PTSD Prolonged Exposure To More Harm?

We keep talking about how long all of these "projects" have been researched, done, failed and then redone over and over again, but in the following article there is a fabulous reminder of what Wounded Times readers already know.

"In 1991, Roger Pitman, a psychiatry professor at Harvard Medical School, discontinued a pilot study of six Vietnam veterans treated with a technique similar to prolonged exposure, known as imaginal flooding, that resulted in two of the patients becoming suicidal and a third breaking 19 months of sobriety. Other patients became severely depressed or began suffering panic attacks between treatment sessions. The results were so unexpected that Pitman conducted a larger study using 20 Vietnam veterans as subjects, published in 1996 in Comprehensive Psychiatry, and found similar outcomes."

Yep, that long, even longer if you are new to Wounded Times.

Trauma Post Trauma
The “gold standard” treatment for PTSD makes many vets’ symptoms even worse.
Slate.com
By David J. Morris

Medics carry a soldier hit by an IED in 2011 in Kandahar, Afghanistan.

Photo by Johannes Eisele/AFP/Getty Images

The U.S. Department of Veterans Affairs is the world leader in research on post-traumatic stress disorder. No organization spends more money or expends more resources to treat it than the VA. Yet its efforts to stamp out the disorder, which afflicts upward of 30 percent of veterans today and is the fourth most common mental health condition in the world, are often strikingly wasteful and driven by shoddy science. In 2006, the VA began treating veterans with a form of therapy charmingly known as prolonged exposure. It is now a central piece in the VA’s war on PTSD and its most popular type of individual psychotherapy. Prolonged exposure is heavily promoted by the VA, which describes it as the “gold standard” treatment for PTSD.

Prolonged exposure therapy works roughly like this: After taking a brief inventory of the patient’s military service, the therapist asks the veteran to recount the story of his or her worst trauma over and over and over again with eyes closed until the memory of it becomes “habituated,” losing its traumatic charge and becoming like any other normal autobiographical memory. The typical course of treatment lasts about eight weeks and, according to Marsden McGuire, the deputy consultant for mental health care standards at the VA, produces some improvement in 60 percent of veterans who undergo it.

The problem with prolonged exposure is that it also has made a number of veterans violent, suicidal, and depressed, and it has a dropout rate that some researchers put at more than 50 percent, the highest dropout rate of any PTSD therapy that has been widely studied so far.
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Healing PTSD Requires Truth Exposure

There is a different conversation going on in this country and this is one we've been having for a while. Exposure therapy works for some folks but not all of them. As a matter of fact, not even the majority of them yet it has been pushed on far too many PTSD veterans. What works is what therapists have been doing for decades, talking and teaching their bodies how to relax again. Still the best experts add in one more thing when PTSD is inside a veteran. They add in spiritual help so the mind, body and spirit are treated with equal importance and then they see healing instead of numbing by medication alone. This article looks at exposure therapy.

Psychiatry’s Identity Crisis, New York Times, Richard Friedman, July 17, 2015

Anyone who doubts the need for psychotherapy research should consider the case of post-traumatic stress disorder, for which the mainstay of treatment has been exposure therapy.

This requires patients to re-experience the circumstances of their traumatic event, which is meant to desensitize them and teach them that their belief that they are in danger is no longer true.

But we know that many patients with PTSD do not respond to exposure, and many of them find the process emotionally upsetting or intolerable.

Dr. John C. Markowitz, a professor of clinical psychiatry at Columbia University, recently showed for the first time that PTSD is treatable with a psychotherapy that does not involve exposure. Dr. Markowitz and his colleagues randomly assigned a group of patients with PTSD to one of three treatments: prolonged exposure, relaxation therapy and interpersonal psychotherapy, which focuses on patients’ emotional responses to interpersonal relationships and helps them to solve problems and improve these relationships. His federally funded study, published in May’s American Journal of Psychiatry, reported that the response rate to interpersonal therapy (63 percent) was comparable to that of exposure therapy (47 percent).
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'Prolonged exposure' therapy may help vets with PTSD

Like anything else, it can help if it is done right. If they just make the veterans relive it, then it won't help them heal. If they address every other part of it including the "moral injury" when necessary depending on the stressor, then it does wonders.

'Prolonged exposure' therapy may help vets with PTSD
By Genevra Pittman
NEW YORK
Wed Jul 17, 2013

(Reuters Health) - Therapy that involves repeatedly processing painful memories and approaching anxiety-provoking situations in a safe way may ease symptoms of posttraumatic stress disorder (PTSD) among veterans, a new study suggests.

Although there is good evidence so-called prolonged exposure therapy can help people with PTSD, researchers said most of the data come from civilians, including women who have been sexually assaulted.

"One of the important factors in chronic PTSD is avoidance - avoiding thinking about the trauma and avoiding going to places that remind you of the trauma or are similar," said Edna Foa, head of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania in Philadelphia and a developer of prolonged exposure therapy.

The idea behind prolonged exposure is "helping the patient confront the memories and confront the situations they avoid," added Foa, who wasn't involved in the new study.

"They realize they can talk about this event, and they don't fall apart. It gives them a sense of control over the memory, rather than the memory controlling them."

One Veterans Affairs report showed that of about 830,000 veterans who were treated at VA medical centers over the last decade, 29 percent had a diagnosis of PTSD and 22 percent were depressed.
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Linked from CNN

Exposure Therapy Effective To PTSD

Exposure Therapy Effective To Prevent Post-Traumatic Stress Disorder
Editor's Choice
Main Category: Anxiety / Stress
Also Included In: Psychology / Psychiatry; Depression
Article Date: 02 Jun 2008 - 13:00 PDT

The progression from acute stress disorder to post-traumatic stress disorder may be prevented by exposure-based therapy, in which trauma survivors are guided to relive a troubling event. These reults were published in an article released on June 2, 2008 in the Archives of General Psychiatry, one of the JAMA/Archives journals.

Acute stress disorder, sometimes called shock, involves the development of a strong stress response after a traumatic event. Symptoms are brought on when the sympathetic nervous system reacts, in the familiar fight or flight response. If this threat is perceived as unusually serious, a more intense and prolonged physiological response can results. The presence of shock after a traumatic event is linked to the subsequent development of post-traumatic stress disorder (PTSD), an anxiety disorder that involves prolonged reaction to the event or events. PTSD is associated with other mental and physical disorders, as well as a reduced quality of life and increased cost of health care.

Cognitive restructuring, which entails rebuilding the thoughts and responses to a traumatic event to be more accurate and beneficial for the patient, is one common form of therapy to help prevent PTSD in those with acute stress. Exposure therapy is another therapy used to this end in which the patient is re-exposed in some way to the source of the trauma, in the hopes of habituating the patient and thus decreasing the response. There is some evidence that many clinicians do not use the latter form of therapy because it can cause distress for recent survivors of trauma.

The study was completed by 63 of the participants. After the completion of treatment, the following proportions of patients met the criteria for PTSD: in the exposure therapy group, 33% (10 patients,); in the cognitive restructuring group 63% (19 patients,) and in the wait-list group 77% (23 patients.) After the six month follow-up, 37% (11 patients) in the exposure therapy group met the criteria for PTSD in contrast with the 63% (19 patients) in the cognitive restructuring group. Additionally, in the exposure group, 47% (14 patients) achieved full remission, while only 13% (4 patients) achieved this in the cognitive group. In all, this indicates relative success on the part of exposure therapy to prevent PTSD.

go here for more
http://www.medicalnewstoday.com/articles/109599.php

What we know is the sooner treatment begins, the better the result. This study seems to have proven it very well.

It is what people working in the field have been pushing for. The question is how do we get there from here?

Today and tomorrow I'm in CISM training. Critical Incident Stress Management at a local hospital. We're covering the need to address stressful/traumatic events head on. Chaplains know this works and so does every police department, fire department along with emergency responders and hospitals. Hurricane and tornado victims, survivors of all kinds of traumatic events know that if someone is looking out for them, they are a lot better off than if they go through it alone. To have another survivor does little good if that person is also under stress and suffering from the trauma. The other person has to be from outside the event itself. This is why it does not work very well when it is a unit under attack in combat.

While it does tend to help to have someone to lean on, they are individually dealing with the event on their own terms or avoiding it. Having someone to go to, removed from the event but attached enough to show they care is vital. Most of the time if the survivor of trauma has someone to vent to, cry on the shoulder of or just have them sit by their side, it does a world of good. This would happened in every unit deployed into combat but that only happens in a perfect world. Most of the time there is no one to do this with them.

When a police officer is involved in a traumatic event, most departments have a Chaplain they can call upon to talk to. This way they unload what is going on inside of them and they face it. Otherwise, with no one to talk to, they tend to stuff it in the back of their brain and move on, believing they "got over it" yet only to have to face it later on when the damage is being done.

With a soldier this happens more than not. They may find their buddies back to normal when they are waking up in the middle of the night covered with sweat and shaking from the nightmare they just had so vivid it was like reliving the entire experience. If their buddies are sleeping soundly, they tend to be reluctant to say anything. As the changes become more and more deeply imbedded within them, they tend to close down even more, afraid to say anything. Again, in a perfect world, there would be a Chaplain or a mental health professional right there for them to go to.

When they come home, they have suffered from and stuffed it back in their memory, believing that back home they will "get over it" and move past it. This does not happen when it is the wound of PTSD they have carried back with them. The changes become apparent to the family but most of the time the family has no clue what it is.

Now think of what it would be like if the family were fully aware of the signs to watch out for. They would be the first to see the changes and help the veteran to face them, seek help for them and they could heal as a family together. What if the veteran knew when it was something beyond getting over on their own? They would seek treatment as soon as possible understanding that once they did, they would begin to heal and would not get worse.

There is so much that needs to be done but again, with PTSD, the sooner the better. These delays in therapy and treatment cut the wound deeper. Education has to be provided immediately and the stigma of PTSD has to be placed where it needs to be and that is on anyone getting in the way of these veterans from seeking help. The the next step is to educate all the family members what they need to watch out for when in communication with their soldier while deployed and what to watch out for when they get home.

We need more mental health professionals and we need more Chaplains dealing with the tsunami coming. Failing to do this will increase the suicide rate, the divorce rate, the homeless rate and the crime rate along with driving under the influence. We need to spend money wisely on this right now to save money later and at the same time save the veterans futures.