Challenges of Treating PTSD in Veterans

October 30, 2008 - November 2, 2008, San Diego, California

Norra Macready


December 03, 2008

Veterans with post-traumatic stress disorder (PTSD) may require treatment tailored to the unique nature of combat, military culture, and their individual circumstances, Rachel Yehuda, PhD, said at the annual meeting of the US Psychiatric and Mental Health Congress.

Dr. Yehuda, Professor of Psychiatry and Director of the Traumatic Stress Studies Division at the Mount Sinai School of Medicine in New York City, cited a review in which the authors, Foa and Meadows, suggested that people may develop certain worldviews, or "cognitive schemas," in response to the traumatic event.[1] Those schemas state that:

  • The world is overly dangerous;

  • The self is incompetent to minimize damage; and

  • The self is to blame for the traumatic exposure.

Some people may be predisposed to develop PTSD because "maybe the person had these schemas before the event," she said. The schemas might act as risk factors for PTSD, which is then triggered by the traumatic event. "PTSD may be associated with individual characteristics that are expressed in the presence of trauma. As a result, certain people don't deploy their natural recovery processes following trauma exposure but may develop symptoms 15 or 20 years later," Dr. Yehuda explained.

Research vs Reality

Over the past decade, cognitive behavioral treatments (CBT) such as exposure therapy or cognitive processing therapy have become the standard of practice for PTSD with demonstrated efficacy in clinical trials. Most of these studies were conducted on women who had been victims of interpersonal violence, or men and women who had been through motor vehicle accidents or natural disasters such as earthquakes. A few studies have involved refugees. Given the nature of traumatic combat experience, "there are reasons to suspect that combat trauma differs from other types of events," Dr. Yehuda noted.

The premise of behavioral therapy is that recovery occurs through gradual repeated exposure to the situation associated with the trauma in an attempt to decrease the PTSD symptoms and subsequent avoidant behavior. For example, the survivor of a plane crash who now fears flying might start by sitting in an airplane and eventually progress to taking a short flight. Over time, the person re-habituates to the situation, and the anxiety resolves. The cognitive therapy component of treatment helps to modify the cognitive distortions developed from the traumatic event, thereby reducing the intensity of the associated emotional reaction. Often these 2 therapies (CBT) are combined for behavioral exposure with alteration of cognitive schema.

This approach may work for PTSD associated with a single or time-limited event, but has questionable value for PTSD arising from warfare, which involves repetitive and chronic exposure to combat trauma, Dr. Yehuda pointed out. In fact, there are many real-life obstacles to using CBT on people with PTSD, regardless of its cause. When in combat, soldiers are often sent back to combat after a short time so severe PTSD and avoidant behavior do not develop. However, when veterans return home, this approach would be inappropriate.

Research findings are often limited in their clinical utility because trials frequently exclude the most challenging patients, such as people who are suicidal, substance abusers, or have comorbidities. "The patients that clinicians see may be very different than those examined in clinical trials," she explained. So clinical trials offer guidance to treatment but clinicians need to decide on the most effective approach for their specific patient given individual variables.

Studies in Veterans

Several studies have examined PTSD in veterans. In 1 study, 360 Vietnam veterans with PTSD were randomized to undergo either trauma-focused group psychotherapy, or a present-centered comparison treatment that avoided focusing specifically on trauma. An intention-to-treat analysis showed no differences between the groups on any treatment outcome.[2] Sixty veterans with chronic military-related PTSD participated in a wait-list controlled study of cognitive processing therapy (CPT). The dropout rate was 20% from the CPT group and 13% from the waiting list. At the post-treatment evaluation, 90% of the people in the CPT group either no longer met the diagnostic criteria for PTSD or experienced significant symptom improvement. Interestingly, there was no relationship between these outcomes and PTSD disability status.[3] Similarly, the intensity of PTSD symptoms diminished among 59 Croatian veterans who participated in dynamic group psychotherapy for 5 years, but there was no change in other neurotic symptoms or defense mechanisms.[4] Virtual reality showed promise in a study of eight Vietnam veterans exposed to a "virtual Vietnam." After 8 to 16 sessions, there was a significant reduction in symptoms compared to baseline. This effect persisted at 3 months but not at 6 months, although there was a trend toward fewer intrusive thoughts and less avoidance.[5] In a study comparing eye movement desensitization and reprocessing (EMDR) to biofeedback and routine clinical care in the treatment of PTSD in combat veterans, EMDR was associated with a significantly greater treatment effect that was maintained at 3 months.[6] Because of the small number of subjects (10 subjects underwent EMDR, 13 received biofeedback, and 12 got routine care), Dr. Yehuda cautioned drawing definitive conclusions from this study.

Barriers to Care

Along with all of the questions about clinical trials and CBT, veterans have their own set of issues and concerns that complicate any attempts to treat PTSD, Yehuda suggested. Many of these may conspire to make veterans treatment resistant; for example:

  • Their PTSD may be more severe or chronic than the PTSD seen in civilians;

  • Veterans who use Veterans Affairs (VA) hospitals may be a self-selecting group; they may differ from veterans who seek private care or simply try to tough things out on their own;

  • They may have comorbidities, such as traumatic brain injuries (TBI) or other medical or psychiatric conditions that make them harder to treat. For example, some of the drugs used to treat TBI may exacerbate the symptoms of PTSD. Substance abuse may further complicate treatment; and

  • The VA's own structure, which requires an extensive consent process, could be a barrier to research.

In Dr. Yehuda's opinion, the relationship between psychotherapy and pharmacotherapy requires more study. Veterans often are more open than the general public to the idea of taking medication, unfortunately, because psychotherapy is usually administered by a different clinician in the VA system, treatment fragmentation occurs. "This provides a confusing message for the veteran patient," she said.

Treatment Recommendations

Behavioral disturbances ascribed to PTSD in veterans may actually result from other causes, Dr. Yehuda warned. Clinicians should assess whether the disability results from PTSD or from a pre-existing pattern of self-damaging behaviors or poor coping skills. She made the following recommendations for treating combat veterans:

  • Recommend that each veteran undergo a comprehensive evaluation that includes psychosocial, vocational, interpersonal, and medical conditions, as well as psychiatric illness;

  • Establish a therapeutic alliance aimed at a long-term relationship;

  • Do more outreach: Veterans require more than people in conventional settings;

  • Educate veterans; help them realize that treatment as soon as possible after the traumatic event is more beneficial than waiting;

  • Anticipate the tendency to drop out of treatment; work with the patient to develop a plan for handling that temptation early in the treatment course; and

  • Use specialized treatments judiciously.

Dr. Yehuda also emphasized the importance of the group dynamic in veterans' care. These patients often mistrust non-veterans and feel that only their fellow service people can truly understand what they have been through. "Recently returning veterans do not trust the government to fix problems they think the government caused -- they have to learn that the VA is not the Department of Defense," Dr. Yehuda explained. She pointed out that many veterans are reluctant to seek mental healthcare at all, and do so only under pressure from their families. Those who do try to navigate their way through the healthcare system often find that the services available are not the ones they need. To be optimally helpful to veterans, she said, "mental health should be incorporated into the bigger picture of healthcare in a more seamless manner."


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