Post-traumatic stress disorder symptoms and symptom management in combat veterans

Posttraumatic stress disorder (PTSD) has been recognized by a growing number of healthcare authorities and U.S. governmental agencies as a serious and potentially debilitating condition in combat veterans returning from tours of duty in Iraq and Afghanistan. Although estimates vary from troubling to extremely alarming, the incidence and prevalence of PTSD among this population is far higher than for the general population in the United States, and the adverse effects of the condition are further exacerbated by a number of other factors, including early life stress, different levels of individual resiliency and a potential genetic predisposition as well. The consequences of untreated PTSD can be severe, including suicide, another trend taking place among the combat veteran population that has researchers scrambling for answers and efficacious treatments. This study provides a review of the relevant literature concerning PTSD to determine its causes, symptoms and treatments. The study found that at present, two diametrically different treatment modalities are being used by the Departments of Defense and Veterans Affairs for PTSD. The findings that emerged from this study and personal experiences to date, though, indicate that there is no "magic bullet" available and clinical interventions remain focused on treating the symptoms of PTSD while the search for a cure continues.

Table of Contents

Introduction

Review of the Literature

Proposed Project Method

Findings

Conclusions and Discussion

Post-Traumatic Stress Disorder: Symptoms and Symptom Management in the Combat Veteran

Introduction

This study, "Post-Traumatic Stress Disorder: Symptoms and Symptom Management in the Combat Veteran," is focused on identifying current treatments for post-traumatic stress disorder (PTSD) in general and for American combat veterans returning from tours of duty in the Middle East in particular. This study was important because the estimated prevalence of PTSD among U.S. Iraq War veterans currently exceeds 12% among veterans who recently returned from overseas, and even higher at 16% among service members evaluated a year following their return from duty in Iraq (Vasterling, Proctor, Friedman, Hoge, Heeren, King & King, 2010). These PTSD rates are comparable to those experienced among veterans return from combat tours in Afghanistan where combined samples of U.S. service members have been estimated at 14% with the development of new cases exceeding 7% for service members exposed to combat (Vasterling et al., 2010).

The implications of these trends are alarming because of the enormous human and economic consequences that are associated with PTSD. In this regard, Shad, Suris and North (2011) emphasize that, "Post-traumatic stress disorder (PTSD) is increasingly recognized as a serious and potentially debilitating condition in combat veterans returning from Iraq and Afghanistan" (p. 4). Moreover, current estimates may be low because of the confounding nature of PTSD and how it manifests in different people. For example, Shad and her associates add that, "Because PTSD can take months or years to fully manifest and many troops are subjected to multiple deployments, the prevalence of veteran PTSD may be expected to increase" (p. 4). Likewise, Nelson (2011) emphasizes that while the prevalence rates for PTSD among the general population is around 7.8%, the prevalence rates of PTSD for combat veterans returning from combat tours in the Middle East are estimated to be at least 17% and most authorities agree that this estimate is low -- in some cases far too low (Kearney, McDermott, Malte, Martinez & Simpson, 2012).

Moreover, other authorities believe that the actual prevalence rate of PTSD among the combat veteran population may be as high as 52% (Corso, Bryan, Morrow, Appolonio, Dodendorf & Baker, 2009) or 60% (Kearney et al., 2012), and some go so far as to suggest that the actual prevalence rate of PTSD among returning combat veterans may be far higher because the overwhelming majority (about 90%) of combat veterans who develop PTSD do not seek treatment (Kilmer, Eibner, Ringel and Pacula, 2011). Because of the complexity of the condition and the different ways it manifest over time, clinicians have met with mixed results in their different therapeutic approaches. For instance, Southwick, Gilmartin, McDonough and Morrissey (2006) emphasize that, "Chronic combat-related post-traumatic stress disorder is notoriously difficult to treat. While numerous therapeutic approaches have been tried in this population, success rates generally have been modest to moderate" (p. 161)..

The results of the most recent research indicate veterans returning from tours of duty in the Middle East as part of America's Global War on Terrorism (i.e., Operation Enduring Freedom or OEF and Operation Iraqi Freedom or OIF) diagnosed with psychiatric disorders are at higher risk for suicide (Jakupcak, Vannoy, Imel, Cook, Fontana, Rosenheck & McFall, 2010; Lighthall, 2010; Gomulka, 2010). The onset of suicidal ideation or attempting suicide may represent preliminary steps toward completed suicide. Hence, active suicidal ideation or recent suicide attempts are often used as markers of elevated suicide risk. To prevent suicides, it is critical to identify and understand the risk and protective factors for elevated suicide risk among OEF/OIF Veterans with mental disorders (Jakupcak et al., 2010). Beyond the enormous toll PTSD exacts in terms of human costs, the social costs associated with treating PTSD among combat veterans has been estimated to be as high as a billion dollars over the next 2 years (Kilmer et al., 2011).

In addition, Jakupcak and his associates (2007) stress that in spite of the consistent relationships that have been identified with respect to PTSD and anger, PTSD and hostility, and PTSD and aggression, the majority of the research to date has been focused on the experiences of Vietnam combat veterans and these studies have evaluated their experiences decades after their military service. According to Jacupcak et al., "With a growing number of combat veterans returning from deployments in Iraq and Afghanistan, additional research is needed to determine whether these relationships exist among this new cohort" (p. 946). Moreover, the nation is already facing a veritable epidemic of dementia among the elderly, and Qureshi, Kimbrell, Pyne, Magruder, Hudson, Petersen, Yu, Schulz and Kunik (2010) report that there is already an increased prevalence and incidence of dementia in older veterans who suffer from PTSD, and these rates can be expected to rise further in the future. Therefore, taken together, these trends clearly indicate that perhaps even hundreds of thousands more returning Iraq and Afghanistan combat veterans may go on to develop PTSD in the future with a corresponding need for efficacious treatments that remain elusive today. This study was based on continuing personal and professional interest in the treatment and management of PTSD.

Review of the Literature

This chapter provides a review of the relevant peer-reviewed and scholarly literature concerning PTSD and its effects on combat veterans. The study's guiding research question is followed by a discussion of issues to be explored below.

Research Question. The study's guiding research question was, "What are the typical symptoms of PTSD and how are these symptoms currently being treated and managed in combat veterans?

Issues to be Explored. Three fundamental issues are explored in the literature review chapter as follows:

1. The causes of PTSD;

2. The symptoms of PTSD; and,

3. The treatment and management of PTSD.

Review of the Relevant Literature

The causes of PTSD. The Diagnostic and Statistical Manual of Mental

Disorders, 4th edition text revision (2000) (DSM-IV) indicates that PTSD is characterized by re-experiencing the traumatic event/s, hyperarousal, avoidance of stimuli associated with the trauma/s and a general numbing of emotions. The latest diagnostic criteria established by the DSM-IV state that an individual must have:

1. Witnessed, experienced, or otherwise been confronted with an event that involved actual or possible death, grave injury, or threat to physical integrity; and,

2. The individual's response to such a traumatic event must include severe helplessness, fear or horror.

Researchers working with the Department of Veterans Affairs and the University of Texas Southwestern Medical Center, Dallas further define PTSD as "an anxiety disorder that may develop following exposure to trauma" (Shad, Suris & North, 2011, p. 4). A consistent theme that quickly emerges from the literature is that while anyone can develop PTSD, exposure to combat conditions in particular appears to be a precipitating factor. In this regard, Shad et al. report that, "Qualifying trauma exposures may include personal experience of, or directly witnessing, a sudden, unexpected event that threatens life or limb, such as combat trauma, a serious motor vehicle accident, terrorist attacks, natural disasters, or violent personal assault (e.g., rape), as well as learning of the sudden traumatic death of a loved one" (2011, p. 4).

Although everyone is unique and different levels of resiliency can mitigate some of these effects (Hagenaars & van Minnen, 2011), some people appear to be at higher risk because of preexisting mental schemas or past traumatic life experiences that can exacerbate future traumatic experiences. For instance, according to Cockram, Drummond and Lee (2010), "A number of factors appear to determine the course, severity and nature of post-trauma psychological reactions. These are usually divided into pre-trauma, trauma and post-trauma factors" (p. 166). While the severity of the trauma, such as combat exposure, is a primary factor in the etiology of PTSD, it is reasonable to speculate that the potential effect of other PTSD-associated risk factors differs according to the severity of the stressor (Cockram et al., 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, intensity, complexity and exposure to the suffering of others), can adversely affect the symptomological course of the condition, meaning that the type of trauma that is experienced is also a risk factor in the development of PTSD (Cockram et al., 2010). Studies have also shown, though, that post-trauma factors such as stress management skills and social support systems can help to mitigate the development of PTSD as well as help facilitate recovery from the condition (Cockram et al., 2010).

The body of research on the onset of PTSD indicates that various aspects of the social support construct predict the development of PTSD. Interpersonal stressors (such as friction and negative social reactions) and interpersonal resources (such as availability of emotional, instrumental, and perceived support) each predict PTSD onset (Laffeye et al., 2008). Negative social factors (i.e., interpersonal stressors such as friction and negative social reactions to trauma disclosure) are more predictive of PTSD than positive social factors (i.e., such as availability of emotional support, instrumental support, and support satisfaction) (Laffeye et al., 2008). It has been proposed that negative social factors may emerge following trauma exposure through a path that is separate from the path between trauma and positive social factors. Thus, it is important for research on the relationship between social support and PTSD to examine both negative and positive social factors (Laffeye et al., 2008).

The symptoms of PTSD. One of the more perplexing aspects of PTSD is the different ways it manifests in different people, with some cases involving several years or even decades between the traumatic episode and the emergence of symptoms. Once they occur, though, the symptoms of PTSD can be truly debilitating and even life-threatening. For instance, according to Kearney et al., (2012), "Symptoms of PTSD often persist for decades, and typically result in major disruptions in interpersonal relationships, physical comorbidity, substance abuse, affective disorders, impaired ability to work, and a high rate of attempted suicide" (p. 101). The most common types of symptoms of PTSD include (a) intrusion (i.e., nightmares, flashbacks, intrusive thoughts), (b) constriction (i.e., numbing, disassociation, avoidance), and (c) hyperarousal (i.e., increased vigilance, overly jumpy, insomnia) (Nelson, 2011). In addition, the diagnostic criteria for PTSD include diminished interest or participation in previously enjoyed activities (criterion C4) and a reduced ability to feel emotions, particularly those associated with intimacy, tenderness, and sexuality (DSM-IV, 2000, p. 464). Such diminished interest or participation in previously enjoyed activities is termed anhedonia and Frewen, Dozois and Lanius (2012) report that, "Research also shows that symptoms of emotional numbing may be particularly related to anhedonia" (p. 1).

Comorbid substance use disorder and PTSD has been linked with greater symptom severity, worse treatment outcomes, and increased medical and legal problems than with PTSD alone (Peller, Najavitis, Nelson, LaBrie & Shaffer, 2010). Likewise, the results of a study by Jason, Mileviciute, Aase, Stevens, DiGangi, Contreras and Ferrari (2011) showed that PTSD is associated with increased risk for substance use disorders (SUDs). According to these researchers, "Studies have found rates of PTSD and SUD comorbidity as high as 25-59%. Having PTSD and increased psychiatric distress associated with comorbid disorders is associated with poorer substance use outcomes" (Jason et al., 2011, p. 175). In addition, dually diagnosed patients are less likely to be in remission when compared to an SUD-only group, but that they did have more severe levels of distress. However, other studies suggest that there are no significant differences for treatment outcomes between those with comorbid PTSD and SUD, and SUD-only groups (Jason et al., 2011).

Several theorists believe that using substances for extended periods of time may be a causal factor in mental health symptomatology, or that it exacerbates existing psychiatric symptoms (Jason et al., 2011). The type of substance used or abused may also have different effects of PTSD sufferers. For example, Jason et al. (2011) report that medication theorists assert that individuals use substances as a coping mechanism for negative emotions. Alcohol may have dampening effects that help regulate the anxiety of patients with PTSD and that cocaine may increase hypervigilance and self-confidence to help individuals with PTSD feel more in control in social situations. There is some evidence for both theoretical points-of-view (Jason et al., 2011).

The symptoms of PTSD typically involve both physiological and psychological responses to traumatic memories that occur following the traumatic episode along a contextual and/or temporal continuum with three groups of symptoms generally occurring together in PTSD as described in Table 1 below.

Table 1

PTSD Symptom Groups

Group

Description

Group B

Intrusion symptoms for this group include re-experience of traumatic memories at night (i.e., nightmares) and during the day (i.e., flashbacks and intrusive recollection of traumatic events with physiological reactivity).

Group C

Symptoms for this group include avoidance of reminders of the trauma (e.g., inability to talk about the experience or return to the site) and numbing of general responsiveness (e.g., emotional numbing, feeling of detachment or estrangement from others, and sense of foreshortened future).

Group D

Hyper-arousal symptoms for this group are insomnia, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response.

Source: Adapted from APA, 2000

According to Jovanovic, Norrholm, Blanding, Davis, Duncan, Bradley and Ressler (2010), the first symptom category, referred to as cluster B, covers symptoms of re-experiencing the event, such as intrusive thoughts, nightmares, and flashbacks induced by reminders of the event. Cluster C symptoms include avoidance of stimuli associated with the trauma, while cluster D incorporates symptoms of increased arousal. The latter two symptom clusters include restricted range of affect, emotional detachment, loss of interest, difficulty sleeping, and impaired concentration that are also cardinal symptoms of MDD. Furthermore, suicidality is frequently seen in both disorders. This overlap in clinical presentation of the two disorders has lead some researchers to argue for a distinct depressive subtype of PTSD, rather than the presence of two separate disorders (Jovanovic et al., 2010).

According to Shad et al. (2011), the most common groups are B. And D; however, group C. is regarded as an essential element in the psychopathology of PTSD. The importance of group C. symptoms in the diagnosis of PTSD, however, does not preclude a potentially pivotal role of group B. And D. symptoms in mechanisms involved in the development of PTSD and maintenance of its symptoms. For example, a number of studies have noted that intrusion and hyper-arousal symptoms may predict or even lead to group C. symptoms of avoidance/numbing responses. Since numbing has been proposed to result after effortful avoidance of intrusion symptoms and hyper-arousal fails, prevention or eradication of groups B. And D. symptoms could help to prevent the occurrence of group C. symptoms and ultimately PTSD.

According to Dyer, Dorahy, Hamilton, Corry, Shannon, MacSherry and Elder (2009), these symptom clusters seem effective at explaining the central difficulties of those exposed to singularly occurring, acute traumatic events. However, in isolation they are less well-suited for the spectrum of symptoms and personality disturbance often exhibited by individuals who have experienced prolonged trauma. Consequently, "complex PTSD" or "disorders of extreme stress not otherwise specified" (DESNOS) emerged to account for the organized and complicated array of problems described by those who experience early onset, protracted, and repeated traumatic events usually involving interpersonal victimization. Examples of these complex traumata include torture, childhood abuse, domestic violence, chronic combat exposure, and severe social deprivation (Dyer et al., 2009).

Therefore, the importance of treating intrusion and hyper-arousal symptoms is not only for reduction of these unpleasant symptoms themselves, but also to further reduce the development of avoidance and numbing symptoms that may occur in response to intolerable intrusion and hyper-arousal symptoms (Shad et al., 2011). Post-traumatic symptoms involving sleep are insomnia (a hyper-arousal symptom) and nightmares (an intrusion symptom). Dysregulation of rapid eye movement (REM) sleep is thought to play a pivotal role in the development and persistence of nightmares and other sleep disturbances in PTSD. Sustained increases in brain adrenergic activity have been shown to accompany dysregulation of REM sleep in PTSD. According to Shad et al. (2011), "These findings implicate an overactive, hyper-aroused sympathetic nervous system in the generation of sleep-related PTSD symptoms such as nightmares" (p. 5). Given the centrality of restful sleep to health, sleep-related symptoms have become the focus of an increasing amount of attention from PTSD researchers. For instance, Wright, Britt, Bliese, Adler, Pichionni and Moore (2011) emphasize that, "Sleep disturbances are commonly reported by soldiers returning from combat. The prevalence of sleep problems is not surprising given that sleep disturbance is a diagnostic criterion for posttraumatic stress disorder (PTSD) and is also co-morbid with a range of psychological problems" (p. 1240). These researchers add, though, that there is a growing body of evidence that indicates sleep disturbance plays a key role in mental health in that insomnia often precedes the development of conditions such as depression, anxiety, and alcohol abuse (Wright et al., 2011).

To date, a number of measures have been developed for various PTSD outcome studies, including those described in Table __ below.

Table

Measures Used for PTSD Outcome Studies

Measure

Description

Interviews

The Structured Clinical Interview for DSM (SCID) is probably the most widely used diagnostic interview measure, and it is generally considered the so-called gold standard against which other measures are compared. Although useful as an indicator of diagnostic status before and after treatment, the SCID cannot be used to determine symptom severity.

The PTSD Interview (PTSD-I) and the Structured Interview for PTSD (SI-PTSD) have adequate psychometric properties but have not been validated with victims of a wide range of traumas.

The Clinician-Administered PTSD Scale (CAPS) permits a diagnosis and severity measure of PTSD, but its administration requires about 45-60 minutes. More importantly, its psychometric properties were determined exclusively in a veteran population.

The PTSD Symptom Scale Interview (PSS-I) includes a combined frequency/severity rating of each of the 17 PTSD symptoms and thus yields both a diagnosis and a continuous severity rating. Unlike the CAPS, the PSS-I takes only about 15-20 min to administer, which saves valuable clinician time. To date, the PSS-I has not been as widely used as the CAPS.

Self-Report Measures

Revised Impact of Events Scale (RIES) is a self-report measure that yields two factors: intrusion and avoidance. Although the RIES has demonstrated high test-retest reliability and internal consistency, it does not assess all PTSD symptoms and thus cannot indicate diagnostic status. A revised version of the RIES includes hyperarousal items, but it has shown mixed results in reliability studies and still does not correspond fully to the DSM PTSD symptoms.

The PTSD Symptom Scale-Self Report (PSS-SR) and its descendent, the PTSD Diagnostic Scale (PDS) were developed as self-report instruments that would provide information about each of the 17 DSM-IV symptoms. Therefore, they yield both diagnostic and severity information. The PSS-SR demonstrated good reliability and validity in a sample of female assault victims. The PDS aims at assessing all DSM-IV criteria, and thus it includes information about the nature of the traumatic event and the level of functional interference. It was validated in a sample of victims of a wide range of traumas, and thus it can be confidently employed in outcome studies of various trauma populations. The PDS has demonstrated satisfactory test-retest reliability, internal consistency, and convergent and concurrent validity

Source: Adapted from Foa & Meadows, 1999

The treatment and management of PTSD. There is a general consensus that absent psychiatric disturbances, the experiencing of a trauma does not constitute sufficient basis for receiving treatment (Foa & Meadows, 1999). In fact, many PTSD treatments can be highly stressful and should only be used when there is sufficient clinical evidence to justify their application. In this regard, Foa and Meadows emphasize that, "Significant trauma-related psychopathology, such as the presence of PTSD or other common reactions to trauma (e.g. depression), should be present to justify treatment" (p. 450). Just as in the business world, it is also axiomatic in healthcare settings that in order to improve something, it must first be measured and this is also the case with PTSD diagnoses and treatments. For instance, Foa and Meadows add that, "Whatever the target symptom or syndrome, it should be defined clearly so that appropriate measures can be employed to assess improvement. In addition to ascertaining diagnostic status, it is also important to specify a threshold of symptom severity as an inclusion criterion for entering treatment" (p. 450). Excluding patients who suffer from mild symptoms of PTSD may improve treatment findings for two reasons:

1. It is more difficult to detect improvement in such individuals; and,

2. They are likely to exhibit very mild symptoms following treatment simply because of their relatively low initial psychopathology. These two scenarios may lead to opposite biases, the first minimizing treatment efficacy and the second inflating its effects. (Foa & Meadows, 1999, p. 450).

When treatment for PTSD is deemed warranted, there remains the fundamental issue of what treatment modality is most appropriate -- or even available. In spite of significant advancements in psychopharmacologic research in recent years, the pharmacotherapeutic agents that are currently available for treating PTSD remain only partially effective at best (Shad et al., 2011). Likewise, Weissman and his associates (2000) emphasize that:

Treatment selection should consider a wide range of options -- rather than simply the therapist's personal preference -- and weigh the evidence for the likely efficacy of each: that is, treatment should be considered in the light of differential therapeutics. Hundreds of different psychotherapies have been described, yet only a few have been tested and demonstrated to treat particular disorders. IPT and CBT are both proven approaches to treating major depression, as is antidepressant medication. (p. 4)

To date, the clinical trial studies that have employed existing first-line agents for PTSD such as selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) have yielded unsatisfying remission rates of only 23 -- 51% over 3 -- 6 months of treatment in studies of civilians. The effectiveness of these agents has been even more dismal in clinical trials of veterans with combat-related PTSD (Shad et al., 2011). A review of approximately 25 placebo-controlled studies concluded that response to treatment is inadequate for a large proportion of veterans with PTSD.

Generally speaking, the use of SSRIs for the treatment of intrusion symptoms has only been shown to be slightly more effective in either veteran or civilian populations and have failed to provide adequate treatment response for both nightmares and flashbacks in particular (Shad et al., 2001). Likewise, a recent review of SSRI-related studies reviewed by Shad and his colleagues found that SSRIs were ineffective for the treatment of the trauma-related sleep symptoms of insomnia or nightmares. In sum, Shad et al. conclude that, "These disappointing responses to SSRIs and SNRIs in the treatment of both daytime and night-time posttraumatic intrusion and arousal symptoms leave large numbers of PTSD patients continuing to suffer from unabated symptoms. Thus, there is a need to investigate innovative combination strategies targeting multiple symptoms of PTSD to enhance treatment response in PTSD" (2011, p. 5).

Although pharmacological interventions have been used with mixed results, the most promising approach to effectively treating PTSD appears to be evidence-based clinical interventions (Sharpless & Barber, 2011). A number of such evidence-based approaches have been used to date to treat veterans suffering from PTSD, also with mixed results. Cognitive-behavioral therapies (CBT), for instance, are the most widely used and have been shown to be effective primarily with asymptomatic PTSD patients (Sharpless & Barber, 2011). More promising interventions have also been identified based on the CBT model, including various exposure therapies (also referred to as flooding, imaginal, in vivo, or directed exposure) including the so-called "prolonged exposure" approach (Rothbaum & Schwartz, 2002). According to Corso et al., "Prolonged exposure is based on numerous studies finding that habituation to feared stimuli eventually decreases physiological anxiety symptoms" (2009, p. 120). This evidence-based intervention involves PSTD sufferers undergoing between eight to 15 weekly 90-minute sessions in which they revisit and discuss their traumatic experiences; the prolonged exposure intervention also incorporates relaxation and slowed breathing techniques (Sharpless & Barber, 2011). This finding is supported by Corso and his associates that, "Most empirically-based protocols utilizing prolonged exposure recommend 90 minutes per session" (2009, p. 120).

This evidence-based intervention has been found to be effective in treating combat Vietnam veterans suffering from PTSD (Falsetti & Resnick, 2000). As to its operation, according to Nelson, "Prolonged exposure therapy uses repeated imaginal and in vivo exposure techniques to help patients process the emotional and cognitive aspects of their traumatic memories in a safe environment" (2011, p. 53). Among the primary goals of exposure therapy interventions is to encourage patients to repeatedly confront the traumatic event in a safe environment until the event loses its ability to adversely affect the PTSD sufferer. For instance, Fasetti and Resnick note that prolonged exposure therapy "is similar to watching a frightening movie over and over again. At first it may be very frightening, but by the 20th viewing it would not be as frightening. Analogously, replaying a frightening memory becomes less frightening as it is recounted numerous times in an objectively safe environment" (2000, p. 262). Likewise, Corso et al. report that, "Through repeated exposure to the memory, the individual learns to habituate to the fear network -- both within and between treatment sessions -- which eventually decreases emotional arousal and modifies beliefs and perceptions of the event" (2009, p. 120).

Table

Summary of Exposure Therapy Studies in the Treatment of PTSD

Source

Key Findings

Comments

Sharpless & Barber, 2011

Exposure therapy is used by both the Department of Defense for treating active duty service members as well as the Department of Veterans Affairs for treating veteran patients for PTSD.

The use of exposure therapy by these governmental departments is based on its proven efficacy to date.

Taylor, 2004

Exposure therapy, together with EMDR (discussed further below), are the two most effective treatments for PTSD available at present.

Many of the studies to date are flawed.

Rothbaum & Schwartz, 2002

The efficacy of exposure treatment for PTSD was first demonstrated with several case reports on war veterans. To date, exposure therapy has more empirical evidence for its efficacy than any other treatment developed for the treatment of trauma-related symptoms.

Reviews of the extant literature on the treatment of PTSD are quite positive regarding exposure therapy.

Burke, H.S., Degeneffe, C.E. & Olney, M.F., 2009, p. 6

The cognitive behavioral technique of exposure therapy has been found to be effective in treating panic disorders, phobias and PTSD in a wide range of populations including combat veterans.

Exposure therapy involves gradual exposure of the traumatized person to the stimuli that trigger a fear reaction while in a safe and supportive environment. Creative uses of exposure techniques using computer technology have proven to be both practical and effective.

Sharpless and Barber conclude that, "Exposure therapy in general, and prolonged exposure in particular, has been found to be highly effective in reducing PTSD symptoms and of all the PTSD treatments heretofore described (both pharmacological and psychological) likely possesses the most evidence in favor of its efficacy" (2011, p. 38). Based on the positive results obtained using prolonged exposure in treating PTSD sufferers thus far, prolonged exposure was one of just two psychotherapies that have been selected by the Department of Veterans Affairs and the armed forces for widespread use (Sharpless & Barber, 2011). The use of prolonged exposure therapy is bolstered by the findings of a recent study by Hagenaars and van Minnen (2011) that identified negative association between posttraumatic growth and PTSD. Follow-up evaluation by Hagenaars and van Minnen (2011) determined that avoidance (particularly emotional numbing) was negatively related to posttraumatic growth, whereas reexperiences and arousal were not. "This suggests that the inability to feel emotions is related to an inability to experience growth" (Hagenaars & van Minnen, 2011, p. 506).

It remains unclear, though, whether treatments should be adjusted to increase posttraumatic growth, or that posttraumatic growth just adds a new perspective to existing psychotherapies (Hagenaars & van Minne, 2011). Irrespective, the research to date does suggest that prolonged exposure is efficacious in the treatment of PTSD symptoms associated with a variety of traumas including combat. According to Rauch, Defever, Favorite, Duroe, Garrity, Morris and Liberzon (2011), "Prolonged exposure significantly reduces PTSD symptoms, general anxiety, depression, guilt, and anger. Prolonged exposure is a first line treatment for PTSD symptoms including a guideline for treatment of PTSD in returning veterans from Iraq and Afghanistan. Nevertheless, PE is often not accessible to veterans seeking PTSD treatment in the VA system" (p. 60).

Interpersonal Psychotherapy (IPT)

In the alternative, Rafaeli and Markowitz (2011) report that the use of Interpersonal Psychotherapy (IPT) has also demonstrated some positive clinical outcomes in recent years among veterans. Described as a "a time-limited, evidence-based treatment" by these researchers, Rafeali and Markowitz add that the intervention "has shown efficacy in treating major depressive disorder and other psychiatric conditions [and] initial evidence suggests that IPT may also benefit patients with PTSD" (p. 206). There are at least two rationales for testing IPT for this population:

1. IPT does not utilize exposure to trauma reminders. Although extensive evidence supports the efficacy of exposure-based therapies for PTSD, IPT offers an alternative to patients who may refuse exposure techniques or not respond to them. Highly traumatized patients who dissociate may fare better receiving affect-focused therapy than exposure-based therapy.

2. IPT works by improving patients' interpersonal functioning and emotion regulation, which are commonly impaired in PTSD and therefore, important targets for change. Social support, which IPT helps patients to mobilize, has been shown to be a key factor in preventing and recovering from PTSD (Rafaeli & Markowitz, 2011).

In contrast to exposure-based CBT approaches, IPT eschews focusing on the trauma and instead concentrates on the patient's current life events, particularly on social and interpersonal aspects

(Rafaeli & Markowitz, 2011). The basic premise of IPT for PTSD is trauma shatters the patient's sense of interpersonal safety, leading to withdrawal from interpersonal relationships and impaired ability to use social supports to process the traumatic event. By withdrawing, individuals with PTSD cut off vital social supports needed when they are most vulnerable. Because they are interpersonally hypervigilant, emotionally detached or dysregulated, patients with PTSD mistrust relationships. Interpersonal Psychotherapy helps the patient to understand rather than avoid feelings, to tolerate such affects, to use them to enhance communication and effectively manage interactions with others, and thereby, to rebuild interpersonal trust. Finding ways to reconnect meaningfully to one's surrounding world may reinstate severed social networks and reduce PTSD symptoms (Rafaeli & Markowitz, 2011).

A summary of recent studies concerning the efficacy of the use of IPT in the treatment of PTSD is provided in Table __ below.

Table

Summary of IPT Studies in the Treatment of PTSD

Source

Key Findings

Comments

Rafaeli & Markowitz, 2011, p. 206

IPT is efficacious in treating major depression, bulimia, and other conditions, including PTSD, based on initial evidence.

IPT helps patients understand rather than avoid feelings, to tolerate such affects, to use them to enhance communication and effectively manage interactions with others, and thereby, to rebuild interpersonal trust. Finding ways to reconnect meaningfully to one's surrounding world may reinstate severed social networks and reduce PTSD symptoms.

Agras et al., 2000

IPT is normally a brief treatment, usually administered in the acute phase of depression. Therapy starts with a diagnostic phase, in which the patient's disorder is identified and explained. The therapist highlights the ways in which the patient's current functioning, social relationships, and expectations within these relationships may have been causal in the depression.

There is an educational aspect to this process, whereby the therapist links depressive symptoms to one of four interpersonal areas: grief, interpersonal role disputes, role transitions, or interpersonal deficits. In the second phase of treatment, the therapist pursues strategies specific to one of these problem areas

Wilfley, Mackenzie, Welch, Ayres & Weissman, 2000, p. 4

IPT has been studied in various populations including the elderly, adolescents, couples, and patients with comorbid medical conditions such as human immunodeficiency virus. In addition, a number of new research applications are currently under investigation for various disorders, including dysthymia, posttraumatic stress disorder, social phobia, body dysmorphic disorder, chronic somatization, borderline personality disorder, and anorexia nervosa.

IPT has been translated into several languages and modified for group as well as for long-term treatment.

Weissman, Markowitz & Klerman, 2000, p. 5

IPT is a focused, time-limited psychotherapy that emphasizes the link between mood and the current interpersonal relations of the depressed patient while recognizing the roles of genetic, biochemical, developmental, and personality factors in the causation of and vulnerability to depression.

IPT is not a causal explanation for depression, but a pragmatic treatment for it

Group Therapy Techniques

Because different sources of social support may have differing effects on recovery from PTSD, many combat veterans find group therapy more effective since it offers an opportunity for sharing experiences that others will likely not fully understand. According to Laffaye, Cavella, Drescher and Rosen (2008), "The association between PTSD and relationship difficulties among male veterans has been well documented. However, despite the clinical emphasis on the importance of peer relationships among veterans with PTSD stemming from military trauma, there is no research on the specific effect of these relationships on PTSD symptoms. A key rationale for the widespread use of group psychotherapy with veterans is that groups provide an opportunity for validation and support from peers" (p. 394).

The use of group psychotherapeutic interventions is based on the rationale that combat veterans are a "band of brothers" who share a common experience that others cannot fully grasp.

"In our own clinical experience, veterans in treatment often report that they have better relationships with other veterans than with nonveterans, and they view such peer relationships as important to their recovery. However, to our knowledge, no research has specifically examined the role of veteran-to-veteran support in recovery from PTSD. Lack of social support is a posttrauma risk factor for the development of PTSD among Vietnam veterans. The link between low social support and the development of PTSD has also been found in cross-sectional and retrospective studies using civilian samples, including among adults who were living in New York City on September 11, 2001, victims of violent crimes, and female victims of both sexual and nonsexual assault" (Laffeye et al., 2008, p. 395).

A summary of studies concerning the use of group therapy for treating PTSD in general and for combat veterans in particular is provided in Table __ below.

Table

Summary of Group Therapy Studies in the Treatment of PTSD

Source

Key Findings

Comments

Armstrong & Rose, 1997

Because partners of combat veterans often speak of their sense of isolation and disconnection from others, group psychotherapy seemed a logical approach to addressing these problems.

Further group therapy activities with this population could explore prevention of contagion factors of those who live with people with PTSD.

Southwick, Gilmartin, McDonough & Morrissey, 2006

The PTSD program at the Connecticut Veterans' Hospital provides treatment groups that focus on PTSD psychoeducation, psychosocial skill building, substance abuse, anger management and relaxation techniques.

In the outpatient treatment group, each member contributes uniquely to the collective process and fills a valued role in the group (writer, spokesman, computer expert) in contrast to previous negative identities ("psych" patient, disabled veteran).

Von Lunen, 2010

Outpatient PTSD program at Fort Hood, known as the Warrior Combat Stress Reset Program, is an intensive outpatient treatment designed to help service members who are experiencing hyperarousal. When soldiers begin the program, they go through extensive psychological testing. Clinicians report a general 10% decrease in PTSD assessment scores and upon later follow-up, another 10% drop. What distinguishes Reset from other similar PTSD treatment programs is its integrative approach, combining traditional and alternative therapies.

Some Warrior Combat Stress Reset soldiers have recently returned from their first deployment; others have been home a year or more. Clinically, the more times people are deployed, the more likely they are to develop PTSD. The components of the interdisciplinary Reset program include:

1. Group counseling.

2. Self-regulation and biofeedback.

3. Coping-skills education training.

4. Individual counseling.

5. Movement exercises,

6. Alternative therapies (i.e., massage, acupuncture, yoga, Reiki).

7. Directed homework assignments.

Eye Movement Desensitization and Reprocessing (EMDR)

So-called Eye Movement Desensitization and Reprocessing (EMDR) therapy has been used in the treatment of traumatized victims in a number of settings. In fact, since it introduction in 1990, EMDR has "become the most researched treatment for post-traumatic stress disorder (PTSD) and its efficacy has been widely recognized. Nevertheless, controversy concerning the efficacy and appropriateness of the treatment modality remains. According to the definition provided by one therapist, "EMDR is a comprehensive treatment protocol in which the client attends to emotionally disturbing material in short sequential doses while simultaneously focusing on an external stimulus (therapist-directed eye movements, hand-tapping, auditory tones)" (Figley, 2002, p. 148).

Although the intervention is not widely viewed as a "cure-all" approach, Protinsky, Sparks and Flemke (2001) report that, based on their clinical practice, "EMDR as an intervention seems to fit well within an emotionally and experientially-based treatment approach and can increase its therapeutic effectiveness" (p. 158). In a number of other cases, though, the efficacy of EMDR approaches the Panglossian according to many clinicians that have used the modality in their own practices. In this regard, McCabe (2004) emphasizes that:

While many treatment modalities can provide relief to patients experiencing traumatic memories, perhaps none is so acclaimed, so scorned, or so steeped in controversy as eye movement desensitization and reprocessing. Reasons why this therapeutic intervention is gaining popularity include the apparent simplicity of the procedure and reports of dramatic, rapid improvement after only brief treatment with EMDR. Yet while volumes of case and anecdotal reports attest to the value of EMDR in reducing complex patient symptoms, questions linger regarding the scientific bases and empirical evidence supporting rational use of the modality. (p. 105)

Notwithstanding the questions that remain outstanding, there is a growing body of evidence concerning the efficacy of EMDR in the treatment of PTSD in general and among combat veterans in particular as described further in Table __ below.

Table

Summary of EMDR Studies in the Treatment of PTSD

Source

Key Findings

Comments

Burke et al., 2009, p. 6

EMDR entails identifying a traumatic memory, having the individual articulate a negative and positive thought associated with the targeted memory, and then tracking the therapist's fingers back and forth as they moved in front of their eyes while focusing on the negative memory.

Assessment of belief of the positive or negative thought would be recorded and the procedure repeats until positive beliefs increased and anguish decreased.

Boudewyns, Stwertka, Hyer, Albrecht, & Sperr, 1993; Pitman et al., 1996

EMDR appears to be as effective as CBT in treating PTSD among Vietnam combat veterans and may require less time and be less painful compared to exposure therapy.

EMDR, with its alternating dosed exposure and client-directed focus, seems to be better tolerated and preferred over exposure therapy by both clients and therapists. It is important to note that the Boudewyns et al. study (1996) involved combat veterans who also received adjunctive concurrent treatments, thereby confounding the effect of the experimental conditions, and making it impossible to determine the unique effects of the EMDR intervention.

Van Etten & Taylor (1998)

Psychological therapies were more effective than drug therapies, and of these, CBT and EMDR were most effective.

The high drop-out rate in this study (36%) suggests that serotonin specific reuptake inhibitors (SSRIs) may not be a treatment of choice for PTSD.