Clinician's Trauma Update Online Newsletter
(CTU-Online)

Editor: Paula P. Schnurr, Ph.D.
Associate Editors: Susan Stevens, Psy.D.
Editorial Manager: Elizabeth Forshay, M.S.W.

CTU-Online includes brief updates on the latest clinically relevant research. Issues include an ID number so you can find the article in the PILOTS database and a link to the abstract or full article, if you have access through your library privileges. If not, see below.*

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CTU-Online, 2(4), August 2008 Printable PDF

CTU-Online, 2(4), August 2008

Treatment

Virtual Reality Exposure therapy for combat veterans

Virtual reality therapy (VRE) is beneficial in the treatment of anxiety disorders and some research indicates it may be helpful for the treatment of PTSD. Proponents have suggested that the ability of computer technology to simulate detailed and realistic combat situations could make it easier for newly returned soldiers to connect with their traumatic situations and to emotionally process their trauma, which is thought to be the key mechanism of action in exposure therapies. The authors of a recent paper illustrate the use of VRE with a male soldier diagnosed with PTSD due to military trauma in Iraq. A psychologist who had previous training in exposure therapy for PTSD delivered 6 90-minute sessions of VRE. Like standard exposure-based therapies, the treatment included psychoeducation and relaxation components as well as in vivo exposures. To make the virtual scene more realistic and reminiscent of the patient’s experience, the therapist created visual and audio simulations of explosions, passenger casualties, ambushes, and small arms fire. Following treatment, the patient’s score on the PTSD Checklist was reduced from 58, indicating severe symptoms, to 29, indicating mild symptoms (the lowest possible score is 17). The patient also reported a significant improvement in overall functioning. Although the paper does not discuss the complexities of treating an active duty soldier, it offers a helpful description of the theoretical rationale for how VRE could work for PTSD and explains how VRE can be applied in clinical practice.

Read the Article
Reger, G.M., & Gahm, G.A. (2008). Virtual reality exposure therapy for active duty soldiers. Clinical Psychology, 64, 940-946. PILOTS ID 31051.

Couples therapy for PTSD--An emerging treatment option

There is considerable evidence that PTSD profoundly affects intimate relationships. Despite this, few therapies have been developed to treat both the individual pathology of PTSD and the relational dysfunction often associated with it. One therapy that attempts to simultaneously improve PTSD and relationship functioning is Cognitive-Behavioral Conjoint Therapy, or CBCT, for PTSD. In a recent paper, the developers of CBCT for PTSD describe treating a couple in which the husband is an Iraq War veteran diagnosed with PTSD. CBCT for PTSD is a 15-session, manualized couples therapy based on cognitive theory for PTSD and mental health recovery principles. The therapy proposes a complex and reciprocal relationship between PTSD and disturbed intimate relations. The investigators describe the stages of therapy and depict the ideal course of treatment through a case illustration. Although there is little empirical evidence on the efficacy of CBCT so far, this paper offers a good introduction and rationale for the use of CBCT in the treatment of PTSD. CBCT for PTSD is novel for its use of a systematic approach to PTSD treatment, and could broaden the scope of treatment for many returning veterans who are facing ruptured relationships in the aftermath of trauma.

Read the Article
Monson, C.M., Fredman, S.J., & Adair, K.C. (2008). Cognitive-Behavioral Conjoint Therapy for posttraumatic stress disorder: Application to Operation Enduring and Iraqi Freedom veterans. Journal of Clinical Psychology, 64, 958-971. PILOTS ID 31050.

Preliminary evidence on cognitive-behavioral treatment of panic disorder in veterans with PTSD

Investigators at the Houston VA recently reported the results of a pilot study to test the effectiveness of an empirically supported cognitive-behavioral treatment for panic symptoms in veterans with PTSD. The high comorbidity between PTSD and panic disorder, coupled with evidence that comorbid PTSD reduces the efficacy of cognitive-behavioral interventions for panic, make it important to find effective treatments for panic in PTSD patients. Thirty-five male and female veterans were randomized to receive either Panic Control Treatment or a supportive comparison treatment. The investigators found partial support for their hypothesis that Panic Control Treatment would be more effective than the comparison treatment for reducing the occurrence, severity, and fearfulness of panic attacks. Over 3 in 5 Panic Control patients were panic-free at the end of treatment, in comparison with only 1 in 5 comparison patients, although the groups converged at follow-up. Patients who received Panic Control Treatment had relatively greater improvements in panic severity than patients in the comparison group at the end of treatment and in panic-related fear at 3 months. There were no changes in anxiety, depression, or PTSD. The small sample size makes it difficult to draw firm conclusions about the lack of differences, but the findings suggest that it is feasible and useful to treat panic in PTSD patients. However, a key question is whether a cognitive-behavioral treatment for PTSD might be a better strategy to address both panic and PTSD.

Read the Article
Teng, E.J., Bailey, S.D., Chaison, A.D., Peterson, N.J., Hamilton, J.D., & Dunn, N.J. (2008). Treating comorbid panic disorder in veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 76, 704-710. PILOTS ID 31106.

Pharmacotherapy for PTSD in VA patients

Medications are widely used for treating PTSD in VA, DoD and civilian settings. Practice guidelines recommend selective serotonin reuptake inhibitors (SSRIs) as the medication of choice for PTSD, and clinical trials suggest that other medications may be helpful for patients who do not fully respond or for managing specific symptoms, e.g., prazosin for nightmares. But guidelines are not requirements, so clinical practice may differ from recommendations. A new study from the Northeast Program Evaluation Center provides a look at what VA clinicians actually prescribe. The investigators examined records of 274,297 VA patients with PTSD who were treated between 10/1/03 and 9/30/04. On average, 4 out of 5 received medication: 84.0% of those seen in a mental health clinic and 51.5% of those seen in another type of clinic. Of veterans who received medication, 88.6% received an antidepressant (85% SSRI), 60.7% received an anxiolytic/sedative-hypnotic, and 33.6% received an antipsychotic. Comorbid disorders increased the likelihood of disorder-specific prescriptions, e.g., anxiety disorder increased the likelihood of receiving an anxiolytic. However, although psychotic and bipolar disorders increased the likelihood of receiving an antipsychotic, so did depression, alcohol or drug abuse, and dementia. The investigators acknowledge that administrative data do not permit them to understand why antipsychotics are used in the absence of psychotic disorders. They speculate that the most likely reason is symptom management, and go on to suggest the need for research that addresses the question often faced by clinicians: how to manage symptoms and not just disorders.

Read the Article
Mohamed S., & Rosenheck R.A. (2008). Pharmacotherapy of PTSD in the U.S. Department of Veterans Affairs: Diagnostic- and symptom-guided drug selection. Journal of Clinical Psychiatry, 69, 959-965. PILOTS ID 30955.

OIF/OEF Veterans

Alcohol problems linked to combat deployment

Substance abuse is strongly associated with exposure to traumatic stress and the development of PTSD. One hypothesized mechanism is that traumatized individuals self-medicate with drugs or alcohol to help cope with the trauma. PTSD and other comorbid disorders can also make it difficult to initiate quitting attempts in individuals whose substance abuse predates their traumatic exposure. Typically the onset of substance abuse in relation to traumatic exposure is determined based on retrospective reports. A recent paper from the Millennium Cohort Study reports prospective data showing that exposure to combat during military deployment is associated with the development of alcohol problems. The Millennium Cohort Study began in 2001 with over 55,000 military personnel being followed prospectively to understand their physical and mental health outcomes. According to the new findings, deployment with combat exposure was associated with greater likelihood of new-onset of binge drinking in active duty personnel and new-onset of binge drinking, heavy drinking, and alcohol problems in Guard and Reserve personnel. PTSD and depression at baseline increased the risk of some outcomes, but the key finding is that deployment with combat exposure had independent effects—meaning that we should not assume post-deployment alcohol problems are the result of comorbid mental health disorders. Even people who do not need care for other disorders may need help with alcohol problems after serving in combat.

Read the Article
Jacobson, I.G., Ryan, M.A.K., Hooper, T.I., Smith, T.C., Amoroso, P.J., Boyko, E.J., Gackstetter, G.D., Wells, T.S., & Bell, N.S. (2008). Alcohol use and alcohol-related problems before and after military combat deployment. Journal of the American Medical Association, 300, 663-675. PILOTS ID 82076.

How do OIF/OEF veterans differ from veterans of prior wars?

Much has been said about the differences between the wars in Iraq and Afghanistan and recent wars the US has fought. Analyses of data from veterans who sought care from VA’s specialized PTSD program suggest that the warriors themselves are different too. Investigators from the Northeast Program Evaluation Center examined data from a large sample of VA mental health patients, comparing OIF/OEF veterans with veterans who served during the Persian Gulf War and the Vietnam War. Because the cohorts differed substantially in age and time since military service, comparisons were made two ways: using data collected between 2004 and 2006 for all cohorts, and using the 2004-2006 data for OIF/OEF veterans and data from Persian Gulf and Vietnam War veterans who sought care between 1992-1994. The investigators also made statistical adjustments for age. The OIF/OEF veterans differed most from Vietnam veterans in terms of demographic and clinical characteristics. But the OIF/OEF veterans also differed from Persian Gulf War veterans, even in the comparisons with cohorts from 1992-1994. Although the OIF/OEF veterans were more likely to meet criteria for PTSD and be service-connected for PTSD, overall they appeared to be have less functional impairment, e.g., they were less likely to be violent or have drug or alcohol problems or other comorbid disorders. The investigators emphasize the importance of providing effective treatment now in order to prevent deterioration of functioning in our newest veterans.

Read the Article
Fontana, A., & Rosenheck, R. (2008). Treatment-seeking veterans of Iraq and Afghanistan: Comparison with veterans of previous wars.Journal of Nervous & Mental Disease,196, 513-521. PILOTS ID 31032.

Physical Health

PTSD associated with increased risk of heart-disease mortality in Vietnam era and theater veterans

Every day it seems there is a news story about how psychological stress is bad for physical health, so it should comes as no surprise that PTSD is associated with poor health. A causal connection has not been established, but prospective studies in which healthy people are tracked over time provide helpful information about the development of health problems. Now a new study shows that PTSD is associated with increased mortality due to early heart disease in male veterans who served in the Army during the Vietnam War. The 4,328 men were initially assessed in 1985, when they underwent physical exams and psychological assessment. None had heart disease then, although some had PTSD: 10% of theater veterans and 3% of era veterans. The investigators tracked participants’ mortality through the end of 2000. Among all veterans, the risk of heart disease mortality was doubled among the men with PTSD, although the finding was no longer statistically significant when the investigators adjusted for the effects of depression. However, among the theater veterans, the risk of PTSD remained doubled even after adjustment for depression and combat exposure. (All of the models included adjustment for various factors that could independently lead to heart disease, such as smoking and obesity.)  Although more research is needed to determine whether PTSD could have caused the heart disease, the findings have important implications for prevention. Effective early treatment for PTSD may be able to reduce the risk of future health problems.

Read the Article
Boscarino, J.A. (2008). A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: Implications for surveillance and prevention. Psychosomatic Medicine, 70, 668-676. PILOTS ID 31053

Smoking is a significant risk in OIF/OEF male veterans with PTSD

Military deployment is related to the initiation of cigarette smoking. Given that people with PTSD also tend to be heavy smokers, the link between deployment, smoking, and PTSD in recent veterans is highly relevant. This link was the focus of a recent descriptive study that examined the rates of smoking and smoking severity in a group of male OIF/OEF veterans. Investigators at the Durham VAMC evaluated 90 male veterans who presented to a VA outpatient PTSD clinic. The assessments included measures of PTSD and other symptoms, smoking, and readiness to quit smoking according to Prochaska's stages of change model. Almost 1/3 of the veterans were currently smokers, which is higher than the national average of 23%. Half of those veterans smoked 20 or more cigarettes a day. Many of the current smokers (71%) were planning to or trying to quit smoking. PTSD symptom severity was not related to veterans’ stage of change for smoking cessation. Although this study looked at a small sample of male veterans, its findings suggest a critical need for developing smoking cessation programs that would be effective for OIF/OEF veterans in order to prevent them from developing smoking-related health problems in the future.

Read the Article
Kirby, A.C., Hertzberg, B.P., Collie, C.F., Yeatts, B., Dennis, M.F., McDonald, S.D., Calhoun, P.S., & Beckham, J.C. (2008). Smoking in help-seeking veterans with PTSD returning from Afghanistan and Iraq. Addictive Behaviors, (in press), May 22. PILOTS ID 31049.

CTU-Online, 2(4), August 2008 Printable PDF

*Articles authored by National Center for PTSD staff are available in full text. For other articles we provide a link to where you might be able to access the full text.

**PROBLEMS ACCESSING FULL TEXT? VA clinicians might have privileges through their university affiliation. However, VA firewalls sometimes block the permissions to access reference materials. If you cannot access the Full Text version of any article, we suggest you contact your local librarian or web/internet technical person.

If you usually have access to full text from the journal in which an article is published, but are not seeing it from the link provided, try accessing it directly through your university library system. Many online services have password access that only works through a user's library system.

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CTU-Online is published by the Executive Division of the National Center for Posttraumatic Stress Disorder in White River Junction, VT. We welcome feedback from readers about content and format. Please feel free to email us at ncptsd@va.gov.