Trauma Management Therapy for OEF and OIF Combat Veterans

Transcription

1 Trauma Management Therapy for OEF and OIF Combat Veterans Nina Wong, M.S. Deborah C. Beidel, Ph.D., ABPP B.Christopher Frueh, Ph.D. Sandra Neer, Ph.D. Center for Trauma, Anxiety, Resilience and Prevention University of Central Florida History of Trauma Management Therapy (TMT) Ini<ated research in 1996 (Frueh, Turner & Beidel) trea<ng Vietnam- era combat veterans with PTSD exposure alone led to less anxiety but no improvement in quality of life Development of TMT Exposure effec<ve for posi<ve symptoms of anxiety and fear less effec<ve for avoidance, anger, social and occupa<onal maladjustment, emo<onal numbing 1

2 Trauma Management Therapy Exposure therapy Individualized to address the unique elements of their trauma<c event Group therapy To address other elements of PTSD Social and asser<ve skills Anger management Behavioral ac<va<on Structure of TMT Treatment Week Session No. Format Component 1-2 (3x/week) 1-6 Individual Exposure (EXP) 3-5 (3x/week) 7-15 individual EXP + Programmed Prac<ce 6-7 (2x/week) Group Social skills/social Integra<on 8-9 (1x/week) Group Social skills/social Integra<on (1x/week) Group Anger Management (1x/week) Group Behavioral Ac<va<on 2

3 Preliminary Outcome (Frueh et al., 1996) Age Race/Ethnicity Employment Status Receiving Disability Payments for PTSD Seeking Disability or Increase in Disability for PTSD Demographic Characteris;cs (n=15) 47.9 years 60% Caucasian; 40% African American 40% employed 47% 73% Comorbid Axis I Disorder 100% Comorbid Axis II Disorder 73% Results (Frueh et al., 1996) 1 Symptom Ra;ngs Pre Tx Post Tx p Sleep (hours/week) Nightmares (# per week) Flashbacks Heart Rate (during exposure scene) 89.7 (bpm) 77.0 (bpm).0005 CAPS Social Ac<vi<es (# per week) N=11; Vietnam veterans in SC 3

4 Recent RCT (Beidel, Frueh, et al., 2011) Vietnam- era male combat veterans with PTSD Compare the clinical efficacy of two cogni<ve- behavioral interven<ons: Trauma Management Therapy (Exposure plus social and emo<onal rehabilita<on) Exposure plus typical VA group treatment (psychoeduca<on and rap groups) N = 49 ITT = 36 Completers = 30 (TMT = 14, EXP = 16) RCT: Demographics TMT EXP Age 58.9 years 59.8 years % Caucasian 100% 100% % Married 85.7% 73.3% % High School Diploma 61.5% 60% % in Army 69.2% 86.7% % Honorably Discharged 100% 100% 4

5 RCT: Assessment Strategy PTSD symptoms Clinician Administered PTSD Scale (CAPS) PTSD Checklist- Military Version Self- Monitoring: Nightmares, Flashbacks Social and Emo<onal Func<oning CAPS social subscale Self- Monitoring: Frequency and Dura<on of Social Interac<ons Other Psychiatric Condi<ons Clinical Global Impressions Scale Hamilton Ra<ngs Scales for Anxiety and Depression RCT Results: PTSD symptoms TMT EXP P Pre TX Post TX Pre TX Post TX CAPS (T) Nightmares (per week) Flashbacks (per week) (T) (T) PCL- M (T) 5

6 RCT Results: CGI, Anxiety, Depression TMT EXP P Pre TX Post TX Pre TX Post TX CGI Severity (T) HAM- A (T) HAM- D (T) RCT Results: Social Func<oning TMT EXP P Pre Mid Post Pre Mid Post CAPS- Social (T) Social Ac<vi<es (per week) Social Ac<vi<es (mins/day) (TxG; pre vs post) (TxG; pre vs. post) Socialization improvement occurred only in TMT group and only after group treatment 6

7 Challenges for Exposure Therapy for OEF/ OIF Veterans Typically, exposure therapy is conducted using either imaginal or in vivo methods. Virtual reality (VR) to augment EXP has been recently introduced into many treatment settings. 1-4 VR is particularly promising for OIF/OEF veterans When in vivo exposure is not possible (e.g., car bombings cannot be re-created) VR environment overcomes a significant hurdle for many individuals with PTSD: inability to engage in imagery of sufficient detail and affective magnitude. OEF = Operation Enduring Freedom; OIF = Operation Iraqi Freedom. 1 Anderson P et al. Behav Ther. 2006;37(1):91-7; 2 Klinger E et al. Cyberpsychol Behav. 2005;8(1):76-88; 3 Ready DJ et al. Cyberpsychol Behav Soc Netw. 2010;13(1):49-54; 4 Rothbaum BO et al. Behav Ther. 2006;37(1): Virtual Iraq/Afghanistan 7

8 Virtual Iraq/Afghanistan Developed by Skip Rizzo, Ph.D. Ins<tute for Crea<ve Technologies, University of Southern California Uses sights, sounds, and smells VR is customizable to tailor the exposure scene to replicate the actual event 8

9 Why Olfac<on? Olfactory cues, paired with aversive s<muli, produce condi<oned fearful behavior to both the odor and the context in which the odor is presented (Kroon et al., 2008). In the clinical sekng, pa<ents with PTSD associate odors with their trauma<c events and described specific olfactory cues as primary precipitants of PTSD flashbacks (Kline & Rausch, 1985; Vermenen & Bremner, 2003). This is par<cularly so for veterans of OIF/OEF who frequently report memories of the novel smell of the desert, smells from IEDs, garbage and related smells such as Middle Eastern spices TMT of OIF/OEF Veterans Beidel, D.C., Frueh, B.C., & Lejuez, C. Trauma Management Therapy for OIF/OEF Veterans. Department of Defense Congressionally Directed Medical Research Program, Using Virtual Iraq thanks to Skip Rizzo and Virtually Bener, Inc. TMT specifically addresses social dysfunc<on, anger management and depression Addi<on of economic cost assessment Examines pace of treatment delivery 9

10 Research Ques<on(s)/Hypotheses Does VR assisted EXP reduce core symptoms flashbacks, nightmares, sleep disturbances? Does TMT provide addi<ve benefits - increased social interac<ons, decreased anxiety, anger and depression? Are TMT and EXP cost- effec<ve treatments for PTSD, and does TMT produce added savings over EXP alone? Can TMT be delivered in an intensive fashion using daily treatment (3 weeks vs. 17 weeks total treatment <me)? Design and Methodology 180 par<cipants (3 arms) randomized to 17 week TMT 17 week EXP +TAU 3 week TMT Treatment 17 week arms: 5 weeks individual VR assisted EXP (3x/week) followed by 12 weeks group tx (either TMT or TAU) 3 week arm: daily individual VR assisted EXP (am) and TMT group (pm) designed for ac<ve duty troops 10

11 Design and Methodology Outcome assessment includes Clinical Domain PTSD, Social Func<oning, Other Symptoms Process Variables Credibility, Adherence, Sa<sfac<on; Dura<on of treatment Economic Variables Treatment- Modality Related Expenses, Resource U<liza<on Study Progress 20 months into 60 month study Total sample to date: 92 assessed WTU, vets, ac<ve duty, Na<onal Guard, Reserve 16 failed screen 16 chose not to enroll 56 ini<ated treatment 16 completed so far; others s<ll in treatment 11

12 Thanks Co- Principal Inves;gators B. Christopher Frueh, Ph.D. University of Hawaii, Hilo Thomas W. Uhde, M.D. Medical University of South Carolina Funding NIMH (Vietnam Study) US Army Military Opera;onal Medical Research Program (OIF/OEF study) Co- Inves;gators UCF Sandra Neer, Ph.D. MUSC Bernadette Cortese, Ph.D. -MUSC Ron Acierno, Ph.D. - MUSC Rebecca Knapp, Ph.D. - MUSC Anouk Grubaugh, Ph.D. Libby Dismuke, Ph.D. University of Maryland Carl Lejuez, Ph.D. 12