Treatment Of Combat-related Posttraumatic Stress Disorder Research Articles

Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.

Deployed Military Medical Personnel: Impact of Combat and Healthcare Trauma Exposure.

Limited research has been conducted on the impact of deployment-related trauma exposure on post-traumatic stress symptoms in military medical personnel. This study evaluated the association between exposure to both combat experiences and medical duty stressors and post-traumatic stress symptoms in deployed military medical personnel. U.S. military medical personnel (N = 1,138; 51% male) deployed to Iraq between 2004 and 2011 were surveyed about their exposure to combat stressors, healthcare stressors, and symptoms of post-traumatic stress disorder (PTSD). All participants were volunteers, and the surveys were completed anonymously approximately halfway into their deployment. The Combat Experiences Scale was used as a measure of exposure to and impact of various combat-related stressors such as being attacked or ambushed, being shot at, and knowing someone seriously injured or killed. The Military Healthcare Stressor Scale (MHSS) was modeled after the Combat Experiences Scale and developed for this study to assess the impact of combat-related healthcare stressors such as exposure to patients with traumatic amputations, gaping wounds, and severe burns. The Post-traumatic Stress Disorder Checklist-Military Version (PCL-M) was used to measure the symptoms of PTSD. Eighteen percent of the military medical personnel reported exposure to combat experiences that had a significant impact on them. In contrast, more than three times as many medical personnel (67%) reported exposure to medical-specific stressors that had a significant impact on them. Statistically significant differences were found in self-reported exposure to healthcare stressors based on military grade, education level, and gender. Approximately 10% of the deployed medical personnel screened positive for PTSD. Approximately 5% of the sample were positive for PTSD according to a stringent definition of caseness (at least moderate scores on requisite Diagnostic and Statistical Manual for Mental Disorders criteria and a total PCL-M score ≥ 50). Both the MHSS scores (r(1,127) = 0.49, p < 0.0001) and the Combat Experiences Scale scores (r(1,127) = 0.34, p < 0.0001) were significantly associated with PCL-M scores. However, the MHSS scores had statistically larger associations with PCL-M scores than the Combat Experiences Scale scores (z = 5.57, p < 0.0001). The same was true for both the minimum criteria for scoring positive for PTSD (z = 3.83, p < 0.0001) and the strict criteria PTSD (z = 1.95, p = 0.05). The U.S. military has provided significant investments for the funding of research on the prevention and treatment of combat-related PTSD, and military medical personnel may benefit from many of these treatment programs. Although exposure to combat stressors places all service members at risk of developing PTSD, military medical personnel are also exposed to many significant, high-magnitude medical stressors. The present study shows that medical stressors appear to be more impactful on military medical personnel than combat stressors, with approximately 5-10% of deployed medical personnel appearing to be at risk for clinically significant levels of PTSD.

Firearm ownership in veterans entering residential PTSD treatment: Associations with suicide ideation, attempts, and combat exposure

This study aimed to describe the frequency of firearm ownership in veterans entering residential treatment for posttraumatic stress disorder (PTSD) and examine the association of firearm ownership with suicide ideation and suicide attempt history, combat exposure, and PTSD symptom severity. Two samples of veterans entering residential PTSD treatment were assessed at intake using self-report measures. Approximately one third of participants endorsed firearm ownership across the two samples. Analyses with a sample predominantly comprised of Vietnam Veterans found that those who endorsed both suicide ideation and prior suicide attempts were less likely to own a firearm compared to suicide ideators and non-suicidal participants. In addition, more frequent combat exposure, but not PTSD symptom severity, was associated with firearm ownership in both samples and most participants endorsed using safe storage practices. These lower rates of firearm ownership generally, and in those with suicide ideation and prior attempts in particular, may reflect an increased focused on means restriction in treatment for combat-related PTSD. Means restriction counseling among PTSD treatment seeking veterans should target those with combat exposure.

Perspectives on Research on the Use of Heart Rate Variability Biofeedback for Combat-Related Posttraumatic Stress Disorder

The process of doing interventional research using a randomized clinical trial design to test the efficacy of heart rate variability (HRV) biofeedback as a treatment for combat-related posttraumatic-stress disorder (PTSD) in Veterans with PTSD is described from two perspectives: by the study Principal Investigator and by one of the research staff. The history, context, and results of the study are briefly presented.

Eye Movement Desensitization and Reprocessing (EMDR) as Treatment for Combat-Related PTSD: A Meta-Analysis

Although the symptom presentation of post-traumatic stress disorder (PTSD) in the general and military population is very similar, combat-related PTSD is typically thought to be more severe due to repeated and prolonged exposure to traumatic events. One of the treatments of choice, eye-movement desensitization and reprocessing (EMDR) has, however, not been validated for the military population. A meta-analysis was carried out on literature ranging back to 1987. The analysis thus far resulted in a failure to support the effectiveness of EMDR in treating PTSD in the military population. Several possible explanations are given, of which the limited number of well-designed randomized controlled trials (RCTs) seems to be the most important one. Until more research is done, EMDR as treatment of choice for combat-related PTSD should be used only if other treatment protocols have proven unsuccessful.

Does substance abuse affect outcomes for trauma-focused treatment of combat-related PTSD?

Comorbidity of substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) among combat Veterans is common, which creates a need for special consideration of treatment options. Controversy regarding trauma-focused treatments for individuals with comorbid SUDs may cause barriers to treatment delivery. Cognitive processing therapy (CPT) is frequently recommended for treatment of PTSD, but little is known about whether substance use comorbidity affects the outcome. This study compared outcomes for Veterans with PTSD and a substance misuse pattern against Veterans with PTSD without a comorbid SUD, who participated in a six-week residential group CPT treatment program. Lack of significant differences between groups on outcomes for PTSD or depression, p > 0.05, suggests that individuals with comorbid substance misuse have outcomes for PTSD and depression similar to those without substance use comorbidity. Trauma-focused treatments may not be as problematic in this population as many clinicians believe. Attrition and demographic differences between the groups were also explored.

Assessment and Treatment of Combat-Related PTSD in Returning War Veterans

Over the past 9years approximately 2 million U.S. military personnel have deployed in support of Operation Iraqi Freedom in Iraq and Operation Enduring Freedom in and around Afghanistan. It has been estimated that 5-17% of service members returning from these deployments are at significant risk for combat-related posttraumatic stress disorder (PTSD). Many of these returning war veterans will seek medical and mental health care in academic health centers. This paper reviews the unique stressors that are related to the development of combat-related PTSD. It also reviews evidence-based approaches to the assessment and treatment of PTSD, research needed to evaluate treatments for combat-related PTSD, and opportunities and challenges for clinical psychologists working in academic health centers.

Key Elements in Couples Therapy With Veterans With Combat-Related Posttraumatic Stress Disorder.

If a client dealing with combat-related posttraumatic stress disorder (PTSD) presents for psychotherapy, should you consider including his or her partner in treatment? How could couples therapy be beneficial? What framework do you have to conceptualize the relational issues and potential treatment? Although clinicians have long been encouraged to include families in the treatment of combat-related PTSD, few specific couple-family therapies exist, and outcome research is scarce. Because of the adverse effects of PTSD on relationships, couples therapy can be a powerful adjunct treatment; however, few receive this service. A new framework for conceptualizing couples therapy organizes treatment around the 3 PTSD symptom clusters (reexperiencing, avoidance, and arousal). Relationship consequences of each symptom cluster are summarized, followed by useful treatment interventions and a case study.

Posttraumatic Stress, Depression and Dissociation as Predictors of MMPI-2 Scale 8 Scores in Combat Veterans with PTSD

ABSTRACT Findings from a previous study of sexual abuse trauma victims (Elhai, Gold, Mateus, & Astaphan, 2001) were replicated to assess whether posttraumatic stress disorder (PTSD), depression, and dissociation symptoms account for Minnesota Multiphasic Personality Inventory-2 (MMPI-2) scale 8 scores in combat trauma victims. Participants were 122 male veterans seeking outpatient treatment for combat-related PTSD. Hierarchical regression analysis assessed whether PTSD symptoms incrementally accounted for variation in scale 8 scores above and beyond depression and dissociation symptoms. Results revealed that PTSD symptoms did not incrementally account for additional scale 8 variation. However, negative and positive symptoms of psychosis did account for variance in scale 8. Clinical implications for assessment of PTSD and psychosis with trauma victims are discussed.

Treatment outcome in Australian veterans with combat-related posttraumatic stress disorder: a cause for cautious optimism?

This study investigated treatment outcome in combat-related posttraumatic stress disorder (PTSD). Participants were 419 Australian Vietnam veterans who completed a 12-week hospital-based program. A comprehensive protocol assessed PTSD, comorbidity, and social functioning at admission and at 3 and 9 months posttreatment. Overall, the group showed significant improvements in core PTSD symptoms, anxiety, depression, alcohol abuse, social dysfunction, and anger. Changes occurred mostly between admission and 3 months posttreatment, with gains maintained at 9 months. Ratings by patients and their partners indicated perceived improvement and strong satisfaction with treatment. Nevertheless, treatment gains were variable and, for most veterans, considerable pathology remained following the programs. The current study provides grounds for cautious optimism in the treatment of combat-related PTSD.

A Virtual Environment for the Treatment of Chronic Combat-Related Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is one of the most disabling psychopathological conditions affecting the veteran population. An estimated 830,000 U.S. veterans currently have symptoms of chronic combat-related PTSD. No therapeutic approach has proven to be consistently effective in the management of combat-related PTSD. Behavior therapies with an exposure element have proven more effective than most other types of treatment, but a significant number of patients do not seem to benefit from them, possibly because of difficulties imagining, visualizing, or describing their traumatic experiences. In this article, we describe Virtual Vietnam, a set of two virtual environments we have developed for the treatment of combat-related PTSD, and its use as one component of a comprehensive treatment program.

Hope, coping, and social support in combat-related posttraumatic stress disorder.

Dispositional hope, coping, and perceived social support were assessed among Vietnam combat veterans upon admission to and discharge from inpatient treatment for posttraumatic stress disorder (PTSD). Veterans reported lower dispositional hope than any previously described sample, and hope did not increase at discharge from treatment. At admission, higher hope was correlated with greater perceived social support coming from family (this relationship persisted when controlling for depression and PTSD symptoms). At discharge, higher hope was associated with greater perceived social support coming from family and friends and the use of adaptive coping strategies. Results indicate that hope confers a beneficial effect once veterans undergo treatment for combat-related PTSD, a finding that suggests that hope may be "gone but not lost" for these individuals.