The Andrew Brannan case and treatment of combat-related PTSD

Trauma-Related Disorders and Recommended Treatment

Clinical Presentation of Trauma-Related Disorders and Recommended Treatments

On January 13, 2015, Andrew Brannan, a 66-year-old Vietnam veteran was executed in Georgia for killing police officer Kyle Dinkheller in 1998 (Hoffman, 2015). At the time, Brannan had been living in a bunker on his mother's property without water or electricity and had stopped taking his medications. According to the Veterans Administration (VA), he was 100% disabled due to combat-related post-traumatic stress disorder (PTSD). He also suffered from bipolar disorder, had lost two brothers to a military plane crash and suicide, and lost a father to cancer. Veterans groups, death penalty critics, and mental health advocates, all petitioned the Georgia Supreme Court for a stay of execution unsuccessfully. The veterans groups were particularly interested in preventing the death of yet another veteran who developed severe psychiatric problems while serving his or her country.

Trauma in general has affected a substantial portion of the estimated 2.6 million military personnel who have served in Iraq and Afghanistan (Ruiz, 2013). Over a million have suffered non-lethal injuries and approximately one sixth will receive a diagnosis of PTSD (Dursa, Reinhard, Barth, & Schneiderman, 2014). These figures should not be surprising given that 60 to 90% of all service members who have served in Afghanistan and Iraq have been ambushed, shot at, survived rocket or mortar attacks, or know someone who was killed or seriously injured in combat (VAHC, 2014). An unknown number have also been exposed to sexual harassment and assault.

Even if combat exposure is excluded, the American public is no stranger to trauma. As Jones and Cureton (2014) point out, close to 80% of all individuals seeking mental health services in the U.S. have suffered a traumatic event. From their perspective, trauma exposure has reached epidemic levels as the United States entered the first part of the 21st century. Among the most common sources of trauma exposure is school and community violence. Jones and Cureton (2014) also argue that trauma-induced mental health problems are among the most controversial diagnostically, second only to dissociative identity disorder. This is reflected in the substantial changes that have been made to the diagnostic boundaries, symptoms, assumptions, and clinical utility associated with a diagnosis of PTSD in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). To better understand how trauma affects mental health, recent research publications and expert opinions concerning the epidemiology, etiology, diagnosis, and treatment of PTSD, and its related disorders, will be critically reviewed here.

Trauma Epidemiology

Recent estimates suggest the prevalence of PTSD among past and current service members who saw combat in Afghanistan and Iraq is approximately 15.7%, compared to 10.9% among service members never exposed to combat (Dursa et al., 2014). By comparison, the 12-month prevalence for PTSD was 1.8 and 5.2% among civilian adult men and women, respectively; whereas, the lifetime prevalence of PTSD among adult men and women is 3.6 and 9.7%, respectively (Gradus, 2014). These rates have been stable since the early 90s, but based on these statistics, simply serving in the military without combat exposure increases the risk of developing PTSD substantially.

PTSD prevalence rates, however, tends to hide important considerations from a clinical perspective. According to a recent study, American civilians least likely to seek mental health services for trauma in Southern California are male, African-American, poor, and lack mental health literacy (Ghafoori, Barragan, & Palinkas, 2014). More troubling was the finding that the higher the number of trauma exposures the less likely mental health services will be accessed. The most common traumatic events reported included physical assault and abuse, mugging, robbery, being threatened with a weapon, or being involved in a life-threatening accident. Interestingly, study participants with a history of sexual assault were more likely to have sought mental health services. In terms of mental disorder diagnosis, between 40 and 50% of study participants met the criteria for PTSD, generalized anxiety disorder (GAD), and/or depression. Reported symptoms included emotional pain, avoidance, irritability, sadness, anxiety, hopelessness, and depression. The psychosocial effects included unemployment, economic stress, and social problems. Among the reasons given for not seeking treatment was anxiety over unwanted side effects of medication and having to revisit the traumatic event(s).

Etiology and Diagnosis

Trauma- and stressor-related disorders is an umbrella classification for any psychological disorder where a diagnosis requires trauma exposure or severe stress as part of the etiology (APA, 2013, p. 265). This includes PTSD, acute stress disorder, reactive attachment disorder, disinhibited social engagement disorder, and adjustment disorders. Individuals can react to traumatic or extremely stressful events in a variety of ways, besides clinically severe anxiety or fear, such as anhedonia, dysphoria, anger, aggression, and/or dissociation. The current PTSD diagnostic criteria for anyone over the age of 6 includes direct or secondhand exposure to a traumatic event, avoidance behaviors, negative affect and behaviors, sleep problems, impaired social or occupational functioning, and/or intrusive memories, dreams, somatic reactions, or reliving of the event (APA, 2013, pp. 271-280). Secondhand exposure for anyone over the age of 6 is limited to witnessing an unnatural or threatened death, serious injury, medical catastrophe, war, disasters, or sexual assault involving another person, or learning of a close family member or friend experiencing unnatural death, serious injury, sexual assault, disaster, or suicide. Exposure to trauma through news and electronic media is excluded diagnostically, unless the exposure is required by work-related obligations. When a child 6-years of age or younger is exposed to trauma indirectly the person traumatized must be a caregiver to meet PTSD diagnostic criteria. A diagnosis of PTSD is appropriate when symptoms last for more than a month and cannot be attributed to a medical condition or pharmacological agents (APA, 2013, pp. 271-280). A PTSD diagnosis may earn a qualifier if manifestation of symptoms is delayed for months or accompanied by dissociative symptoms.

The traumas experienced directly that can trigger PTSD symptoms include combat, actual or threatened physical assault, actual or threatened sexual violence, kidnapping/hostage/prisoner of war, torture, severe automotive accident, or exposure to a terrorist attack, natural disaster, or man-made disaster (APA, 2013, p. 274). More specifically, diagnostically-relevant traumas include criminal victimization, rape, abusive sexual contact, sexual harassment, sexual trafficking, and experiencing sudden, catastrophic medical events, such as waking during surgery or anaphylactic shock. In children, merely experiencing developmentally-inappropriate sexual events in the absence of violence or injury can elicit clinically-relevant symptoms. When the trauma is inflicted intentionally by another person the symptoms are often severe and long-lasting. Obvious examples if the intentional infliction of trauma would be torture and sexual assault.

PTSD Risk Factors

Not everyone exposed to trauma will develop PTSD symptoms. For example, exposure to combat elicited PTSD symptoms in 15.7% of American troops serving in Iraq or Afghanistan (Dursa et al., 2014). This statistic implies that some individuals are predisposed to developing trauma-related mental health issues compared to others. Some of these risk factors include age, such that younger adults will more likely develop symptoms when compared to older adults (APA, 2013, pp. 277-278). A history of childhood emotional problems manifesting before age 6 is another risk factor, as is prior exposure to traumatic events. A history of externalizing behaviors, anxiety problems, panic disorder, depression, obsessive-compulsive disorder, and PTSD are all risk factors. Low socioeconomic status, cultural traditions, academic achievement, race/ethnicity, family mental health history, genetics, social isolation, and cognitive impairment are factors that can modify risk. In addition, the severity and duration of trauma exposure are important determinants, as are poor coping strategies in the aftermath of exposure.

Comorbidity

Comorbidity is very common among PTSD patients (APA, 2013, p. 280). Major depression, bipolar, anxiety, and substance abuse disorders are among the most common. The prevalence of mild traumatic brain injury among Iraq and Afghanistan War veterans suffering from PTSD, for example, was found to be 48%. Comorbidity among children, however, is distinct from adult patterns, with oppositional defiant and separation anxiety disorders representing the most common conditions. Major neurocognitive disorder is closely related to delirium and dementia, but many of the symptoms for this disorder are often shared with PTSD sufferers, resulting in a dual diagnosis.

PTSD Controversy

The prevalence of PTSD comorbidities should not be surprising since most mental disorders emerge within patients having a history of adversity (Paris, 2013, p. 125). Biological and social factors also contribute to the prevalence of trauma-related disorders; therefore, the etiological complexity of PTSD undermines the common belief that authors of diagnostic manuals understand PTSD etiology, at least according to Joel Paris (2013). From his perspective, it is more useful to consider the fact that most people exposed to trauma do not develop PTSD and those who do, have had mental health issues in the past. The 12-month PTSD prevalence rate of 1.8 and 5.2% for adult U.S. men and women (Gradus, 2014), respectively, supports Paris's (2013) argument, since an estimated 25% of the U.S. population in 2004 reported suffering from a mental illness during the preceding year (Reeves et al., 2011, p. 1).

The DSM published by the American Psychiatric Association (APA) has included PTSD for the past three editions, but the diagnostic criteria have expanded with each revision (Paris, 2013, p. 126). According to Paris (2013) the increasingly inclusive diagnostic criteria undermine research efforts and encourage clinicians to make incorrect associations between symptoms and past events. For example, the most common reaction to trauma exposure is resilience and recovery; therefore, it is important to consider the underlying personality traits that modify the risk of developing PTSD. Paris (2013) further criticized the inclusion of dissociative and aggression symptoms in the latest DSM version, DSM-5, because these symptoms can also manifest in individuals suffering from personality disorders. Paris (2013) recommends that clinicians limit PTSD diagnoses to individuals whose lives have been truly compromised by flashbacks and avoidance behaviors lasting months and years. According to the DSM-5, the functional consequences of PTSD include severe social, occupational, and physical disability (APA, 2013, p. 279) and may include suicide ideation and attempts. The possibility of personality disorders representing an important and prevalent predisposing factor for PTSD development, however, has been undermined by the findings of a recent empirical study examining more than a dozen adults suffering from PTSD and childhood trauma (Thornback, Muller, & Rosenkranz, 2014). Based on their analysis, personality disorder features were not predictive of trauma treatment efficacy and trauma recovery occurred despite persistent personality disorder features.

Evidence-Based Treatment (EBT) Approaches

Over 250 VA clinical staff providing mental health services to veterans in 38 residential treatment programs were asked about the efficacy of different treatment modalities (Cook et al., 2014). The occupations of study participants included psychiatrist, psychologist, social worker, nurse, and administrator. The greatest consensus was reached in favor of evidence-based treatment (EBT) and milieu therapy, which 25 and 23% of participants, respectively, believed provided the greatest reductions in PTSD symptoms for combat veterans. By comparison, only 5 and 4% of participants believed psychoeducation and cognitive restructuring, respectively, were effective, despite considerable effort to promote these EBT approaches system-wide. Cognitive restructuring is an important element of cognitive processing therapy (CPT), an approach that has been shown repeatedly to be among the most effective treatment paradigms for PTSD.

Milieu therapy attempts to create an environment within which healing from trauma can take place, primarily by offering practical coping strategies (Lawson, 1998). The five components of milieu therapy are "containment, structure, support, involvement, and validation" (p. 100). Containment is possible when clinicians are able to create a place of safety, within which trauma victims can come to terms with their experiences. The clinician traits needed for this to happen include being knowledgeable, empathic, and physically strong without being intimidating. Clinicians must also be on guard against secondary trauma and employ methods of social interactions that create and maintain barriers; barriers designed to help a child, teenager, or adult feel safe. Signs of successful containment include reductions in aggression, suicidal ideation, suicide attempts, and PTSD symptomology. A well-structured schedule helps traumatized children and adolescents begin to manage their emotions and circadian rhythms appropriately, learn to self-soothe, develop independence, and replace aggression with assertive discussion. Reaching these milestones is essential for beginning trauma recovery work. Support, involvement, and validation address PTSD symptoms by encouraging engagement in recovery activities. Common barriers include dissociation, fear of intimacy, and intolerance towards self due to perceived shortcomings. The benefits include improved self-esteem, healthy social risk-taking, reduced social anxiety, engagement in social activities, and resilience in the face of adversity.

Milieu therapy creates a therapeutic environment, within which a diverse array of therapeutic approaches can be implemented. Cognitive processing therapy, a form of cognitive behavioral therapy (CBT), has received a lot of attention as an evidenced-based therapy for U.S. combat veterans and adult survivors of childhood abuse suffering from PTSD. A recent meta-analysis revealed large and significant effect sizes for studies comparing trauma-focused CBT with wait-listed adult survivors of childhood abuse or treatment as usual (Ehring et al., 2014, p. 653). Trauma-focused CBT is designed to directly confront and work through trauma memories, in part by learning about PTSD symptoms, minimizing dissociation from internal experiences, developing the skills needed to cope with trauma-associated thoughts and feelings, and understanding how trauma changes a person's beliefs about the world in which they live. The authors of this study concluded that contrary to popular opinion, trauma-focused treatments do not put patient safety at risk by dredging up trauma memories. Based on their analysis, trauma-focused therapies are superior and the dropout rate of patients is similar to other therapeutic modalities.

A meta-analysis of studies examining the efficacy of treatment modalities for combat veterans suffering from PTSD revealed similar findings. The most consistent support among studies incorporating a control group was for exposure therapies, while a single controlled study examining CBT vs. wait-listed veterans revealed a large effect size consistent with other published findings (Goodson et al., 2011). The effect sizes for non-controlled studies using CBT or CPT were also large. In a separate study, VA clinicians favored EBT interventions for treating PTSD (25%), yet survey results revealed only 4 and 7.5% believed in vivo exposure and trauma processing groups, respectively, to be effective (Cook et al., 2014). These studies revealed significant problems with translating empirical findings into clinical practice.

The vast majority of PTSD treatment efficacy studies among combat veterans have relied on study samples taken from discharged veterans, yet many active duty service members develop PTSD following combat tours. To remedy this gap in the research literature, Resick and colleagues (2015) tested the relative efficacy of group CPT and group present-centered therapy. Present-centered therapy differs from CBT or CPT, because the focus is exclusively on how PTSD symptoms are affecting the patient's current life, rather than revisiting the trauma. Such an approach would be predicted to avoid adverse reactions due to clinic-triggered flashbacks, which many clinicians believe CBT and similar exposure therapies would cause (Ehring et al., 2014). The comparison between CPT and present-centered therapy revealed both were equally effective in reducing PTSD symptoms in combat-experienced active duty military personnel and the benefits persisted for at least 12-months (Resick et al., 2015). However, the number of adverse events was generally higher for present-centered therapy than for CPT during treatment (72 vs. 56%) and the follow-up period (42 vs. 16%). The adverse events more common in the present-centered therapy group during treatment included depression, suicidal ideation, suicide attempts, and pain. Post-treatment adverse events included homicidal ideation, substance abuse, and social disturbance. A comparison of study participant demographic traits revealed no significant differences, although a larger sample size (N = 108) may have conferred enough power for the number of deployments to reach significance, with the present-centered group having an average of 0.3 more deployments. This could explain the higher rate of adverse events among this treatment group.

Serving in the military provides its own special challenges, which may exacerbate PTSD symptomology (reviewed by Voelkel, Pukay-Martin, Walter, & Chard, 2015). While combat-induced PTSD has long been the focus of clinical researchers, effective treatment approaches for military sexual trauma victims has only recently begun to be studied in earnest. Estimates suggest that up to 71% of women who serve are victimized by sexual assault or persistent sexual harassment, while close to 1% of men experience the same. To better understand the efficacy of CPT for treating military sexual trauma, PTSD symptoms of men and women reporting or not reporting sexual victimization were compared before and after treatment. Overall, CPT effectively reduced PTSD symptoms for all groups, regardless of military sexual trauma history. Treatment, however, was more effective for women than men and men were assessed by clinicians as having more severe symptoms prior to treatment. The most common comorbidity for women was an anxiety disorder, while for men it was substance abuse. These findings reveal that CPT is effective for reducing PTSD symptoms severity and prevalence, regardless of the nature of the trauma.

Discussion

Most people react to trauma exposure with resilience and recovery, but a significant percentage will eventually develop PTSD. The lives of these children, adolescents, and adults can be dramatically degraded and their futures clouded unless mental health services are sought. Although pharmacological interventions have been widely dispensed by clinicians, the empirical evidence supporting their use for treating PTSD is inconsistent at best (e.g., Krystal et al., 2011). Seritonin-reuptake inhibitors (SSRIs) are the only agent the FDA has approved for treating PTSD, yet the efficacy of these antidepressants in relation to PTSD are limited (reviewed by Krystal et al., 2011); therefore, counseling remains the most consistently effective intervention for treating PTSD.

The number of possible counseling strategies that can be administered to help relieve the symptoms of PTSD is quite large, but the number of interventions garnering empirical support is quite limited. Exposure therapies, including CBT and CPT, are among the most intensely studied and come highly recommended by scientists, policymakers, and clinicians alike, but clinical implementation, at least in VA healthcare clinics, has received little support by clinicians. Despite a lack of motivation for translating research into clinical practice, treatment modalities encouraging trauma victims to revisit and reexamine trauma memories within a safe and supportive clinical environment tend to produce the greatest reduction in PTSD symptoms.

One study reviewed here revealed present-centered therapy was equally effective to CPT, which suggests that revisiting trauma-related memories may be unnecessary to obtain a significant clinical benefit (Resick et al., 2015). The CPT used in this study was limited to the cognitive component of CBT, which involved an examination of beliefs about trauma causation and testing those beliefs against facts. Accordingly, traditional CPT may have been more effective that present-centered therapy. In addition, the number of reported adverse events was higher during treatment and at follow-up for present-centered therapy. Although additional research is needed to validate the adverse event data, these finding suggest CBT and CPT remain the most effective and best-supported intervention for all adults suffering from PTSD.