PTSD treatment modalities in combat veterans returning from Iraq and Afghanistan

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.

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.

Chambless et al. (1998)

EMDR, exposure therapy, and stress inoculation therapy were all judged "probably efficacious treatments."

No other therapies were deemed to be empirically supported by controlled research for any PTSD population.

Chemtob, Tolin, van der Kolk, & Pitman, 2000; Rothbaum, Meadows, Resick, & Foy, 2000

EMDR was designated as being an efficacious treatment for PTSD.

CBT was also so designated.

Carlson, Chemtob, Rusnak, Hedlund, and Muraoka (1998)

Thirty-five (35) Vietnam combat veterans with an adequate course of treatment (12 sessions). EMDR was compared to wait-list and to biofeedback relaxation, and resulted in significantly lower scores on measures of PTSD and self-reported symptoms. Both treatment groups and the wait-list control showed significant improvement on physiological measures, with no differences between groups, and with the decrease in physiological arousal maintained at 3-month follow-up.

At 9-month follow-up, 78% of the EMDR subjects no longer met diagnostic criteria for PTSD.

McCabe (2004)

EMDR has most consistently been used as a treatment modality for PTSD. EMDR use remains controversial. Although it is safe, little is known regarding the mechanism of action of any therapeutic effect; more rigorous empirical establishment of efficacy is needed. Proponents of EMDR maintain that the modality should only be used by licensed mental health providers who are adequately trained in its use. To date, more than 20,000 mental health professionals have been formally trained. Standards set by the EMDR International Association require a minimum of 18 hours of lecture content accompanied by 13 supervised clinical hours, with 31 hours of training seen as the minimal training before a provider should attempt EMDR with patients. While some trainers have provided less rigorous workshop trainings, the EMDR International Association criteria are widely accepted.

EMDR shares goals common to other desensitization therapies, with a chief aim of making individuals so accustomed to the traumatic memories that these lose their distress-inducing capacity. Although additional stringency for approved trainers, consultants, and supervisors has been identified by the EMDR International Association, there continues to be no legislative or regulatory restriction on untrained clinicians performing this procedure with patients.

Finally, the results of a recent study by Matsumura, Noguchi, Nishi and Matsuoka (2012) suggest that dietary supplementation with omega-3 fatty acids (otherwise known as fish oil) immediately after the occurrence of a traumatic event could be effective in the secondary prevention of PTSD.

Proposed Project Method

Research Method. Qualitative researchers have a number of methods available to them, including historical methodology, ethnography, phenomenology, hermeneutics, field-based case study, grounded theory and action research (Burton & Steane, 2004) as well as evaluation or program research (Babbie, 2001). Given the purpose and focus of this study, a program research approach was deemed most suitable because it provides is a form of applied research that can be used to evaluate the effectiveness of social programs or interventions (Babbie, 2001). According to Babbie, "The topics appropriate to evaluation research are limitless. When the federal government abolished the selective service system (the draft), military researchers began paying special attention to the impact on enlistment. As individual states have legalized marijuana, researchers have sought to learn the consequences, both for marijuana use and other forms of social behavior" (2001, p. 333). A program research approach can also incorporate both quantitative and qualitative data in the analysis. In this regard, Babbie emphasizes that, "The most effective evaluation research is one that combines qualitative and quantitative components. While making statistical comparisons is useful, so is gaining an in-depth understanding of the processes producing the results-or preventing the expected results from appearing" (2001, p. 344).

Data-Collection Procedures. The data for this study were secondary peer-reviewed journal articles published within the last few years concerning the etiology of PTSD, including its causes, symptoms and treatments. Other data consulted included reliable online research resources such as EBSCO and Questia, using key word searches such as "post-traumatic stress disorder," "PTSD," "combat veterans," "Iraq," "Afghanistan," and so forth, using appropriate Boolean search delimiters. This approach is congruent with the guidance provided by Dennis and Harris who advise, "Secondary data are information that has been collected earlier for a different purpose, but which may still be useful to the research project under consideration" (2002, p. 39). The data collected with be synthesized in the findings below, followed by a summary of the research and a discussion of these findings in the concluding chapter.

Findings

The research showed that the psychological symptoms of PTSD are categorized into three general clusters: (a) reexperiencing, (b) avoidance/numbing, and (c) increased arousal. The first cluster (reexperiencing symptoms such as nightmares, flashbacks) is widely regarded as the defining characteristic of PTSD. The second cluster is comprised of symptoms that involve effortful avoidance (in other words, intentionally taking steps to avoid trauma-related stimuli) and symptoms of emotional numbing which are also widely regarded as being distinguishing features of PTSD. Finally, the third symptom cluster, increased arousal, involves experiencing symptoms such as difficulty sleeping, hypervigilance, and irritability.

The research also showed that the current estimated prevalence of PTSD among service members returning from combat duty in the Middle East is comparable to the prevalence rates experienced in America's previous wars (Vasterling et al., 2010). The research also showed that while noncombat veterans can also develop PTSD, not surprisingly, the incidence is far higher among combat veterans because of the traumatizing nature of these types of experiences, particularly for service members who may be predisposed to the condition by virtue of early life stress episodes or potential genetic factors. This finding is congruent with Vasterling et al.'s observation that, "Military deployment to Iraq is associated with pre- to post-deployment increases in PTSD symptoms, even after adjusting for baseline levels of PTSD symptoms. Nondeployed soldiers did not show symptom increases, suggesting that pre- to post-deployment increases could not be attributed to nonspecific factors inherent to military life" (p. 48).

Other salient findings that emerged from the research was that while no universal "one-size-fits-all" approach is available for treating PTSD, there are a number of treatment modalities being used with differing results as summarized in Table __ below.

Table

Comparison of Cognitive-Behavioral Therapy, Psycho/pharmacological, Group Therapy and EMDR Treatment Modalities

Cognitive-Behavioral Therapy (CBT)

Psycho / pharmacological

Group Therapy

EMDR

Core aspect of therapy

Working with conditions to change emotions, thoughts, and behaviors.

Medications targeted at discrete symptom clusters.

Using group factors of cohesion, safety, universality, and problem solving to reduce symptoms through shared experiences.

Eye move-ments, hand taps, sounds used to create an alteration in distress level of intrusive memories.

Level on evidence of efficacy

High

High

High

Low to moderate

Level of acceptance

High

High

Moderate

Moderate

Source: Adapted from McCabe, 2004, p. 105

Based on this author's personal experiences (I am a 2 tour combat veteran of Iraq, 2003-2004, Operation Iraqi Freedom, 2004-2005 Abu Ghraib prison; after the scandal). I was combat medic who has been diagnosed by the Department of Veterans Affairs as suffering from PTSD and my prevalent symptoms are hypervigilance, nightmares, irritability, and work-related difficulties. My original research pursuit was a treatment modality that has stood the test of time. The search for a "magic bullet" cure has made me realize that there is no cure, just symptom management. My own treatment has been 8 wks of a psycho-ed symptom management class and 12 weeks of CPT. To date, I have no experience as of yet with EMDR Eye Movement Desensitization and Reprocessing but the several studies reviewed indicate that this may be a viable treatment alternative.

Conclusions and Discussion

Conclusions. The findings that emerged from this review of the causes, symptoms and treatments for PTSD confirm the lack of a universally applicable treatment model, and virtually all authorities agree that patients will benefit from the most individualized treatment plan possible. Since the healthcare world is imperfect, identifying what works best for most people most of the time is therefore necessary. In this regard, 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).

Discussion. It is not surprising that some combat veterans may not want to subject themselves to prolonged exposure therapy. After all, many of these American heroes are already suffering as a result of reliving past traumatic episodes and there is a "Clockwork Orange" quality about the concept of forcing people to become desensitized to trauma by exposing them to it over and over. Despite this constraint, the alternative, IPT, may likewise be less than effective if PTSD sufferers do not have the support system in place that is needed over the long-term in the treatment of this condition. It is also not surprising that the rates of PTSD among combat veterans returning from tours of duty in Iraq and Afghanistan are so high. The recent shooting rampage by an American soldier in Afghanistan, for instance (the second such incident), underscores just how eerie military service can be for those service members deployed to these regions. In this regard, Burke, Degeneffe & Olney (2009) emphasize that this theater of operations is almost designed to produce PTSD in American service members. According to these clinicians, "Deployments into volatile combat conditions in Iraq, in which the rules of engagement are often strained due to concern of collateral damage, can result in a prolonged experience of stress and anxiety. These environmental elements can result in disproportionate release of stress hormones with likely detrimental consequences impacting coping ability, health preservation and restitution" (p. 6). In sum, then, although the current estimates of the prevalence and incidence of PTSD among combat veterans returning from tours of duty in Iraq and Afghanistan are already alarming, it is reasonable to conclude that these rates will climb dramatically in the future as diagnostic methods are fine-tuned and more veterans begin to experience the long-term and debilitating effects of PTSD in the future.