Combat PTSD & Treatment

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I thought it might be helpful to have a thread devoted to forms of treatment. I came across this reference just the other day...

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Ecstasy is the key to treating PTSD

At last the incurably traumatised may be seeing the light at the end of the tunnel. And controversially, the key to taming their demons is the ‘killer’ drug Ecstasy. That’s what it took to make Donna Kilgore feel alive again – that and the doctor who prescribed it. As the pill began to take effect, she giggled for the first time in ages. She felt warm and fuzzy, as if she was floating. The anxiety melted away. Gradually, it all became clear: the guilt, the anger, the shame.

Before, she’d been frozen, unable to feel anything but fear for 10 years. Touching her own arms was, she says, “like touching a corpse”. She was terrified, unable to respond to her loving husband or rock her baby to sleep. She couldn’t drive over bridges for fear of dying, was by turns uncontrollably angry and paralysed with numbness. When she spoke, she heard her voice as if it were miles away; her head felt detached from her body. “It was like living in a movie but watching myself through the camera lens,” she says. “I wasn’t real.”

Unknowingly, Donna, now 39, had post-traumatic stress disorder (PTSD). And she would become the first subject in a pioneering American research programme to test the effects of MDMA – otherwise known as the dancefloor drug Ecstasy – on PTSD sufferers.

Some doctors believe MDMA could be the key to solving previously untreatable deep-rooted traumas. For a hard core of PTSD cases, no amount of antidepressants or psychotherapy can rid them of the horror of systematic abuse or a bad near-death experience, and the slightest reminder triggers vivid flashbacks.

PTSD-specific psychotherapy has always been based on the idea that the sufferer must be guided back to the pivotal moment of that trauma – the crash, the battlefield, the moment of rape – and relive it before they can move on and begin to heal. But what if that trauma is insurmountable? What if a person is so horrified by their experience that even to think of revisiting it can bring on hysterics? The Home Office estimates that 11,000 clubbers take Ecstasy every weekend. Could MDMA – the illegal class-A rave drug, found in the system of Leah Betts when she died in 1995, and over 200 others since – really help? Dr Michael Mithoefer, the psychiatrist from South Carolina who struggled for years to get funding and permission for the study, believes so. Some regard his study – approved by the US government – as irresponsible, dangerous even. But Mithoefer’s results tell a different story.

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Donna had never taken Ecstasy before. “I was a little afraid, but I was desperate. I had to have some kind of relief. I didn’t want to live any more. This was no way to wake up every morning. So I met Dr Mithoefer. I said, ‘Doctor, I will do anything short of a lobotomy. I need to get better.’ ” That’s how, in March 2004, Donna became the first of Mithoefer’s subjects in the MDMA study. Lying on a futon, with Mithoefer on one side of her and his wife, Annie, a psychiatric nurse, on the other, talking softly to her, she swallowed the small white pill. It was her last hope.

“After 5 or 10 minutes, I started giggling and I said, ‘I don’t think I got the placebo,”’ she recalls. “It was a fuzzy, relaxing, on-a-different-plane feeling. Kind of floaty. It was an awakening.” For the first time Donna faced her fears. “I saw myself standing on top of a mountain looking down. You know you’ve got to go down the mountain and up the other side to get better. But there’s so much fog down there, you’re afraid of going into it. You know what’s down there and it’s horrible.

“What MDMA did was clear the fog so I could see. Down there was guilt, anger, shame, fear. And it wasn’t so bad. I thought, ‘I can do this. This fear is not going to kill me.’ I remembered the rape from start to finish – those memories I had repressed so deeply.” Encouraged by the Mithoefers, Donna expressed her overwhelming love for her family, how she felt protected by their support and grateful for their love.

MDMA is well known for inducing these compassionate, “loved-up” feelings. For Donna, the experience was life-changing.

So what happened when she went home? Was she cured? She sighs. “I don’t know if there’s such a thing as a cure. But after the first session I got up the next day and went outside, and it was like walking into a crayon box – everything was clear and bright. I did better in my job, in my marriage, with my kids. I had a feeling I’d never had before – hope. I felt I could live instead of exist.”

What makes MDMA so useful, Mithoefer believes, is the trust it establishes. “Many people with PTSD have a great deal of trouble trusting anybody, especially if they’ve been betrayed by someone who abused their trust, like a parent or a caregiver,” he says. “MDMA has this effect of lowering fear and defences. It also allows more compassion for oneself and for others. People can revisit the trauma, feel the original feelings but not be retraumatised, not feel overwhelmed or have to numb out to cope with it.”

Read the full article here: Ecstacy & PTSD and please, don't try this at home. The drug used in this study was a purified form whereas the drugs available for "recreational" use are typically cut with any variety of substances. If you are interested in pursuing this form of treatment I would encourage you to seek out a practioner who can monitor and oversee the treatment.

See also: Dr. Ecstacy Will See You Now


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Virtual reality to treat combat trauma:
BBC News is reporting on a AAAS presentation on how virtual reality is being used to treat soldiers who have suffered post-traumatic stress disorder (PTSD) after combat.

Symptoms of PTSD include intrusive memories, pathological avoidance of things related or loosely-related to the trauma, and persistent arousal.

Cognitive behaviour therapy or CBT is one of the most effective treatments for PTSD.

Among its key methods is to slowly reintroduce the person to things associated with the trauma, while dealing with the negative thoughts that are triggered by the situation.

This is relatively straightforward if the person was traumatised by a car crash, as cars, roads and traffic are readily available.

If the person was traumatised by war, however, it is not always feasible to expose the person to 'low level' combat conditions as it may be too dangerous, or the person may have been taken out of the combat zone already.

Virtual reality is a possible way of doing this without putting the soldier at risk, while being realistic enough to treat the condition.

This research is part of a project led by Dr Albert Rizzo, which was the subject of a 2005 NPR radio programme which explored the treatment and its benefits.

While the project has been running for a while, the AAAS presentation contained the latest results, which reportedly suggest a promising outcome for soldiers treated with this method.

Source: Mind Hacks


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The following is a treatment protocol that has been developed in Israel. Although it doesn't offer a specific form of treatment such as those detailed above, it does offer a treatment model that could possibly be adapted for one's personal use.

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From combat experience in recent years, and on the basis of treatment in whole army units that experienced combat traumas from the Yom Kippur War onward, we have found that sticking to the unit structure is of utmost importance. The trauma victims themselves have indicated that the assistance they received from their friends at division or platoon level was more vital for them than professional help. We have also learned that the correct psychological approach entails preventive measures before battle and immediately after it.

Another lesson learned through work with army units suffering from combat trauma is the need to make a professional distinction between treatment for mourning over comrades who have fallen in battle and treatment for post-trauma symptoms. Failure to do so can result in either pathological mourning or the perpetuation of combat trauma.

In consequence of the recent war on the northern border, we suggest taking innovative measures for the prevention and treatment of combat trauma victims:

We need to establish a professional framework that would operate within the psychological-educational system at Retorno, for the prevention of combat trauma. Set up workshops on two levels: daily workshops for regular combat units, and workshops to be held twice or three times a day for units that have suffered difficult traumas such as the death of comrades in battle or physical wounds among many of the participants, the two major causes of combat trauma. The proposed workshops are suitable for both regular army and reserve units.

Preparation for the workshops:
Prior to each workshop a meeting will be held between the staff in charge of the workshop and army unit commanders, to identify the unit’s special needs and to prepare the commanders for the workshop. The scope of the workshop should be determined at these meetings.

Workshop Activities:

Unit Meetings – At the start and conclusion of the workshop, a meeting with the whole unit (at platoon level) to set expectations and provide information. These meetings will include the participation of both Retorno staff and unit commanders.

Division Meetings – Division level meetings will raise the following issues:
1. What have you been through since the traumatic event?
2. What did you go through during the traumatic event itself?
3. Mourning over friends who are no longer with us.
4. How can we carry on in a positive manner?

These meetings provide preventive means and include psychological-educational guidance in the area of reaction to battle, which plays an important role in both prevention and treatment.

The coordinators of the meetings will be professionals in the fields of psychology and spiritual health who served as morale officers in the IDF, joined by professional staff from Retorno. The coordinators and staff that will participate in the meetings will receive steady instruction from the professionals in charge of the workshops, Dr. Haim Kanobler and Yoram Ben Yehuda.

Group Activities:
In parallel to the meetings there will be group activities, enabling participants to learn different kinds of relaxation:
Challenging sports such as horseback riding and mountain biking; group musical activities; group art workshop; group meditation workshop; field trips in the region.

Detecting Post-Trauma Cases:
From our experience with similar workshops in the areas of combat trauma and drug abuse prevention, there have been cases in which post-trauma symptoms are detected, and other cases when participants apply for treatment in the course of a workshop. Participants at the workshops who are interested in continuing treatment will be referred to the appropriate therapists by our professional staff. For this purpose each workshop will include a senior staff member in charge of giving referrals to all those attending the workshops who are in need of therapy.

Follow-up and Assessment:
In units for which the IDF/ Ministry of Defense are interested in follow-up, it will be possible to evaluate both the influence of the meetings and the state of the participants’ post-traumatic symptoms over a length of time. It is advisable to set up at least one follow-up meeting for units at risk, a half year after the initial intervention.

Retorno will conduct reviews to assess the efficiency of the workshops by handing out questionnaires that relate to the satisfaction of the participants and the post-traumatic symptoms.

Conclusion
There is no substitute for the prevention of combat trauma under a full professional framework. Treatment should take place within a year following a battle, with the most effective period for treatment falling between one month and half a year after the wartime event.

The main causes of late treatment for chronic cases of combat trauma include:
1. Lack of awareness and stigmas (among victims and therapists alike)
2. Inability to deal with post-trauma victims through bureaucratic channels
3. Delayed appearances of Late Onset and Reactivation syndromes

Source: Retorno



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A very good article on medications for combat treatment by the Sidran Institute...

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About Medications for Combat PTSD
By Jonathan Shay, M.D., Ph.D.
Staff Psychiatrist, Boston VA Outpatient Clinic

A note to the reader: This article is applicable to anyone who seeks to understand the role of medication within the treatment framework of PTSD. Although it specifically addresses the veteran community, we have found the information given to be extremely valuable and well suited for any reader seeking information on this topic.

Dr. Shay sincerely regrets that he is not available for consultation on psychopharmacology or questions you may have related to this article. If you would like further information in regard to medication and PTSD, please contact the Sidran Help Desk.

A. Point of View

Everything I say here is my point of view, and carries no claim of special authority. Also, what I say here is no way complete. I have left out many important subjects, such as drug interactions, what medical conditions forbid the use of a given drug, overdoses and toxicity, and most specific side-effects. Also, many psychiatrists who also care about combat veterans will disagree with what I say here, particularly about the benzodiazepines like Ativan. Combat PTSD is moral, social, philosophical, and spiritual injury. The biological nature of human beings is to be moral, social, philosophical, and spiritual, so the injury also shows itself as medical disorders.

Healing is psychological, social, spiritual—no medicine can cure combat PTSD. However, healing can never mean a return to 17-year old innocence. Healing means building a good human life with others—a life that a veteran can embrace as his own.

Combat trauma brings about long-lasting changes in brain chemistry. We do not know whether these are permanent or can be reversed by psychological/social healing. A few existing medications can help some men with some symptoms of PTSD. We also do not know whether this changes the long-term outcome for the better, but the human payoff in reduced suffering is unmistakable.

Read the full article here


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Clinical Conversation on Treating Post-Traumatic Stress Disorder (PTSD) Related to Military Combat

Dr. Phelps: Where do individuals who have returned from combat get treated for their mental health needs?

Dr. Keane: The Department of Veterans Affairs (VA) operates an integrated health care system dedicated to providing comprehensive health care and mental health care to military veterans. The VA health care system's mental health programs comprise a wide range of services including inpatient care, outpatient care, the Vet Center (psychological and social services in storefront settings), residential treatment programs, vocational rehabilitation programs, substance abuse treatment programs, sexual trauma treatment programs and homeless domiciliary programs, among other services. This care is provided to eligible men and women veterans.

Typically, VA provides health care to those who were injured during their military service or who developed a disease/disorder during the time of their service. Additional eligibility is conferred on those whose annual income is below a certain level and who do not have alternative sources of health care available to them. Elderly veterans over the age of 65 can also receive care at VA.

Historically, VA provided care to approximately 20 percent of all veterans. Eighty percent of veterans received their health care elsewhere. Veterans from the current conflicts in Iraq and Afghanistan are accessing VA health care at a higher level. Approximately one third of eligible veterans have been to a VA setting for some type of care. Generally, the problems driving this care are musculoskeletal complaints, dental needs and, naturally, mental health problems. Of course, combat-related PTSD is the most common psychological problem, but veterans also present with depression, substance abuse, chronic pain, traumatic brain injury (TBI) and other anxiety disorders.

The vast majority of veterans and their family members receive their mental health care from the private sector. For this reason, it's important for mental health practitioners of all types to assess for veteran status. Making this determination may provide important information for case formulation and treatment planning. Practitioners who feel the need for additional training in the assessment and treatment of military veterans (male and female) may find helpful information through APA and state, provincial and territorial psychological associations and through a wide range of Web training initiatives.

Dr. Phelps: How do various subgroups such as active duty military and National Guard/Reserve members access treatment?

Dr. Keane: Active duty military have their own health care system provided by the Department of Defense (DoD). For active duty military, mental health services can be provided by the DoD directly or through a mechanism known as One Source. Providers affiliated with One Source consist of psychologists and other mental health professionals who contract with the DoD to provide a limited number of assessment/therapy sessions to individuals and their families.

National Guard and Reservists are not ordinarily eligible for VA health care, nor are they typically eligible for DoD healthcare when they are inactive. However, an act of Congress created time-limited eligibility for these military members to utilize VA services. This legislative action has been a great source of mental health care for the returning Reservists and National Guard personnel.

The VA provides care largely to individual veterans themselves. Family members, and especially family members of those activated and serving in the war zones, are not deemed eligible for VA services. With a wide range of psychiatric and psychological services available in diverse settings, VA is a living example of the goals of the President's New Freedom Commission on Mental Health. It may well be the model system that the rest of the country could emulate.

Dr. Phelps: What is important for psychologists to know about the demographics of returning service members?

Dr. Keane: Several key demographic features of the current military force are important to appreciate. First, it is a decidedly diverse, multicultural military. More than 40 percent of active duty military personnel is a racial or ethnic minority. This figure represents greater diversity than in the U.S. population at large.

Second, women constitute more than 10 percent of the military serving in Afghanistan and Iraq, and they perform a wide range of professional roles and combat roles. This situation is different than Vietnam, for example, when women were disproportionately represented in nursing and administrative positions and served in the war zone in far lower percentages of the total military force.

Third, there is a bifurcated distribution of age among service members. Some members serving in their first enlistment might be in their late teens or early twenties. Others are Reservists and National Guard members who might be in their later thirties or forties. Accordingly, their backgrounds and issues are very different and reflect their age, vocational and family structures.

Dr. Phelps: How do family members - spouses, children, parents and other family members - factor into treatment for returning service members?

Dr. Keane: Veterans themselves are the ones deemed eligible for VA care. The VA's statutory authority to treat family members is limited.

Family members are treated to the extent to which they are directly involved in the veteran's care. For example, if a veteran develops depression or PTSD as a consequence of his or her service, the veteran's spouse could be actively involved in a marital treatment program for these conditions. If a veteran is injured by an improvised explosive device (IED) and his/her cognitive processes are compromised, the parents could be involved in a psycho-educational rehabilitative program in conjunction with the veteran. This treatment would be fully provided by VA to the veteran and their family members.

Dr. Phelps: How generalizable are skills in treating trauma to treating people exposed to combat? How likely is someone with a practice focused generally on trauma, such as helping victims of abuse, to be well skilled in meeting the needs of returning service personnel?

Dr. Keane: I'd like to think that the specific skills and conceptual models for understanding and treating one type of trauma are directly generalizable to another form of trauma exposure. This notion is fundamental to much of the work accomplished by our group at the National Center for PTSD over the past 30 years.

Yet, specific contextual factors are important to consider if one is to succeed in navigating the transition from working with one group of trauma-exposed people to another group. In the instance of combat trauma, it is critical to understand general military contextual variables and the specific details associated with the war itself, and to have an appreciation of the stressors and pressures under which the individual served. Even understanding the political climate in Afghanistan or Iraq during the time of service may communicate to your patient important things about your competence. Learning about the contextual factors associated with a particular type of trauma exposure would, in my view, be far easier and quicker to master than the acquisition of new therapy skills.

The principles for treating trauma survivors are far better understood today than 30 years ago when we first started to treat combatants. Importantly, the models and techniques that guide psychological assessment and psychological treatment of PTSD now possess reliability and validity data that transcend the various types of trauma to which people are exposed. These same principles appear to be effective across racial, ethnic and cultural boundaries. These facts are enormously encouraging to me.

Dr. Phelps: What is important for practitioners to know about the combat-related experience that today's returning soldiers may bring to treatment that's different from other trauma-related life experiences?

Dr. Keane: Fundamentally, trauma is about exposure to life-and-death situations. Trauma may also be secondary to exposure to events that challenge one's personal integrity or may inculcate shame or humiliation. For combatants, their experience in a war zone may transcend all of these experiences and exposure to these experiences often happens multiple times over the period of service.

Combat is not exposure to a uniform, single traumatic event. Rather, it often involves multiple types of life-and-death experiences associated with strong and wide-ranging emotional reactions in the context of a malevolent living environment that is estranged from the usual forms of family and social support. As a result, it's vital to conduct a comprehensive assessment of exposures both in the war zone and prior to service in the war zone.

My experience is that veterans can be extraordinarily open in describing the devastation of war but may be reluctant to express details of events in which they might have had an active role. Patience is needed to understand the precise role of the individual in certain war events, their immediate reactions to those events and the long-term impact of this participation. Combatants are often actively and passively involved in acts of violence; understanding the boundary conditions of war is pivotal in making progress in the psychological treatment of war veterans regardless of their rank at the time of service.

Dr. Phelps: What specific treatments show the greatest promise for successful treatment of combat-related PTSD?

Dr. Keane: The general principles that guide treatment of PTSD are derived from several different models of care. First, the development of a strong therapeutic alliance is pivotal for all future work. It may determine the extent to which particular patients might even share with you the details of their military experiences. Conflict about one's participation in combat is a function of what one does in the war zone and what happens to that person in the war zone. The complex emotions that emerge can be fear, anxiety, dread, horror, shame, guilt and disgust - the strongest and most aversive of human emotions.

Treatment of these emotional responses initially involves a quieting of the strong emotions often employing relaxation or meditational strategies, accompanied by psycho-educational efforts to inform the patient of the psychological, physiological and interpersonal consequences of trauma exposure. Reframing the experiences using cognitive restructuring models that focus upon realistic appraisals of the situation and the circumstances found in a war zone by combatants also is an important component of psychological care. Finally, emotional processing of the details associated with difficult combat events is also demonstrably effective in helping patients to overcome their reactions. Emotional processing can take many forms, including prolonged exposure therapy, systematic desensitization, eye movement desensitization and reprocessing (EMDR) and other approaches that focus directly upon the emotional reactions precipitated by the traumatic events per se.

Dr. Phelps: Of course psychologists are trained to pay attention to countertransference. But are there potential blind spots for certain practitioners, such as those unfamiliar with military service or opposed to war, that they should be mindful of in working with returning service members?

Dr. Keane: Yes, I think so. The therapeutic alliance can be a challenge in any setting and with any type of patient, but there are some key features that will determine whether veteran patients will return for continuing care. Listening attentively to the description of service, while asking informed questions about location, duties and training, can communicate to the veteran an understanding of their experience in important ways.

Most people who join the military do so for the honor and defense of their country. Their belief system is such that they respect those who join the military and they consider the work of the military among the most worthwhile things possible. Challenging this belief or even demonstrating a political position on the value and merits of a particular war may inadvertently damage the therapeutic alliance in ways that aren't remediable.

For many war veterans, even those in their eighties today, the work they did for their country in the military was among the most rewarding life experiences they've had. Supporting this belief is important to moving to the next stage of treatment.

Read the full article here


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A website detailing Traumatic Incident Reduction. Background, case studies, practioners and forums are offered.

Traumatic Incident Reduction

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Although this link might only be useful to those in the Margarita, CA area, there may be other similar programs operating in your locale.

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Back from Iraq & Afghanistan

This Back From Iraq & Afghanistan Support Group is specifically designed for the people who have been in the war in Iraq or Afghanistan (OEF, OIF). They may still be in the military or be out for some time.

This is a free group given to help the troops who need to wait for services at the VA, or who want to have complete confidentiality.

Many people don't want their leaders to know that they want help, for fear of appearing weak or it may affect their military record.

Because of these issues, this group was formed. The troops may also want individual or family counseling.

Source: Back from Iraq


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