Treating Combat Veterans with PTSD: Using Group-Based Exposure Therapy LAURA M. WELLS, BSN, RN GEORGINE R. BERENT, EdD, RN-BC DISCLOSURE The speakers have no conflicts of interest, commercial support, or off-label use to disclose. ISSUE AT HAND Veterans returning from combat zones in support of Operation Enduring Freedom & Operation Iraqi Freedom are: Often subjected to multiple deployments Resulting in an increased risk for Posttraumatic Stress Disorder With limited success using traditional treatment options Congressional Budget Office. (2012) Wells, Berent 1
MULTIPLE EXPOSURE Potential Traumatic Events (PTEs) Combat exposure Norm within military lifestyle Cumulative effects Stress on service members, spouses, children, families, & relationships Risk for acute stress disorder, depression, & Posttraumatic Stress Disorder [Caban, (2011); Frincu-Mallas, (2010); Price, Gros, Strachan, Ruggio, & Acierno, (2013)] Diagnostic Criteria History of exposure Four symptom clusters Duration of symptoms Functioning Not attributable to substance abuse and/or co-morbidities [American Psychiatric Association (2013); U.S. Department of Veterans Affairs (2014)] Criterion A: Stressor Criterion B: Intrusion symptoms Criterion C: Avoidance Criterion D: Negative alterations in cognitions and mood (two required) Criterion E: Alterations in arousal or reactivity (two required) Criterion F: Duration Criterion G: Functional Significance Criterion H: Exclusion Specifications [American Psychiatric Association. (2013); U.S. Department of Veterans Affairs (2014)] Wells, Berent 2
Major Revisions New class of trauma and stressor related disorders Four clusters Former Criterion C separated into two criteria Three new symptoms added Clarification of symptom expression Removal of Criterion A2 Clinical subtype [American Psychiatric Association (2013); U.S. Department of Veterans Affairs (2014)] Manualized outpatient program Group therapy twice a week/three hours a day Small group sizes Sixteen-eighteen week outpatient program Three phases Didactic training Exposure therapy Relapse prevention Phase One: Didactic (1-5 Weeks) Group dynamics & stress management techniques Didactic presentations Symptom identification Breathing retraining & grounding Thought stopping Avoidance Member presentation Wells, Berent 3
Phase Two: Group Exposure (8-9 Weeks) Alumni sponsorship War-trauma presentation Interviews Recording Responses to presentations Exposure. Phase Three: Relapse Prevention (3 Weeks) Imagined funeral for a fallen comrade Grief and guilt Chaplain and alumni sponsorship Relapse prevention Certificate of completion Discussion Five studies reviewed Findings: A positive reduction in PTSD symptoms post therapy Two studies: Some clients no longer met the diagnostic criteria for PTSD subsequent treatment Two articles: Addressed depression & reported moderate to significant reductions in symptoms GBET: A potentially successful treatment in this particular cohort [Mott et al. (2013); ; Ready, Sylvers et al. (2012); Ready, Thomas et al. (2012); Sutherland et al. (2012)] Wells, Berent 4
A LOOK AHEAD Group Based Exposure Therapy Chronic war-related PTSD Clinical Trials Adaptability to civilian services Pre-deployment preparedness REFERENCES American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, (5 th ed.). Washington, DC: Author. Caban, A. (2011). Stressors of multiple deployments. Veterans Journal: Around the Web. Retrieved from http://www.veteranjournal.com/stressors-of-multiple-deployments/. ClinicalTrials.gov. Group based exposure therapy for combat-related PTSD. Retrieved from http://clinicaltrials.gov/ct2/show/results/nct00535223?term=gbet&rank=1. Congressional Budget Office. (2012). The Veterans Health Administration s treatment of PTSD and traumatic brain injury among recent combat veterans. Retrieved from http://www.cbo.gov/sites/default/files/ cbofiles/attachments/02-09-ptsd.pdf. Frincu-Mallas, C. (2010). Multiple deployments in soldiers linked to increased risk for PTSD. Medscape Medical News. Retrieved from medscape.com/viewarticle/718358. Mott, J. M., Sutherland, R. J., Williams, W., Lanier, S. H., Ready, D. J., & Teng, E. J. (2013). Patient perspectives on the effectiveness and tolerability of group-based exposure therapy for posttraumatic stress disorder: Preliminary self-report findings from 20 veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 5(5), 453 461. doi: 10.1037/a0029386 REFERENCES Price, M., Gros, D., Strachan, M., Ruggio, K., & Acierno, R. (2013). Combat experiences, pre-deployment training, and outcome of exposure therapy for post-traumatic stress disorder in operation enduring freedom and operation Iraqi freedom veterans. Clinical Psychology Psychotherapy, 20(4). 277-285. doi: 10.1002/cpp.1768 Ready, D. J., Sylvers, P., Worley, V., Butt, J., Mascaro, N., & Bradley, B. (2012). The impact of group-based exposure therapy on PTSD and depression of 30 combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 4(1), 84 93. doi: 10.1037/a0021997 Ready, D. J., Thomas, K. R., Vega, E. M., Worley, V., & Bradley, B. (2012). Combining group- based exposure therapy with prolonged exposure to treat U.S. Vietnam veterans with PTSD: A Case Study. Journal of Traumatic Stress, 25(5), 574-577. doi: 10.1002/jts.21734 Ready, D. J., Thomas, K. R., Worley, V., Backscheider, A. G., Harvey, L. A., Baltzell, D., & Rothbaum, B. O. (2008). A field test of group based exposure therapy with 102 veterans with war-related posttraumatic stress disorder. Journal of Traumatic Stress, 21(2), 150-157. doi: 10.1002/jts.20326 Sutherland, R. J., Mott, J. M., Lanier, S. H., Williams, W., Ready, D. J., & Teng, E. J. (2012). A pilot study of a 12- week model of group-based exposure therapy for veterans with PTSD. Journal of Traumatic Stress, 25(2), 150-156. doi: 10.1002/jts.21679 U.S. Department of Veterans Affairs (2014). DSM-5 criteria for PTSD. Retrieved from http:// www.ptsd.va.gov/professional/ptsd-overviewe/dsm5_criteria_ptsd.asp Wells, Berent 5