Treatments for combat-related PTSD

Posttraumatic stress disorder (PTSD) is a very broad category involved in psychological disorders. PTSD is "consequence of terrifying occurrences, both natural and manmade, which shock the psychological system and violate core assumptions that life is predictable, safe, and secure" (Sharpless). Combat PTSD is common in soldiers that have experienced time in combat on the battlefield where they were exposed to many different traumatic scenes and situations. In the United States, the people that are involved with the treatment of combat PTSD are most likely employed by Veteran Affairs (VA). The treatments and therapies discussed will be prolonged exposure therapy, eye movement desensitization and reprocessing, cognitive processing therapy, drug therapy, and a few other therapies that are less practiced.

Psychotherapy

Prolonged Exposure Therapy (PE)

This type of therapy involves exposing the patient to traumatic or scary memories. In this treatment, there will most likely be from 8 to 15 sessions of this exposure. They will first be exposed to a past traumatic memory; following is an immediate discussion about the traumatic memory and, "in vivo exposure to safe, but traumarelated situations that the client fears and avoids".^[1] The goal of this therapy is "to reduce their emotional impact in terms of cognitive (thoughts), behavioral (behavior), or physiological effects (physical)".^[2] Slowed breathing techniques and educational information is also touched on in these sessions.

Eye Movement Desensitization and Reprocessing (EMDR)

There are eight phases of EMDR treatment. The therapy involves clients or patients to think of upsetting images while they track the therapist moves her fingers back and forth in front of the patient. Adding to that, the client is asked to think of positive thoughts while they follow the fingers back and forth, then they write down what they are thinking.^[1] This treatment is found to be similarly effective as exposure therapy.

EMDR is successful because of its neurophysiological basis. The development of PTSD is related to an error in the storage of the memory of the event. This dysfunction is often caused by the memory of the trauma being stored with the same emotionally arousing state that it was encoded in. Because of this, the information does not progress through the normal steps of integration and instead results in “continual activation” of the information by certain stimuli.^[3] This manifests itself in the common symptoms of flashbacks, nightmares, etc. It has also been hypothesized that these symptoms are the result of “repeated unsuccessful attempts of the information-processing mechanism to complete its own processing.”^[3]

The processing of emotionally arousing information results in an earlier activation of the amygdala and subsequently disrupts integration. This arousal causes the information from the trauma to be “stored as sensory fragments, with emotions experienced as physical states rather than verbally coded experiences free of excessive affective load.” ^[3] There is also evidence that PTSD symptoms correlate with neurobiological changes in the brain.

A proposed neurophysiological basis behind EMDR is that it mimics REM sleep, which plays a vital role in memory consolidation. Imaging studies suggest that “eye movements in both REM sleep and wakefulness activate similar cortical areas.”^[4] Thus, the reorientation facilitated by EMDR “shifts the brain into a memory processing mode” without “integration of traumatic memories into associative cortical networks without interference from hippocampally mediated episodic recall.”^[4] The information can then be integrated completely, which consequently weakens the episodic memory of the event and the associations it produced. The restoration of the pathway can lead to recovery from PTSD.

Some other theories are similar in that they propose a physiological component of PTSD, whether it be specific structures or hormones or a combination. It is an area that is still not fully understood.

Cognitive Processing Therapy (CBT)

This involves both cognitive (thinking) and exposure elements. It is a type of cognitive behavioral therapy that focuses on cognitive (thinking) interventions. There are usually 12 sessions of the treatment that involve writing and reading activities. In short, activities involved with this therapy include the clients being asked to write about their traumatic or scary memories in detail, and then read these memories to themselves daily and aloud in therapy sessions.^[1]

Other Therapies

Nightmare Therapy

Many veterans that suffer from combat-related PTSD sometimes suffer from reoccurring nightmares from past traumatic or scary experiences. The positive outcomes from this type of therapy suggest that it is highly effective. For this type of therapy, the therapist needs to select techniques for treatment that will help increase the understanding of the anxiety-producing features of the nightmares. These techniques should be based on the likely chance of getting rid of the nightmare or decreasing the anxiety-producing features of the nightmare.^[5] One form of treatment for nightmares is through learned lucid dreaming, causing one to become aware they are dreaming enabling a sense of control.^[6]

Trauma Group Therapy

In trauma group therapy, the groups range from 12 to 18 members and are completed over a 10 to 12 week period. The goal of the group therapy is help the patients remember and examine their war experiences so that they can work them in with the rest of their lives. They are encouraged to remember their experiences as clear as possible without hiding or omitting details. The group part of this therapy helps the veterans develop the feeling that they belong because of the other veterans that are experiencing the same problems. This allows them to establish positive relationships with other group therapy members. It provides a sort of safe and supportive peer group.^[7]

Virtual Reality Therapy

Virtual Reality or VR technology is now being introduced to help treat patients with PTSD. Researchers began experimenting with VR in 1997 with the advent of the “Virtual Vietnam” scenario. Virtual Vietnam was used as a graduated exposure therapy treatment for Vietnam veterans meeting the qualification criteria for PTSD. A 50-year-old Caucasian male was the first veteran studied. The results concluded improvement post-treatment across all measures of PTSD and maintenance of the gains at the 6-month follow up. Subsequent open clinical trial of Virtual Vietnam using 16 veterans, showed a major reduction in PTSD symptoms. Positive results are being shown using VR for treating people suffering from PTSD after a traumatic event.^[8]

Soul and Energy based Healing Methods

Psychotherapy, translated from the original Greek, means therapy of the psyche, or the soul. As part of the healing process, PTSD sufferers need to make peace with their dead friends, relatives, ancestors, and others that they had a relationship with. Accepting their presence is critical in healing the trauma of death and pain for the survivors. Allowing themselves to feel the pain, to grieve and forgive, re-humanizing and honoring the other, makes the soul return to its initial healed state. Alternative PTSD treatment, such as shamanic healing, Emotional Freedom Techniques (EFT), BodyTalk and others, address the necessary elements to heal the psyche in its core.

Transcendental Meditation technique

The David Lynch Foundation works with the US Department of Veterans Affairs to give the Transcendental Meditation technique to veterans.^[9] Foundation launches in 2006 "Operation Warrior Wellness".^[10] Recent research shows that regular practice of Transcendental Meditation enables some active duty service members battling post-traumatic stress disorder to reduce or even eliminate their psychotropic medication and get better control of their often-debilitating symptoms, researchers report in the journal Military Medicine.^[11] Transcendental Meditation technique shows marked efficacy in treating anxiety disorders says a meta-analysis of randomized controlled trials, "TM practice is more effective than treatment as usual and most alternative treatments, with greatest effects observed in individuals with high anxiety."^[12] And a meta-analysis says: "Differential effects of relaxation techniques on trait anxiety: a meta-analysis. Effect sizes for the different treatments (e.g., Progressive Relaxation, EMG Biofeedback, various forms of meditation, etc.) were calculated. Most of the treatments produced similar effect sizes except that Transcendental Meditation had significantly larger effect size (p less than .005)" ^[13]

Pharmacotherapy

Drug therapy, known as pharmacotherapy, is widely used as a treatment for PTSD. Drug therapy is considered less time consuming and easier to continue than psychotherapy (talk therapy) but it is encouraged for patients who participate in pharmacotherapy to also participate in psychotherapy (talk therapy) simultaneously. The key to successful medication treatment is matching the medicine to the patient. In particular, antidepressants are highly used in the treatment of PTSD because of the likelihood of depression involved with PTSD patients. The most popular types of medications for drug therapies are monoamine oxidase inhibitors (MAO), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), mostly focusing on SSRIs because MAOIs and tricyclics have more harmful side effects.^[14]

Selective Seretonin Reuptake Inhibitors (SSRIs)

The only two medications for PTSD that are approved by the FDA and have the strongest empirical evidence of being safe and well tolerated are SSRIs called Paxil and Zoloft. Paxil and Zoloft are ranked as the first-line (first choice) treatments for PTSD. These medications focus on the neurotransmitter serotonin and are helpful in regulating mood, anxiety, appetite, and sleep.^[15] They increase the amount of serotonin, contributing to a more positive mood. To achieve maximum benefits from SSRIs, treatment focuses on the correct dosages and duration of treatment. According to the APA Practice Guidelines, "SSRIs have proven efficacy for PTSD symptoms and related functional problems".^[16]

Tricyclic Antidepressants

There is not as much research to support TCAs' effectiveness as there is for SSRIs. If a patient did not respond to or tolerate SSRIs, the therapist might move on to prescribing a TCA. Some studies have shown them to be more effective than the placebo which allows them to still have a role in the treatment of PTSD.^[16]

Monoamine Oxidase Inhibitors (MAOIs)

MAOIs are a third-line medication if other medications like SSRIs and TCAs proved ineffective for a patient. They are third-line due to the possible side effects and the strict diet (minimizing dietary intake of the amino acid tyramine) patients have to adopt while taking this type of medication. If patients observe the dietary restrictions, MAOIs can be clinically effective in reducing PTSD symptoms.^[16]

Additional Reading

Non-fiction

Coleman, P. (2006). Flashback: posttraumatic stress disorder, suicide, and the lessons of war. Boston: Beacon Press.

Esposito, M. (2008). PTSD: Get a Better understanding. Chicago, United States. (Electronic resource).

Graff, J. (2008). The Powerful Patient: After the battle post-traumatic stress. Chicago, United States. (Electronic resource).

Hoge, C. (2010). Once a warrior- always a warrior: navigating the transition from combat to home - including combat stress, PTSD, and mTBI. Guilford, Conn: GPP Life.

Jasper, M. (2009). Veterans' rights and benefits. New York: Oceana.

Lawhorne, C. P. (2010). Combat-related traumatic brain injury and PTSD: a resource and recovery guide. Lanham: Government Institutes.

Lawlis, G. F. (2010). The PTSD breakthrough: the revolutionary science-based compass reset program. Naperville: Sourcebooks.

Paulson, D. S. (2010). Haunted by combat : understanding PTSD in war veterans.

Fiction

Abbott, J. (2006). Fear. New York: Dutton.

Ellis, D. (2012). The wrong man. New York: G. P. Putnam's Sons.

Woolston, B. (2010). The freak observer. Minneapolis: Carolrhoda Lab.

References