Effective treatments for Post-Traumatic Stress Disorder (PTSD)

Abstract

This special assignment intends to study the effects of combat operations in the mental health of American combat soldiers and veterans. More specifically, the assignment will explore how combat operations contribute to Post Traumatic Stress Disorder (PTSD) on American soldiers along with exploring effective treatments. Comer (2015) defines PTSD as a traumatic incident in which an individual witnesses the death of other people, is at risk of death, suffers severe injury, and/or experiences sexual abuse or violation. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.); American Psychiatric Association [APA], (2013), which researchers and clinicians commonly accept as the official standard to diagnose mental health issues, officially recognizes PTSD as a serious mental health disorder. APA (2013) diagnosis criteria include individually experiencing or witnessing the traumatic event in others, learning that the incident has happened to a significant family member or friend, and continuous exposure to aversive particulars of traumatic events.

Overview of the Disorder

Symptoms of PTSD include frequent, spontaneous, flashbacks, disturbing upsetting recollections, and dreams of the traumatic event (APA, 2013). PTSD brings along consequences that cause distress in social, occupational, or any other areas of functioning. According to APA (2013), an individual with PTSD may avoid stimuli linked to the traumatic incident, may have difficulties remembering important features of the event, have alterations in cognition and mood, could exhibit insistent negative belief about self, and experiences minimum interest in participating in activities he uses to enjoy. Additionally, individuals with PTSD are associated with reckless or self-destructive behaviors such as alcohol/drug abuse, suicidal ideation, and suicide attempts.

Learning about PTSD is important because it addresses an issue that not only affects the USAF; it also affects the American population in general. As combat veterans complete their military careers, they are transferring to a society in which they may feel unwelcome, rejected, and disconnected. Along with exposure to traumatic events in the field, they are now facing other life stressing events in society, which can increase their anxiety and disconnection. As a result, they might turn to less than helpful ways to cope with stress. Hence, it is important to recognize PTSD or related symptoms in veterans to offer adequate mental health services. Ignoring the issues at hand could be much more costly than confronting the situation. Hence, the mental health community should be mindful in protecting our interests by looking out for the mental health of the American warriors. Recognizing the relationship between combat operations and PTSD can help in developing courses of action to prevent, identifying, and treating those individuals affected.

In addition to PTSD dynamics, one should be mindful about the elevated level of stress that returning veterans might confront (Brenner et al., 2008). Stress can prompt individuals to seek for coping mechanisms that not always are the most appropriate ones. According to Brenner et al. (2008), as individuals search for ways to diminish stress, they can go astray in adopting risky behaviors. Hence, individuals can begin or increase consumption of illegal substances, affecting their mental health. Brenner et al. (2008) maintains that soldiers are more prone to engage in risky behaviors, such as attempting or committing suicide.

The authors associate three suicide risk factors with combat operations. Habituation to pain (continuous exposure to fear, physical or emotional pain, increases tolerance, and decreases response) is a risk factor that contributes to substance abuse. Brenner et al. (2008) suggest that combat veterans experience habituation to pain in combat zones, which contributes to increments in pain tolerance and decreasing responsiveness to emotions after completion of tours. Concerning burdensomeness, veterans report diminishing self-value and confronting difficulties transitioning to civilian life. Combat veterans report a sense of failed belongingness. They recognize the inability to connect with people not in the military, choosing to separate and staying away from society. Brenner et al. (2008) conclude that exposure to combat operations and military training increase the susceptibility to risky and suicidal behavior.

Current Research

Numerous studies, such as Markowitz (2007) and Castro (2014) suggest that American combat veterans are at a much higher risk to suffer from PTSD. Most studies focus on the American soldier male population; little information is available addressing the female soldiers. Nonetheless, the military has been transitioning in such manner that female soldiers are also at risk of exposure to combat field operations (Vogt et al., 2011). The Iraqi military captured Jessica Lynch during OIF in 2003, the first American female prisoner of war (Holland, 2006). Currently, significant amounts of female soldiers, more than previous times, are vulnerable to experiencing PTSD while performing duties in the military (Vogt, et al., 2011). The inclusion of females in combat support roles calls for further research to find correlations between their combat field exposures and PTSD.

According to Comer (2015), during previous USAF combat operations like, soldiers experienced what clinicians identified as shell shock (World War I) and combat fatigue during War World II. Among other symptoms, shell shock and combat fatigue include extreme anxiety, depression, irritability, social detachment, and suicidal ideation. After Vietnam War, mental health providers learned that the effects of combat operations transcended the battlefield and the consequences follow soldiers beyond their tour of duty; hence, manifesting as psychological symptoms (Comer, 2015). He maintains that among Vietnam veterans, as much as 29% experienced PTSD. Additionally, the author indicates that an additional 10% of those veterans are currently troubled with PTSD symptoms like flashback, nightmares, and unwanted memories and thoughts. Comer (2015) indicates that the amount of soldiers presently suffering from PTSD as result of OIF and OEF is 20%, 45% reported witnessing traumatic events on others, and another 10% has suffered injuries requiring hospitalization. With such an alarming number of veterans suffering or being at risk to develop PTSD, it is imperative to adopt measures to treat those veterans in need.

Different studies, such as Vogt et al. (2011) and Castro (2014) suggest that combat operations contribute to PTSD. Markowitz (2007) maintains that the duration and intensity of combat operations are good predictors for PTSD. His study documents successful treatment of a combat veteran who did not receive PTSD management for about 60 years. The article wakes conscience that untreated PTSD will persist, even as long as 60 years or longer if not treated. According to Markowitz (2007), about 20% of individuals experiencing traumatic events will develop PTSD. Although PTSD diagnosis is more common today, this is not a new phenomenon. People mention it more frequently now due to recent military operations in the Middle East (Iraq/Afghanistan). The United States engaged in combat operations with Iraq during OIF in 2003. Subsequently, the USAF maneuvers extended to Afghanistan in support of OEF. Although the number of American military personnel in both countries is reducing over time, its military presence is still evident, adding to the susceptibility of traumatic events (Sherman, Larsen, & Borden, 2015).

Bryan, Cukrowicz, West, and Morrow (2010) contradict the previous finding that habituation, burdensomeness, and failed belongingness are main contributors to suicidal ideation. Bryan et al. (2010) maintain that perceived burdensomeness and thwarted belongingness do not play a big role in acquiring the capacity to suicidal ideation. This report indicates that combat operation contains a small variance in acquiring the capacity for suicide. Further research can focus on investigating other factors contributing to such risky behaviors. This research also contains limitations found in self-report studies.

Bush, Skopp, McCann, and Luxton (2012) research explores stressing events from the context of protective factors against suicide. Bush et al. (2012) refer to them as posttraumatic growth (PTG). PTG includes positive changes that help individuals reorganize priorities, values, spiritual standing, compassion, and empathy. The study supports the prediction that higher PTG scores translates into less amount of suicides. Such interpretation is vital to combat statistics indicating that veterans likelihood of suicide is double than nonveterans (Bush, Skopp, McCann, & Luxton, 2012). Limitations in this study include collecting self-reported data before consultation with mental health providers, and the unavailability of official diagnoses at the end of the study. Future research can focus on exploring the complex relationships concerning combat operations, PTG, and PTSD.

Barrera, Graham, Dunn, and Teng (2013) identify PTSD as the most common mental health issue (21-23%) affecting combat OIF/OEF veterans. Their study supports the initial anticipation that suicidal ideation in veterans with PTSD (12.9%) is higher than suicidal ideation in veterans without PTSD diagnosis. Additionally, OIF/OEF veterans with higher levels of combat experience are at much higher risk for developing PTSD or comorbid panic, in comparison to other mental health disorders. A limitation in this report is that participants received diagnoses during routine evaluations and unavailability of medical records at the end, precluding verification of diagnoses. Future research can study “prevalence of panic disorder and co-occurring PTSD in other samples of returning veterans” (Barrera et al., 2013).

Castro (2014) documents a significant amount of mental health concerns with OIF/OEF veterans. His data includes 118,000 active duty veterans with a PTSD diagnosis. His figures include another 50,000 soldiers wounded in action, leaving room for possible additions to those already diagnosed. Castro (2014) estimates that about 7.6 – 8.7 % of soldiers returning from combat will develop PTSD in comparison to 1.4 – 3.0 % of the ones in non-combat status. Similar to Castro’s findings (2014), McDevitt-Murphy, Williams, Murphy, Monahan, and Bracken-Minor (2015) highlight the mental health issues surrounding returning combat veterans. McDevitt-Murphy et al. (2015) identify heavy drinking as an increased risk for soldiers to deal with traumatic events. Combat operations increase risks for PTSD and PTSD increases the likelihood of alcohol misuse. The study by Hahn, Tirabassi, Simons, and Simons (2015) continue seeking relationships between combat operations and PTSD. Hahn et al. (2015) measure military sexual trauma (MST) and negative urgency (reckless behaviors) to forecast PTSD and succeeding alcohol issues among OIF/OEF combat veterans. Their study maintains that although combat exposure and MST contributes to PTSD, negative urgency is more significant in developing PTSD. This study contains cross-sectional limitations and data is unable to sustain causal evidence. As PTSD symptoms affect combat soldiers, the consequences can also affect their spouses. Renshaw, Rodrigues, and Jones (2008) investigate how does PTSD in combat veterans affects their marriages. The initial hypothesis implies a correlation between veterans’ PTSD symptoms and marriage dissatisfaction. This study accounts for about 10% PTSD cases in returning veterans, in contrast to another study accounting for 20% (Markowitz, 2007).

Evidenced-Based Treatments

Cognitive Behavioral Therapy or CBT is stated to be one of the most influential types of counseling for treating PTSD. CBT helps military clients to recognize the correlation between thoughts, emotions and behavior patterns. CBT also allows military clients to replace negative or distressing thoughts/images with more direct positive beliefs. The two forms of CBT that are popularly utilized among clinicians are exposure therapy and cognitive processing therapy (Schumm, Pukay-Martin and Gore, 2017).

Exposure therapy includes the desensitizing of oneself relating to the trauma by repeatedly processing the traumatic events until oneself feels less overpowered by them. Typically, most military clients refrain from talking about these traumatic events which actuality can help create empowerment. A clinician would process with a military client about relaxation and breathing techniques to help calm down the body and mind. Sometimes these techniques can be overbearing which can result in the military client to feel threatened by re-traumatizing the event. It is very important for a military client to have open channels with their clinician whenever they feel these unwanted feelings and/or thoughts (Kengne, Fossaert, Girard and Menelas, 2018).

Cognitive processing therapy or CPT deescalates the power of negative memories by stimulating the negative memory while importing new information that is conflicting with assumptions surrounding the memory. For instance, a clinician may process with a military client about a combat trauma with a belief that it was their fault but in actuality, they were only following direct orders from an officer during a mission. CPT informs PTSD symptoms, promotes understanding about thoughts and feelings, promotes more positive beliefs, and develops new techniques that launch intuition into actions (Galovski, Harik, Blain, Farmer Turner and Houle, 2016).

Eye movement desensitization and reprocessing or EMDR therapy was established in 1989 and discovered by Dr. Francine Shapiro. The EMDR therapy works on an eight-phase treatment outline that allows military clients to process trauma, learn appropriate coping skills and allow them to naturally heal accordingly (Ironson, Frued, Strauss and Williams, 2002). EMDR therapy allows military clients to find their “safe place” while explaining upsetting memories during “back and forth” eye movements (bilateral stimulation), tapping/snapping and body scans.  EMDR therapy allows military clients to process upsetting memories, thoughts, and feelings related to the trauma at a much faster pace. EMDR therapy typically involves one/three months of weekly 50-90 minute sessions. Some studies have shown that many military clients start to notice improvement after a few sessions which will allow military clients to quickly return back to post and future deployments (Ironson, et al. 2002).

Complementary and Alternative Medicine or CAM interventions are very effective relaxation, mindfulness, and yoga techniques utilized for PTSD. CAM interventions primarily target the autonomic nervous system (ANS). The ANS includes the sympathetic and parasympathetic nervous system. Essentially, CAM interventions can help regulate and find ways to help maintain composure for the body and mind during distressing times (Lake, 2014).

Micro

The micro practice is based upon the concentration of problem-solving in situations surrounding the client. Social workers are responsible for solving the problem through the resources of systematic development. Through the micro approach, the social worker is primarily focused on the person. Social workers often practice rapport as a micro skill which is about dissolving resistance and to allow clients to make steady changes. Social workers are also responsible for building alliances with clients to help better understand them (Forenza and Eckert, 2018).

Macro

With social planning and community organization as a macro approach, social workers often work within communities and organizations on how to solve social problems that range from local issues to international issues that may arise. Under this macro practice, social workers are typically taught all the different types of social planning that can be analytical, political or both on social problems that are affecting the community daily (Forenza and Eckert, 2018).

Mezzo

Engagement is often utilized by social workers as a mezzo level approach especially during group therapy (Forenza and Eckert, 2018).  For example, social workers will often keep PTSD veterans steady active to help them learn whatever new material (coping skills, house-keeping skills, etc.) that are brought up during group discussion. Having group therapy with PTSD veterans allows them to interact in different ways into developing healthy personal beliefs, appropriate social skills, and values and to be consistent with change. It will also allow PTSD veterans to develop long-lasting friendships with each other.

Conclusion

The United States Armed Forces (USAF) main objective is to defend our land, whether domestically or internationally, and this requires a significant amount of risks that expose our troops to obvious traumatic events. Since defending our interests is an ongoing battle by itself, our soldiers will be continually vulnerable to experiencing PTSD. Hence, the mental health community should be mindful in protecting our interests by looking out for the mental health of the American warriors. Exploring the relationships between combat operations and PTSD can help in developing courses of action to prevent, identifying, and treating those individuals affected.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
• Barrera, T. L., Graham, D. P., Dunn, N., & Teng, E. J. (n.d.). Correction to Barrera, Graham, Dunn, and Teng (2013 … Retrieved from https://www.researchgate.net/publication/263923283_Correction_to_Barrera_Graham_Dunn_and_Teng_2013
• Brad, Eckert, & Caitlin. (2017, November 13). Social Worker Identity: A Profession in Context. Retrieved from https://academic.oup.com/sw/article/63/1/17/4621303
• Brenner, L., Gutierrez, P., Cornette, M., Betthauser, L. Bahraini, N., & Staves, P. (2008). A Qualitative Study of Potential Suicide Risk Factors in Returning Combat Veterans, Journal of Mental Health Counseling, 3093), 211-225. doi:10.17744/mehc.30.3.n6418tm72231j606
• Bryan, C. J., Cukrowicz, K. C., West, C. L., & Morrow, C. E. (2010). Combat experience and the acquired capability for suicide. Journal of Clinical Psychology, 66(10), 1044-1056. doi:10.1002/jclp.20703
• Bush, N.E., Skopp, N.A., McCann, R., & Luxton, D.D. (2012). Posttraumatic growth may protect against suicidal ideation among service members following combat deployment. PsychEXTRA Dataset. doi:10.1037/e555092012-018
• Castro, C.A. (2014). The US framework for understanding, preventing, and caring for the mental health needs of service members who served in combat in Afghanistan and Iraq: A brief review of the issues and the research. European Journal of Psychotraumatology, 5(1), doi:10.3402/ejpt.v5.24713
• Comer, R. J. (2015). Abnormal psychology (9th ed.). New York: Worth Publishers.
• Galovski, T. E., Harik, J. M., Blain, L. M., Farmer, C., Turner, D., & Houle, T. (2016, March 26). Identifying Patterns and Predictors of PTSD and Depressive Symptom Change During Cognitive Processing Therapy. Retrieved from https://link.springer.com/article/10.1007/s10608-016-9770-4
• Hahn, A. M., Tirabassi, C. K., Simons, R. M., & Simons, J. S. (2015). Military sexual trauma, combat exposure, and negative urgency as independent predictors of PTSD and subsequent alcohol problems among OEF/OIF veterans. Psychological Services, 12(4), 378-383. doi:10.1037/ser0000060
• Hale, A. C., Rodriguez, J. L., Wright, T. P., Driesenga, S. A., & Spates, C. R. (2018, November 28). Predictors of change in cognitive processing therapy for veterans in a residential PTSD treatment program – Hale – 2019 – Journal of Clinical Psychology – Wiley Online Library. Retrieved from https://www.onlinelibrary.wiley.com/doi/10.1002/jclp.22711
• Holland, S. L. (2006). The dangers of playing dress-up: Popular representations of Jessica Lynch and the controversy regarding women in combat. Quarterly Journal of Speech, 92(1), 27-50. doi:10.1080/00335630600687123
• Ironson, G., Freund, B., Strauss, J., & Williams, J. (2001, December 12). Comparison of two treatments for traumatic stress: A community‐based study of EMDR and prolonged exposure – Ironson – 2002 – Journal of Clinical Psychology – Wiley Online Library. Retrieved from https://onlinelibrary.wiley.com/doi/10.1002/jclp.1132
• Kengne, S. A. K., Fossaert, M., Girard, B., & Menelas, B.-A. J. (2018). Action-Centered Exposure Therapy (ACET): A New Approach to the Use of Virtual Reality to the Care of People with Post-Traumatic Stress Disorder. Behavioral Sciences (2076-328X), 8(8), 76. https://doi-org.ezproxy.net.ucf.edu/10.3390/bs8080076
• Lake, J. (2014, July 25). A Review of Select CAM Modalities for the Prevention and Treatment of PTSD. Retrieved from https://www.psychiatrictimes.com/integrative-psychiatry/review-select-cam-modalities-prevention-and-treatment-ptsd/page/0/1
• Markowitz, J.D. (2007), Post-Traumatic Stress Disorder in an Elderly Combat Veteran: A Case Report. Military Medicine, 172(6), 659-662.doi:10.7205/milmed.172.6.659
• McDevitt-Murphy, M. E., Williams, J. L., Murphy, J. G., Monahan, C. J., & Bracken-Minor, K. L. (2015). Brief intervention to reduce hazardous drinking and enhance coping among OEF/OIF/OND veterans. Professional Psychology: Research and Practice, 46(2), 83-89. doi:10.1037/a0036771
• Renshaw, K. D., Rodrigues, C. S., & Jones, D. H. (2008). Psychological symptoms and marital satisfaction in spouses of Operation Iraqi Freedom veterans: Relationships with spouses’ perceptions of veterans’ experiences and symptoms. Journal of Family Psychology, 22(4), 586-594. doi:10.1037/0893-3200.22.3.586
• Schumm, J. A., Pukay-Martin, N. D., & Gore, W. L. (2017). A Comparison of Veterans Who Repeat Versus Who Do Not Repeat a Course of Manualized, Cognitive-Behavioral Therapy for Posttraumatic Stress Disorder. Behavior Therapy, 48(6), 870–882. https://doi-org.ezproxy.net.ucf.edu/10.1016/j.beth.2017.06.004
• Sherman, M. D., Larsen, J., & Borden, L. M. (2015). Broadening the focus in supporting reintegrating Iraq and Afghanistan veterans: Six key domains of functioning. Professional Psychology: Research and Practice, 46(5), 355-365. doi:10.1037/pro0000043
• Vogt, D., Vaughn, R., Glickman, M. E., Schultz, M., Drainoni, M., Elwy, R., & Eisen, S. (2011). Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF veterans. Journal of Abnormal Psychology, 120(4), 797-806. doi:10.1037/a0023452