Theoretical and empirical issues in the treatment of post-traumatic stress disorder in Vietnam veterans

Posttraumatic stress disorder and mortality in VA patients with implantable cardioverter-defibrillators

BACKGROUND

The association between posttraumatic stress disorder (PTSD) and mortality in patients undergoing implantable cardioverter-defibrillator (ICD) placement has not been evaluated in US veterans.

HYPOTHESIS

PTSD in veterans with ICD is associated with increased mortality.

METHODS

We studied a retrospective cohort of 25 678 veterans who underwent ICD implantation between September 30, 2002, and December 31, 2011. Of these subjects, 3280 carried the diagnosis of PTSD prior to ICD implantation. Primary outcome was all-cause mortality between date of ICD implantation and end of follow-up (September 30, 2013). We used Cox proportional hazard models to compute multivariable adjusted hazard ratios with corresponding 95% confidence intervals for the relation between PTSD diagnosis and death following ICD placement.

RESULTS

During a mean follow-up of 4.21 ± 2.62 years, 11 015 deaths were reported. The crude incidence rate of death was 87.8 and 103.9/1000 person-years for people with and without PTSD, respectively. We did not find an association between presence of PTSD before or after ICD implantation and incident death when adjusted for multiple risk factors (hazard ratio: 1.003, 95% confidence interval: 0.948-1.061). In secondary analysis, no statistically significant association was found.

CONCLUSIONS

In this retrospective cohort study among more than 25 000 veterans undergoing ICD implantation, almost 13% had a diagnosis of PTSD. Subjects with PTSD were significantly younger, yet they had a higher incidence of coronary heart disease, major cardiac comorbidities, cancer, and mental health conditions. We found no association between presence of PTSD before or after ICD implantation and incident death when adjusting for all covariates.

Recent Developments in Posttraumatic Stress Disorder

The traumatic stress field has expanded dramatically over the last 10 years. This paper provides a review of progress in three areas from the domain of posttraumatic stress responses. First, recent developments in diagnosis are discussed, with particular reference to the proposed diagnostic criteria for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; American Psychiatric Association, in press). Second, a theoretical formulation based on cognitive processing principles is presented and, where available, empirical support for such a conceptualisation is provided. Third, the implications of a cognitive processing paradigm for treatment are discussed briefly, with reference to recent research findings. Suggestions for future development of the field are provided.

Symptoms of Anxiety, Depression, and Posttraumatic Stress Among Survivors of the 2005 Pakistani Earthquake

Objectives: To assess and compare the prevalence of psychological morbidity among survivors of the 2005 northern Pakistan earthquake from Azad Kashmir and the Northwest Frontier Province (NWFP).

Methods: We conducted a cross-sectional study among randomly sampled survivors (N = 361) of the earthquake living in camps at the time of the interview, approximately 6 months after the earthquake.

Results: The prevalence of posttraumatic stress disorder (PTSD) symptoms in the total sample was 51.5% and the prevalence of individuals who received positive scores on the Hopkins Symptom Checklist (HSCL) was 75%. The prevalence rates for anxiety and depression symptoms were 77.3% and 70.9%, respectively. The prevalence in Azad Kashmir was 57.9% for PTSD and 79.8% for positive HSCL, and NWFP had 41.3% PTSD and 67.4% positive HSCL. Study subjects from Azad Kashmir were approximately 2 times as likely to have PTSD or a positive HSCL when compared to subjects from NWFP (odds ratio 1.95, confidence interval 1.27-3.0; P = .0024) and (odds ratio 1.91, confidence interval 1.18-3.1; P = .0085), respectively.

Conclusions: Nearly half of the northern Pakistan earthquake survivors had symptoms of PTSD. Six months after the incident, more than three-fourths exhibited symptoms of an anxiety disorder.

(Disaster Med Public Health Preparedness. 2011;5:293–299)

Coping Strategies in PTSD

The aim of this study is to analyse the type of coping strategies used by patients with post-traumatic stress disorder (PTSD). For that purpose, two groups of war veterans (40 subjects in each group) were compared. The first group was made up of patients with PTSD, and the second (control) group comprised veterans who suffered combat trauma, but did not show any PTSD symptoms. Coping strategies were assessed using the Questionnaire of Coping Responses (McCrae, 1984).

The results show that out of 118 items (examples of coping strategies) 10 show statistically significant differences between the group with PTSD and the one without it. PTSD patients used more maladaptive strategies (avoidance, pseudo-planning, fantasizing, impulsive and depressive behaviour), while subjects from the control group were more likely to use the strategy of controlling impulses.

Preclinical assessment for selectively disrupting a traumatic memory via postretrieval inhibition of glucocorticoid receptors

BACKGROUND

Traumatic experiences may lead to debilitating psychiatric disorders including acute stress disorder and posttraumatic stress disorder. Current treatments for these conditions are largely ineffective, and novel therapies are needed. A cardinal symptom of these pathologies is the reexperiencing of the trauma through intrusive memories and nightmares. Studies in animal models indicate that memories can be weakened by interfering with the postretrieval restabilization process known as memory reconsolidation. We previously reported that, in rats, intraamygdala injection of the glucocorticoid receptor antagonist RU38486 disrupts the reconsolidation of a traumatic memory. Here we tested parameters important for designing novel clinical protocols targeting the reconsolidation of a traumatic memory with RU38486.

METHODS

Using rat inhibitory avoidance, we tested the efficacy of postretrieval systemic administration of RU38486 on subsequent memory retention and evaluated several key preclinical parameters.

RESULTS

Systemic administration of RU38486 before or after retrieval persistently weakens inhibitory avoidance memory retention in a dose-dependent manner, and memory does not reemerge following a footshock reminder. The efficacy of treatment is a function of the intensity of the initial trauma, and intense traumatic memories can be disrupted by changing the time and number of interventions. Furthermore, one or two treatments are sufficient to disrupt the memory maximally. The treatment selectively targets the reactivated memory without interfering with the retention of another nonreactivated memory.

CONCLUSIONS

RU38486 is a potential novel treatment for psychiatric disorders linked to traumatic memories. Our data provide the parameters for designing promising clinical trials for the treatment of flashback-type symptoms of PTSD.

Psychological debriefing: controversy and challenge

OBJECTIVE

The efficacy of psychological debriefing following potentially traumatising events has become extremely controversial. This review aims to identify the issues underlying this controversy and their theoretical, social and political ramifications which are important in other areas of psychiatry and the social sciences.

METHOD

The historical background to the debriefing debate and the (largely negative) results of recent randomised controlled trials (RCTs) are reviewed.

RESULTS

Despite the negative results of recent RCTs, psychological debriefing remains the most widely used structured intervention following potentially traumatising events, designed to reduce the incidence of long-term psychiatric morbidity. The clinical relevance these trials and their applicability in vivo is questioned. There are implicit difficulties in conducting rigorous randomised controlled trials of group debriefing, and such trials may be unachievable.

CONCLUSIONS

Demonstrating the efficacy of debriefing or other preventive interventions presents major challenges to investigators and it is unlikely the controversy will be resolved in the near future.

Effects of psychotherapeutic treatments for PTSD: a meta-analysis of controlled clinical trials

This meta-analysis synthesized the results from controlled, clinical trials of psychotherapeutic treatments for posttraumatic stress disorder (PTSD). Psychotherapeutic modalities included behavioral, cognitive, and psychodynamic treatments, in group and individual settings. Participants in the studies included combat veterans from the Vietnam and Lebanon Wars, crime-related victims, and severe bereavement sufferers. The impact of psychotherapy on PTSD and psychiatric symptomatology was significant, d = .52, r = .25, when measured immediately after treatments were administered. Similarly, there was no decay in the effect of treatment at follow-up, d = .64, r = .31. Moreover, for target symptomes of PTSD and general psychological symptomes (intrusion, avoidance, hyperarousal, anxiety, and depression), effect sizes were significant, ranging from r's of .2-.49. Results suggest substantial promise for improving psychological health and decreasing related symptoms for those suffering from PTSD.

Australian Vietnam veterans: factors contributing to psychosocial problems

OBJECTIVE

The objective of the present paper is to present comprehensive models of the current psychosocial morbidity of Australian Vietnam veterans. Seldom has research in this area attempted to 'untangle' direct and indirect influences on current functioning via possible pre-army, Vietnam and homecoming pathways.

METHOD

The Australian Vietnam Veterans' Health Study gathered data on a sample of 641 veterans throughout Australia drawn randomly from army Vietnam tour lists of the era. The data arose from interview and army records of the era, and fall into four temporal categories: pre-army, Vietnam service, homecoming after Vietnam, and current state. Path analysis models of the veterans' current psychological morbidities and social wellbeing are used to identify direct aetiological influences of earlier era constructs on current state, free of confounding by indirect (often selection) effects.

RESULTS

Our results indicate that psychological morbidity (particularly posttraumatic stress disorder) is largely influenced by combat and poor homecoming experiences, although pre-military characteristics do play some direct roles in symptomatology. Social dysfunction measures show smaller effects of the Vietnam War, which may be accounted for by an indirect association with Vietnam-related psychological morbidity. Some social measures show evidence of compensatory influences of combat, high combat leading to social dysfunction because of morbidity, but simultaneously being associated with healthier social disposition (possibly because of increased exservice activity).

CONCLUSIONS

For Australian Vietnam veterans, combat-related and homecoming effects persist on a range of psychosocial endpoints 20-30 years after exposure. These effects are not explicable in terms of veterans pre-Vietnam characteristics.

Taped imaginal exposure as a treatment for post-traumatic stress reactions

The efficacy of taped imaginal exposure as a treatment for Post-Traumatic Stress Reactions (PTSR) was assessed in eighteen consecutive outpatients, including Gulf War veterans. Detailed present-tense scripts of their personal traumatic experiences were prepared and in all but two cases audio-taped and listened to regularly. The severity of PTSR and standard questionnaire scores (including the IES, BDI, GHQ8 and the SCL 90) all showed statistically significant improvements post treatment and at three month follow-up. This case series confirms the potential efficacy of taped imaginal exposure in the treatment of full and partial forms of Post-Traumatic Stress Disorder (PTSD). The simplicity of its administration and acceptability to the individual suggest that it is worthy of more thorough research.

Eye movement desensitization across subjects: subjective and physiological measures of treatment efficacy

Eye movement desensitization (EMD) was investigated in an experimental multiple baseline across subjects design. Six subjects who met the diagnostic criteria for Posttraumatic Stress Disorder (PTSD) were included in the study. While the EMD technique advanced by Shapiro has been reported to be clinically effective, major methodological issues have been raised which remain to be addressed. One issue raised is whether exposure to the traumatic image is sufficient to account for the reported clinical effects of EMD or whether the addition of saccadic eye movements is central to the treatment. This study attempted to address this concern by comparing two EMD-based procedures: a Non-saccade phase (without the saccadic eye movements) which functioned as a control and a second that included saccadic eye movements. Dependent variables included self-report information (SUDs, behavioral symptoms reports) and physiological data (heart rate and systolic blood pressure). The results showed no significant decreases in SUDs level with the EMD minus the saccadic eye movements procedure. However, five of the six subjects reported clinically significant decreases in their SUDs levels with the inclusion of the saccadic eye movements. This study appears to corroborate previous work employing single-case design as well as pre and postcomparisons.

Psychotherapy for Vietnam-related Posttraumatic Stress Disorder

There are a wide range of psychotherapeutic treatments for Vietnam-related Posttraumatic Stress Disorder. This paper reviews some of the more commonly used interventions which are the behavioral, psychodynamic, family, and group therapies. Commonalities among these diverse treatments are shown to involve reconfronting trauma stimuli and the attempt to reintegrate traumatic experiences into ongoing personality functioning. It is shown that there are virtually no methodologically sound, empirically based studies that compare two or more treatments within a given study. Experimentally controlled, comparative studies are needed to advance our knowledge of effective treatments of this disorder.

Eye-movement desensitisation to overcome post-traumatic stress disorder

A new treatment using a saccadic eye-movement desensitisation (EMD) procedure has recently been introduced to treat post-traumatic stress disorder, a disorder that has been difficult to treat in the past. The treatment is claimed to be very rapid and successful. This paper reports the treatment of a woman with posttraumatic stress disorder following a horrific road traffic accident using the EMD procedure.

Exposure therapy for post-traumatic stress disorder. Four case studies

Four cases of PTSD, and their treatment, are described. Symptoms responded differently to two behavioural approaches. In-vivo exposure was effective for phobic anxiety while imaginal exposure improved dysphoria and some phobic symptoms. Audio-taped imaginal exposure may be important as part of treatment.

Eye movement desensitization: a new treatment for post-traumatic stress disorder

The use of saccadic eye movements for treating post-traumatic stress disorder is described. The procedure involves eliciting from clients sequences of large-magnitude, rhythmic saccadic eye movements while holding in mind the most salient aspect of a traumatic memory. This results in (1) a lasting reduction of anxiety, (2) changes in the cognitive assessment of the memory, and (3) cessation of flashbacks, intrusive thoughts, and sleep disturbances. The procedure can be extremely effective in only one session, as indicated by a previous controlled study and a case history presented here. It does not require a hierarchical approach, as in desensitization, or the elicitation of disturbingly high levels of anxiety over a prolonged period of time, as in flooding. Some speculations are offered concerning the basis for the effectiveness of the procedure.

Treatment outcomes of Vietnam veterans with PTSD and the consistency of the MCMI

This study addresses two issues: treatment changes on the MCMI of Vietnam veterans with PTSD and test-retest reliability of the Millon Clinical Multiaxial Inventory (MCMI). Fifty Vietnam veterans carefully were identified for the diagnosis Post-Traumatic Stress Disorder (PTSD). They were admitted to a Special PTSD Treatment Unit that consisted of an intense 5-week period with focus on the revivified Vietnam experience. They also were given the MCMI at two points in time, treatment inception and 35 days later at discharge. Results show that 17 of 20 scales on the MCMI changed in the negative direction as a result of treatment. Also, the MCMI has adequate test-retest reliability, and the personality scales (with the exception of Borderline) have higher reliability coefficients than do symptom scales. The use of the MCMI is encourged both as a monitor of treatment for these veterans and for its stability.