling toward them.” (Source: Live Science)
  • As described in the sections above, the stellate ganglion connects directly to the sympathetic nervous system, which is responsible for the fight-flight-freeze response. Thus, the stellate ganglion is a ready entry point to targeting the part of the nervous system that keeps individuals with PTSD keyed up.
The stellate ganglion block and its history

 

The SGB injection/procedure

 

SGB risks and side effects

Note:

  1. When reading about side effects (SE) of SGB, we recommend you look at the total SGB literature – not just SGB for PTSD, as it’s the same procedure – but SGB was around long before its use for PTSD. This gives the medical world a much more robust view of potential SEs.
  2. Be careful to distinguish potential SEs when the SGB is administered with use of imaging (e.g., ultrasound, x-ray) vs. blindly via the doctor feeling for “landmarks.” The latter is considered more risky.
  3. There is a difference between SEs (e.g., hoarseness, droopy eyelid) and complications (e.g., erroneous punctures).

 

How long does it last?

  • Based on our readings, it is suggested that the benefits of an SGB for PTSD can last from months to years, and researchers and providers are reporting that it is unclear who will need one injection vs. who will need multiple injections (aka: a course of treatment).
    • Similar readings have suggested that some individuals can receive one injection and be good to go, whereas others need repeated injections for up to 2 years.
  • In our clinical experience (i.e., our observations of our patients and loved ones who have received SGB for PTSD), most people are receiving maximal benefit from getting an SGB every 2 months for the first 6-12 months, and thereafter, they can better tolerate spacing their injections further apart.
    • We don’t have sufficient scientific data at this point to understand the differences in people’s responses/needs, but we have a running hypothesis that those with chronic and/or childhood trauma will need more injections across a longer period of time. We hypothesize this because trauma reactions (including at the limbic system level) are a learned behavior. Through repeated trauma exposure, we learn that the world is a dangerous place. That is, we have neural pathways – or “muscle memory” – for trauma, which trains our brain to remain alert and sensitized to potential threat. It makes sense, then, that it would take more administrations of SGB to “reset” or “retrain” the limbic system to have a normal orientation to threat.
    • In contrast, a single exposure to trauma doesn’t habituate the brain to trauma and threat as thoroughly. That is, the “habit” of trauma isn’t as deep or robust. Therefore, it stands to reason that an individual with single-exposure PTSD would have a more malleable limbic system that is more readily responsive to a single dose of SGB (or fewer doses of SGB).
  • SGB treatments aren’t a race or competition. There’s no blue ribbon for only needing one injection, so don’t set yourself up by having unrealistic expectations about the number of injections you’ll need. We recommend you approach SGB as a “course of treatment”…preemptively committing to continuing your treatment regimen until symptoms reside and don’t return.

Cautionary statements

  • Don’t expect “happy,” as “happy” is not the goal of SGB for PTSD. Rather, our clinical observations suggest that “calm” or “at ease” are better and more frequent descriptors of what people achieve from SGB treatment.
  • As noted previously, SGB for PTSD is not a panacea or “cure all.” It merely calms the limbic system – resetting your limbic system from 8,000 rpm to 2,000 rpm.
  • There are many other symptoms of PTSD that aren’t automatically corrected by calming the limbic system. For example:
    • Relationship problems
    • Occupational functioning
    • Beliefs about yourself and/or others (e.g., trust issues)
    • Grief
    • Avoidance
    • Inflexibility
    • Depression
    • Social isolation
    • Communicating unpleasant emotions through anger
    • Risky and self-destructive behaviors
    • Substance misuse
    • Suicidality
    • Shame, guilt, and self-blame
  • SGB works best in conjunction with psychotherapy – the latter of which can target the above symptoms.
  • There are many forms of psychotherapy, and no single form of therapy is the best fit for everyone.
    • Even though some therapists (or websites) may tell you that theirs is the “gold standard” treatment for PTSD, the research is actually much more convoluted than this messaging lets on. For example, controlled studies on “gold standard treatments” have shown that up to 70% of veterans dropout prematurely.
    • Thus, we recommend that you are a discerning consumer — actually believing what your own senses tell you about what is/isn’t best for you.
    • If the approach seems gimmicky or makes promises that seem unrealistic, you might want to reconsider.
    • If the premise of the approach is offensive to you, you might want to reconsider.
    • If the approach sends you into a tailspin and presses on without regard to you no longer being able to function, you might want to reconsider.
    • In sum, we encourage individuals with PTSD to move away from the old-school mentality of “the doctor knows best.” You are the expert on you, and an excellent, trauma-informed therapist honors that.
  • Relatedly, the personality of a therapist is critical to your therapeutic success. It’s important for you to select a therapist who is a good fit for you, as decades of psychological research have concluded that the therapeutic relationship (i.e., the relationship between patient and therapist) is the single best predictor of treatment outcomes.

Cost and insurance coverage

  • As of this writing, health insurances are not known to cover the cost of SGB for PTSD, as the procedure is currently considered “experimental.”
  • There are a few VAs that have made SGB available for PTSD, so we recommend that veterans research VA and DoD availability for the latest coverage information.
  • Cost per injection varies widely, as we’ve seen some doctors charge $2,000 per injection vs. others who charge $300 per injection.
  • Recently, there have been legislative efforts to require the VA to cover the cost of SGB injections for veterans with PTSD. We’re still in the early stages of these efforts, however, but we anticipate that with additional research data, coverage will be more broad.