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Cognitive Behavioral Therapy for Combat Veterans With Post Traumatic Stress Disorder
Although not limited to veterans, Post Traumatic Stress Disorder (PTSD) may be the single most significant mental health risk to veterans, particularly to those veterans that have seen combat. PTSD is an anxiety disorder, which occurs after a person has seen or experienced a traumatic event including, but not limited to: assault, domestic abuse, prison stay, rape, terrorism, war, or natural disaster (Vorvick et al., 2011). In fact, PTSD is unique among psychiatric diagnosis in that it "requires a specific type of event to occur from which the person affected does not recover" (Resick et al., 2008). Veterans are at high risk of PTSD because they experience war, but they also experience many of the other traumatic events that can trigger PTSD in the course of the war. PTSD can have serious lifelong effects for veterans. It can impair their ability to hold down a steady job, interfere with interpersonal relationships, and, in the most extreme cases, even lead to an increased risk of violence that makes veterans a danger to themselves and others. Therefore, it is critical for PTSD to be identified and successfully treated in order to ensure the best possible quality of life for veterans.
While trauma is a triggering event for PTSD, it is not appropriate to say that trauma causes PTSD. This is clear because not all persons experiencing trauma develop PTSD, even when the trauma is extreme, such as experiencing combat. On the contrary, "The cause of PTSD is unknown. Psychological, genetic, physical, and social factors are involved. PTSD changes the body's response to stress. It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters). It is not known why traumatic events cause PTSD in some people but not others" (Vorvick et al., 2011). What is known is that a history of trauma can increase the individual risk of developing PTSD after a traumatic event, which might help explain why veterans, who have almost certainly experienced a series of traumas, are at such high risk for the disorder. Furthermore, there are risk factors that are associated with the development of PTSD, including the nature, severity, and duration of the trauma exposure, prior history of trauma exposure, lack of social support, and additional life stressors (The Management of Post-Traumatic Stress Working Group, 2010). What these factors make clear is that it might be possible to predict those soldiers who are most at risk of developing PTSD before ever sending them into combat, and, with careful post-combat monitoring, it might even be possible to prevent the development of PTSD.
PTSD can manifest in various different ways, which fall into three main categories: reliving the event, avoidance, and arousal. Reliving the event can include flashbacks, nightmares, and upsetting memories of the event (Vorvick et al., 2011). Avoidance includes feelings of detachment, difficulty remembering parts of the trauma, emotional numbing, flat affect, a lack of interest in normal activities, and avoiding things that might trigger memories of the event (Vorvick et al., 2011). Arousal might be the element of PTSD that is most frequently associated in the minds of people when thinking about how PTSD manifests in veterans and includes: difficulty concentrating, startling easily, an exaggerated startle reflex, hypervigilance, irritability, angry outbursts, and difficulty sleeping (Vorvick et al., 2011). In addition to those three main categories, PTSD sufferers might suffer a general range of anxiety symptoms including: agitation, excitability, dizziness, fainting, racing heartbeat, and headache (Vorvick et al., 2011). As clear by the symptoms, there is no one definitive element that differentiates PTSD from other anxiety disorders and its symptoms can overlap with other disorders, such as depression. Therefore, a diagnosis has to be based upon symptoms, how long symptoms have lasted, and whether the presence of any other disorder can explain the symptoms (Vorvick et al., 2011).
Once diagnosed, there are several different ways to treat PTSD. Each of these methods has various strengths and weaknesses, and there is no single approach that has been proven effective in all cases of PTSD. Instead, PTSD treatment must be somewhat individualized, with the realization that a treatment that is effective for some people may not prove effective in other patients. Despite that caveat, there is substantial support for the most widely-utilized PTSD treatments. "The evidence-based psychotherapeutic interventions for PTSD that are most strongly supported by RCTs can be considered broadly within in the trauma-focused psychotherapy category or stress inoculation training" (The Management of Post-Traumatic Stress Working Group, 2010). These trauma-focused therapies center on helping the patient deal with the trauma and are based on "learning theory, cognitive theory, emotional processing theory, fear-conditioning models, and other theories. They include a variety of techniques most commonly involving exposure and/or cognitive restructuring (e.g. Prolonged Exposure, Cognitive Processing Therapy and Eye movement Desensitization and Reprocessing). They are often combined with anxiety management/stress reduction skills focused specifically on alleviating the symptoms of PTSD" (The Management of Post-Traumatic Stress Working Group, 2010). While these CBT techniques have proven very effective, non-trauma focused CBT interventions are not as effective. The most commonly used approach is desensitization, which involves controlled exposure to the traumatic event with the goal of making the memories of the event less frightening. Another approach is cognitive therapy. It is important to note that PTSD may manifest in veterans in similar ways as in the rest of the population, but, given the training and experiences of veterans, may be a potentially more dangerous disease in that subpopulation than in the rest of people suffering from PTSD. The reality is that combat veterans have not only been trained to kill, but, in many ways, may be desensitized to the real impact of violence in a non-combat scenario. Therefore, their PTSD-influenced reactions, which might be entirely rational in a combat scenario, could have dire consequences outside of the context of war. Moreover, the potential negative impact is not limited to peacetime environments. Attacks on civilians in wartime environments can, in some cases, be triggering incidents for PTSD, but might also be evidence of PTSD in the perpetrators.
Furthermore, because wartime scenarios are so different from peacetime scenarios, dealing with PTSD in veterans can present special issues. Another issue that can complicate the treatment of PTSD in veterans is the impact that military sexual trauma (MST) can have on the prevalence of PTSD in veterans (Kimmerling et al., 2010). It seems like there is an ever-increasing awareness of sexual assault in the military, and one must be cognizant of the possibility when treating any veteran presenting with PTSD symptoms. There are two main approaches to treating PTSD in combat veterans: cognitive processing therapy (CPT) and prolonged exposure therapy (PE). In addition, mindfulness-based cognitive behavioral therapy techniques have shown promise in treating PTSD in veterans.
It is important to understand that while PTSD may be an illness, it is also a reflection of a normal processing system that has gone wrong. The body is supposed to feel anxiety in the face of a scary or traumatic situation; anxiety is the way the body processes the production of those hormones necessary to respond in high-danger scenarios. However, this heightened anxiety existing when there is no actual danger can present real problems for the person suffering from any anxiety disorder, including PTSD. In patients with PTSD, the underlying traumatic event has caused fear and this fear is then inappropriately generalized outside of the context of the initial trauma. Emotional processing theory (EPT), which is used to explain many anxiety disorders, helps explain PTSD and inform treatment structures for PTSD. EPT "posits that the fear structures of trauma survivors with PTSD include two basic dysfunctional cognitions that underlie the development and maintenance of PTSD. First, the world if completely dangerous…Second, one's self is totally incompetent" (Rauch & Foa, 2006). The combination of these two beliefs means that the patient not only feels constantly in a state of danger, but also feels as if he or she is unequipped to deal with that danger in an appropriate manner. In other words, the patient feels helpless. Therefore, most believe that treating PTSD means modifying the fear structure so that it is not responding in an irrational manner to stimuli that should not create fear. CBT seeks to do this by confronting the patient with the trauma and having them associate rational responses to triggers, rather than rely upon the trauma-induced irrational responses.
Myths about trauma-focused therapy continue to create a barrier to effective PTSD treatment; both because these myths make some practitioners reluctant to engage in trauma-focused therapy and it can even lead some patients to fear the impact of trauma-focused therapy. Some practitioners feel that encouraging trauma survivors to relive the trauma is cruel or revictimizing, but this reflects faulty reasoning on the part of the practitioner. "The therapist is not creating new pain, but must access the emotions to assist the patient in emotionally processing the memory so it can become less painful" (Rothbaum…[continue]
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, 2010). This point is also made by Yehuda, Flory, Pratchett, Buxbaum, Ising and Holsboer (2010), who report that early life stress can also increase the risk of developing PTSD and there may even be a genetic component involved that predisposes some people to developing PTSD. Studies of Vietnam combat veterans have shown that the type of exposure variables that were encountered (i.e., severe personal injury, perceived life threat, longer duration,
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