Danell Pugh Exposure Therapy Treatment for PTSD

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  • Post traumatic stress disorder (PTSD) is an illness that affects several people every year, including our military members who are returning from their tours over in Iraq and Afghanistan. In fact, the number of veterans receiving compensation from VA for PTSD has increase 79.5% from 1999 to 2004 (Frueh, Grubbaugh, Elhai, & Buckley, 2007) This is huge population of our military members who need treatment in order for them to cope with their painful and traumatic memories. In this review, I will focus mainly on the development of PTSD, how PTSD affects the Soldiers quality of life after returning home from deployments, and discuss the findings on how exposure therapy has been shown to be an effective treatment in reducing the symptoms associated with this disorder.
  • Before that question can be answered, lets discuss how PTSD is developed and the affect that this disorder has on the Veterans.
  • PTSD affects people who have been exposed to traumatic experiences, such as military combat, being kidnapped or taken hostage, personal assault, terrorist attacks, or incarceration as a prisoner of war (Rizzo, Pair, Graap, Manson, McNerney, Wiederhold, et al, n.d.). There are several factors involved that can determine if one will exhibit the symptoms associated with PTSD. Some of these factors are the intensity of the trauma, the length of the event, the loss of a close family member or friend, the proximity to the incident, and the amount of support after the event (Department of Veterans Affairs, n.d.). Strong emotions caused by tragic experiences can create changes in the brain which may result in a diagnosis of PTSD.
  • There are several factors associated with the current conflicts that may determine why the number of veterans with PTSD has increased as compared to past wars.
  • According to Salvatore (2009), one of these factors is that our Soldiers are having a difficult time distinguishing civilians from their enemies. Their opposition does not wear a specific uniform; instead, they choose to dress like regular civilians (Salvador, 2009). This makes it more difficult in determining who the good guy is versus the bad guy. If the Soldier kills someone that he thinks is an enemy and it turns out that person was an innocent civilian, the Soldier will face serious legal consequences and have to live with the ramifications of killing someone for the rest of their life.
  • Another issue is that the tours have increased from a standard 12 month tour in Vietnam to tours in Iraq and Afghanistan that can last up to 18 months (Salvador, 2009). In Vietnam, the Soldiers were deployed once and that was considered the end of their tour. With the current conflicts, Soldiers are deployed numerous times. The constant deployments increase their exposure to tragic events, thus increasing their risk of obtaining PTSD.
  • The Diagnostic and Statistical Manual of Mental Disorders , 4 th edition (1994) identifies six diagnostic measures for PTSD. They are traumatic stressors, intrusive symptoms, avoidant symptoms, hyperarousal, symptoms length, and significance. Traumatic stressors occur when one has experienced or witnessed an event that involved actual or threatened death or injury. Intrusive symptoms are those that relive the traumatic event, such as flashbacks and nightmares. Avoidant symptoms consist of patients avoiding situations that may ultimately trigger the painful memories. This measure includes “psychic numbing and avoidance of places, persons, or things associated with the trauma” (American Psychiatric Association, 1994, p. 2166). Patients who suffer from hyperarousal are “always on their toes”. They are constantly alert and attentive to their surroundings so that if danger arises they will be able to react quickly. Some other symptoms associated with hyperarousal are insomnia, difficulty concentrating, extreme startle response, and irritability (American Psychiatric Association, 1994). The Soldiers symptoms must have lasted for at least one month in order for them to be diagnosed with PTSD. Significance is determined when the “patient suffers significant social, interpersonal, or work-related problems as a result of the PTSD symptoms” (American Psychiatric Association, 1994). The majority of the articles that were reviewed have determined that these criteria are needed in order to properly diagnose PTSD.
  • Due to these signs and symptoms, the military member’s quality of life has significantly decreased. They face fears, depression, and anxiety on a daily basis. Their relationships with family, friends, and peers are, sometimes, severely affected. They choose not to partake in activities that, at one time, they really enjoyed. They are irritable and their mood changes in seconds. These Soldiers feel a constant sense of hopelessness and despair. For some, there is a stigma attached with mental illnesses, to include PTSD. The Soldier is afraid that their mental health appointment may negatively affect their career or they think that their leadership will treat them differently. These Soldiers do not want to be seen as weak and they are fearful that will happen if they seek assistance for their issues.
  • A study conducted by Wright, Cabrera, Bliese, Adler, Hoge, & Castro (2009) determined that if the “lowest stigmas and barriers to care scores were associated with a combination of high leadership ratings and high unit cohesion” (p. 113). The stigma was related to the views that the Soldiers had of their leadership. If the military member was assigned to a unit with a positive environment, they were more likely to seek treatment; however, if they are in a unit with a negative climate, stigmas are more likely present.
  • Exposure Therapy is one treatment that been shown to effectively reduce the symptoms for veterans and military personnel who were diagnosed with PTSD as a result of their deployments.
  • Virtual Reality (VR) is an exposure therapy technique that “integrates real-time computer graphics, body-tracking devices, visual displays, and other sensory input devices (Ready, Pollack, Rothbaum, & Alarcon, 2006, p. 202). The therapist is able to manipulate virtual reality technology in order to match the patient’s experience. They can add voices, people, smoke, gun fire, and grenades to imitate the events found on the combat field. They can tailor the video game to the Soldier’s actual memories. One of the main benefits of the virtual reality exposure (VRE) therapy is that it desensitizes the Soldier’s painful memories by allowing them to relive the situations in a safe environment (Ready, et al, 2006). The Soldiers are able to vocalize the situation and the therapist is able to recreate the events.
  • Several studies have proven that exposure therapy is one of the most successful therapies at relieving the symptoms of PTSD. One article I reviewed was a study conducted by Wood, Murphy, Center, McLay, Reeves, Pyne, et al, (2007) titled Combat Related Post-Traumatic Stress Disorder: A Case Report Using Virtual Reality Exposure Therapy with Physiological Monitoring . They included an introduction that outlines the cause and symptoms that are common in PTSD. They seem quite knowledgeable about how the diagnosis is directly affecting the military and veterans. They included several statistics and numbers that estimate the amount of military members who suffer with PTSD. The authors presented a case study in which a patient, who participated in the Vietnam War and as a result suffered from Post Traumatic Stress Disorder, volunteered to undergo virtual reality graded exposure therapy (VRGET) in order to decrease his symptoms. They listed the patient’s diagnoses, as well as his experiences during deployment. They described the procedure in depth as it was given to the patient and gave an overview as to what equipment was being used to track the patient’s physiological measures (Wood et al, 2007). They explained the process that the patient would endure during the ten 90-minute appointments. They concluded the article with the results that were found based on the psychologists and equipment findings. The overall conclusion for this study was that VRGET was shown to decrease patient’s skin conductance and heart rate, as well as increase temperature. These factors mean that the patient was less aroused by the original stressors (Wood et al, 2007).
  • Another study that was reviewed was Virtual Reality Exposure Therapy for Active Duty Soldiers conducted by Reger and Gahm (2008). The therapists performed six, 90 minute sessions on their patient over a four week period. Their patient was exposed to the virtual reality treatment for, on average, 35 minutes per session. The equipment was the same as the other studies, in that the therapist manipulated the tools available to recreate the patient’s view of the scenarios. As a result of the exposure therapy, he also “reported a meaningful decrease in problematic symptoms, increased socialization, and improved functioning. He returned to previously enjoyed hobbies and improvements in functioning were also reported by family members” (Reger & Gahm, 2008, p. 944).
  • Another article, Virtual Reality Exposure for Veterans with Posttraumatic Stress Disorder was authored by Ready, Pollack, Rothbaum, and Alarcon (2006). Ready and colleagues (2006) included information from previous studies that showed the effectiveness behind VRE. This article gives more in depth information on the benefits and advantages of VRE as a PTSD treatment. They detailed the exact criteria that were used in choosing the participants. The other articles were not as thorough, in this aspect.
  • This therapy is available for Soldiers and veterans who are in need of a successful treatment for their symptoms and painful memories. Our countries heroes no longer have to suffer with this mental illness. They need to be made aware of the treatments available, especially exposure therapy, that reduces their anxiety and fears. Frey (2003) suggests that patients who receive treatment directly after the trauma occurs, has the best possibility of making a full recovery.

Transcript

  • 1. By: Danell Pugh Argosy University PSY 250 (Microsoft ClipArt, 2009)
  • 2. Introduction
    • Post traumatic stress disorder (PTSD) affects several people every year, including our military members who are returning from their tours over in Iraq and Afghanistan.
    • According to Frueh, Grubbaugh, Elhai, & Buckley (2007), the number of veterans receiving compensation from VA for PTSD has increase 79.5% from 1999 to 2004.
    • Exposure therapy has been shown to be an effective treatment in reducing the symptoms associated with this disorder.
  • 3. Focal Question:
    • How has exposure therapy proven as an effective treatment for Veterans who are suffering from PTSD?
    • (Microsoft ClipArt, 2009)
  • 4. Development of PTSD
    • PTSD affects people who have been exposed to traumatic experiences, such as:
    • military combat
    • being kidnapped or taken hostage
    • personal assault, terrorist attack
    • confinement as a prisoner of war
    • ((Rizzo, Pair, Graap, Manson, McNerney, Wiederhold, et al, n.d.).
    (Ruach, 2003)
  • 5. Factors associated with PTSD
    • According to the Department of Veterans Affairs (n.d.), there are several factors involved that can determine if one will exhibit the symptoms associated with PTSD, such as:
    • Intensity of the trauma
    • Length of the event
    • Loss of a close family member
    • or friend
    • Proximity to the incident
    • Amount of support after the event
    (Photographer unknown, n.d.)
  • 6. Possible causes of increased PTSD Diagnosis
    • The military member’s opposition does not wear a specific uniform; instead, they choose to dress like the regular civilians (Salvatore, 2009). This makes it more difficult in determining who the ally is versus the adversary.
    (Riley, 2008)
  • 7. Another possible cause
    • The tours have increased from a standard 12 month tour in Vietnam to tours in Iraq and Afghanistan that can last up to 18 months (Salvatore, 2009). In Vietnam, the Soldiers were deployed once and that was considered the end of their tour. With the current conflicts, Soldiers are deployed numerous times. The constant deployments increase their exposure to tragic events, thus increasing their risk of obtaining PTSD.
  • 8. Diagnostic Measures for PTSD
    • The Diagnostic and Statistical Manual of Mental Disorders , 4 th edition, composed by the American Psychiatric Association (1994) identifies six diagnostic measures for PTSD.
    • Traumatic stressors: tragic experience
    • Intrusive symptoms: flashbacks and nightmares
    • Avoidant symptoms: avoiding painful triggers
    • Hyper arousal: constant alertness, insomnia, irritability, extreme startle response
    • Symptoms length: at least one month of symptoms
    • Significance: suffers significant social, interpersonal, or work-related problems
    (Microsoft ClipArt, 2009)
  • 9. Stigmas attached to Soldiers with PTSD
    • The Soldier is afraid that their mental health appointment may negatively affect their career or they think that their leadership will treat them differently. These Soldiers do not want to be seen as weak and they are fearful that will happen if they seek assistance for their issues.
  • 10. Stigma Study
    • A study conducted by Wright, Cabrera, Bliese, Adler, Hoge, & Castro (2009) determined that the “lowest stigmas and barriers to care scores were associated with a combination of high leadership ratings and high unit cohesion” (p. 113). The results of this research were similar to others that had been performed. The stigma was related to the views that the Soldiers had of their leadership.
    • Military member assigned to a unit with a positive environment, they were more likely to seek treatment; however, if they are in a unit with a negative climate, stigmas are more likely present.
    (Photographer Unknown, 2009)
  • 11. Exposure Therapy: PTSD Treatment
    • Exposure Therapy is one treatment that has been shown to effectively reduce the symptoms for veterans and military personnel who have been diagnosed with PTSD as a result of their deployments.
    • Exposure therapy is a technique that is used to confront feared memories and thoughts.
  • 12. Virtual reality
    • Virtual reality(VR) is an exposure therapy technique that “integrates real-time computer graphics, body-tracking devices, visual displays, and other sensory input devices (Ready, Pollack, Rothbaum, & Alarcon, 2006, p. 202).
    • Main benefit of virtual reality exposure (VRE) therapy is that it desensitizes the Soldier’s painful memories by allowing them to relive the situations in a safe environment (Ready, et al, 2006).
    (Jardin, 2009)
  • 13. Exposure therapy study #1
    • A study conducted by Wood, Murphy, Center, McLay, Reeves, Pyne, et al, (2007), located a Veteran volunteer to undergo virtual reality graded exposure therapy (VRGET) in ten, 90-minute sessions in order to decrease his PTSD symptoms.
    The overall conclusion for this study was that VRGET was shown to decrease PTSD patient’s skin conductance and heart rate, as well as increase temperature. These factors mean that the patient was less aroused by the original stressors (Wood, et al, 2007). (Liewer, 2008)
  • 14. Exposure Therapy Study #2
    • A study conducted by Reger and Gahm (2008) placed a PTSD diagnosed Veteran in six, 90-minute sessions of virtual reality treatment.
    • As a result of the exposure therapy, the patient “reported a meaningful decrease in problematic symptoms, increased socialization, and improved functioning. He returned to previously enjoyed hobbies and improvements in functioning were also reported by family members” (Reger & Gahm, 2008, p. 944).
  • 15. Exposure Therapy Study #3
    • A study conducted by Ready, Pollack, Rothbaum, and Alarcon (2006), examined 16 patients and placed them in 8 to 20 virtual reality exposure sessions as determined by standardized tests.
    • The results of this study showed that fourteen of the sixteen patients revealed a decrease in symptoms after their treatments had ended.
  • 16. Conclusion
    • It is apparent that exposure therapy is an effective procedure in reducing the symptoms of PTSD.
    • Our countries heroes no longer have to suffer with this mental illness. There are helpful treatments available.
    • Frey (2003) suggests that patients who receive treatment directly after the trauma occurs, has the best possibility of making a full recovery.
    (Jardin, 2005)
  • 17. References:
    • American Psychiatric Association. 309.81 Posttraumatic Stress Disorder. In: Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition. American Psychiatric Association, Washington 1994:424-429. Retreived on 4 June 2009, from http://www.cirp.org/library/psych/ptsd2/ .
    • Department of Veterans Affairs, (n.d). National center for PTSD factsheet. Retrieved on 4 June 2009, http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_what_is_ptsd.html .
    • Frey, R. (2003). Post-traumatic stress disorder. In M. Harris & E. Thackerey (Eds.) The Gale Encyclopedia of Mental Disorders , 2 (pp. 776-781) Detroit: Gale Retrieved May 27, 2009, from Gale Virtual Reference Library via Gale: http://go.galegroup.com/ps/start.do?p=GVRL&u=lirn_main .
    • Frueh, B.C., Grubaugh, A.L.,  Elhai, J.D., & Buckley, T.C. (2007). US Department of Veterans Affairs Disability Policies for Posttraumatic Stress Disorder: Administrative Trends and Implications for Treatment, Rehabilitation, and Research.  American Journal of Public Health,   97 (12), 2143-5.  Retrieved May 27, 2009, from ProQuest Psychology Journals database. (Document ID: 1392878281).
    • Jardin, X., (2009). Virtual Reality Therapy for Combat Stress. Retrieved on 25 June 2009, from http://www.npr.org/templates/story/story.php?storyId=4806921 .
    • Jardin, X., (2005). VR goggles heal scars of war.. Retrieved on 25 June 2009, from http://www.wired.com/science/discoveries/news/2005/08/68575.
  • 18. References:
    • Liewer, S., (2008). Virtual reality goes to war vs. stress disorder. Retrieved on 23 February 2010, from http://www.signonsandiego.com/uniontrib/20080909/news_1n9virtual.htm.
    • Microsoft ClipArt, (2009). Retrieved on 23 February 2010, from http://office.microsoft.com/enus/clipart/results.aspx?CategoryID=CM7 90019601033#1188 .
    • Photographer unknown, (n.d.). Retrieved on 23 February 2010, from an email.
    • Salvatore, R., (2009, May). Posttraumatic Stress Disorder: A Treatable Public Health Problem. Health & Social Work , Retrieved 5 February 2010, from Psychology and Behavioral Sciences Collection database.
    • Rauch, Laura, (2003). First Day of the Ground War. Retrieved on 23 February 2010, from http://www.laurarauch.com/ .
    • Ready, D., Pollack, S., Rothbaum, B., & Alarcon, R. (2006). Virtual reality exposure for veterans with posttraumatic stress disorder. Journal of Aggression, Maltreatment & Trauma , 12 (1), 199-220. Retrieved 5 February 2010, from PsycINFO database.
  • 19. References:
    • Reger, G., & Gahm, G. (2008, August). Virtual reality exposure therapy for active duty soldiers. Journal of Clinical Psychology , 64 (8), 940-946. Retrieved 5 February 2010 , doi:10.1002/jclp.20512.
    • Riley, S., (2008). Iraq Pictures. Retrieved on 23 February 2010 , from http://iraqpictures.blogspot.com/.
    • Rizzo, A., Pair, J., Graap, K., Manson, B., McNerney, P., Wiederhold, B., (n.d.). In M. Roy (Ed.) Nato Advanced Research Workshop on Novel Appraoches to the Diagnosis and Treatment of Posttraumatic Stress Disorder. (pp. 235-250). Washington D.C: IOS Press.
    • Wood, D., Murphy, J., Center, K., McLay, R., Reeves, D., Pyne, J., et al. (2007, April). Combat-Related Post-Traumatic Stress Disorder: A Case Report Using Virtual Reality Exposure Therapy with Physiological Monitoring. CyberPsychology & Behavior , 10 (2), 309-315. Retrieved 5 February 2010 , doi:10.1089/cpb.2006.9951.
    • Wright, K., Cabrera, O., Bliese, P., Adler, A., Hoge, C., & Castro, C. (2009, May). Stigma and barriers to care in soldiers postcombat. Psychological Services , 6 (2), 108-116. Retrieved 5 February 2010 , doi:10.1037/a0012620.