Intensive Outpatient Prolonged Exposure for Combat-Related PTSD: A Case Study

The prevalence rates for combat-related posttraumatic stress disorder (PTSD) in U.S. military personnel returning from deployments to Iraq and Afghanistan indicate a significant demand for efficacious treatments that can be delivered in military-relevant formats. According to research with civilian and veteran populations, prolonged exposure is a first-line treatment for PTSD. However, research examining the generalizibility of prolonged exposure to active-duty military service members is scarce. Modifications to the standard prolonged exposure protocol may be required to meet military operational needs and to circumvent unique treatment barriers associated with the military. Intensive outpatient or compressed treatment delivered over a short time period has the potential for significant operational utility for active-duty military populations. Intensive outpatient practice formats have been found to be efficacious for the treatment of other anxiety disorders (i.e., specific phobia, obsessive-compulsive disorder). The present case report is the first to evaluate the use of intensive outpatient prolonged exposure for combat-related PTSD in an active-duty military service member. Treatment consisted of 10 full-day outpatient sessions over a 2-week period. The patient’s PTSD, depression, and anxiety were dramatically reduced by the end of treatment, and she no longer met diagnostic criteria for PTSD. She remained in full remission at the 6-month follow-up.     

Use of Internet Resources to Support Prolonged Exposure for Combat-Related PTSD

In vivo exposure as part of Prolonged Exposure (PE) requires the patient and therapist to generate a list of cues that are reminiscent of the trauma and generative of distress. In contrast to civilian trauma, it can be more challenging to build a robust in vivo hierarchy for a combat-related index trauma. Internet resources such as databases that list casualties from different wars, memorial pages of those who died in theater, and lists of unit association memberships and reunions are useful sources for in vivo hierarchies. These materials can provide opportunities for exposure to additional cues reminiscent of the traumatic event, provide information about the traumatic event that the veteran had been unable to recall, and create opportunities for veterans to reestablish relationships with veteran peers. Case illustrations are provided and reasons for caution are discussed.     

Intensive Outpatient Program Using Prolonged Exposure for Combat-Related PTSD: A Case Study

Although prolonged exposure (PE) has been identified as a first-line treatment for posttraumatic stress disorder (PTSD), research has found that military service members and veterans have smaller reductions in symptom severity compared to civilians. The nature of trauma in a deployed combat setting and the unique complexities of military culture have been proposed as explanations for greater rates of PTSD and poorer treatment response to first-line psychotherapies in military and veteran populations. This paper presents a case study to highlight how a novel, intensive outpatient program utilizing prolonged exposure therapy (IOP-PE) may benefit military personnel with combat-related PTSD. The patient is a Caucasian man in his early 40s seeking treatment for PTSD after more than 10 years of enlisted, active duty military service across two branches and three combat deployments. The IOP-PE includes the standard PE components and eight, nonstandard treatment augmentations tailored for military personnel. In contrast to standard PE, which typically is delivered weekly over several months, IOP-PE consists of 15 daily, 90-minute PE sessions conducted over 3 weeks. The patient demonstrated large reductions on the Clinician-Administered PTSD Scale (28 points) and PTSD Checklist (48 points) by the 6-month posttreatment follow-up point. Findings provide support for conducting further research that determines whether IOP-PE is effective and tolerable in military and veteran populations.     

Assessment and Treatment of Combat-Related PTSD in Returning War Veterans

Over the past 9 years approximately 2 million U.S. military personnel have deployed in support of Operation Iraqi Freedom in Iraq and Operation Enduring Freedom in and around Afghanistan. It has been estimated that 5–17% of service members returning from these deployments are at significant risk for combat-related posttraumatic stress disorder (PTSD). Many of these returning war veterans will seek medical and mental health care in academic health centers. This paper reviews the unique stressors that are related to the development of combat-related PTSD. It also reviews evidence-based approaches to the assessment and treatment of PTSD, research needed to evaluate treatments for combat-related PTSD, and opportunities and challenges for clinical psychologists working in academic health centers.     

The Importance of Group Cohesion in Inpatient Treatment of Combat-Related PTSD

Abstract

Post-traumatic stress disorder (PTSD) is the most widespread mental illness resulting from exposure to combat, necessitating an increase in the provision of group therapy. This pilot study examined the efficacy of, and treatment outcome predictors associated with, group inpatient treatment of combat-related PTSD. Participants included 38 active duty military personnel deployed during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), diagnosed with PTSD, and consecutive admissions to an inpatient PTSD treatment facility. A paired samples t-test revealed significant change in symptom severity and global functioning between pre- and post-treatment. Multiple regression analyses supported the predictive utility of baseline symptomatology and group cohesion (> 50% of the variance in treatment outcome), highlighting the importance of group cohesion in the efficacy of group treatment for combat-related PTSD.     

The Impact of Benefit Finding and Leadership on Combat-Related PTSD Symptoms

Benefit finding and unit leadership have been identified as buffers against the negative effects of combat exposure on posttraumatic stress disorder (PTSD) symptoms. However, little is known about how these different buffers work together to protect military personnel from the negative effects of combat. We examined benefit finding and leadership as buffers of the combat–PTSD symptoms link in a sample of recently returned combat veterans (N?=?583). Results revealed that when higher levels of noncommissioned officer (NCO) leadership and benefit finding (BF) were reported, fewer PTSD symptoms were endorsed. Additionally, BF buffered the relationship between combat stress and PTSD symptoms, but only under conditions of supportive officer leadership. Implications of these findings for military settings are discussed.     

The Susceptibility of the Rorschach Inkblot Test to Malingering of Combat-Related PTSD

The ability of subjects to alter their responses on the Rorschach and self-report measures to fake the symptoms of combat-related Posttraumatic Stress Disorder (PTSD) was investigated. Subjects were 40 White male undergraduates, randomly assigned to either a control or role-informed malingerer group, and 20 White Vietnam veterans with PTSD. Subjects were administered the Rorschach, MMPI-2 validity scales, and Mississippi Scale for Combat-Related PTSD. Results indicated that malingerers were able to achieve scores similar to the PTSD patients on the Mississippi Scale and some Rorschach variables. However, they evidenced significant differences on the MMPI-2 validity scales and several important Rorschach variables. Malingerers typically gave responses that were overly dramatic and less complicated, less emotionally restrained, and indicated an exaggerated sense of impaired reality testing as compared to PTSD patients. Behavioral differences were also noted between the groups. Findings are discussed in the context of the study's limitations and the practical detection of malingered PTSD in clinical settings.     

A Case Study of Cognitive-Behavioral Conjoint Therapy for Combat-Related PTSD in a Same-Sex Military Couple

Military deployments to Iraq and Afghanistan are associated with increased risk for posttraumatic stress disorder (PTSD), depression, and relationship impairment. Unfortunately, the perceived stigma associated with seeking deployment-related behavioral health care in military settings has been a significant barrier to care. Historically, active-duty military service members involved in same-sex intimate relationships have experienced further stressors and barriers to care related to additional stigma and lack of social support. Prior federal regulations excluded sexual minorities from openly serving in the military, thereby limiting the available behavioral health services for same-sex couples. Since this ban was lifted after the repeal of the U.S. policy known as "Don’t Ask, Don’t Tell" in 2010, gay and lesbian service members have increased opportunities to obtain behavioral health care. One therapy that is newly available to sexual minority military couples is Cognitive-Behavioral Conjoint Therapy (CBCT), which effectively addresses co-occurring PTSD and relationship dysfunction. This case study illustrates the use of CBCT for the treatment of deployment-related PTSD in a same-sex active-duty military couple. After completing all 15 CBCT sessions, the couple reported clinically meaningful changes in the service member’s PTSD symptoms, which was maintained at the 2-month follow-up. The results of this case study indicate that CBCT for PTSD can have positive treatment outcomes with military same-sex couples. Further clinical implications are discussed.     

A Clinician's Guide to PTSD Treatments for Returning Veterans

What options are available to mental health providers helping clients with posttraumatic stress disorder (PTSD)? In this paper we review many of the current pharmacological and psychological interventions available to help prevent and treat PTSD with an emphasis on combat-related traumas and Veteran populations. There is strong evidence supporting the use of several therapies including prolonged exposure (PE), eye movement desensitization and reprocessing (EMDR), and cognitive processing therapies (CPT), with PE possessing the most empirical evidence in favor of its efficacy. There have been relatively fewer studies of non-exposure based modalities (e.g., psychodynamic, interpersonal, and dialectical behavior therapy perspectives), but there is no evidence that these treatments are less effective. Pharmacotherapy is promising (especially paroxetine, sertraline, and venlafaxine), but more research comparing the relative merits of medication vs. psychotherapy and the efficacy of combined treatments is needed. Given the recent influx of combat-related traumas due to ongoing conflicts in Iraq and Afghanistan, there is clearly an urgent need to conduct more randomized clinical trials research and effectiveness studies in military and Department of Veterans Affairs PTSD samples. Finally, we provide references to a number of PTSD treatment manuals and propose several recommendations to help guide clinicians' treatment selections.     

Killing Versus Witnessing Trauma: Implications for the Development of PTSD in Combat Medics

Killing in combat uniquely predicts elevated PTSD symptomatology among military veterans. This study investigated the effects of combat killing in a sample of 345 U.S. Army combat medics who had recently returned from operational deployments to Iraq or Afghanistan. Combat medics provide frontline medical care before, during, and after battles but also fight alongside other soldiers when under attack. Attempting to kill in combat was a significant predictor of PTSD symptomatology even after accounting for passively witnessing trauma in fellow soldiers. Medics may be well prepared to cope with the passive experiencing and witnessing of war-zone trauma, but may benefit from training to cope with the negative consequences of taking actions to kill.     

Fear Learning in Veterans With Combat-Related PTSD Is Linked to Anxiety Sensitivity: Evidence From Self-Report and Pupillometry

Several studies have observed heightened Pavlovian fear conditioning in PTSD. However, it is unclear how fear conditioning in PTSD is related to risk factors for the disorder, such as anxiety sensitivity. Fifty-one combat-exposed veterans (20 with PTSD, 31 without PTSD) completed a differential fear conditioning task in which one colored rectangle (CS +) predicted a loud scream (US), whereas a different colored rectangle (CS-) predicted no US. Veterans with PTSD were characterized by greater anxiety to the CS + but not the CS- during acquisition and extinction, and greater US expectancy during the CS + but not the CS- at extinction. Also, veterans with PTSD had greater pupil dilation to both CSs at extinction, but not at acquisition. Anxiety sensitivity was correlated with anxiety and US expectancy in response to the CS +, but not the CS-, at both acquisition and extinction, and also with pupil diameter to both the CS + and CS- at extinction. Nearly all of these relations held when covarying for PTSD symptoms and trait anxiety. These findings suggest that increased fear conditioning in PTSD may be related to elevated anxiety sensitivity.     

Parameters of Aggressive Behavior in a Treatment-Seeking Sample of Military Personnel: A Secondary Analysis of Three Randomized Controlled Trials of Evidence-Based PTSD Treatments

Aggressive behavior is prevalent among veterans of post-9/11 conflicts who have posttraumatic stress disorder (PTSD). However, little is known about whether PTSD treatments reduce aggression or the direction of the association between changes in PTSD symptoms and aggression in the context of PTSD treatment. We combined data from three clinical trials of evidence-based PTSD treatment in service members (N = 592) to: (1) examine whether PTSD treatment reduces psychological (e.g., verbal behavior) and physical aggression, and; (2) explore temporal associations between aggressive behavior and PTSD. Both psychological (Estimate = -2.20, SE = 0.07) and physical aggression (Estimate = -0.36, SE = 0.05) were significantly reduced from baseline to posttreatment follow-up. Lagged PTSD symptom reduction was not associated with reduced reports of aggression; however, higher baseline PTSD scores were significantly associated with greater reductions in psychological aggression (exclusively; ß = -0.67, 95% CI = -1.05, -0.30, SE = -3.49). Findings reveal that service members receiving PTSD treatment report substantial collateral changes in psychological aggression over time, particularly for participants with greater PTSD symptom severity. Clinicians should consider cotherapies or alternative ways of targeting physical aggression among service members with PTSD and alternative approaches to reduce psychological aggression among service members with relatively low PTSD symptom severity when considering evidence-based PTSD treatments.     

Skill Acquisition and Utilization During Evidence-Based Psychosocial Treatments for Childhood Disruptive Behavior Problems: A Review and Meta-analysis

We review 85 empirical articles published since 2000 that measured the acquisition and/or utilization of parent management skills and/or child cognitive-behavioral skills in the context of an evidence-based treatment (EBT) for childhood behavior problems. Results showed that: (1) there are no standardized measures of skill acquisition or skill utilization that are used across treatments, (2) little is known about predictors, correlates, or outcomes associated with skill acquisition and utilization, and (3) few studies systematically examined techniques to enhance the acquisition and utilization of specific skills. Meta-analytic results from a subset of 68 articles (59 studies) showed an overall treatment–control ES = .31, p < .01 for skill acquisition and ES = .20, p = ns for skill utilization. We recommend that future research focus on the following three areas: (1) development of standardized measures of skill acquisition and utilization from a “common elements” perspective that can used across EBTs; (2) assessment of the predictors, correlates, and outcomes associated with skill acquisition and utilization; and (3) development of innovative interventions to enhance the acquisition and utilization of cognitive-behavioral and parent management skills.     

Barriers and Facilitators to the Implementation of Intensive Treatments for PTSD: Early Lessons Learned From the Field

This article addresses the barriers and facilitators associated with the implementation of PTSD Intensive Outpatient Programs (IOP) across three VHA Medical Centers. Each site developed programs that delivered EBPs in a massed or condensed format and relied on implementation science and the i-PARIHS model to help direct the innovation. Face-to-face, virtual, and combined platforms were used, demonstrating flexibility in design. While each site experienced unique challenges associated with local contextual factors, multiple themes emerged across sites that may help guide future IOP and massed EBP implementations. Common facilitators of the implementation process included: the availability or presence of a credible lead (i.e., champion) to guide the innovation, opportunities to consult with national or outside experts, strong team engagement, processes in place that allowed for ongoing review, clinic operations that are aligned with principles of PTSD specialty care (e.g., time-limited, evidence-based, utilization of measurement based care, willingness to treat complex cases), and leadership support. Alternately, shared barriers included limitations on available resources, options for provider coverage, early staff buy-in, and organizational factors. Solutions to address these barriers and recommendations for future direction are shared.     

A New Appraisal of Combined Treatments for PTSD in the Era of Psychotherapy Adjunctive Medications

Combinations of pharmacologic and psychosocial interventions have garnered much enthusiasm over the past 30 years. Unfortunately, this enthusiasm is often disproportionate to the empirical support for these approaches. However, a new wave of basic, translational, and clinical research has demonstrated that the use of some substances—themselves having little to no therapeutic benefit—may help to increase or potentiate the effectiveness of certain psychological treatments. While these drugs have shown promise in the treatment of other anxiety disorders, they have yet to be thoroughly studied in PTSD populations. This article will describe the movement towards the use of pharmacologic substances as adjuncts to psychotherapy and will describe the rationale, initial support, implications, and future directions of their use in the treatment of PTSD.     

JUST LIES: Finding Augustine's Ethics of Public Lying in His Treatments of Lying and Killing

Augustine famously defends the justice of killing in certain public contexts such as just wars. He also claims that private citizens who intentionally kill are guilty of murder, regardless of their reasons. Just as famously, Augustine seems to prohibit lying categorically. Analyzing these features of his thought and their connections, I argue that Augustine is best understood as endorsing the justice of lying in certain public contexts, even though he does not explicitly do so. Specifically, I show that parallels between his treatments of killing and lying along with his “agent (auctor)–instrument (minister)” distinction, in which God is the true agent or “author” of certain acts and humans are merely God's instruments, together imply that he would regard certain instances of public lying as permissible and even obligatory. I buttress my argument by examining several key but neglected passages and by responding to various objections and rival interpretations. Throughout, I challenge standard interpretations of Augustine's ethics of killing and lying and seek to deepen our overall understanding of these dimensions of his thought. In so doing, I contribute to ongoing discussions of public and private lying and to the task of relating Augustine's thought to contemporary debate and deliberation on war, killing, and lying.