Virtual Reality Exposure for Veterans with Posttraumatic Stress Disorder

Abstract

Two open trials of Virtual Reality based exposure therapy (VRE) to desensitize Vietnam veterans with Posttraumatic Stress Disorder (PTSD) to some of their traumatic memories are described. A total of 21 patients were exposed to one of two virtual Vietnam computer-generated environments in which their individual traumatic experiences were simulated in response to their recounting these events. Although two patients experienced significant increases in symptoms during VRE, all patients' PTSD symptoms were below baseline by the 3-month post-treatment assessment. When the data from the two open trials was combined, clinically meaningful and statistically significant reductions in PTSD symptoms were found. These changes were long lasting as evidenced by the 6-month follow-up assessments. Two case examples are provided and future applications of this treatment are discussed.     

Posttraumatic Stress Disorder and Vietnam Veterans

Many unemployed Vietnam veterans may be sufferers of posttraumatic stress disorder (PTSD). Symptoms and behaviors of PTSD are reviewed to assist employment counselors in identifying such individuals, and suggestions for referral are made.     

Cross-Lagged Relationships Between Insomnia and Posttraumatic Stress Disorder in Treatment-Receiving Veterans

Insomnia is a risk factor for the development of posttraumatic stress disorder (PTSD) while it is also plausible that PTSD symptoms can maintain insomnia symptoms. The present study examined longitudinal bidirectional relationships between insomnia and PTSD symptoms in treatment-seeking veterans. Participants were 693 ex-serving members of the Australian Defence Force who participated in an accredited, hospital-based outpatient PTSD program. Participants completed self-reported assessments of PTSD and insomnia symptoms at four time points: intake, discharge, 3-month, and 9-months posttreatment follow-up.Cross-lagged pathway analyses indicated significant bi-directional pathways between insomnia symptoms and PTSD symptoms at most time points. A final cross-lagged model between insomnia symptoms and the PTSD symptom clusters indicated that the PTSD symptom paths on insomnia symptoms, between intake and discharge, were attributable to reexperiencing PTSD symptoms. In contrast, across posttreatment follow-up time points there were significant paths of insomnia symptoms on all PTSD symptom clusters except from insomnia at 3-months to avoidance symptom at 9-months. PTSD symptoms and insomnia symptoms have bidirectional associations over time that may lead to the mutual maintenance or exacerbation of each condition following PTSD treatment. Where residual insomnia symptoms are present post-treatment, a sleep-focussed intervention is indicated and a sequenced approach to treatment recommended.     

Gender Differences in Trauma Types and Themes in Veterans with Posttraumatic Stress Disorder

Background: This study aimed to determine whether there were gender differences in trauma types and cognitive-emotional themes among veterans with deployment-related posttraumatic stress disorder (PTSD). Methods: Case notes or writing excerpts from two pilot studies were reviewed to determine types of traumas and emerging themes, with 20 women and 31 men comprising the sample. Results: Most women developed PTSD after sexual assault, with reactions emphasizing mistrust, betrayal, and anger. Men experienced more combat, with reactions including survivor guilt, moral injury, and horror. Conclusions: Both genders developed PTSD, but the causes of and reactions to their traumas differed. Emerging themes can be useful treatment foci.     

Posttraumatic Growth in Combat Veterans

Combat veterans and their families face significant challenges not only to their abilities to cope, but often to their fundamental belief systems. Traumatic events represent assaults on core beliefs, yet at times, produce cognitive processing that can ultimately result in personal transformations called posttraumatic growth (PTG). Clinicians can utilize a systematic therapeutic approach to facilitate PTG as they carry out a relationship of expert companionship. PTG in service members is described in this article, as well as the approach to facilitation of PTG.     

Duty-Related Posttraumatic Stress Symptoms in 911 Telecommunicators: The Roles of Childhood Trauma Exposure and Emotion-Focused Coping

A history of childhood trauma exposure has been linked to the development of posttraumatic stress symptoms in adulthood following new exposure. Unhealthy coping behaviors that could develop or be utilized in response to early trauma could lend themselves to psychological issues in adulthood. Emotion-focused and problem-focused coping strategies in relation to stressful duty-related situations are examined as indirect pathways through which childhood trauma exposure could be associated with duty-related posttraumatic stress symptoms in 911 telecommunicators (N = 808). Multiple mediation models revealed that 3 of the 4 emotion-focused coping strategies, but not the problem-focused strategies, functioned as significant mediators in the association between childhood exposure and duty-related posttraumatic stress symptoms. Pairwise comparisons showed that self-controlling and escape-avoidance strategies were the strongest pathways of the indirect childhood trauma exposure–posttraumatic stress symptoms association. Implications of results regarding coping in response to new traumatic events in adulthood and potential research and intervention directions are discussed.     

Personality Assessment Inventory (PAI) Profiles of Male Veterans With Combat-Related Posttraumatic Stress Disorder

The Personality Assessment Inventory (PAI; L. C. Morey, 1991) is a promising tool for the assessment of Posttraumatic Stress Disorder (PTSD), but few studies have examined the PAI profiles of individuals with the diagnosis. In this study, the PAI was administered to 176 combat veterans with PTSD. Results showed significant elevations on scales measuring depression, somatic complaints, anxiety, anxiety-related disorders, schizophrenia, and negative impression management. The Traumatic Stress subscale was the highest point in the mean score profile and was moderately correlated with several established measures of PTSD. Veterans with and without comorbid major depression differed on PAI scales assessing depression, anxiety, and warmth. Analysis of two-point codetypes for the PAI and the MMPI-2 revealed substantial heterogeneity in symptom endorsement on both instruments, suggesting that there may be no clear PTSD profile on either instrument. Results provide a reference point for future work with the PAI in PTSD samples.     

Aftermath of Violence: Posttraumatic Stress Disorder Among Vietnam Veterans

Posttraumatic stress disorder (PTSD) frequently occurs in the aftermath of violence. A comprehensive four-phase treatment approach for Vietnam veterans with PTSD is presented. Phases in the recovery process are assessment, stabilization of symptoms, working through the trauma, and reintegration into the family and society.     

Traditional Machismo and Caballerismo as Correlates of Posttraumatic Stress Disorder,Psychological Distress,and Relationship Satisfaction in Hispanic Veterans

An online survey was used to examine 45 Hispanic male veterans’ traditional machismo and caballerismo as correlates of posttraumatic stress disorder (PTSD), psychological distress, and relationship satisfaction. Higher traditional machismo was associated with higher PTSD severity and distress and lower relationship satisfaction. Psychometric properties of the Traditional Machismo and Caballerismo Scale were explored. Se utilizó una encuesta en línea para examinar el machismo y el caballerismo tradicionales de 45 veteranos hispanos varones, y su correlación con el trastorno de estrés post‐traumático (PTSD, por sus siglas en inglés), la angustia psicológica y la satisfacción en sus relaciones. Un mayor nivel de machismo tradicional se asoció con una mayor severidad del PTSD, así como con angustia y una menor satisfacción en las relaciones. Se exploraron las propiedades psicométricas de la Escala de Machismo y Caballerismo Tradicionales.     

Pavlovian Eyeblink Conditioning in Combat Veterans With and Without Post-Traumatic Stress Disorder

Several recent studies have investigated relationships between post-traumatic stress disorder (PTSD) and learning and memory problems. These reports have found in general that not only does PTSD affect trauma-related memories, but when patients with PTSD are compared with similar trauma patients without PTSD, general memory impairments have been found. The present paper reports a study in which associative learning, using Pavlovian eyeblink conditioning, was investigated in combat veterans with and without chronic PTSD, using interstimulus intervals of 500 and 1000 msec in two separate experiments. Although several recent reports suggest that larger-magnitude autonomic conditioned responses occur in patients with PTSD during Pavlovian conditioning, the present study found evidence of impaired Pavlovian eyeblink conditioning in combat veterans with and without PTSD, compared to non-combat veterans. Although these data suggest that combat leads to an impaired associative learning process regardless of whether PTSD is apparent, a group of community-dwelling combat veterans not under medical treatment showed normal conditioning, suggesting that variables other than prior combat must also be involved.     

The Relationship Between Postdeployment Factors and PTSD Severity in Recent Combat Veterans

Combat traumas precipitate posttraumatic stress disorder (PTSD); however, nontraumatic deployment and postdeployment factors may also contribute to PTSD severity. The Deployment Risk and Resilience Inventory (DRRI) was used to investigate pre-, peri-, and postdeployment factors associated with current PTSD severity in 150 recent combat veterans with PTSD and hazardous alcohol use. Hierarchal linear regression analyzed what factors independently predicted PTSD severity when controlling for sociodemographic characteristics and combat specific variables. Four postdeployment factors independently predicted PTSD severity: unemployment, alcohol use, social support, and stressful (nontraumatic) life events. The centrality of trauma in the maintenance of PTSD and clinical implications for treatment providers are discussed.     

MMPI-2 Assessment of Varying Levels of Posttraumatic Stress in Vietnam Combat Veterans

The effectiveness of the MMPI-2 in the detection of posttraumatic stress (PTS) symptomatology was investigated. Forty-nine veterans at a VA posttraumatic stress clinic were evaluated for PTS symptomatology according to DSM-III-R criteria. The ability of the MMPI-2 to differentiate between Vietnam combat veterans (VCV) who met DSM-III-R criteria for posttraumatic stress disorder (PTSD; N = 36) and those who reported varying levels of posttraumatic stress symptoms (PTSS; N = 13) was examined. Overall, the MMPI-2 was effective in differentiating between the two groups of veterans. Of the 15 MMPI-2 scales used to evaluate PTS symptomatology, 12 significantly differentiated veterans with PTSD from those with PTSS. Diagnostic efficiency statistics for the MMPI-2 PTSD scales (PS and PK) were calculated at four cutoff points (T 65, 70, 75, and 80). The PS Scale was the most robust and effective index in differentiating between veterans with PTSD and those with PTSS. Implications for the assessment of varying degrees of PTS are discussed.     

MMPI Configural Interpretation as Applied to Posttraumatic Stress Disorder in Vietnam Veterans

This study investigated the systems of Minnesota Multiphasic Personality Inventory (MMPI) configural interpretation of Skinner and Jackson (1978) and Kunce (1979) with Vietnam veterans with posttraumatic stress disorder (PTSD). MMPI profiles of four groups differing in combat exposure were compared on four MMPI configural variables from Kunce (1979) and Skinner and Jackson (1978). The four groups were (a) PTSD sufferers, (b) Vietnam combat veterans without PTSD, (c) Vietnam noncombat veterans, and (d) Vietnam era veterans. All groups were further divided into hospitalized versus nonhospitalized subgroups. Dependent variables were Skinner and Jackson's (a) sociopathic modal profile, (b) neurotic profile, (c) psychotic profile, and (d) Kunce's emotional expression (enthusiastic-reserved) dimension. Results indicated that hospitalized PTSD subjects had significantly higher scores on Skinner and Jackson's neurotic profile; both hospitalized and nonhospitalized PTSD subjects had higher scores on the psychotic profile and were more "reserved" on Kunce's emotional expression dimension. Results were interpreted in terms of configural MMPI interpretation systems and the adjustment of Vietnam veterans with PTSD. PTSD was viewed as exhibiting cognitive, somatic, and affective features.     

The Relationship Between a Hierarchical Transdiagnostic Model of Vulnerability Factors and Posttraumatic Stress Disorder Symptom Clusters

The latent structure of Post-Traumatic Stress Disorder (PTSD) symptomology is the subject of ongoing deliberation. The cognitive vulnerabilities of Negative Affect, Anxiety Sensitivity and Intolerance of Uncertainty have been shown to explain symptoms clusters in multiple anxiety and mood disorders, and may be able to offer further insight to explain PTSD symptomology. Using structural equation modelling, this study examines whether a hierarchical model consisting of the general cognitive factor of Negative Affect and the transdiagnostic risk factors of Anxiety Sensitivity and Intolerance of Uncertainty can explain variability among PTSD symptom clusters as defined by the DSM-5 and/or Dysphoria models of PTSD. Anxiety Sensitivity and Intolerance of Uncertainty were tested as mid-level factors between Negative Affect and the PTSD symptom constructs. The hierarchical model fit the data well in both the DSM-5 and Dysphoria models. Negative Affect consistently showed significant direct effects on each symptoms cluster in both models. Anxiety Sensitivity served as a significant mediator of Negative Affect for several symptom clusters in both models. Intolerance of Uncertainty was non-significant either as a direct effect or as a mediator of Negative Affect in all analyses. This study demonstrates how the hierarchical model of Negative Affect, Anxiety Sensitivity and Intolerance of Uncertainty may fit upon multiple PTSD symptom constructs and offers new directions for conceptualizing this disorder.

     

Rumination,Resilience, and Posttraumatic Stress Disorder Symptom Severity Among Veterans of Iraq and Afghanistan

This study investigated the relationships among combat exposure, intrusive, and deliberate rumination, resilience, and posttraumatic stress disorder (PTSD) among service members who deployed to Iraq or Afghanistan (N = 191). Participants completed an online survey and hierarchical linear regression results indicated that enlisted rank, higher combat exposure, lower resilience, and higher intrusive rumination predicted higher levels of PTSD symptom severity. Resilience moderated the relationship between combat exposure and PTSD symptom severity, such that participants who had higher levels of resilience had lower levels of PTSD symptom severity at all levels of combat exposure. These findings suggest the importance of increasing resilience in combat veterans, specifically those of enlisted rank and veterans exposed to higher levels of combat. Findings also suggest that teaching veterans how to control or minimize intrusive rumination might help lower PTSD severity.     

Family Characteristics and Posttraumatic Stress Disorder: A Follow-Up of Israeli Combat Stress Reaction Casualties

This study assessed the role of family status and family relationships in the course of combat-related posttraumatic stress disorder (PTSD). The sample consisted of 382 Israeli soldiers who suffered a combat stress reaction episode during the 1982 Lebanon War. Results showed that one year after the war married soldiers had higher rates of PTSD than did unmarried soldiers. Furthermore, higher rates of PTSD were associated with low expressiveness, low cohesiveness, and high conflict in the casualties' families. Theoretical, methodological, and clinical implications are discussed.