Massed cognitive processing therapy for combat-related posttraumatic stress disorder: Study design and methodology of a non-inferiority randomized controlled trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent among military personnel. Cognitive processing therapy (CPT) is identified as one of the most effective treatments for PTSD, although smaller effects have been found in military populations. High rates of dropout from treatment may contribute to reduced efficacy, and military personnel may face unique barriers to treatment completion. One method of improving efficacy may be to reduce dropout by decreasing the time required to receive a full dose of treatment. This paper describes the design and methodology of the first randomized clinical trial testing whether CPT delivered in an intensive format is non-inferior to standard delivery of CPT.

METHOD

Participants are 140 active duty service members randomized to receive CPT in a 5-day combined group and individual intensive outpatient format (MCPT) or standard CPT (delivered individually twice weekly over 6 weeks). Participants are assessed at baseline, and 1 month, 4 months, and 1 year following the conclusion of the therapy. Reduction in PTSD symptomatology is the primary outcome of interest. Secondary outcomes include comorbid psychological symptoms, health, and functioning. A secondary objective is to examine predictors of treatment outcome to determine which service members benefit most from which treatment modality.

CONCLUSION

If determined to be non-inferior, MCPT would provide an efficient and accessible modality of evidence-based PTSD treatment. This therapy format would improve access to care by reducing the amount of time required for treatment and improving symptoms and functioning more rapidly, thereby minimizing interference with work-related activities and disruption to the mission.

Elton Mayo and Thomas Henry Reeve Mathewson: the forgotten Australian pioneers of the treatment of patients with shell shock, neurasthenia and nervous breakdown

The contributions of Australians on shell shock are absent from the literature. However, two Australians were pioneers in the treatment of shell shock: George Elton Mayo (1880-1949) and Dr Thomas Henry Reeve Mathewson (1881-1975). They used psychoanalytic approaches to treat psychiatric patients and introduced the psychoanalytic treatment of people who suffered from shell shock. Their 'talking cure' was highly successful and challenged the view that shell shock only occurred in men who were malingering and/or lacking in fortitude. Their work demonstrated that people experiencing mental illness could be treated in the community at a time when they were routinely treated as inpatients. It also exemplified the substantial benefits of combining science with clinical knowledge and skill in psychology and psychiatry.

Trauma, treatment and Tetris: video gaming increases hippocampal volume in male patients with combat-related posttraumatic stress disorder

BACKGROUND

Tetris has been proposed as a preventative intervention to reduce intrusive memories of a traumatic event. However, no neuroimaging study has assessed Tetris in patients with existing posttraumatic stress disorder (PTSD) or explored how playing Tetris may affect brain structure.

METHODS

We recruited patients with combat-related PTSD before psychotherapy and randomly assigned them to an experimental Tetris and therapy group (n = 20) or to a therapy-only control group (n = 20). In the control group, participants completed therapy as usual: eye movement desensitization and reprocessing (EMDR) psychotherapy. In the Tetris group, in addition to EMDR, participants also played 60 minutes of Tetris every day from onset to completion of therapy, approximately 6 weeks later. Participants completed structural MRI and psychological questionnaires before and after therapy, and we collected psychological questionnaire data at follow-up, approximately 6 months later. We hypothesized that the Tetris group would show increases in hippocampal volume and reductions in symptoms, both directly after completion of therapy and at follow-up.

RESULTS

Following therapy, hippocampal volume increased in the Tetris group, but not the control group. As well, hippocampal increases were correlated with reductions in symptoms of PTSD, depression and anxiety between completion of therapy and follow-up in the Tetris group, but not the control group.

LIMITATIONS

Playing Tetris may act as a cognitive interference task and as a brain-training intervention, but it was not possible to distinguish between these 2 potential mechanisms.

CONCLUSION

Tetris may be useful as an adjunct therapeutic intervention for PTSD. Tetris-related increases in hippocampal volume may ensure that therapeutic gains are maintained after completion of therapy.

Enhanced exposure therapy for combat-related Posttraumatic Stress Disorder (PTSD): Study protocol for a randomized controlled trial

BACKGROUND

PTSD, which has been identified in up to 23% of post-9-11 veterans, often results in a chronic, pernicious course. Thus, effective treatments are imperative. The Institute of Medicine (IOM) concluded that the only intervention for PTSD with sufficient evidence to conclude efficacy is exposure therapy. This Phase III trial compares the efficacy of exposure therapy for combat-related PTSD delivered in two different formats- via virtual reality exposure therapy (VRE) or prolonged exposure therapy (PE)- combined with D-Cycloserine (DCS), a cognitive enhancer shown to facilitate the extinction of fear.

METHODS/DESIGN

Military personnel of any duty status and civilians deployed to Iraq and Afghanistan were eligible. Participants were randomly assigned to 9 sessions of exposure therapy (VRE or PE) and medication (50 mg DCS or placebo). Participants were treated at three geographically diverse sites. Participants were re-assessed at 3-months post-treatment. The co-primary hypotheses are that (1) DCS will augment response to exposure therapy (both VRE and PE) on PTSD symptoms; (2) VRE will be associated with greater improvement than PE. Genetic and psychophysiological markers will be evaluated as potential moderators and mediators of treatment outcomes as well as secondary outcomes.

DISCUSSION

This study is the first to compare the relative efficacy of DCS-augmented VRE versus PE on PTSD symptoms. The design has several advantages: participants received an active, effective treatment and predictors of response to treatment included genetic and psychobiological measures. The results may directly influence the future delivery of services, and contribute to the development of a standardized treatment protocol.

TRIAL REGISTRATION

NCT01352637.

Psychiatric Care of the Post-September 11 Combat Veteran: A Review

BACKGROUND

Post-September 11, 2001 combat veterans represent a growing cohort of patients with unique mental health needs, particularly around post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). The United States (US) remains engaged in conflicts around the globe, so this patient cohort will continue to grow in number. With around 40% of American combat veterans from Iraq and Afghanistan seeking mental health care outside of the Veterans Affairs, understanding the psychiatric needs of the post-September 11 combat veteran is an important goal for all psychiatrists. These patients are relevant to consultation-liaison (C-L) psychiatrists because of their high comorbidity of conditions such as TBI, obstructive sleep apnea, insomnia, and chronic pain. This article reviews the current literature on mental health care for the post-September 11 combat veteran, emphasizing PTSD and TBI treatment, and culling evidence-based recommendations from randomized controlled trials of combat veterans. Emphasis is also placed on the Veterans Affairs/Department of Defense Clinical Practice Guidelines. The authors also bring unique clinical expertise of having served on active duty as psychiatrists for the US Army, including in a combat zone, and both currently work in a Veterans Affairs Iraq and Afghanistan combat veteran mental health clinic.

OBJECTIVE

This review outlines useful treatment approaches for PTSD and TBI and briefly covers the comorbid conditions of major depression, chronic pain, and substance use disorders. This review will prepare C-L psychiatrists to care for this challenging patient cohort.

Design of a clinical effectiveness trial of in-home cognitive processing therapy for combat-related PTSD

Approximately 14% of military personnel and veterans who have deployed to the combat theater are at risk for combat-related posttraumatic stress disorder (PTSD). The treatment of combat-related PTSD in active duty service members and veterans is challenging. Combat trauma may involve multiple high levels of exposure to different types of traumatic events (e.g., human carnage after explosive blasts, life threat/injuries to self/others, etc.). Many service members and veterans are unable or unwilling to receive treatment in government facilities due to avoidance, scheduling difficulties, transportation or parking problems, concerns about career advancement, or stigma associated with seeking treatment. Innovative treatment-delivery approaches are needed to help overcome these barriers. The present study is a randomized clinical trial to evaluate three versions of Cognitive Processing Therapy (CPT; [54]) for the treatment of combat-related PTSD in active duty military service members and veterans: (1) standard In-Office CPT, (2) In-Home Telebehavioral Health CPT from the provider's office to the participant's home, and (3) In-Home CPT in which the provider delivers treatment in the participant's home. Use of an equipoise-stratified randomization design allows participants to decline one of the treatment arms. This research design partly overcomes the problems active duty military and veterans face when receiving PTSD treatment by allowing them to opt out of one inappropriate or unacceptable treatment modality and still permitting randomization to the two remaining treatment modalities. This manuscript provides an overview of the research design and methods for the study.

Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.

Real-time fMRI amygdala neurofeedback positive emotional training normalized resting-state functional connectivity in combat veterans with and without PTSD: a connectome-wide investigation

Self-regulation of brain activation using real-time functional magnetic resonance imaging neurofeedback (rtfMRI-nf) is an emerging approach for treating mood and anxiety disorders. The effect of neurofeedback training on resting-state functional connectivity warrants investigation as changes in spontaneous brain activation could reflect the association between sustained symptom relief and brain alteration. We investigated the effect of amygdala-focused rtfMRI-nf training on resting-state functional connectivity in combat veterans with and without posttraumatic stress disorder (PTSD) who were trained to increase a feedback signal reflecting left amygdala activity while recalling positive autobiographical memories (Zotev et al., 2018). The analysis was performed in three stages: i) first, we investigated the connectivity in the left amygdala region; ii) next, we focused on the abnormal resting-state functional connectivity identified in our previous analysis of this data (Misaki et al., 2018); and iii) finally, we performed a novel data-driven longitudinal connectome-wide analysis. We introduced a longitudinal multivariate distance matrix regression (MDMR) analysis to comprehensively examine neurofeedback training effects beyond those associated with abnormal baseline connectivity.

These comprehensive exploratory analyses suggested that abnormal resting-state connectivity for combat veterans with PTSD was partly normalized after the training. This included hypoconnectivities between the left amygdala and the left ventrolateral prefrontal cortex (vlPFC) and between the supplementary motor area (SMA) and the dorsal anterior cingulate cortex (dACC). The increase of SMA-dACC connectivity was associated with PTSD symptom reduction. Longitudinal MDMR analysis found a connectivity change between the precuneus and the left superior frontal cortex. The connectivity increase was associated with a decrease in hyperarousal symptoms. The abnormal connectivity for combat veterans without PTSD - such as hypoconnectivity in the precuneus with a superior frontal region and hyperconnectivity in the posterior insula with several regions - could also be normalized after the training. These results suggested that the rtfMRI-nf training effect was not limited to a feedback target region and symptom relief could be mediated by brain modulation in several regions other than in a feedback target area. While further confirmatory research is needed, the results may provide valuable insight into treatment effects on the whole brain resting-state connectivity.

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fMRI neurofeedback training effect on resting-state connectivity was examined

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Left amygdala activity was trained to increase with positive memory

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Neurofeedback normalized altered connectivity in veterans with and without PTSD

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PTSD symptom reductions were significant but not specific to group (exp/ctrl)

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Connectivity-symptom association was seen in mPFC and precuneus

Abrupt treatments of hysteria during World War I, 1914-18

Case reports of the abrupt recovery of hysterical disorders during World War I (1914-18), though undoubtedly subject to publication bias, raise both aetiological and treatment issues regarding pseudo-neurological conversion symptoms. Published clinical anecdotes report circumstantial, psychotherapeutic, hypnotic, persuasive (and coercive) methods seemingly inducing recovery, and also responses to fright and alterations of consciousness. The ethics of modern medical practice would not allow many of these techniques, which were reported to be effective, even in the chronic cases.

Edgar Adrian (1889-1977) and Shell Shock Electrotherapy: A Forgotten History?

The English electrophysiologist Edgar Adrian (1889-1977) was the recipient of the Nobel Prize for physiology in 1932 for his research on the functions of neurons. During World War I, at Queen Square in London, he devised an intensive electrotherapeutic treatment for shell-shocked soldiers. The procedure, developed with Lewis Yealland (1884-1954), was similar to "torpillage," the faradic psychotherapy used in France. Adrian and Yealland considered that the pain accompanying the use of faradic current was necessary for both therapeutic and disciplinary reasons, especially because of the suspicion of malingering. According to Adrian, this controversial electric treatment was only able to remove motor or sensitive symptoms. After the war, he finally admitted that war hysteria was a complex and difficult phenomenon.

Attention training modulates resting-state neurophysiological abnormalities in posttraumatic stress disorder

Recent research indicates the relative benefits of computerized attention control treatment (ACT) and attention bias modification treatment (ABMT) for posttraumatic stress disorder (PTSD); however, neural changes underlying these therapeutic effects remain unknown. This study examines how these two types of attention training modulate neurological dysfunction in veterans with PTSD. A community sample of 46 combat veterans with PTSD participated in a randomized double-blinded clinical trial of ACT versus ABMT and 32 of those veterans also agreed to undergo resting-state magnetoencephalography (MEG) recordings. Twenty-four veterans completed psychological and MEG assessments at pre- and post-training to evaluate treatment effects. MEG data were imaged using an advanced Bayesian reconstruction method and examined using statistical parametric mapping. In this report, we focus on the neural correlates and the differential treatment effects observed using MEG; the results of the full clinical trial have been described elsewhere. Our results indicated that ACT modulated occipital and ABMT modulated medial temporal activity more strongly than the comparative treatment. PTSD symptoms decreased significantly from pre- to post-test. These initial neurophysiological outcome data suggest that ACT modulates visual pathways, while ABMT modulates threat-processing regions, but that both are associated with normalizing aberrant neural activity in veterans with PTSD.

Treatment Seeking for Posttraumatic Stress in Israel Defense Forces Veterans Deployed in the 2006 Israel-Hezbollah War: A 7-Year Post-War Follow-Up

BACKGROUND

To determine the long-term prevalence of combat-related treatment seeking for PTSD in Israel Defense Force (IDF) veterans deployed to war.

METHODS

A seven-year surveillance records-based study determined the prevalence of treatment seeking and DSM-IV-TR diagnosis among treatment seeking IDF veterans in relation to the 2006 Israel-Hezbollah War. The whereabouts and combat exposure of veterans during the war was determined based on the IDF's Operations Directorate records.

RESULTS

Overall prevalence of psychological/psychiatric treatment seeking was 1.32%, and was significantly higher in soldiers deployed to high combat-exposure zones (2.19%), relative to low combat-exposure zones (0.24%), OR=9.20, CI=6.68-12.66, p<0.001. Treatment seeking did not differ between soldiers deployed in low combatexposure zones and soldiers deployed elsewhere than the war area (0.26%), OR=0.90, CI=0.65-1.24, p=0.45: 42% of care-seeking contacts occurred within the 3.5 months of the war's end. An additional 27.9% of all contacts occurred during the ensuing year, and decreased drastically in subsequent years. PTSD was more prevalent among treatment-seeking veterans deployed in high combatexposure zones relative to veterans who were deployed in low exposure zones or elsewhere.

CONCLUSIONS

Based on previous reports on postcombat PTSD prevalence using stratified samples, there appears to be a service-gap of anywhere between 3-11% between treatment seeking by IDF veterans following war deployment and the actual prevalence of PTSD and related symptoms in this soldier population. As in prior research, treatment seeking and PTSD strongly related to level of combat exposure.

Patients with multiple traumatic amputations: An analysis of operation enduring freedom joint theatre trauma registry data

INTRODUCTION

Improvised Explosive Devices (IED) are the primary wounding mechanism for casualties in Operation Enduring Freedom. Patients can sustain devastating traumatic amputations, which are unlike injuries seen in the civilian trauma sector. This is a database analysis of the largest patient registry of multiple traumatic amputations.

METHODS

The Joint Theater Trauma Registry was queried for patients with a traumatic amputation from 2009 to 2012. Data obtained included the Injury Severity Score (ISS), Glasgow Coma Score (GCS), blood products, transfer from theatre, and complications including DVT, PE, infection (Acinetobacter and fungal), acute renal failure, and rhabdomyolysis. Comparisons were made between number of major amputations (1-4) and specific outcomes using χ² and Pearson's rank test, and multivariable logistic regression was performed for 30-day survival. Significance was considered with p<0.05.

RESULTS

We identified 720 military personnel with at least one traumatic amputation: 494 single, 191 double, 32 triple, and 3 quad amputees. Average age was 24.3 years (18-46), median ISS 24 (9-66), and GCS 15 (3-15). Tranexamic acid (TXA) was administered in 164 patients (23%) and tourniquets were used in 575 (80%). Both TXA and tourniquet use increased with increasing number of amputations (p<0.001). Average transfusion requirements (in units) were packed red blood cells (PRBC) 18.6 (0-142), fresh frozen plasma (FFP) 17.3 (0-128), platelets 3.6 (0-26), and cryoprecipitate 5.6 (0-130). Transfusion of all blood products increased with the number of amputations (p<0.001). All complications tested increased with the number of amputations except Acinetobacter infection, coagulopathy, and compartment syndrome. Transfer to higher acuity facilities was achieved in 676 patients (94%).

CONCLUSION

Traumatic amputations from blast injuries require significant blood product transfusion, which increases with the number of amputations. Most complications also increase with the number of amputations. Despite high injury severity, 94% of traumatic amputation patients who are alive upon admission to a role II/III facility will survive to transfer to facilities with higher acuity care.

What does the literature say about the needs of veterans in the areas of health?

This paper reports on a systematic review undertaken in 2013 aimed at identifying evidence and dismissing some of the myths surrounding the needs of the veteran community. Papers were retrieved from a wide range of sources to ensure that literature covered the key areas of health concerns and focused also on time spent in service. Of the twenty eight papers reviewed categories relating to mental health (including PTSD and suicide), the use of alcohol, trauma, hearing loss, cancer and obesity were identified. Outcomes from the review established that while early service leavers were the most vulnerable there were also aspects within service that had an impact on future life events such as the type of leadership experienced, the cohesion of the unit and facing combat situations. The use of alcohol as a coping mechanism is also considered prevalent with adverse effects as is the worry of family situations at home. The impact of service life on the veteran, especially if suffering trauma will have long lasting psychological and physical outcomes, although it is recognised that veterans in the main have excellent physical and psychological strength and many physical illnesses are not greatly exaggerated from that of the general public.

Serum concentrations of TNF-α and its soluble receptors during psychotherapy in German soldiers suffering from combat-related PTSD

BACKGROUND

Changes in serum concentrations of tumor necrosis factor-α (TNF-α) and its soluble receptors (sTNF-R) p55 and p75 have been shown to be associated with various psychiatric treatments.

SUBJECTS AND METHODS

Before and after treatment, serum levels of TNF-α, sTNF-R p55 and sTNF-R p75 were measured in 38 German soldiers who had been deployed abroad and suffered from combat-related post-traumatic stress disorder (PTSD). Patients were randomized either to inpatient psychotherapy (N=21) including eye movement desensitization and reprocessing (EMDR) or to outpatient clinical management (N=17). Symptoms of PTSD were measured using the Post-traumatic Stress Diagnostic Scale (PDS).

RESULTS

The PDS score significantly decreased across time in both groups. Serum concentrations of TNF-α increased, while sTNF-R p55 and sTNF-R p75 levels decreased significantly. After the treatment period, we could not detect any significant difference regarding TNF-α, sTNF-R p55 or sTNF-R p75 levels between the inpatient psychotherapy group and the outpatient clinical management control group.

CONCLUSIONS

This relatively small clinical study suggests that specific inpatient psychotherapy but also non-specific supportive outpatient treatment for PTSD are associated with changes in the TNF-α system. This may represent an immunological effects or side effects of psychotherapy.

Toward a Phenomenology of Trance Logic in Posttraumatic Stress Disorder

Some induction procedures result in trance logic as an essential feature of hypnosis. Trance logic is a voluntary state of acceptance of suggestions without the critical evaluation that would destroy the validity of the meaningfulness of the suggestion. Induction procedures in real and simulated conditions induce a conflict between two contradictory messages in experimental hypnosis. In military induction the conflict is much more subtle involving society's need for security and its need for ethics. Such conflicts are often construed by the subject as trance logic. Trance logic provides an opportunity for therapists using the phenomenology of “presence” to deal with the objectified concepts of “avoidance,” “numbing” implicit in this kind of dysfunctional thinking in Posttraumatic Stress Disorder. An individual phenomenology of induction procedures and suggestions, which trigger trance logic, may lead to a resolution of logical fallacies and recurring painful memories. It invites a reconciliation of conflicting messages implicit in phobias and avoidance traumas. Such a phenomenological analysis of trance logic may well be a novel approach to restructure the meaning of trauma.

Neurology in the Vietnam War

Between December 1965 and December 1971, the United States maintained armed forces in Vietnam never less than 180,000 men and women in support of the war. At one time, this commitment exceeded half a million soldiers, sailors, and airmen from both the United States and its allies. Such forces required an extensive medical presence, including 19 neurologists. All but two of the neurologists had been drafted for a 2-year tour of duty after deferment for residency training. They were assigned to Vietnam for one of those 2 years in two Army Medical Units and one Air Force facility providing neurological care for American and allied forces, as well as many civilians. Their practice included exposure to unfamiliar disorders including cerebral malaria, Japanese B encephalitis, sleep deprivation seizures, and toxic encephalitis caused by injection or inhalation of C-4 explosive. They and neurologists at facilities in the United States published studies on all of these entities both during and after the war. These publications spawned the Defense and Veterans Head Injury Study, which was conceived during the Korean War and continues today as the Defense and Veterans Head Injury Center. It initially focused on post-traumatic epilepsy and later on all effects of brain injury. The Agent Orange controversy arose after the war; during the war, it was not perceived as a threat by medical personnel. Although soldiers in previous wars had developed serious psychological impairments, post-traumatic stress disorder was formally recognized in the servicemen returning from Vietnam.

French Neurologists during World War I

The Great War accelerated the development of neurological knowledge. Many neurological signs and syndromes, as well as new nosological entities such as war psychoneuroses, were described during the conflict. The period between 1914 and 1918 was the first time in which many neurologists were concentrated in wartime neurology centres and confronted with a number of neurological patients never seen before. This concentration led to the publication of papers concerning all fields of neurological sciences, and these reports pervaded scientific journals during the conflict and the post-war years. The careers of French neurologists during the war were highly varied. Some were mobilised, whilst others enlisted voluntarily. They worked as regiment physicians at the front or in wartime neurology centres at the front or at the rear. Others were academics who were already authoritative names in the field of neurology. Whilst they were too old to be officially mobilised, they nevertheless worked in their militarised neurology departments of civil hospitals. We present here the careers of a few French neurologists during the Great War, including Charles Foix (1882-1927), René Cruchet (1875-1959), Georges Guillain (1876-1961), Jean Lhermitte (1877-1959), Clovis Vincent (1879-1947), Gustave Roussy (1874-1948), and Paul Sollier (1861-1933).

Veterans' Experiences using Complementary and Alternative Medicine for Posttraumatic Stress: A Qualitative Interpretive Meta-Synthesis

Combat Veterans struggling with combat-related post(*)traumatic stress disorder and subthreshold symptoms often look outside the conventional behavioral health care system for treatment because standard care has not met their needs. This study utilized a qualitative interpretive metasynthesis to describe the lived experience of combat Veterans seeking complementary and alternative health therapies for posttraumatic stress symptoms. This research aimed to understand what attracts these Veterans to complementary and alternative medicine techniques and how they benefit from their experiences with nonconventional therapies. Findings suggest the need for further research into increasing access and eliminating disparities for Veterans seeking more integrative care.

The Colour Treatment: A Convergence of Art and Medicine at the Red Cross Russell Lea Nerve Home

When the Red Cross opened its new convalescent home at Russell Lea in Sydney in 1919, it contained a coloured room designed for treating ‘nerve cases’. This room was painted by Roy de Maistre, a young artist, and was modelled on the Kemp Prossor colour scheme trialled at the McCaul Convalescent Hospital in London for the treatment of shell shock. Dubbed the ‘colour cure’ by the popular press, this unconventional treatment was ignored by the Australian medical profession. The story of de Maistre's colour experiment is not widely known outside the specialist field of Australian art history. Focusing on the colour room as a point of convergence between art and medicine in the context of the First World War, this article investigates Red Cross activities and the care of soldiers suffering from nervous conditions.

Tackling Shell Shock in Great War Oxford: Thomas Saxty Good, William McDougall, and James Arthur Hadfield

Shell shock was an important object of diagnostic and therapeutic concern in Oxford during the Great War. The efforts of three Oxford physicians--Thomas Saxty Good, William McDougall, and James Arthur Hadfield--are of particular significance to our story. All worked on the problem at various sites throughout the city. They often collaborated. All were committed to employing innovative techniques such as psychotherapy and hypnosis. Each rose, to differing extents, to prominence in the field of psychological medicine during the succeeding decades. Yet all have been neglected in the current historiography. I argue that a close examination of their practices reveals a curious combination of therapeutic pragmatism and psychoanalytically informed techniques that later helped inform clinical psychology's challenge to psychiatry's dominance over the concept and care of mental disorder.

The Integrative Health and Wellness Program: Development and Use of a Complementary and Alternative Medicine Clinic for Veterans

CONTEXT

A movement exists within the Veterans Health Administration (VHA) toward incorporating complementary and alternative medicine (CAM) as an integrative complement to care for veterans. The Integrative Health and Wellness (IHW) Program is a comprehensive CAM clinic offering services such as integrative restoration (iRest) yoga nidra, individual acupuncture, group auricular acupuncture, chair yoga, qigong, and integrative health education.

OBJECTIVES

The current study intended to detail the development of the CAM program, its use, and the characteristics of the program's participants.

DESIGN

Using a prospective cohort design, this pilot study tracked service use and aspects of physical and mental health for veterans enrolled in the program.

PARTICIPANTS

During the first year, the IHW Program received 740 consults from hospital clinics; 325 veterans enrolled in the program; and 226 veterans consented to participate in the pilot study.

OUTCOME MEASURES

Outcome measures included data from self-report questionnaires and electronic medical records.

RESULTS

Veterans enrolled in the program reported clinically significant depression, stress, insomnia, and pain-related interference in daily activities and deficits in health-related quality of life. Regarding use of the program services, individual acupuncture showed the greatest participation by veterans, followed by group auricular acupuncture and iRest yoga nidra. Of the 226 veterans who enrolled in the program and consented to participate in this study, 165 (73.01%) participated in >1 services in the first year of programming. Broadly speaking, enrollment in services appeared to be associated with gender and service branch but not with age or symptom severity.

CONCLUSIONS

Results have assisted with a strategic planning process for the IHW Program and have implications for expansion of CAM services within the VHA.

Analisys of the therapeutic factors in the Therapeutic Community Podsused among the war related diagnosis and the others

Therapeutic community/TC/ is a sociotherapeutic method that uses sociotherapeutic and psychotherapeutic techniques for various mental disorders. In Croatia, during and after the war many war veterans have been in treatment through TC and many of them still participate in it. Majority of them were diagnosed with PTSD diagnosis, but some of them also had other diagnosis, e.g. depression, paranoid delusion, etc. In this paper we describe principles of TC that we use in Croatia and we also try to find out which curative factors of TC are the most important for this population. We applied semistructured intervju based on Yalom book of practice and theory of psychotherapy to explore what factors do war veterans find the most important and relevant for their resilience and better coping with everyday issues.

Large-Scale Simulation for Teaching Combat and Operational Stress Control: Operation Bushmaster

Large-scale high-fidelity casualty simulation and exposure to realistic environmental stressors in Operation Bushmaster represents a unique teaching environment that challenges military medical students to apply skills in assessment and acute management of stress responses. While this training event is specific to military medical students, the skills demonstrated could be readily applied in natural disaster or other mass civilian casualties. Schools seeking to teach mass casualty response could implement many of the elements of the curriculum outlined in this article on a smaller scale. Doing so exposes students to decision making in a disaster where the number of patients exceeds available resources and damage to infrastructure may limit their capabilities. Our experience with large-scale simulation suggests that this is an effective teaching tool.

[Military psychiatry in a theatre of operations: on mission in Mali]

The recent missions of military psychiatrists in the theatres of operation underline the reactivity of the French healthcare system, focused on the expertise of the combat unit doctor. Operation Serval in Mali illustrates in particular the methods of medical-psychological support in exceptional situations, across a vast geographical area and in very difficult climatic conditions. The concept of "forward psychiatry" has a particularly important role to play in the early screening and treatment of psychological disorders in order to preserve the operational capacity of the deployed personnel.

[Clinical approach to post-traumatic stress disorders]

A confrontation with death can lead to acute reactions of stress, followed possibly, after a phase of latency, by post-traumatic stress disorder (PTSD). PTSD is characterised by the appearance of a repetition syndrome combining reliving, hypervigilance and avoidance; comorbidities frequently arise, increasingthe risk of suicide. Caregivers have an important role to play in identifying them.

Shell shock in Ireland: The Richmond War Hospital, Dublin (1916-19)

The history of mental disorders occasioned by World War I is a complex and important history, indelibly linked with social, political and cultural circumstances, and the history of the war itself. The Richmond War Hospital was a 32-bed establishment on the grounds of the large Richmond District Asylum in Dublin which, from 16 June 1916 until 23 December 1919, treated 362 soldiers with shell shock and other mental disorders, of whom more than half were considered to have recovered. Despite the limitations of the Richmond War Hospital, it was a generally forward-looking institution that pointed the way for future reform of Ireland's asylum system and, along with the other war hospitals, brought significant changes to the practice of psychiatry.

[Working closely with units to treat war-related psychological trauma]

French soldiers are carrying out more operational missions than ever and are consequently exposed to potentially traumatic events. At the beginning of 2013, psychologists were posted to four military medical centres. Working as closely as possible to the units, military psychologists can thereby provide early, specific and continuous treatment to soldiers with psychological injuries.

[Role of a military psychiatrist in Afghanistan]

Operational conditions expose soldiers to situations which are potentially traumatic on a psychological level. The specific and non specific psychological disorders which can result require relatively flexible treatment tools which can be adapted to the circumstances.As the first "link in the chain", the intervention of a psychiatrist in a theatre of operations enables the psychological care to begin at an early stage to be followed by long-term treatment when necessary. This article focuses on a mission in Afghanistan.

Importance of Virtual Reality to Virtual Reality Exposure Therapy, Study Design of a Randomized Trial

Post Traumatic Stress Disorder (PTSD) can be a debilitating problem in service members who have served in Iraq or Afghanistan. Virtual Reality Exposure Therapy (VRET) is one of the few interventions demonstrated in randomized controlled trials to be effective for PTSD in this population. There are theoretical reasons to expect that Virtual Reality (VR) adds to the effectiveness of exposure therapy, but there is also added expense and difficulty in using VR. Described is a trial comparing outcomes from VRET and a control exposure therapy (CET) protocol in service members with PTSD.

'An atmosphere of cure': Frederick Mott, shell shock and the Maudsley

Although recognized as a medical scientist, the work of Frederick Mott as a physician, educator and clinical policymaker has been overshadowed. As a late entrant to the asylum system, Mott questioned established practices of treating mentally-ill patients and campaigned for reform. During World War I, entrusted with the management of the Maudsley neurological section, he sought to raise clinical standards and experimented with a range of therapies designed to treat the most severe or intractable forms of shell shock. While Mott believed that psychiatric disorder was underwritten by inherited characteristics, he did not dismiss the impact of the environment. The diversity of his interests has led to an understatement of his contribution as a physician, not only to the design and founding of the Maudsley Hospital but also to the therapeutic regime practised there during the interwar period.

Battle for the mind: World War 1 and the birth of military psychiatry

The 100th anniversary of the outbreak of World War 1 could be viewed as a tempting opportunity to acknowledge the origins of military psychiatry and the start of a journey from psychological ignorance to enlightenment. However, the psychiatric legacy of the war is ambiguous. During World War 1, a new disorder (shellshock) and a new treatment (forward psychiatry) were introduced, but the former should not be thought of as the first recognition of what is now called post-traumatic stress disorder and the latter did not offer the solution to the management of psychiatric casualties, as was subsequently claimed. For this Series paper, we researched contemporary publications, classified military reports, and casualty returns to reassess the conventional narrative about the effect of shellshock on psychiatric practice. We conclude that the expression of distress by soldiers was culturally mediated and that patients with postcombat syndromes presented with symptom clusters and causal interpretations that engaged the attention of doctors but also resonated with popular health concerns. Likewise, claims for the efficacy of forward psychiatry were inflated. The vigorous debates that arose in response to controversy about the nature of psychiatric disorders and the discussions about how these disorders should be managed remain relevant to the trauma experienced by military personnel who have served in Iraq and Afghanistan. The psychiatric history of World War 1 should be thought of as an opportunity for commemoration and in terms of its contemporary relevance-not as an opportunity for self-congratulation.

'Shell shock' revisited: an examination of the case records of the National Hospital in London

During the First World War the National Hospital for the Paralysed and Epileptic, in Queen Square, London, then Britain's leading centre for neurology, took a key role in the treatment and understanding of shell shock. This paper explores the case notes of all 462 servicemen who were admitted with functional neurological disorders between 1914 and 1919. Many of these were severe or chronic cases referred to the National Hospital because of its acknowledged expertise and the resources it could call upon. Biographical data was collected together with accounts of the patient's military experience, his symptoms, diagnostic interpretations and treatment outcomes. Analysis of the notes showed that motor syndromes (loss of function or hyperkinesias), often combined with somato-sensory loss, were common presentations. Anxiety and depression as well as vegetative symptoms such as sweating, dizziness and palpitations were also prevalent among this patient population. Conversely, psychogenic seizures were reported much less frequently than in comparable accounts from German tertiary referral centres. As the war unfolded the number of physicians who believed that shell shock was primarily an organic disorder fell as research failed to find a pathological basis for its symptoms. However, little agreement existed among the Queen Square doctors about the fundamental nature of the disorder and it was increasingly categorised as functional disorder or hysteria.

Deep brain stimulation of the basolateral amygdala for treatment-refractory combat post-traumatic stress disorder (PTSD): study protocol for a pilot randomized controlled trial with blinded, staggered onset of stimulation

BACKGROUND

Combat post-traumatic stress disorder (PTSD) involves significant suffering, impairments in social and occupational functioning, substance use and medical comorbidity, and increased mortality from suicide and other causes. Many veterans continue to suffer despite current treatments. Deep brain stimulation (DBS) has shown promise in refractory movement disorders, depression and obsessive-compulsive disorder, with deep brain targets chosen by integration of clinical and neuroimaging literature. The basolateral amygdala (BLn) is an optimal target for high-frequency DBS in PTSD based on neurocircuitry findings from a variety of perspectives. DBS of the BLn was validated in a rat model of PTSD by our group, and limited data from humans support the potential safety and effectiveness of BLn DBS.

METHODS/DESIGN

We describe the protocol design for a first-ever Phase I pilot study of bilateral BLn high-frequency DBS for six severely ill, functionally impaired combat veterans with PTSD refractory to conventional treatments. After implantation, patients are monitored for a month with stimulators off. An electroencephalographic (EEG) telemetry session will test safety of stimulation before randomization to staggered-onset, double-blind sham versus active stimulation for two months. Thereafter, patients will undergo an open-label stimulation for a total of 24 months. Primary efficacy outcome is a 30% decrease in the Clinician Administered PTSD Scale (CAPS) total score. Safety outcomes include extensive assessments of psychiatric and neurologic symptoms, psychosocial function, amygdala-specific and general neuropsychological functions, and EEG changes. The protocol requires the veteran to have a cohabiting significant other who is willing to assist in monitoring safety and effect on social functioning. At baseline and after approximately one year of stimulation, trauma script-provoked 18FDG PET metabolic changes in limbic circuitry will also be evaluated.

DISCUSSION

While the rationale for studying DBS for PTSD is ethically and scientifically justified, the importance of the amygdaloid complex and its connections for a myriad of emotional, perceptual, behavioral, and vegetative functions requires a complex trial design in terms of outcome measures. Knowledge generated from this pilot trial can be used to design future studies to determine the potential of DBS to benefit both veterans and nonveterans suffering from treatment-refractory PTSD.

TRIAL REGISTRATION

PCC121657, 19 March 2014.

Evaluation of a group intervention for veterans who experienced military-related trauma

Military-related trauma and veteran status have been linked with posttraumatic stress symptoms, depressive symptoms, and other personal and interpersonal difficulties. While many treatment evaluations for people with posttraumatic stress exist, few veteran populations or group formats have been evaluated. This report presents an evaluation of the Veterans Transition Program (VTP)-a group-based treatment for veterans who experienced a military-related trauma that is negatively impacting their lives. Fifty-six veterans attended the VTP; all attended every session and completed pre- and post-tests assessing posttraumatic stress and depressive symptoms. Significant pre- to post-test improvement was found on all scales. These findings demonstrate the potential benefit of the VTP and encourage further research.

[Research and treatment of war neuroses at the Clinic for Nervous and Mental Diseases at the Jagiellonian University in Krakow before World War II in the context of psychiatry in Europe]

The aim of this article is to offer an overview of the research into diagnosis and treatment of war neuroses at the Clinic for Nervous and Mental Diseases at the Jagiellonian University in Krakow before the outbreak of World War II. It also includes a profile of the work of Prof. Jan Piltz, the then director of the Clinic, and his major scientific achievements. The publications cited in the article date in the main from the period of World War I, and comprise clinical analyses of the consequences of stress suffered at the front as well as a description of the ways in which they were treated. These are presented alongside other major findings related to war neuroses being made in Europe at the time. The article draws attention to the very modern thinking on treatment of war neuroses, far ahead of the average standards of the day, evinced by Prof. Piltz and his team. The most important innovative elements of their treatment of these conditions were the fact that they perceived the cause of the neurosis to lie in previous personality disorders in the patients, their recommendation of psychotherapy as the main method of treatment, and their emphasis on the need for further rehabilitation following the completion of the course of hospital treatment. They also paid significant attention to the importance of drawing up individual therapy plans for each patient.

PTSD in active combat soldiers: to treat or not to treat

In this paper, we consider ethical issues related to the treatment of posttraumatic stress disorder (PTSD) in combat zones, via exposure therapy. Exposure-oriented interventions are the most well-researched behavioral treatments for PTSD, and rigorous studies across contexts, populations, and research groups provide robust evidence that exposure therapy for PTSD is effective and can be widely disseminated. Clinical procedures for Prolonged Exposure therapy, a manualized exposure-oriented protocol for PTSD, are reviewed, and we illustrate the potential benefits, as well as the potential difficulties, associated with providing this treatment in combat zones. Several ethical considerations are identified: (1) Assuming successful treatment, is it ethical to send individuals with a known risk of developing PTSD back into combat? (2) If treatment is unsuccessful in theater (perhaps due to the confounding factor of ongoing danger), could that impact treatment effectiveness for soldiers who attempt therapy again post-deployment? (3) If the military finds combat-zone treatment effective and useful in maintaining an efficient work force, will treatment become mandatory for those diagnosed with PTSD? (4) What unintended consequences might be associated with large-scale dissemination of exposure therapy in or near combat, outside of mental health care infrastructures? (5) How would genetic variations known to be associated with PTSD risk influence decisions regarding who receives treatment or returns to combat? We conclude with a review of the personal and societal costs associated with not providing evidence-based PTSD treatments wherever possible.

[Use of hypnosis in the treatment of combat post traumatic stress disorder (PTSD)]

Clinical reports and observations going back almost two centuries consistently indicate that hypnotherapy is an effective modality for the treatment of post traumatic stress disorder (PTSD). Pierre Janet was the first clinician to describe the successful initiation of stepwise hypnotic techniques in PTSD symptom reduction. Hypnotherapy may accelerate the formation of a therapeutic alliance and contribute to a positive treatment outcome. Hypnotic techniques may be valuable for patients with PTSD who exhibit symptoms such as anxiety, dissociation, widespread somatoform pain complaints and sleep disturbances. Hypnotic techniques may also facilitate the arduous tasks of working through traumatic memories, increasing coping skills, and promoting a sense of competency. In this review we will present guidelines for the stepwise implementation of hypnotherapy in PTSD. Since most data regarding the use of hypnotherapy in PTSD has been gathered from uncontrolled clinical observations, methodologically sound research demonstrating the efficacy of hypnotic techniques in PTSD is required for hypnotherapy to be officially added to the therapeutic armamentarium for this disorder.

Rationale and methods of the Substance Use and Psychological Injury Combat Study (SUPIC): a longitudinal study of Army service members returning from deployment in FY2008-2011

The Substance Use and Psychological Injury Combat Study (SUPIC) will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N = 643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N = 487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.

Enlightened or barbaric? Re-evaluating shell shock treatment

The vastly contrasting treatment approaches for shell shock devised by Dr William Rivers at the Craiglockhart War Hospital in Edinburgh and Dr LewisYealland at the Queen Square Neurological Hospital in London are indicative of the disparate response of WWI medical professionals to the unprecedented number of afflicted soldiers. Their respective legacies have been subject to equally contrasting evaluations in modern times: Rivers is heralded as a 'founding father' in psychotherapy; his methods celebrated for their compassion and humanity, while Yealland's techniques have found closer comparison with torture and sadistic experimentation. This paper argues that judgments of these two physicians are guilty of oversight, and consequently, in Yealland's case particularly, warrant a more nuanced assessment. Besides the miles of destroyed countryside, maimed bodies, and interminable bloodshed, the horrors of trench warfare gave rise to a new kind of malady. It chose no sides, but in all cases, having suffered no discernible physical injury, soldiers succumbed to a variety of debilitating and yet mysterious behaviours: shrieking fits, paralysis, blindness or muteness, to name but a few. This neurosis decimated the soldier's ability to function, let alone fight, and the victims began to congest military hospitals, puzzling doctors more accustomed to dealing with conventional battle field casualties. Charles Myers, a British psychologist, ascribed the symptoms to extreme mental stress, utilising a term already familiar to men in the trenches: 'shell shock'.

Armed Forces Health Surveillance Center (AFHSC). Medical evacuations from Afghanistan during Operation Enduring Freedom, active and reserve components, U.S. Armed Forces, 7 October 2001-31 December 2012

From October 7, 2001 to 31 December 2012, over 20,000 service members were medically evacuated from the Operation Enduring Freedom (OEF) theater of combat operations to a medical treatment facility outside of theater. During the period the number, rates, and underlying causes of medical evacuations sharply varied in relation to the natures of ongoing military operations. During every month of the period, medical evacuations for disease and non-battle injuries exceeded those for battle-related injuries. The majority of evacuations (88.7%) occurred among males; however, the rate of medical evacuations was 22 percent higher among females. The major causes of medical evacuations differed among male and female deployers; however, rates of battle injuries and mental health disorders increased in both sexes during the period. Rates of medical evacuations were highest among white, non-Hispanics, soldiers, and in service members in the reserve component, junior enlisted, and in combat-specific occupations. Most service members were discharged back to duty after medical evacuation. The findings enforce the need to tailor force health protection policies and practices to the characteristics of the deployed force and the nature of the military operation.

Traumatic event management in Afghanistan: a field report on combat applications in regional command-south

This article provides information on the use of Traumatic Event Management (TEM) strategies to debrief combat arms personnel whose units sustained traumatic losses in Afghanistan. The specific focus is on the application of Event-Driven Battlemind Psychological Debriefings to combat units. This article offers the first published account of TEM services employed in southern Afghanistan during intensive surge operations in 2009-2010. This article unfolds in three parts: (1) background to the region in which the debriefings occurred; (2) three case examples with a data summary of types of incidents observed; and (3) discussion of observations, lessons learned, and recommendations for training future clinicians to provide effective debriefings to combat arms personnel.

French neuropsychiatry in the Great War: between moral support and electricity

In World War I, an unprecedented number of soldiers were suffering from nervous disturbances, known as war psychoneuroses. Mechanisms of commotion, emotion, and suggestion were defined in order to explain these disturbances. In France, emphasis was placed on the mechanism of suggestion, based on pithiatism, introduced by Joseph Babinski (1857-1932) before the war to highlight the concept of suggestion and its hazy border with simulation. As a result, many soldiers suffering from war neuroses became considered as simulators or malingerers who were merely attempting to escape the front. A medical-military collusion ensued with the aim of sending as many of these nervous cases back to the front as possible through the use of painful or experimental therapies. Aggressive therapies flourished including torpillage, a particularly painful form of electrotherapy developed by Clovis Vincent (1879-1947) and subsequently by Gustave Roussy (1874-1948). At the end of the war, some psychiatrists, such as Paul Sollier (1861-1933), Georges Dumas (1866-1946), and Paul Voivenel (1880-1975), developed a more psychological approach. In Great Britain, where Charles Myers (1873-1946) coined the term shell shock in 1915 to describe these cases, psychological theories were more successful. In Germany, aggressive therapies developed by Fritz Kaufmann (1875-1941) emerged in the second part of the war. In Austria, the future Nobel Prize winner Julius Wagner-Jauregg (1857-1940) was accused of performing violent therapies on patients with war neuroses. These methods, which now seem barbarian or inhuman, were largely accepted at the time in the medical community and today should be judged with caution given the cultural, patriotic, and medical background of the Great War.

[Treating mentally wounded patients within the French armed forces]

The French army has put in place a doctrine aimed at treating mentally wounded soldiers. A real treatment pathway comprising different specialised medical staff, places and time frames supports the soldier from the theatre of operations to France.