A test of behavioral family therapy to augment exposure for combat-related posttraumatic stress disorder

Social Company Disrupts Fear Memory Renewal: Evidence From Two Rodent Studies

Renewal of fear outside treatment context is a challenge for behavioral therapies. Prior studies suggest a social buffering effect that fear response is attenuated in the presence of social company. However, few studies have examined the role of social company in reducing fear renewal. Here, we used a Pavlovian fear conditioning procedure including acquisition, extinction and test stages to examine social buffering effect on fear memory renewal in male rats. The test context was manipulated to be either different from the extinction one in ABC model, or same as that in ACC model. All conditioned subjects underwent extinction individually in Experiment 1 but with a partner in Experiment 2. In test, both experiments manipulated social company (alone vs. accompanied) and context (ABC vs. ACC). Experiment 1 showed more freezing in ABC than in ACC model during the test-alone condition, indicating a fear renewal effect which, however, was absent during the test-accompanied condition. Also, accompanied subjects showed less freezing compared to alone subjects in the ABC model. In Experiment 2, animals showed a similar freezing in ABC and ACC models despite being tested alone, implying that social company offered at extinction disrupted fear renewal. Again, we observed reduced freezing in accompanied relative to alone subjects in the test. These results suggest that social company is effective in disrupting fear renewal after leaving treatment context.

Prolonged exposure therapy for combat-related posttraumatic stress disorder: comparing outcomes for veterans of different wars

There is significant support for exposure therapy as an effective treatment for posttraumatic stress disorder (PTSD) across a variety of populations, including veterans; however, there is little empirical information regarding how veterans of different war theaters respond to exposure therapy. Accordingly, questions remain regarding therapy effectiveness for treatment of PTSD for veterans of different eras. Such questions have important implications for the dissemination of evidence based treatments, treatment development, and policy. The current study compared treatment outcomes across 112 veterans of the Vietnam War, the first Persian Gulf War, and the wars in Afghanistan and Iraq. All subjects were diagnosed with PTSD and enrolled in prolonged exposure (PE) treatment. Veterans from all three groups showed significant improvement in PTSD symptoms, with veterans from Vietnam and Afghanistan/Iraq responding similarly to treatment. Persian Gulf veterans did not respond to treatment at the same rate or to the same degree as veterans from the other two eras. Questions and issues regarding the effectiveness of evidence based treatment for veterans from different eras are discussed.

Observations and insights about strengthening our soldiers SOS

The Special Issue (June 2011) of the Journal of Clinical Psychology in Medical Settings titled Strengthening Our Soldiers (SOS) and Their Families: Contemporary Psychological Advances Applied to Wartime Problems revealed the following important concerns: 1) Who is at risk for psychological sequelae during and following service in the U.S. military? 2) How to deliver the best treatment for our soldiers and veterans with PTSD, Traumatic Brain Injury and Pain? 3) How to train the trainers? and 4) What are the current priorities for service delivery, research and funding? Assessment strategies and tools are provided to assist in identification of suicidal ideation and behaviors, alcohol abuse in spouses, posttraumatic stress disorders, depression, brain injuries and post-concussion syndrome, as well as positive growth experiences. Empirically validated Cognitive Processing and Prolonged Exposure treatments are described as are the empirical results already in evidence in our military populations. The innovative use of Virtual Reality and Telehealth applications is demonstrated in both army and naval settings for preparing and reducing trauma in affected soldiers. The Functional and Occupational Rehabilitation Treatment (FORT) Program and its role in returning function to injured soldiers with musculoskeletal pain and motion restrictions, while also leading to reductions of anxiety, depression and use of medical services, is described. A critique about providing service-research for children's reactions to their parent's deployments and family functioning during separation and reintegration is provided. The need for theoretical-empirical approaches to understanding pain-behavior, anxiety dysregulation as it impacts the brain function and structure is provided by experts in pain, neuropsychology, brain circuitry and anxiety management of multiple traumas. This final paper in SOS provides commentary on SOS and describes possible future implications of current psychological knowledge related to military personnel and their families.

Acupuncture for posttraumatic stress disorder: conceptual, clinical, and biological data support further research

Posttraumatic stress disorder (PTSD) is common, debilitating, and has highly heterogeneous clinical and biological features. With the exception of one published preliminary clinical trial, rationale in support of the efficacy of acupuncture, a modality of Chinese medicine (CM), for PTSD has not been well described. This is a focused review of conceptual and clinical features of PTSD shared by modern western medicine (MWM) and CM, and of biological mechanisms of acupuncture that parallel known PTSD pathology. MWM and CM both recognize individual developmental variables and interactions between external conditions and internal responses in the genesis of PTSD. There is one published and one unpublished clinical trial that preliminarily support the efficacy of acupuncture for PTSD. Although there have been no mechanistic studies of acupuncture in human PTSD, extant research shows that acupuncture has biological effects that are relevant to PTSD pathology. Conceptual, clinical, and biological data support possible efficacy of acupuncture for PTSD. However, further definitive research about simultaneous clinical and biological effects is needed to support the use of acupuncture for PTSD in health care systems.

The applicability of randomized controlled trials of psychosocial treatments for PTSD to a veteran population

The extent to which the results of randomized controlled trials can be expected to generalize to clinical populations has been the subject of much debate. To examine this issue among a population of individuals diagnosed with posttraumatic stress disorder (PTSD), the clinical characteristics of Veterans Affairs (VA) patients with PTSD were compared to the eligibility criteria for clinical trials of psychosocial treatments for PTSD. Administrative data for 239,668 patients who received a diagnosis of PTSD within the VA healthcare system during the 2003 fiscal year were compared with inclusion and exclusion criteria of 31 clinical trials for PTSD. Based on available data, all patients appeared to be eligible for at least one study, and half (50%) were eligible for between 16 and 21 (50% or more) of the 31 studies examined. The studies for which the most veterans with PTSD would have been eligible targeted combat-related trauma or did not specify type of trauma in their eligibility criteria. Veterans who exhibited psychotic symptoms (3% of the sample) were ineligible for most, but not all, of the studies. However, most veterans with comorbid Axis I conditions, such as depression, anxiety disorders, and substance use disorders, were eligible for multiple studies. These findings, which indicate that the existing literature on the efficacy of psychosocial treatment may inform the treatment of the majority of veterans who present with PTSD, have applications for the design of future clinical trials and for consultation of the literature regarding appropriate treatments for veterans with PTSD.

Behavioral couples therapy for comorbid substance use disorders and combat-related posttraumatic stress disorder among male veterans: an initial evaluation

Outcomes after behavioral couples therapy (BCT) were compared for 19 dually diagnosed veterans with combat-related PTSD and a substance use disorder (SUD, primarily alcohol dependence) and 19 veterans with SUD only. Clients with and without comorbid PTSD had very similar pre-treatment clinical profiles on dimensions of substance misuse, relationship functioning, and psychological symptoms. Further, both PTSD and non-PTSD clients showed good compliance with BCT, attending a high number of BCT sessions, taking Antabuse, and going to AA. Finally, both PTSD and non-PTSD groups improved from before BCT to immediately after and 12 months after BCT. Specific improvements noted were increased relationship satisfaction and reductions in drinking, negative consequences of drinking, male-to-female violence, and psychological distress symptoms. Extent and pattern of improvement over time were similar whether the client had PTSD or not. The present results suggest that BCT may have promise in treating clients with comorbid SUD and combat-related PTSD.

PTSD and the Social Support of the Interpersonal Environment: The Development of Social Cognitive Behavior Therapy

We will argue that, although the evidence for the effectiveness of cognitive-behavioral treatment, of PTSD is compelling, not all patients engage or respond to treatment and in those who do, residual symptomatology is not uncommon. We then briefly examine the literature on the influence of the interpersonal and emotional aspects of social support on the development, maintenance, and treatment of post-traumatic stress disorder (PTSD). Two areas of social support are suggested as potentially important to the study of PTSD: (1) the literature on expressed emotion (EE) and the underlying beliefs held by significant others which influence their negative coping behaviors and interactions with the patient, and (2) examination of the concept of reciprocity, the ability to receive and provide social support. Finally, we suggest a range of possible treatment options suggested by this review as possible adjuncts to conventional CBT. These include formal family interventions, re-engagement with social networks, and modification of perceptions of social interactions.