Post-Traumatic Stress Disorder (PTSD): Best Treatment Options for the Military. Workforce. Morgan M. Harden. Auburn University School of Nursing

Transcription

1 Running head: PTSD: BEST TREATMENT OPTIONS 1 Post-Traumatic Stress Disorder (PTSD): Best Treatment Options for the Military Workforce Morgan M. Harden Auburn University School of Nursing

2 PTSD: BEST TREATMENT OPTIONS 2 Post-Traumatic Stress Disorder: Best Treatment Options for the Military Workforce Post-Traumatic Stress Disorder, commonly referred to as PTSD, is a chronic problem found among past and present military workforce. PTSD manifests after experiencing a traumatic, disturbing event during extreme combat, or any other event that is not typically experienced by a human being in day-to-day life (Bellenir, 2005). Other events may include witnessing or participating in the death of enemies or innocent bystanders, watching a friend who is injured or dying in combat or possibly encountering a life-threatening event, such as open fire or ambushes (Friedman, 2006). The severity of a soldier s combat, as well as how long their deployment lasts, has been shown to positively relate to the occurrence of PTSD symptoms (Ottati & Ferraro, 2009). PTSD is presently referred to as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association [APA], 2000). Anxiety on the part of the soldier or veteran comes about after he/she reexperiences the original, traumatic event through intrusive thoughts or images, nightmares, dissociative flashbacks or severe distress on reminders (Creamer, M., Wade, D., Fletcher, S., & Forbes, D., p. 161, 2011). The DSM-IV has certain criteria outlined for PTSD that one must exhibit in the form of behaviors and actions in order to be diagnosed as having the disorder. In correlation with Criterion B of the DSM-IVdiagnosis, Albucher and Liberzon (2002) state that the individual must respond to the event with intense fear, helplessness or horror, while the characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (p. 33). Included in Criterion C, a soldier or veteran must functionally avoid any reminder of the traumatic event (Albucher and Liberzon, 2002). Avoiding reminders may include no longer speaking to certain individuals who remind the

3 PTSD: BEST TREATMENT OPTIONS 3 victim of the event, no longer going to places that spark the slightest association with the trauma or avoiding similar feelings to those experienced during the event at all costs. Due to the growing number of young men and women who are devoting their lives to protecting our United States, effective treatment methods must be discovered and implemented (Creamer et al., 2011). Therefore, the purpose of this paper is to explore the best treatment options for individuals with PTSD that may be used to overcome the functional and emotional impairment that the disorder produces. PTSD and the best available treatment options for it are important to psychiatric nursing because with these in mind, nurses can construct patient care plans and implement interventions in alignment with evidence-based treatment. Nursing Psychiatric nursing approaches to PTSD treatment may include, but are not limited to, screening for the disorder, assessing individuals during semi-structured interviews for physiological tendencies, informing physicians of the patient s traumatic history and implementing different forms of psychotherapy, set out by the patients residing psychiatrist. In terms of screening measures, the PTSD Statistical Prediction Instrument (SPI) has been used successfully to identify individuals at risk for the development of PTSD and subsequent symptoms, such as depression, anxiety, weakened concentration abilities and a reduction in sleeping. Not only are individuals who are at risk for PTSD identified, but also those who are experiencing serious, debilitating PTSD can be determined. The successful identification of individuals at risk for PTSD can allow nurses and practitioners to implement treatment regimens or other forms of evidence based practice. According to current research, in order to accurately diagnose PTSD, semi-structured diagnostic interviews must be conducted. In these interviews, a qualified interviewer interacts with the patient based on a list of questions that align with the

4 PTSD: BEST TREATMENT OPTIONS 4 DSM-IV criteria for the diagnosis of PTSD. The Clinician-Administered PTSD Scale (CAPS) is commonly employed as the interview of choice in clinical settings. When semi-structured interviews are performed, the ambiguity of self-report questionnaires can be eliminated, leading to a more precise diagnosis of PTSD among those at risk (Wisco, B.E., Marx, B.P., & Keane, T.M., 2012). Physiological tendencies that may be identified and assessed during semi-structured interviews include sweating, elevated blood pressure readings and an elevated heart rate. These biological markers indicate an elevated amount of reactivity and stimulation on behalf of the patient in response to the interviewer s questioning. Nurses and other clinicians prove to be fond of the use of biological markers for PTSD diagnosis because these markers are completely separate from the patient s self-report and can therefore lead to an accurate diagnosis of the disorder (Wisco et al., 2012). A review conducted by Walker (2010), concluded from Hassinger (2003), that compassionate mentoring and vigilant monitoring of soldiers who are at risk for PTSD, predominantly young soldiers, can stifle the diagnosis of PTSD and therefore decrease the amount of symptoms experienced by the individual. No matter what intervention the psychiatric nurse is implementing, he/she can provide the PTSD patient with a holistic, therapeutic aspect of health care that no other professional can provide. Medicine The use of pharmacotherapy for the treatment of PTSD is focused on one main drug throughout the research available. Selective Serotonin Reuptake Inhibitors (SSRI s), also known as a type of antidepressants, have been shown to decrease the symptoms associated with PTSD. SSRI s have also been proven effective in reducing relapse rates for patients (Stein et al., 2009).

5 PTSD: BEST TREATMENT OPTIONS 5 Sertraline (Zoloft) and Paroxetine (Paxil) are both labeled as antidepressants that have been approved to treat PTSD (Resnick, Monson & Rizvi, 2008). SSRI s have been confirmed to enhance the quality of life for people living with PTSD, as well as reduce the individual s susceptibility to stress. Beta blockers have also been used in the evidence-based treatment of PTSD to reduce symptoms of panic (Garske, 2011). Not as much evidence exists for the use of beta blockers as compared to the surmounting amount of evidence for the usage of SSRI s. No matter what the form of pharmacotherapy, psychological treatment should be combined with medication regimens whenever possible and applicable (Australian Centre for Posttraumatic Mental Health [ACPMH], 2007; National Institute for Health and Clinical Excellence [NICE], 2005). Psychiatric nurses employ their case management skills to assist PTSD patients and their residing therapists in establishing medication regimens. Medication regimens must be appropriate to patients lifestyles so that medication compliance can be ensured. Complementary Medicine Putting the pharmacological aspect of treatment aside, psychotherapy has been found to be the most effective form of treatment for those affected by PTSD. Psychiatrists seem to be at the forefront when it comes to delegating treatment and deciding on regimens for those individuals affected by PTSD. Many of the same treatment options are repeated throughout the literature available for the disorder. Among these treatment options, Trauma-Focused Cognitive Behavioral Therapies (TFCBT), which includes Cognitive Behavioral Therapies (CBT) and Prolonged Exposure (PE) and Eye Movement Desensitization and Reprocessing (EMDR) stand out as evidence-based PTSD treatment options.

6 PTSD: BEST TREATMENT OPTIONS 6 Trauma-Focused Cognitive Behavioral Therapy, otherwise known simply as Cognitive Behavioral Therapy, which may include prolonged exposure, is described as the main form of psychotherapy (APA, 2004). Cognitive Behavioral Therapy concentrates on the thought process of individuals who are affected by PTSD. This form of therapy requires the patient to rise above the thoughts of shame or guilt that accompany the previous traumatic experience. Examples of thoughts that may be experienced by the patient involve viewing the world or his/her environment as dangerous, as well as possibly believing that the event could have been prevented. The patient may also experience feelings of hopelessness related to his/her guilty thoughts (Friedman, 2006). The patient s therapist may direct the individual to keep track of his/her thoughts in the form of daily journals to be aware of negative thinking, with the possibility of realizing that the thoughts experienced are a misrepresentation of the person (Resick, P.A., Monson, C.M., & Rizvi, S.L., 2008). An additional evidence-based form of psychotherapy is Prolonged Exposure. PE involves exposing the patient to his/her intolerable traumatic memories and through this method, the patient is required to explain the memories to the therapist (Garske, p. 33, 2011). The point of PE is to allow the patient to relive the situation in a non-threatening, yet stimulating environment so that the individual may perceive the trauma in a new, advantageous manner. The primary objective of PE is to allow desensitization to occur in a therapeutic manner, therefore possibly alleviating anxiety associated with the event (Rauch et al., 2009). If the desensitization does not occur in a therapeutic manner, the patient may be harmed further in an emotional sense by seemingly reliving the traumatic event. Nurses play a vital role in the CBT and PE due to the fact that therapeutic communication often occurs between patients and nurses more so than it does between patients and their therapists. In this way, patients can be assured that their nurses

7 PTSD: BEST TREATMENT OPTIONS 7 will stay on track for providing them care in a therapeutic, non-threatening manner that is paradigm for behavioral therapies to be effective. Eye movement desensitization and reprocessing (EMDR) stands out as an effective alternative in comparison to the aforementioned cognitive behavioral therapies. During EMDR, much like during CBT, patients are led by therapists to recall a distressing, traumatic memory and any of the damaging thoughts that may accompany the memory. The thoughts may be related to the guilt or shame that the patient has harbored since the traumatic event occurred. While the patient is recalling the memory, he/she is asked to focus on the rapid eye movement that the therapist is producing with their finger (Friedman, 2006). The rapid eye movements made by the patient during therapy have been considered to be a very important treatment modality because these eye movements are made using the repeated guided visual imagery of the traumatic memory (Zoellner, Fitzgibbons & Foa, p. 34, 2001). EMDR is still considered a controversial form of therapy used in the treatment of individuals with PTSD (Garske, 2011). However, the majority of individuals who have undergone EMDR as their form of PTSD treatment have shown optimal improvement (Bradley et al., 2005). Psychiatric nursing is critical for EMDR to be carried out in that the patient must be cared for holistically to ensure that the somatic symptoms of PTSD are alleviated. Barrier to Care A possible barrier to effective PTSD treatment mentioned throughout the literature is that of stigma. Current military personnel may worry that the diagnosis of a mental illness, such as PTSD, will result in their discharge from the military or that the diagnosis will disturb their family/work life. The stigma associated with PTSD is reportedly greater for those who need

8 PTSD: BEST TREATMENT OPTIONS 8 treatment the worst (Wisco et al., 2012). These individuals would likely benefit from counseling related to their fears associated with the diagnosis so that successful treatment from psychiatric nursing, medicine and complementary therapies can take place. Conclusion In conclusion, PTSD proves to be a debilitating disorder for those who service our country as military personnel. Along with the disease come serious implications for not only the soldier s quality of life but also for the soldier s family (Garske, 2011). Psychiatric nursing, medicine in the form of pharmacotherapy and complementary medicines like Cognitive Behavioral Therapy need to be implemented and sought after by health care professionals to effectively treat our military workforce (Moon, 2006). Providing that young men and women are continued to be sent overseas to fight for our country, health care personnel must continue to search for solutions and evidence-based practices for this devastating disorder (Creamer et al., 2011). PTSD signs and symptoms should be examined for during the psychiatric nurse s assessment to possibly aid in diagnosing an individual early on so that evidence-based treatment can transpire and the patient s quality of life can be maintained.

9 PTSD: BEST TREATMENT OPTIONS 9 References ACPMH (2007). Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne: Australian Centre for Posttraumatic Mental Health. Albucher, R.C., & Liberzon, I. (2002). Pyschopharmacological treatment of ptsd: a critical review. Journal of Psychiatric Research, 36, American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Fourth ed.). Washington, DC: Author. American Psychiatric Association. (2004). Practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder. American Journal of Psychiatry, 16(Nov. Suppl.). Bellenir, K. (Ed.). (2005). Mental health disorders: Sourcebook. Detroit, MI: Omnigraphics. Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multi-dimensional metaanalysis of psychotherapy for PTSD. American Journal of Psychiatry, 16(2), Creamer, M., Wade, D., Fletcher, S., & Forbes, D. (2011). PTSD among military personnel. International Review of Psychiatry, 23, doi: / Friedman, M. J. (2006). Posttraumatic stress disorder among military returnees from Afghanistan and Iraq. American Journal of Psychiatry, 63(4),

10 PTSD: BEST TREATMENT OPTIONS 10 Garske, G. (2011). Military-related PTSD: a focus on the symptomatology and treatment approaches. Journal of Rehabilitation, 77(4), Hassinger, A. D. (2003). Mentoring and monitoring: the use of unit watch in the 4 th infantry division. Military Medicine, 168, Moon, P. K. (2006). Sand play therapy with U.S. soldiers diagnosed with PTSD and their families. [Electronic Version.] ACA Vistas, 13, NICE (National Institute for Health and Clinical Excellence) (2005). Post-traumatic Stress Disorder. London: Royal College of Psychiatrists and the British Psychological Society. Ottati, A., & Ferraro, F. R. (2009). Combat-related ptsd treatment: indications for exercise therapy. Psychology Journal, 6(4), Rauch, S., Defever, E., Favorite, T., Duroe, A., Garrity, C., Martis, B., & Liberzon, I. (2009). Prolonged exposure for ptsd in a veterans health administration ptsd clinic. Journal of Traumatic Stress, 22(1), Reznick, P. A., Monson, C. M., & Rizvi, S. L. (2008). Posttraumatic stress disorder. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual. New York: The Guilford Press. Stein, D. J., Isper, J., & McAnda, N. (2009). Pharmacotherapy of posttraumatic stress disorder: a review of meta-analyses and treatment guidelines. CNS Spectrums, 14, Walker, S. (2010). Assessing the mental health consequences of military combat in Iraq and Afghanistan: a literature review. Journal of Psychiatric and Mental Health Nursing, 17,

11 PTSD: BEST TREATMENT OPTIONS 11 Wisco, B. E., Marx, B. P., & Keane, T. M. (2012). Screening, diagnosis and treatment of posttraumatic stress disorder. Military Medicine, 177, Zoellner, L. A., Fitzgibbons, L. A., & Foa, E. B. (2001). Cognitive-behavioral approaches to ptsd. In J. P. Wilson, M. J. Friedman, & J. D. Lindy (Eds.), Treating Psychological Trauma and PTSD. New York: The Guilford Press.

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