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Ethical Democracy As Lived Practice Blog by Professor Chithra Karunakaran is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.
Based on a work at http://EthicalDemocracy.blogspot.com
Who Co-Wrote "the Narrative"? The US govt. & the Jihadists Proudly Present their Joint Venture!
http://community.nytimes.com/comments/www.nytimes.com/2009/11/29/opinion/29friedman.html?sort=oldest&offset=10
My NYT comment #226.
EthicalDemocracy
New York City
November 29th, 2009
1:03 pm
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EthicalDemocracy
New York City
November 29th, 2009
4:28 am
Friedman said: \"What is scary is that even though he was born, raised and educated in America, The Narrative still got to him.\"
Where to begin with unpacking this assertion? I'll try.
Q. Didn't the US govt. partly write what you call \"the Narrative?
For half a century the US has been a state sponsor of terror. The US has invaded, occupied, tortured, deposed, droned, displaced,nuked, bombed, napalmed, maimed, and in the process killed hundreds of thousands of innocent civilians in sovereign nation-states across the globe.
In the name of freedom, liberty, democracy?
On the other hand Does this necessarily mean the rest of us support that part of \"the narrative\" that has been written by the Jihadists? Not at all. The J's have imagined and then orchestrated a living disaster for us all.
If we don't acknowledge the US govt.'s continuing role in choreographing this madness,right along with the Jihadists, then we have missed the point.
You can obfuscate Friedman but you can't hide.
Satyameva Jayate -- to Truth goes the Victory. Not to you or me, but Truth itself.
Chithra KarunaKaran
http://EthicalDemocracy.blogspot.com
Ethical Democracy As Lived Practice
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NYTimes copyright
http://www.nytimes.com/2009/11/29/opinion/29friedman.html
America vs. The Narrative
By THOMAS L. FRIEDMAN
Why a cocktail of half-truths, propaganda and outright lies about America have taken hold in the Arab-Muslim world since 9/11.
Sunday, November 29, 2009
Sunday, November 1, 2009
The Psychological Cost of War -- Iraq & Af-Pak
my NYT Comment #25.
http://ethicaldemocracy.blogspot.com/2009/11/psychological-cost-of-iraq-and-af-pak.html
additional resource link
http://www.ptsd.va.gov/
EthicalDemocracy
New York City
November 1st, 2009
8:31 am
A Psychological War
"Shock and awe" by Bush in Iraq was psychological warfare. So were Abu Ghraib and Gitmo. All the soldiers returning from "tours" in Iraq and Afghanistan are victims as well as perpetrators of psychological warfare and they will likely develop the full range of psychopathologies to show for it.
And the US taxpayer (me) will bear the medical and social cost.
Let us NEVER forget the hundreds of thousands of innocent Iraqi civilians who have suffered deep psychological scars in the US war against terror.
The real problem is that the US Govt. is a state sponsor of terror.
The US military-corporate complex has commoditized Terror,turned Terror into a branded product that can feed the already skyrocketing profits of the pharmaceutical industry, the media industry, the armaments industry
The psychological scars (in innocent civilian populations under US invasion, occupation and bombardment in Iraq, Afghanistan, Pakistan) are the direct consequence of such terror. Does any govt care about these hapless long-suffering victims?
U.S. Soldiers, why are you whining? If you chose to go to war for the US and you now suffer PTSD, major depression, suicidal and homicidal tendencies, delusions and hallucinations, etc. what did you expect? Speak up against your own govt, your military, your politicians, your homegrown warmongers against innocents elsewhere.
Didn't you know what would happen before you went?
Of course, I feel sympathy for you, I hope you will get better and I most fervently hope that you will WAGE PEACE, instead of war.
However your diagnosis for a combination of psychopathologies, and most commonly Post-Traumatic Stress Disorder (PTSD) comes as no surprise.
Surprise = Profit for the drug industry.
And the 'legal' drug industry is part of that other 'legal' industry, the US Military-Corporate Complex (MCC).
Chithra KarunaKaran
Ethical Democracy As Lived Practice
http://EthicalDemocracy.blogspot.com
-------------------------------------------------
NYTimes copyright
http://www.nytimes.com/2009/11/01/us/01trauma.html
A Combat Role, and Anguish, Too
By DAMIEN CAVE
As women who suffer from post- traumatic stress disorder return to a society unfamiliar with their wartime roles, they often choose isolation over embarrassment.
Women at Arms
A Combat Role, and Anguish, Too
Chip Litherland for The New York Times
Vivienne Pacquette, who served in Iraq, is one of thousands of women who returned from war with a stress disorder. More Photos >
http://www.nytimes.com/2009/11/01/us/01trauma.html
By DAMIEN CAVE
Published: October 31, 2009
For Vivienne Pacquette, being a combat veteran with post-traumatic stress disorder means avoiding phone calls to her sons, dinner out with her husband and therapy sessions that make her talk about seeing the reds and whites of her friends’ insides after a mortar attack in 2004.
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Women at Arms
The Psychological Scars
Articles in this series explore how the wars in Iraq and Afghanistan have profoundly redefined the role of women in the military.
Previous Articles in the Series »
At War
Notes from Afghanistan, Pakistan, Iraq and other areas of conflict in the post-9/11 era.
As with other women in her position, hiding seems to make sense. Post-traumatic stress disorder distorts personalities: some veterans who have it fight in their sleep; others feel paranoid around children. And as women return to a society unfamiliar with their wartime roles, they often choose isolation over embarrassment.
Many spend months or years as virtual shut-ins, missing the camaraderie of Iraq or Afghanistan, while racked with guilt over who they have become.
“After all, I’m a soldier, I’m an NCO, I’m a problem solver,” said Mrs. Pacquette, 52, a retired noncommissioned officer who served two tours in Iraq and more than 20 years in the Army. “What’s it going to look like if I can’t get things straight in my head?”
Never before has this country seen so many women paralyzed by the psychological scars of combat. As of June 2008, 19,084 female veterans of Iraq or Afghanistan had received diagnoses of mental disorders from the Department of Veterans Affairs, including 8,454 women with a diagnosis of post-traumatic stress — and this number does not include troops still enlisted, or those who have never used the V.A. system.
Their mental anguish, from mortar attacks, the deaths of friends, or traumas that are harder to categorize, is a result of a historic shift. In Iraq and Afghanistan, the military has quietly sidestepped regulations that bar women from jobs in ground combat. With commanders needing resources in wars without front lines, women have found themselves fighting on dusty roads and darkened outposts in ways that were never imagined by their parents or publicly authorized by Congress. And they have distinguished themselves in the field.
Psychologically, it seems, they are emerging as equals. Officials with the Department of Defense said that initial studies of male and female veterans with similar time outside the relative security of bases in Iraq showed that mental health issues arose in roughly the same proportion for members of each sex, though research continues.
“Female soldiers are actually handling and dealing with the stress of combat as well as male soldiers are,” said Col. Carl Castro, director of the Military Operational Research Program at the Department of Defense. “When I look at the data, I see nothing to counter that point.”
And yet, experts and veterans say, the circumstances of military life and the way women are received when they return home have created differences in how they cope. A man, for instance, may come home and drink to oblivion with his war buddies while a woman — often after having been the only woman in her unit — is more likely to suffer alone.
Some psychiatrists say that women do better in therapy because they are more comfortable talking through their emotions, but it typically takes years for them to seek help. In interviews, female veterans with post-traumatic stress said they did not always feel their problems were justified, or would be treated as valid by a military system that defines combat as an all-male activity.
“Some of the issues come up because they’re not given the combat title even though they may be out on patrol standing next to the men,” said Patricia Resick, director of the Women’s Health Sciences Division at the National Center for P.T.S.D., a wing of the Department of Veterans Affairs.
While more men over all suffer from the disorder because they are a majority of those deployed, Dr. Resick added, “people underestimate what these women have been through.”
Indeed, at home, after completing important jobs in war, women with the disorder often smack up against old-fashioned ignorance: male veterans and friends who do not recognize them as “real soldiers”; husbands who have little patience with their avoidance of intimacy; and a society that expects them to be feminine nurturers, not the nurtured.
War as Equalizer
When Mrs. Pacquette joined the army in the ’80s — inspired by her father, who served in World War II — men often told her she did not belong. “Women were seen as weak and whiny,” she said. “Men had to go on sick call all the time but when a woman went on sick call, it was a big deal.”
Even before she was deployed to Iraq in 2004, however, she sensed what thousands of women have since discovered: that war would be an equalizer. And it was.
In early October 2004, her convoy of about 30 vehicles set out from Kuwait for Mosul, one of Iraq’s most violent cities. On the way, she said, they were hit three times with roadside bombs. One exploded 200 feet from the unarmored Humvee in which Mrs. Pacquette spent day and night pointing her rifle out an open window.
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A Combat Role, and Anguish, Too
Published: October 31, 2009
(Page 2 of 4)
Gunshots arrived, too, on a bridge in Baghdad. Soldiers took up positions outside their vehicles, and an Iraqi was killed. “It was my birthday,” Mrs. Pacquette said. “I remember thinking, ‘Oh my God, I’m going to die.’ ”
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Enlarge This Image
Ed Zurga for The New York Times
“Just admit that it happened. Then it's over,” said Heather Paxton, Iraq veteran who received a diagnosis of post-traumatic stress, and whose disability claims were rejected three times. More Photos >
Women at Arms
The Psychological Scars
Articles in this series explore how the wars in Iraq and Afghanistan have profoundly redefined the role of women in the military.
Previous Articles in the Series »
At War
Instead, she surprised even herself by remaining calm.
“There were guys on the ground that I was responsible for as an NCO,” she said, adding, “As a leader, I had to keep my fear inside.”
But later on, the war’s consequences began to weigh more heavily. On Dec. 21, an Iraqi suicide bomber walked into a mess tent at a base across the street from her own and blew himself up amid the plastic lunch trays, killing more than 25 people.
Then a mortar attack hit the motor pool where her unit worked. At the scene, she saw three of her friends torn up beyond recognition.
Recalling the scene nearly five years later, Mrs. Pacquette’s dark brown eyes began darting back and forth, as if looking for another rocket. She was in St. Croix, the island where she grew up, but her body stiffened like a wound coil — releasing only after her twin sister brought their faces together, in a silent hug that lasted several minutes.
Her mind had returned to the moment. And this emotional flashback is just one in a long list of post-traumatic stress symptoms that female veterans now know intimately. Fits of rage, insomnia, nightmares, depression, survivor’s guilt, fear of crowds — women with the disorder, like men, can and do get it all.
Mrs. Pacquette’s twin, Jamilah Moorehead, said she noticed it soon after her sister’s first tour. “In the middle of the night, I heard this loud noise and there was Viv,” Mrs. Moorehead said. “She was crouching as if holding a weapon and she was not even awake.”
A military doctor gave Mrs. Pacquette a diagnosis of post-traumatic stress in March 2005, but she refused treatment. “I didn’t want anyone to know,” she said.
That November, she returned to Iraq, where she said she managed to keep the disorder hidden because she often worked alone. She retired from the military in 2006, but is still struggling with how to face the diagnosis.
The worst part, she said, was seeing her personality harden. First, she lost the ability to trust the Iraqi soldiers she served with. Then at home, she said, she fell out of touch with loved ones, though her husband has stood by her side. Now simply standing in line with other people is enough to turn her into what she calls “a witch, but with B.”
Dr. Carri-Ann Gibson, Mrs. Pacquette’s therapist, who runs the Trauma Recovery Program at the James A. Haley Veterans’ Hospital in Tampa, Fla., said the hardest part for women is that they often feel ashamed and guilty because “they’re not supposed to punch a wall, they’re not supposed to get aggressive with their spouse.”
Dr. Gibson said that for men, rage, paranoia and aggression are more accepted, while women are typically expected to snap back into domestic routines without any trouble.
“Women apply that pressure to themselves as well,” she said. “They live with that inner feeling of anger, and that’s why we see more events happening at home than actually out in public.”
Dr. Resick of the National Center for P.T.S.D. said much was still unknown about how the minds of men and women handle war. But at this point, she said, men and women differ mainly in how they manage similar symptoms.
“You put a man and a woman in a truck and they get blasted by an I.E.D., we’re not seeing big differences there,” Dr. Resick said, referring to improvised explosive devices. “That said, there are different context factors that affect how people cope.”
“The women — because they are not surrounded by other women, they may be surrounded by men — may withdraw more,” she continued. “The question is, Who are they with when they come home?”
Homefront Isolation
Many women traumatized by combat stress described lives of quiet desperation, alone, in just a few rooms with drawn shades.
Nancy Schiliro, 29, who lost her right eye as a result of a mortar attack in 2005, said that for more than two years after returning home, she rarely left a darkened garage in Hartsdale, N.Y., that her grandmother called “the bat cave.”
Shalimar Bien, 30, described her life, four years after Iraq, as a nonstop effort to avoid confrontation.
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(Page 3 of 4)
And for those with husbands or young children, finding a social equilibrium is especially difficult. Veterans like Aimee Sherrod, 29, a mother of two, say they constantly struggle to balance their own urge to hide with demands from loved ones to interact.
Women at Arms
The Psychological Scars
Articles in this series explore how the wars in Iraq and Afghanistan have profoundly redefined the role of women in the military.
Previous Articles in the Series »
At War
Ms. Sherrod said that five years after her last deployment to Iraq, she still makes only a few trips a week outside her home in Jackson, Tenn., usually to drop off or pick up her 4-year-old son at school.
She often feels like a failure because her son pushes for what she cannot handle. “I don’t take him to Chuck E. Cheese because I’ll get angry,” she said, noting that the arcade’s bells and bangs make her jumpy. “Take him to a park? It’s a lose-lose. I don’t like open spaces.”
She can identify a handful of causes for what her mind has become. In Baghdad with an Air Force rescue squadron from the fall of 2003 to the spring of 2004, she worked on helicopters, sometimes cleaning off the blood from casualties, and regularly receiving indirect fire. “I was getting mortared all the time,” Mrs. Sherrod said. “So someone was watching me.”
She also feels damaged from her time in Jordan, at the start of the Iraq war. One of only two women in her unit, she said, she was ostracized after asking to be shifted to nights because some of the men would not stop harassing her. Her superiors, she said, broke a promise to keep her complaint quiet and after that, the men in her unit lashed out. “This one guy said if I was on fire he wouldn’t even piss on me to put me out,” Mrs. Sherrod said.
Many female veterans report being treated with respect by male colleagues, more so as they proved themselves. But several women said in interviews that some men made their wartime experiences even harder.
Mrs. Pacquette said that on her second tour, in Baghdad, she took showers with an open knife on the soap dish after seeing a man flee the bathroom trailer, having just attacked a woman inside.
In Mrs. Sherrod’s case, the harm came more from being shunned by her unit. For months in Jordan, she said, she had no e-mail access. No phone. No friends. She was isolated.
So at home, she got used to pushing people away. On her first date with the man who became her husband, she told him she had post-traumatic stress, figuring he would not stick around. He did, but they have struggled to stay together.
She always wanted to be a mother, and described her first child as a product of a whirlwind return from war. She became pregnant with her son within a month of reaching home, she said, after a night of drinking. When she later got pregnant with her daughter, who is 9 months old, she said she still thought the doctors were wrong about her stress disorder.
Now, having finally accepted the diagnosis after connecting with other veterans online, she fears her own temper more than anything else.
The other day, in the car, she lost control when both of her children demanded attention. “I can handle one or the other,” she said, “but she was crying and he kept saying, ‘Mommy, mommy,’ so in the middle of the road, I stopped the car and yelled: ‘If you do not be quiet I’m going to turn around and hit you.’
“The look on his face broke my heart,” Mrs. Sherrod said. “He just wanted to talk to me. He wasn’t doing anything bad.”
She paused, then said: “I’m like that all the time.”
Homefront Ignorance
When Heather Paxton started working at the V.A. hospital in Columbia, Mo., two years ago, she discovered something she did not expect: no one saw her as a veteran.
Despite her service in Iraq, patients assumed she knew nothing of war. A male colleague who chattered about weapons dismissed her like a silly little sister when she chimed in.
“He’d give me the stink eye,” Ms. Paxton said. “He’d just walk away.”
For many female veterans today, war and their roles in it must be constantly explained. For those with post-traumatic stress, the constant demand for proof can be particularly maddening — confirming their belief that only the people who were “over there” can understand them here.
Men express similar sentiments; combat veterans of both sexes often complain about insensitive questions like, “Did you kill anyone?”
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(Page 4 of 4)
But women say they are also treated to another line of inquiry. Would male veterans, they ask, hear friends or relatives say, “How was the shopping?” Or “In that heat, how did you wear makeup?” Or “How could you have P.T.S.D. when you sat at a desk with a typewriter?”
Female veterans say they have heard them all.
They have also seen their sacrifice overlooked, in bars, where strangers slide past them to buy drinks for men who were never deployed; and at “welcome home” events where organizers asked for their husbands.
Tammy Duckworth, a former Black Hawk helicopter pilot who lost her legs to a rocket-propelled grenade in Iraq, said such experiences show that “we’re going through a change — just like in World War II with African-Americans, the military is ahead of the American public.”
What many do not realize, said Ms. Duckworth, who ran for Congress and is now the assistant secretary of public and intergovernmental affairs for the V.A., is that in war today, “it’s not a question, Can women can do a combat job. They just are.”
Some women have found ways to at least minimize the slight.
Ms. Paxton now has a picture above her desk, showing her, her mother and her brother, all in uniform.
Mrs. Pacquette has placed a decal on her cane (like many veterans, she has damaged knees and a bad back from lugging gear) that identifies her as an Iraq war veteran.
Sometimes, though, simple messages are not enough. Renee Peloquin, 25, a member of the Idaho National Guard, had to design a bumper sticker that says “Female Iraqi War Veteran” because the basic “Iraq War Veteran” message on her car led strangers to thank her long-haired boyfriend for serving, even though he has never spent a day in uniform.
“I’m so sick of being stereotyped,” Ms. Peloquin said. “Or being ignored, that’s a better word.”
The military and the Department of Veterans Affairs have worked hard to make the public more aware of women’s roles. There are now Army recruiting advertisements featuring women in war zones. The V.A. has bought hundreds of copies of the documentary “Lioness,” which profiles female veterans in Ramadi, while producing a video of its own with Jane Pauley that shows the history of military women.
Last year, the veterans’ agency also began a systemwide effort to make primary care for female veterans available at every V.A. medical facility nationwide. At Ms. Paxton’s V.A. in Columbia, and Dr. Gibson’s in Tampa, women’s centers take up separate wings of the hospitals, as the V.A. prepares for its population of patients who are women to double over the next few years.
For some women with post-traumatic stress, like Angela Peacock in St. Louis, the V.A. has been a godsend. She said that the doctors who helped her detoxify from drug and alcohol addiction saved her from suicide.
Many others, however, insist that the military, the V.A. and other established veterans organizations have not fully adapted to women’s new roles. The military, they say, still treats them like wives, not warriors.
Some therapists, case workers and female patients also say that because military regulations governing women’s roles have not caught up with reality, women must work harder to prove they saw combat and get the benefits they deserve.
V.A. officials, including Ms. Duckworth, say there is no systemic bias. V.A. statistics show that as of July 2009, 5,103 female Iraq or Afghanistan veterans had received disability benefits for the stress disorder, compared with 57,732 males.
But the V.A. did not provide the number of men and women who had applied, making a comparison of rejection rates impossible.
At best, women are caught in the same bureaucratic morass as men; the backlog for disability claims from all veterans climbed to 400,000 in July, up from 253,000 six years ago. At worst, women are sometimes held to a tougher standard.
Ms. Paxton is one of at least 3,000 female Iraq and Afghanistan war veterans with stress disorder diagnoses and no disability benefit, as shown by the V.A. statistics.
Serving in Tikrit, Iraq, five years ago with a civil affairs unit, she took part in missions several times a week on roads regularly rigged with bombs. She worked closely with two Iraqi translators who were killed — she saw one in his bullet-ridden car just after he had been assassinated — and she came home with nightmares, depression and anger.
Though she received a diagnosis of stress disorder by a V.A. doctor, she had her first disability claim rejected in 2006. A second refusal came a year later, and the third arrived in 2008, despite a letter verifying what happened from a captain with her unit.
Her V.A. case worker, Julie Heese, said the rejections highlighted what made the benefits system so challenging. “The claims process is a tough one because you have to have really clear evidence,” Ms. Heese said. She added that it works best “with a well documented battle or attack,” not with experiences that may go unrecorded, like the death of a translator.
Newly proposed V.A. rules easing requirements for documenting traumatic events could help Ms. Paxton’s case. But she said she feared a fourth disappointment.
She said she no longer cared about getting money. After experiencing the grave shock of war and its never-ending aftermath, she would like a little more recognition.
“Just admit that it happened,” she said, her voice rising, over a meal her husband cooked at their home in Columbia. “Then it’s over.”
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APA monitor copyright
PTSD
PTSD treatments grow in evidence, effectiveness
Several psychological interventions help to significantly reduce post-traumatic stress disorder symptoms, say new guidelines.
By Tori DeAngelis
Print version: page 40
It's a bittersweet fact: Traumatic events such as the Sept. 11 attacks, Hurricane Katrina, and the wars in Iraq and Afghanistan have enabled researchers to learn a lot more about how best to treat post-traumatic stress disorder (PTSD).
"The advances made have been nothing short of outstanding," says Boston University psychologist Terence M. Keane, PhD, director of the behavioral science division of the National Center for Posttraumatic Stress Disorder and a contributor to the original PTSD diagnosis. "These are very important times in the treatment of PTSD."
In perhaps the most important news, in November, the International Society for Traumatic Stress Studies (ISTSS), a professional society that promotes knowledge on severe stress and trauma, issued new PTSD practice guidelines. Using a grading system from "A" to "E," the guidelines label several PTSD treatments as "A" treatments based on their high degree of empirical support, says Keane, one of the volume's editors. The guidelines—the first since 2000—update and generally confirm recommendations of other major practice-related bodies, including the U.S. Department of Veterans Affairs (VA), the Department of Defense, the American Psychiatric Association, and Great Britain's and Australia's national health-care guidelines, he says.
In other PTSD-treatment advances, researchers are adding medications and virtual-reality simulations to proven treatments to beef up their effectiveness. Clinical investigators are also exploring ways to treat PTSD when other psychological and medical conditions are present, and they are studying specific populations such as those affected by the Sept. 11 attacks.
Though exciting, these breakthroughs are somewhat colored by an October Institute of Medicine (IoM) report that concludes there is still not enough evidence to say which PTSD treatments are effective, except for exposure therapies. Many experts, however, disagree with that conclusion, noting that a number of factors specific to the condition, such as high dropout rates, can lead to what may seem like imperfect study designs (see Sidebar).
Treatments that make a difference
The fact that several treatments made the "A" list is great news for psychologists, says Keane. "Having this many evidence-based treatments allows therapists to use what they're comfortable with from their own background and training, and at the same time to select treatments for use with patients with different characteristics," he says.
Moreover, many of these treatments were developed by psychologists, he notes.
They include:
• Prolonged-exposure therapy, developed for use in PTSD by Keane, University of Pennsylvania psychologist Edna Foa, PhD, and Emory University psychologist Barbara O. Rothbaum, PhD. In this type of treatment, a therapist guides the client to recall traumatic memories in a controlled fashion so that clients eventually regain mastery of their thoughts and feelings around the incident. While exposing people to the very events that caused their trauma may seem counterintuitive, Rothbaum emphasizes that it's done in a gradual, controlled and repeated manner, until the person can evaluate their circumstances realistically and understand they can safely return to the activities in their current lives that they had been avoiding. Drawing from PTSD best practices, the APA-initiated Center for Deployment Psychology includes exposure therapy in the training of psychologists and other health professionals who are or will be treating returning Iraq and Afghanistan service personnel (see "A unique training program").
• Cognitive-processing therapy, a form of cognitive behavioral therapy, or CBT, developed by Boston University psychologist Patricia A. Resick, PhD, director of the women's health sciences division of the National Center for PTSD, to treat rape victims and later applied to PTSD. This treatment includes an exposure component but places greater emphasis on cognitive strategies to help people alter erroneous thinking that has emerged because of the event. Practitioners may work with clients on false beliefs that the world is no longer safe, for example, or that they are incompetent because they have "let" a terrible event happen to them.
• Stress-inoculation training, another form of CBT, where practitioners teach clients techniques to manage and reduce anxiety, such as breathing, muscle relaxation and positive self-talk.
• Other forms of cognitive therapy, including cognitive restructuring and cognitive therapy.
• Eye-movement desensitization and reprocessing, or EMDR, where the therapist guides clients to make eye movements or follow hand taps, for instance, at the same time they are recounting traumatic events. It's not clear how EMDR works, and, for that reason, it's somewhat controversial, though the therapy is supported by research, notes Dartmouth University psychologist Paula P. Schnurr, PhD, deputy executive director of the National Center for PTSD.
• Medications, specifically selective serotonin reuptake inhibitors. Two in particular—paroxetine (Paxil) and sertaline (Zoloft)—have been approved by the Food and Drug Administration for use in PTSD. Other medications may be useful in treating PTSD as well, particularly when the person has additional disorders such as depression, anxiety or psychosis, the guidelines note.
Spreading the word
So promising does the VA consider two of the "A" treatments—prolonged exposure therapy and cognitive-processing therapy—that it is doing national rollouts of them within the VA, notes psychologist Antonette Zeiss, PhD, deputy chief consultant for mental health at the agency.
"Enhancing our ability to provide veterans with the psychotherapies for PTSD that have the strongest evidence base is one of our highest priorities," Zeiss says. In fact, the VA began training psychologists to provide the two approaches more than a year before the Institute of Medicine released its report of successful treatments, she says. "We're pleased that the report confirms our emphasis on this training."
The VA system's structure and philosophy make it possible to test the results of treatments in large, realistic samples—a clinical researcher's dream, notes Schnurr, who has conducted a number of such studies, most recently in a study of female veterans that led to the rollout out of prolonged exposure therapy. That study was reported in the Feb. 28, 2007, issue of The Journal of the American Medical Association (Vol. 297, No. 8, pages 820–830).
"The VA was able to support the science, so the research didn't just sit around in a journal and get discussed," Zeiss says. "They put money toward it, and they asked us to help them do a major rollout of the treatment."
Boosting effectiveness
Meanwhile, other researchers are experimenting with add-ons to these proven treatments to increase their effectiveness. Some are looking at how virtual reality might enhance the effects of prolonged-exposure therapy. By adding virtual reality, whereby clients experience 3-D imagery, sounds and sometimes smells that correspond with a traumatic event, "we think it might be a good alternative for people who are too avoidant to do standard exposure therapy, because it puts them right there," says Emory University's Rothbaum.
Other researchers are adding a small dose of an old tuberculosis drug, D-cycloserine, or DCS, to treatment to see if it can mitigate people's fear reactions. Rothbaum's team, which includes psychologist Mike Davis, PhD, and psychiatrist Kerry Ressler, MD, PhD, have recently shown that the drug helps to extinguish fear in animals, so they're hoping for a similar effect in people.
In one study with veterans of the current Iraq war, Rothbaum's team is giving all participants a type of virtual reality that simulates combat conditions in Iraq, then randomizing them into a drug condition where they get DCS, a placebo, or the anti-anxiety drug alprazolam (Xanax).
In a similar vein, researchers at the Program for Anxiety and Traumatic Stress Studies at Weill Cornell Medical College are using virtual reality and DCS to treat those directly affected by the 2001 World Trade Center attacks, including civilians who were in the towers or nearby buildings, witnesses, and firefighters and police officers who were first responders.
Participants receive standard cognitive behavioral treatment enhanced with virtual reality, where they see graded versions of a Twin Towers scenario, starting with simple images of the buildings on a sunny day, and progressing gradually to include the horrific sights and sounds of that day. They also randomly receive either a small dose of DCS or a placebo pill before each session.
While neither study is complete, the researchers say the treatments appear to significantly reduce participants' PTSD symptoms. Rothbaum has recently submitted a grant proposal for a study where she plans to compare traditional and virtual-reality exposure therapies—which hasn't yet been done—in combination with DCS or a placebo.
Addressing comorbidity
Other psychologists are starting to think about ways to treat PTSD when it is accompanied by other psychiatric and health conditions. Psychologist John Otis, PhD, of Boston University and VA Boston, for instance, is testing an integrated treatment that aims to alleviate symptoms of both PTSD and chronic pain in Vietnam veterans and veterans of Operation Iraqi Freedom and Operation Enduring Freedom. The treatment combines aspects of cognitive processing therapy for trauma and cognitive behavioral therapy for chronic pain.
"We think these two conditions may interact in some [psychological] way that makes them more severe and challenging to treat," Otis says. In particular, he and others posit that "anxiety sensitivity"—fear of experiencing one's anxiety-related symptoms—may increase the odds that certain PTSD sufferers have more problems than others.
Again, while the study is not yet finished, results are encouraging, reports Otis. "Many of the veterans who are getting the integrated treatment are experiencing partial or complete remission of both kinds of symptoms," he says.
On a broader scale, the National Center for PTSD's Keane believes that much more research is needed on treating PTSD and psychiatric co-morbidities such as depression, anxiety, substance abuse, personality disorders and psychosis—a common situation that escalates the more severe a person's PTSD symptoms are, he says.
He, for one, would like to examine possible applications to PTSD of the concept of a "unified protocol," a theory and methodology being developed by Boston University psychotherapy researcher David Barlow, PhD, to treat concurrent problems such as panic attacks, anxiety and phobias.
That said, the recent advances promise to help many more people suffering from a condition they did not bring on themselves, says Zeiss.
"While there is still more to learn, we have taken significant steps in developing treatments that have been shown to be effective and that will be increasingly provided both in VA and other mental health care settings," says Zeiss. "Those affected by combat stress and other traumas will be able to reach out for care without feeling ashamed or hopeless."
Tori DeAngelis is a writer in Syracuse, N.Y.
Post-traumatic stress disorder and trauma in children and adolescents is one of the priorities of APA's 2008 President Alan E. Kazdin, PhD. He is forming a task force on the topic, which will be chaired by Annette LaGreca, PhD. The scope of the committee's work will be covered in an upcoming issue of the Monitor.
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http://ethicaldemocracy.blogspot.com/2009/11/psychological-cost-of-iraq-and-af-pak.html
additional resource link
http://www.ptsd.va.gov/
EthicalDemocracy
New York City
November 1st, 2009
8:31 am
A Psychological War
"Shock and awe" by Bush in Iraq was psychological warfare. So were Abu Ghraib and Gitmo. All the soldiers returning from "tours" in Iraq and Afghanistan are victims as well as perpetrators of psychological warfare and they will likely develop the full range of psychopathologies to show for it.
And the US taxpayer (me) will bear the medical and social cost.
Let us NEVER forget the hundreds of thousands of innocent Iraqi civilians who have suffered deep psychological scars in the US war against terror.
The real problem is that the US Govt. is a state sponsor of terror.
The US military-corporate complex has commoditized Terror,turned Terror into a branded product that can feed the already skyrocketing profits of the pharmaceutical industry, the media industry, the armaments industry
The psychological scars (in innocent civilian populations under US invasion, occupation and bombardment in Iraq, Afghanistan, Pakistan) are the direct consequence of such terror. Does any govt care about these hapless long-suffering victims?
U.S. Soldiers, why are you whining? If you chose to go to war for the US and you now suffer PTSD, major depression, suicidal and homicidal tendencies, delusions and hallucinations, etc. what did you expect? Speak up against your own govt, your military, your politicians, your homegrown warmongers against innocents elsewhere.
Didn't you know what would happen before you went?
Of course, I feel sympathy for you, I hope you will get better and I most fervently hope that you will WAGE PEACE, instead of war.
However your diagnosis for a combination of psychopathologies, and most commonly Post-Traumatic Stress Disorder (PTSD) comes as no surprise.
Surprise = Profit for the drug industry.
And the 'legal' drug industry is part of that other 'legal' industry, the US Military-Corporate Complex (MCC).
Chithra KarunaKaran
Ethical Democracy As Lived Practice
http://EthicalDemocracy.blogspot.com
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NYTimes copyright
http://www.nytimes.com/2009/11/01/us/01trauma.html
A Combat Role, and Anguish, Too
By DAMIEN CAVE
As women who suffer from post- traumatic stress disorder return to a society unfamiliar with their wartime roles, they often choose isolation over embarrassment.
Women at Arms
A Combat Role, and Anguish, Too
Chip Litherland for The New York Times
Vivienne Pacquette, who served in Iraq, is one of thousands of women who returned from war with a stress disorder. More Photos >
http://www.nytimes.com/2009/11/01/us/01trauma.html
By DAMIEN CAVE
Published: October 31, 2009
For Vivienne Pacquette, being a combat veteran with post-traumatic stress disorder means avoiding phone calls to her sons, dinner out with her husband and therapy sessions that make her talk about seeing the reds and whites of her friends’ insides after a mortar attack in 2004.
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Women at Arms
The Psychological Scars
Articles in this series explore how the wars in Iraq and Afghanistan have profoundly redefined the role of women in the military.
Previous Articles in the Series »
At War
Notes from Afghanistan, Pakistan, Iraq and other areas of conflict in the post-9/11 era.
As with other women in her position, hiding seems to make sense. Post-traumatic stress disorder distorts personalities: some veterans who have it fight in their sleep; others feel paranoid around children. And as women return to a society unfamiliar with their wartime roles, they often choose isolation over embarrassment.
Many spend months or years as virtual shut-ins, missing the camaraderie of Iraq or Afghanistan, while racked with guilt over who they have become.
“After all, I’m a soldier, I’m an NCO, I’m a problem solver,” said Mrs. Pacquette, 52, a retired noncommissioned officer who served two tours in Iraq and more than 20 years in the Army. “What’s it going to look like if I can’t get things straight in my head?”
Never before has this country seen so many women paralyzed by the psychological scars of combat. As of June 2008, 19,084 female veterans of Iraq or Afghanistan had received diagnoses of mental disorders from the Department of Veterans Affairs, including 8,454 women with a diagnosis of post-traumatic stress — and this number does not include troops still enlisted, or those who have never used the V.A. system.
Their mental anguish, from mortar attacks, the deaths of friends, or traumas that are harder to categorize, is a result of a historic shift. In Iraq and Afghanistan, the military has quietly sidestepped regulations that bar women from jobs in ground combat. With commanders needing resources in wars without front lines, women have found themselves fighting on dusty roads and darkened outposts in ways that were never imagined by their parents or publicly authorized by Congress. And they have distinguished themselves in the field.
Psychologically, it seems, they are emerging as equals. Officials with the Department of Defense said that initial studies of male and female veterans with similar time outside the relative security of bases in Iraq showed that mental health issues arose in roughly the same proportion for members of each sex, though research continues.
“Female soldiers are actually handling and dealing with the stress of combat as well as male soldiers are,” said Col. Carl Castro, director of the Military Operational Research Program at the Department of Defense. “When I look at the data, I see nothing to counter that point.”
And yet, experts and veterans say, the circumstances of military life and the way women are received when they return home have created differences in how they cope. A man, for instance, may come home and drink to oblivion with his war buddies while a woman — often after having been the only woman in her unit — is more likely to suffer alone.
Some psychiatrists say that women do better in therapy because they are more comfortable talking through their emotions, but it typically takes years for them to seek help. In interviews, female veterans with post-traumatic stress said they did not always feel their problems were justified, or would be treated as valid by a military system that defines combat as an all-male activity.
“Some of the issues come up because they’re not given the combat title even though they may be out on patrol standing next to the men,” said Patricia Resick, director of the Women’s Health Sciences Division at the National Center for P.T.S.D., a wing of the Department of Veterans Affairs.
While more men over all suffer from the disorder because they are a majority of those deployed, Dr. Resick added, “people underestimate what these women have been through.”
Indeed, at home, after completing important jobs in war, women with the disorder often smack up against old-fashioned ignorance: male veterans and friends who do not recognize them as “real soldiers”; husbands who have little patience with their avoidance of intimacy; and a society that expects them to be feminine nurturers, not the nurtured.
War as Equalizer
When Mrs. Pacquette joined the army in the ’80s — inspired by her father, who served in World War II — men often told her she did not belong. “Women were seen as weak and whiny,” she said. “Men had to go on sick call all the time but when a woman went on sick call, it was a big deal.”
Even before she was deployed to Iraq in 2004, however, she sensed what thousands of women have since discovered: that war would be an equalizer. And it was.
In early October 2004, her convoy of about 30 vehicles set out from Kuwait for Mosul, one of Iraq’s most violent cities. On the way, she said, they were hit three times with roadside bombs. One exploded 200 feet from the unarmored Humvee in which Mrs. Pacquette spent day and night pointing her rifle out an open window.
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A Combat Role, and Anguish, Too
Published: October 31, 2009
(Page 2 of 4)
Gunshots arrived, too, on a bridge in Baghdad. Soldiers took up positions outside their vehicles, and an Iraqi was killed. “It was my birthday,” Mrs. Pacquette said. “I remember thinking, ‘Oh my God, I’m going to die.’ ”
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Enlarge This Image
Ed Zurga for The New York Times
“Just admit that it happened. Then it's over,” said Heather Paxton, Iraq veteran who received a diagnosis of post-traumatic stress, and whose disability claims were rejected three times. More Photos >
Women at Arms
The Psychological Scars
Articles in this series explore how the wars in Iraq and Afghanistan have profoundly redefined the role of women in the military.
Previous Articles in the Series »
At War
Instead, she surprised even herself by remaining calm.
“There were guys on the ground that I was responsible for as an NCO,” she said, adding, “As a leader, I had to keep my fear inside.”
But later on, the war’s consequences began to weigh more heavily. On Dec. 21, an Iraqi suicide bomber walked into a mess tent at a base across the street from her own and blew himself up amid the plastic lunch trays, killing more than 25 people.
Then a mortar attack hit the motor pool where her unit worked. At the scene, she saw three of her friends torn up beyond recognition.
Recalling the scene nearly five years later, Mrs. Pacquette’s dark brown eyes began darting back and forth, as if looking for another rocket. She was in St. Croix, the island where she grew up, but her body stiffened like a wound coil — releasing only after her twin sister brought their faces together, in a silent hug that lasted several minutes.
Her mind had returned to the moment. And this emotional flashback is just one in a long list of post-traumatic stress symptoms that female veterans now know intimately. Fits of rage, insomnia, nightmares, depression, survivor’s guilt, fear of crowds — women with the disorder, like men, can and do get it all.
Mrs. Pacquette’s twin, Jamilah Moorehead, said she noticed it soon after her sister’s first tour. “In the middle of the night, I heard this loud noise and there was Viv,” Mrs. Moorehead said. “She was crouching as if holding a weapon and she was not even awake.”
A military doctor gave Mrs. Pacquette a diagnosis of post-traumatic stress in March 2005, but she refused treatment. “I didn’t want anyone to know,” she said.
That November, she returned to Iraq, where she said she managed to keep the disorder hidden because she often worked alone. She retired from the military in 2006, but is still struggling with how to face the diagnosis.
The worst part, she said, was seeing her personality harden. First, she lost the ability to trust the Iraqi soldiers she served with. Then at home, she said, she fell out of touch with loved ones, though her husband has stood by her side. Now simply standing in line with other people is enough to turn her into what she calls “a witch, but with B.”
Dr. Carri-Ann Gibson, Mrs. Pacquette’s therapist, who runs the Trauma Recovery Program at the James A. Haley Veterans’ Hospital in Tampa, Fla., said the hardest part for women is that they often feel ashamed and guilty because “they’re not supposed to punch a wall, they’re not supposed to get aggressive with their spouse.”
Dr. Gibson said that for men, rage, paranoia and aggression are more accepted, while women are typically expected to snap back into domestic routines without any trouble.
“Women apply that pressure to themselves as well,” she said. “They live with that inner feeling of anger, and that’s why we see more events happening at home than actually out in public.”
Dr. Resick of the National Center for P.T.S.D. said much was still unknown about how the minds of men and women handle war. But at this point, she said, men and women differ mainly in how they manage similar symptoms.
“You put a man and a woman in a truck and they get blasted by an I.E.D., we’re not seeing big differences there,” Dr. Resick said, referring to improvised explosive devices. “That said, there are different context factors that affect how people cope.”
“The women — because they are not surrounded by other women, they may be surrounded by men — may withdraw more,” she continued. “The question is, Who are they with when they come home?”
Homefront Isolation
Many women traumatized by combat stress described lives of quiet desperation, alone, in just a few rooms with drawn shades.
Nancy Schiliro, 29, who lost her right eye as a result of a mortar attack in 2005, said that for more than two years after returning home, she rarely left a darkened garage in Hartsdale, N.Y., that her grandmother called “the bat cave.”
Shalimar Bien, 30, described her life, four years after Iraq, as a nonstop effort to avoid confrontation.
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And for those with husbands or young children, finding a social equilibrium is especially difficult. Veterans like Aimee Sherrod, 29, a mother of two, say they constantly struggle to balance their own urge to hide with demands from loved ones to interact.
Women at Arms
The Psychological Scars
Articles in this series explore how the wars in Iraq and Afghanistan have profoundly redefined the role of women in the military.
Previous Articles in the Series »
At War
Ms. Sherrod said that five years after her last deployment to Iraq, she still makes only a few trips a week outside her home in Jackson, Tenn., usually to drop off or pick up her 4-year-old son at school.
She often feels like a failure because her son pushes for what she cannot handle. “I don’t take him to Chuck E. Cheese because I’ll get angry,” she said, noting that the arcade’s bells and bangs make her jumpy. “Take him to a park? It’s a lose-lose. I don’t like open spaces.”
She can identify a handful of causes for what her mind has become. In Baghdad with an Air Force rescue squadron from the fall of 2003 to the spring of 2004, she worked on helicopters, sometimes cleaning off the blood from casualties, and regularly receiving indirect fire. “I was getting mortared all the time,” Mrs. Sherrod said. “So someone was watching me.”
She also feels damaged from her time in Jordan, at the start of the Iraq war. One of only two women in her unit, she said, she was ostracized after asking to be shifted to nights because some of the men would not stop harassing her. Her superiors, she said, broke a promise to keep her complaint quiet and after that, the men in her unit lashed out. “This one guy said if I was on fire he wouldn’t even piss on me to put me out,” Mrs. Sherrod said.
Many female veterans report being treated with respect by male colleagues, more so as they proved themselves. But several women said in interviews that some men made their wartime experiences even harder.
Mrs. Pacquette said that on her second tour, in Baghdad, she took showers with an open knife on the soap dish after seeing a man flee the bathroom trailer, having just attacked a woman inside.
In Mrs. Sherrod’s case, the harm came more from being shunned by her unit. For months in Jordan, she said, she had no e-mail access. No phone. No friends. She was isolated.
So at home, she got used to pushing people away. On her first date with the man who became her husband, she told him she had post-traumatic stress, figuring he would not stick around. He did, but they have struggled to stay together.
She always wanted to be a mother, and described her first child as a product of a whirlwind return from war. She became pregnant with her son within a month of reaching home, she said, after a night of drinking. When she later got pregnant with her daughter, who is 9 months old, she said she still thought the doctors were wrong about her stress disorder.
Now, having finally accepted the diagnosis after connecting with other veterans online, she fears her own temper more than anything else.
The other day, in the car, she lost control when both of her children demanded attention. “I can handle one or the other,” she said, “but she was crying and he kept saying, ‘Mommy, mommy,’ so in the middle of the road, I stopped the car and yelled: ‘If you do not be quiet I’m going to turn around and hit you.’
“The look on his face broke my heart,” Mrs. Sherrod said. “He just wanted to talk to me. He wasn’t doing anything bad.”
She paused, then said: “I’m like that all the time.”
Homefront Ignorance
When Heather Paxton started working at the V.A. hospital in Columbia, Mo., two years ago, she discovered something she did not expect: no one saw her as a veteran.
Despite her service in Iraq, patients assumed she knew nothing of war. A male colleague who chattered about weapons dismissed her like a silly little sister when she chimed in.
“He’d give me the stink eye,” Ms. Paxton said. “He’d just walk away.”
For many female veterans today, war and their roles in it must be constantly explained. For those with post-traumatic stress, the constant demand for proof can be particularly maddening — confirming their belief that only the people who were “over there” can understand them here.
Men express similar sentiments; combat veterans of both sexes often complain about insensitive questions like, “Did you kill anyone?”
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(Page 4 of 4)
But women say they are also treated to another line of inquiry. Would male veterans, they ask, hear friends or relatives say, “How was the shopping?” Or “In that heat, how did you wear makeup?” Or “How could you have P.T.S.D. when you sat at a desk with a typewriter?”
Female veterans say they have heard them all.
They have also seen their sacrifice overlooked, in bars, where strangers slide past them to buy drinks for men who were never deployed; and at “welcome home” events where organizers asked for their husbands.
Tammy Duckworth, a former Black Hawk helicopter pilot who lost her legs to a rocket-propelled grenade in Iraq, said such experiences show that “we’re going through a change — just like in World War II with African-Americans, the military is ahead of the American public.”
What many do not realize, said Ms. Duckworth, who ran for Congress and is now the assistant secretary of public and intergovernmental affairs for the V.A., is that in war today, “it’s not a question, Can women can do a combat job. They just are.”
Some women have found ways to at least minimize the slight.
Ms. Paxton now has a picture above her desk, showing her, her mother and her brother, all in uniform.
Mrs. Pacquette has placed a decal on her cane (like many veterans, she has damaged knees and a bad back from lugging gear) that identifies her as an Iraq war veteran.
Sometimes, though, simple messages are not enough. Renee Peloquin, 25, a member of the Idaho National Guard, had to design a bumper sticker that says “Female Iraqi War Veteran” because the basic “Iraq War Veteran” message on her car led strangers to thank her long-haired boyfriend for serving, even though he has never spent a day in uniform.
“I’m so sick of being stereotyped,” Ms. Peloquin said. “Or being ignored, that’s a better word.”
The military and the Department of Veterans Affairs have worked hard to make the public more aware of women’s roles. There are now Army recruiting advertisements featuring women in war zones. The V.A. has bought hundreds of copies of the documentary “Lioness,” which profiles female veterans in Ramadi, while producing a video of its own with Jane Pauley that shows the history of military women.
Last year, the veterans’ agency also began a systemwide effort to make primary care for female veterans available at every V.A. medical facility nationwide. At Ms. Paxton’s V.A. in Columbia, and Dr. Gibson’s in Tampa, women’s centers take up separate wings of the hospitals, as the V.A. prepares for its population of patients who are women to double over the next few years.
For some women with post-traumatic stress, like Angela Peacock in St. Louis, the V.A. has been a godsend. She said that the doctors who helped her detoxify from drug and alcohol addiction saved her from suicide.
Many others, however, insist that the military, the V.A. and other established veterans organizations have not fully adapted to women’s new roles. The military, they say, still treats them like wives, not warriors.
Some therapists, case workers and female patients also say that because military regulations governing women’s roles have not caught up with reality, women must work harder to prove they saw combat and get the benefits they deserve.
V.A. officials, including Ms. Duckworth, say there is no systemic bias. V.A. statistics show that as of July 2009, 5,103 female Iraq or Afghanistan veterans had received disability benefits for the stress disorder, compared with 57,732 males.
But the V.A. did not provide the number of men and women who had applied, making a comparison of rejection rates impossible.
At best, women are caught in the same bureaucratic morass as men; the backlog for disability claims from all veterans climbed to 400,000 in July, up from 253,000 six years ago. At worst, women are sometimes held to a tougher standard.
Ms. Paxton is one of at least 3,000 female Iraq and Afghanistan war veterans with stress disorder diagnoses and no disability benefit, as shown by the V.A. statistics.
Serving in Tikrit, Iraq, five years ago with a civil affairs unit, she took part in missions several times a week on roads regularly rigged with bombs. She worked closely with two Iraqi translators who were killed — she saw one in his bullet-ridden car just after he had been assassinated — and she came home with nightmares, depression and anger.
Though she received a diagnosis of stress disorder by a V.A. doctor, she had her first disability claim rejected in 2006. A second refusal came a year later, and the third arrived in 2008, despite a letter verifying what happened from a captain with her unit.
Her V.A. case worker, Julie Heese, said the rejections highlighted what made the benefits system so challenging. “The claims process is a tough one because you have to have really clear evidence,” Ms. Heese said. She added that it works best “with a well documented battle or attack,” not with experiences that may go unrecorded, like the death of a translator.
Newly proposed V.A. rules easing requirements for documenting traumatic events could help Ms. Paxton’s case. But she said she feared a fourth disappointment.
She said she no longer cared about getting money. After experiencing the grave shock of war and its never-ending aftermath, she would like a little more recognition.
“Just admit that it happened,” she said, her voice rising, over a meal her husband cooked at their home in Columbia. “Then it’s over.”
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APA monitor copyright
PTSD
PTSD treatments grow in evidence, effectiveness
Several psychological interventions help to significantly reduce post-traumatic stress disorder symptoms, say new guidelines.
By Tori DeAngelis
Print version: page 40
It's a bittersweet fact: Traumatic events such as the Sept. 11 attacks, Hurricane Katrina, and the wars in Iraq and Afghanistan have enabled researchers to learn a lot more about how best to treat post-traumatic stress disorder (PTSD).
"The advances made have been nothing short of outstanding," says Boston University psychologist Terence M. Keane, PhD, director of the behavioral science division of the National Center for Posttraumatic Stress Disorder and a contributor to the original PTSD diagnosis. "These are very important times in the treatment of PTSD."
In perhaps the most important news, in November, the International Society for Traumatic Stress Studies (ISTSS), a professional society that promotes knowledge on severe stress and trauma, issued new PTSD practice guidelines. Using a grading system from "A" to "E," the guidelines label several PTSD treatments as "A" treatments based on their high degree of empirical support, says Keane, one of the volume's editors. The guidelines—the first since 2000—update and generally confirm recommendations of other major practice-related bodies, including the U.S. Department of Veterans Affairs (VA), the Department of Defense, the American Psychiatric Association, and Great Britain's and Australia's national health-care guidelines, he says.
In other PTSD-treatment advances, researchers are adding medications and virtual-reality simulations to proven treatments to beef up their effectiveness. Clinical investigators are also exploring ways to treat PTSD when other psychological and medical conditions are present, and they are studying specific populations such as those affected by the Sept. 11 attacks.
Though exciting, these breakthroughs are somewhat colored by an October Institute of Medicine (IoM) report that concludes there is still not enough evidence to say which PTSD treatments are effective, except for exposure therapies. Many experts, however, disagree with that conclusion, noting that a number of factors specific to the condition, such as high dropout rates, can lead to what may seem like imperfect study designs (see Sidebar).
Treatments that make a difference
The fact that several treatments made the "A" list is great news for psychologists, says Keane. "Having this many evidence-based treatments allows therapists to use what they're comfortable with from their own background and training, and at the same time to select treatments for use with patients with different characteristics," he says.
Moreover, many of these treatments were developed by psychologists, he notes.
They include:
• Prolonged-exposure therapy, developed for use in PTSD by Keane, University of Pennsylvania psychologist Edna Foa, PhD, and Emory University psychologist Barbara O. Rothbaum, PhD. In this type of treatment, a therapist guides the client to recall traumatic memories in a controlled fashion so that clients eventually regain mastery of their thoughts and feelings around the incident. While exposing people to the very events that caused their trauma may seem counterintuitive, Rothbaum emphasizes that it's done in a gradual, controlled and repeated manner, until the person can evaluate their circumstances realistically and understand they can safely return to the activities in their current lives that they had been avoiding. Drawing from PTSD best practices, the APA-initiated Center for Deployment Psychology includes exposure therapy in the training of psychologists and other health professionals who are or will be treating returning Iraq and Afghanistan service personnel (see "A unique training program").
• Cognitive-processing therapy, a form of cognitive behavioral therapy, or CBT, developed by Boston University psychologist Patricia A. Resick, PhD, director of the women's health sciences division of the National Center for PTSD, to treat rape victims and later applied to PTSD. This treatment includes an exposure component but places greater emphasis on cognitive strategies to help people alter erroneous thinking that has emerged because of the event. Practitioners may work with clients on false beliefs that the world is no longer safe, for example, or that they are incompetent because they have "let" a terrible event happen to them.
• Stress-inoculation training, another form of CBT, where practitioners teach clients techniques to manage and reduce anxiety, such as breathing, muscle relaxation and positive self-talk.
• Other forms of cognitive therapy, including cognitive restructuring and cognitive therapy.
• Eye-movement desensitization and reprocessing, or EMDR, where the therapist guides clients to make eye movements or follow hand taps, for instance, at the same time they are recounting traumatic events. It's not clear how EMDR works, and, for that reason, it's somewhat controversial, though the therapy is supported by research, notes Dartmouth University psychologist Paula P. Schnurr, PhD, deputy executive director of the National Center for PTSD.
• Medications, specifically selective serotonin reuptake inhibitors. Two in particular—paroxetine (Paxil) and sertaline (Zoloft)—have been approved by the Food and Drug Administration for use in PTSD. Other medications may be useful in treating PTSD as well, particularly when the person has additional disorders such as depression, anxiety or psychosis, the guidelines note.
Spreading the word
So promising does the VA consider two of the "A" treatments—prolonged exposure therapy and cognitive-processing therapy—that it is doing national rollouts of them within the VA, notes psychologist Antonette Zeiss, PhD, deputy chief consultant for mental health at the agency.
"Enhancing our ability to provide veterans with the psychotherapies for PTSD that have the strongest evidence base is one of our highest priorities," Zeiss says. In fact, the VA began training psychologists to provide the two approaches more than a year before the Institute of Medicine released its report of successful treatments, she says. "We're pleased that the report confirms our emphasis on this training."
The VA system's structure and philosophy make it possible to test the results of treatments in large, realistic samples—a clinical researcher's dream, notes Schnurr, who has conducted a number of such studies, most recently in a study of female veterans that led to the rollout out of prolonged exposure therapy. That study was reported in the Feb. 28, 2007, issue of The Journal of the American Medical Association (Vol. 297, No. 8, pages 820–830).
"The VA was able to support the science, so the research didn't just sit around in a journal and get discussed," Zeiss says. "They put money toward it, and they asked us to help them do a major rollout of the treatment."
Boosting effectiveness
Meanwhile, other researchers are experimenting with add-ons to these proven treatments to increase their effectiveness. Some are looking at how virtual reality might enhance the effects of prolonged-exposure therapy. By adding virtual reality, whereby clients experience 3-D imagery, sounds and sometimes smells that correspond with a traumatic event, "we think it might be a good alternative for people who are too avoidant to do standard exposure therapy, because it puts them right there," says Emory University's Rothbaum.
Other researchers are adding a small dose of an old tuberculosis drug, D-cycloserine, or DCS, to treatment to see if it can mitigate people's fear reactions. Rothbaum's team, which includes psychologist Mike Davis, PhD, and psychiatrist Kerry Ressler, MD, PhD, have recently shown that the drug helps to extinguish fear in animals, so they're hoping for a similar effect in people.
In one study with veterans of the current Iraq war, Rothbaum's team is giving all participants a type of virtual reality that simulates combat conditions in Iraq, then randomizing them into a drug condition where they get DCS, a placebo, or the anti-anxiety drug alprazolam (Xanax).
In a similar vein, researchers at the Program for Anxiety and Traumatic Stress Studies at Weill Cornell Medical College are using virtual reality and DCS to treat those directly affected by the 2001 World Trade Center attacks, including civilians who were in the towers or nearby buildings, witnesses, and firefighters and police officers who were first responders.
Participants receive standard cognitive behavioral treatment enhanced with virtual reality, where they see graded versions of a Twin Towers scenario, starting with simple images of the buildings on a sunny day, and progressing gradually to include the horrific sights and sounds of that day. They also randomly receive either a small dose of DCS or a placebo pill before each session.
While neither study is complete, the researchers say the treatments appear to significantly reduce participants' PTSD symptoms. Rothbaum has recently submitted a grant proposal for a study where she plans to compare traditional and virtual-reality exposure therapies—which hasn't yet been done—in combination with DCS or a placebo.
Addressing comorbidity
Other psychologists are starting to think about ways to treat PTSD when it is accompanied by other psychiatric and health conditions. Psychologist John Otis, PhD, of Boston University and VA Boston, for instance, is testing an integrated treatment that aims to alleviate symptoms of both PTSD and chronic pain in Vietnam veterans and veterans of Operation Iraqi Freedom and Operation Enduring Freedom. The treatment combines aspects of cognitive processing therapy for trauma and cognitive behavioral therapy for chronic pain.
"We think these two conditions may interact in some [psychological] way that makes them more severe and challenging to treat," Otis says. In particular, he and others posit that "anxiety sensitivity"—fear of experiencing one's anxiety-related symptoms—may increase the odds that certain PTSD sufferers have more problems than others.
Again, while the study is not yet finished, results are encouraging, reports Otis. "Many of the veterans who are getting the integrated treatment are experiencing partial or complete remission of both kinds of symptoms," he says.
On a broader scale, the National Center for PTSD's Keane believes that much more research is needed on treating PTSD and psychiatric co-morbidities such as depression, anxiety, substance abuse, personality disorders and psychosis—a common situation that escalates the more severe a person's PTSD symptoms are, he says.
He, for one, would like to examine possible applications to PTSD of the concept of a "unified protocol," a theory and methodology being developed by Boston University psychotherapy researcher David Barlow, PhD, to treat concurrent problems such as panic attacks, anxiety and phobias.
That said, the recent advances promise to help many more people suffering from a condition they did not bring on themselves, says Zeiss.
"While there is still more to learn, we have taken significant steps in developing treatments that have been shown to be effective and that will be increasingly provided both in VA and other mental health care settings," says Zeiss. "Those affected by combat stress and other traumas will be able to reach out for care without feeling ashamed or hopeless."
Tori DeAngelis is a writer in Syracuse, N.Y.
Post-traumatic stress disorder and trauma in children and adolescents is one of the priorities of APA's 2008 President Alan E. Kazdin, PhD. He is forming a task force on the topic, which will be chaired by Annette LaGreca, PhD. The scope of the committee's work will be covered in an upcoming issue of the Monitor.
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