Virtual Therapy for PTSD

By Rick Nauert PhD Senior News Editor

Reviewed by John M. Grohol, Psy.D.

New research suggests post-traumatic stress disorder can affect 10 to 30 percent of combat zone soldiers, depending on the conflict in which they served. Given the instability of the global environment the ranks of active duty and retired soldiers will continue to grow.

As such, PTSD is on the rise and is a target for military health care personnel. A number of PTSD-focused studies presented at a military health research forum evaluated the effectiveness of both pharmacologic and alternative treatment options.

A novel intervention included use of virtual environments and new medicines to help military personnel diagnosed with PTSD or other comorbidities. If effective, the therapy technique could be used for the general public.

“PTSD is a condition that has affected decades of war veterans, and treatments continue to evolve,” stated Captain E. Melissa Kaime, M.D., Director of the CDMRP.

According to experts, about 20 percent of combat veterans returning from Iraq suffer from mild traumatic brain injury (mTBI) or PTSD.

Traditional treatment for these conditions consists of medication and psychotherapy, demanding frequent travel to a clinic, a potential hardship for many veterans.

Researchers led by Charles Levy, M.D., are attempting to leverage combat veterans’ comfort and familiarity with communications technology and immersive environments (through cell phones, the Internet, and video games) and build a prototype of a virtual world environment (VWE) in which to conduct therapy.

The VWE will simulate everyday life encounters that are challenging to those with mTBI/PTSD, and allow the veteran and therapist to confront and overcome barriers that block successful social reintegration.

The clinical team chose a supermarket as the virtual scenario where veterans could receive cognitive and emotional challenges, including following a shopping list, purchasing items, making change, colliding with other shopping carts, and engaging with clerks and other patrons at checkout.

Currently, a virtual supermarket is under construction that allows a therapist and patient, each at their own computer, to enter the virtual supermarket and experience these challenges together.

This research explores an innovative new concept. Previous use of virtual reality exposure among combat veterans has been limited to portraying battle as a part of exposure therapy.

“Oftentimes, the nuances of everyday life can unexpectedly trigger angry responses from warfighters hindered by mTBI and PTSD,” Levy said.

“This project shows great potential to expedite and expand care to veterans and wounded warriors in a short timeframe, in a way that minimizes travel for treatment, and in a cost-effective manner.”

Source: US Department of Defense Congressionally Directed Medical Research Programs

Law keeps veterans with post-traumatic stress disorder out of jail

By Chris Roberts
El Paso Times



EL PASO -- Combat veterans with post-traumatic stress disorder who are accused of certain crimes may soon have a choice between a trial or mental-health treatment.

El Paso judges last week took the first step in creating a Veterans Mental Health Treatment Court. They authorized the program for Judge Ricardo Herrera's county criminal court.

"I just think we need to get ahead of the curve a little bit and get this in place," said Herrera, who proposed the idea to the Council of Judges.



He said the court would make sense for El Paso because of Fort Bliss and its explosive growth. The post has about 20,000 active-duty soldiers and is expected to grow to 34,000 by 2013.

The court would be geared to active-duty soldiers or veterans who served in combat zones or other hazardous assignments and suffer from post-traumatic stress disorder, said Cesar Prieto, who works in Herrera's court.

He said the court for veterans would include felonies and misdemeanors, but not the most serious crimes, such as murder and rape. Prosecutors would have to approve a defendant's participation in the program.

The plan is still subject to approval by the El Paso County Commissioners Court. One member, Dan Haggerty, says he supports the idea.

"They used to put a rubber band around your head and tell you to snap out of it," said Haggerty, a Vietnam War veteran. "But some of these people can't. ... Absolutely, we need to move forward with it."

Counties can create such programs under a bill approved by the Texas Legislature. It provides only general guidelines, so details of the El Paso program would be worked out among Fort Bliss attorneys, Beaumont Army Medical Center officials, the El Paso County district attorney's staff, Veterans Affairs officials and others.

Participants in the veterans court would have to have a primary diagnosis of post-traumatic stress disorder, Prieto said. Other service-related disabilities that could be considered are traumatic brain injury and severe depression.

Crimes that could be handled by the court include assault, possession of marijuana, drunken driving and family violence, Prieto said.

The court would have the authority to require attendance in rehabilitation, educational, vocational, medical, psychiatric or substance-abuse programs, he said. It also could require that a participant take medication.

Treatment would last at least six months, but no longer than the period of community supervision normally required for the charged offense. Participants who did not complete the program would be prosecuted.

The court for veterans would be available only to those facing charges in the civilian system. A soldier arrested on post would still be subject to the military justice system, including the possibility of court-martial.

Herrera's staff is preparing to apply for a state grant that would provide $500,000 for one year to create a mental-health court for veterans. If the program is successful, it could qualify for $500,000 each year for five more years. Prieto said the court could be running by the end of the year.

"As more counties follow El Paso's lead, we will be able to keep more veterans out of jail and quickly get them the treatment they need," said state Sen. Rodney Ellis, D-Houston, who sponsored the enabling legislation. "After successfully completing their treatment program, veterans can have their cases dismissed and avoid a criminal conviction, which will ensure they can get a job and provide for their families."

State Rep. Joe Moody, D-El Paso, said the program did not give veterans a "get-out-of-jail-free card." The requirements would be rigorous, he said, and the goal would be to transform an offender into a productive citizen.

"Our success in El Paso is tied to the troops at Fort Bliss and we have to take care of them," Moody said. "If we don't help them, we'll have to take care of it at the back end."

-------------------------

Agony and Ecstasy and PTSD

By Charles H. Elliott, Ph.D.

The anxiety disorder called Post Traumatic Stress Disorder (PTSD) can occur when a person witnesses or is involved in a traumatic experience. In most cases, the person is present at the trauma, but other times the trauma happens to someone very close. The event generally involves a serious threat of death or injury. The person feels intense horror, fear, and helplessness. Here are three examples of PTSD.Although most people don’t have all of these, symptoms of PTSD which occur after a traumatic event include:

• Intrusive and distressing images, thoughts, perceptions of the event
• Recurrent Dreams
• Flashbacks of the event
• Intense distress when reminded of the event
• Over reactive psychological symptoms
• Avoiding talking about the trauma
• Avoiding activities that bring back memories
• Attempts to repress or forget the trauma
• Less interest in life activities
• Feelings of detachment
• Belief that the future is limited
• Increased arousal
• Problems with sleep
• Angry outbursts
• Irritability
• Problems with concentration
• Hypervigilance
• Easily startled

For those with PTSD, cognitive behavioral therapy is a very good therapeutic choice. Like those with OCD, exposure to the feared event is part of the treatment. The problem in the past has been that many people with PTSD avoid getting help because of a strong desire to avoid anything that reminds them of the trauma–and exposure certainly does that.

A few recent studies have introduced a new way to perform exposure. The patient is given 3,4-methylenedioxymethamphetamine (MDMA) during the exposure. Although the studies are preliminary, it appears that MDMA may facilitate exposure.

MDMA, aka, Ecstasy, is known for its positive effects on mood and empathy. The behavioral treatments with exposure and MDMA take no longer (usually 10-12 sessions) than standard behavior therapy. The drug is given under medical supervision only during the session and is discontinued after exposure is complete. Considerably more research is required before we can wholly endorse this approach. However, we thought you might find it interesting to know what’s in the pipeline of possibilities for treating PTSD.

Finally, this should not be tried at home! Nor are we recommending MDMA for other purposes. And we recommend that you avoid Raves as well.

Charles H. Elliott, Ph.D. is a clinical psychologist and a Founding Fellow in the Academy of Cognitive Therapy. He is also a member of the faculty at Fielding Graduate University. He specializes in the treatment of adolescents and adults with obsessive compulsive disorder, anxiety, anger, depression, and personality disorders. Dr. Elliott is coauthor of: Obsessive Compulsive Disorder For Dummies, Seasonal Affective Disorder For Dummies, Anxiety and Depression Workbook For Dummies, Depression For Dummies, Overcoming Anxiety For Dummies, Why Can't I Get What I Want?, Why Can’t I Be the Parent I Want to Be?, and Hollow Kids: Recapturing the Soul of a Generation Lost to the Self-Esteem Myth.

Service Dogs Help With PTSD

New PTSD Program Answers Need

by Capt. Bryan Lewis

LANDSTUHL REGIONAL MEDICAL CENTER, Germany - Symptoms of combat stress and post-traumatic stress disorder include continual nightmares, avoidance behaviors, denial, grief, anger and fear.

Some Soldiers, battling these and other symptoms, can be treated successfully as an outpatient while assuming their normal duties. For others, however, returning to work and becoming their old selves again were challenges recognized by several mental health professionals across the European theater.

"We were looking at how we can best meet the needs of our clientele, and we were identifying that a lot of the Soldiers needed more than once-a-week outpatient, individual therapy and probably needed more than once- or twice-a-week group therapy," said Joseph Pehm, chief of Medical Social Work at Landstuhl Regional Medical Center.

The solution came in the creation of an intensive eight-week therapeutic Post-Traumatic Stress Disorder Day Treatment Program called "evolution" that began in March 2009 at LRMC. During the eight-hour days, patients enrolled in the program participate in multiple disciplines and interests, including art therapy, yoga and meditation classes, substance abuse groups, anger and grief management, tobacco cessation, pain management and multiple PTSD evidence-based practice protocols.

"I am a great believer in the kitchen sink, meaning I throw everything, including the kitchen sink, and something will stick," said Dr. Daphne Brown, chief of the Division of Behavioral Health at LRMC. "And so we've come with all the evidence-based treatment for PTSD that we know about ... We've taken everything that we can think of that will be of use in redirecting symptoms for these folks and put it into an eight-week program."

Brown, Pehm and Sharon Stewart, a Red Cross volunteer who recently received a doctorate in psychology, said the program is designed from research into the effects of traumatic experience and mirrors successful PTSD programs at Walter Reed Army Medical Center and the Department of Veterans Affairs, as well as programs run by psychologists in the U.S.

"We are building on the groundbreaking work that some of our peers and colleagues have done and just expanding it out," said Brown.

During treatment, patients begin the day with a community meeting where they discuss how well they feel and any additional issues or concerns since their last meeting. The remainder of the day depends on the curriculum scheduled for that week.

The first few weeks focus on learning basic coping skills such as how to reduce anxiety and fight fear, as well as yoga and meditation for relaxation. Eye Movement Desensitization and Reprocessing, or EMDR, an evidence-based practice for treating PTSD, is also conducted during the early phases of the treatment program.

"The concept behind EMDR is that, essentially, memories become fixed in one part of our brain and they maintain their power and control over our emotions as long as they are fixed there," said Brown. "And if we can activate a different part of the brain while we're experiencing that memory, we can help to remove some of that emotional valence from it. So we use physiological maneuvers to activate both sides of the brain."

The goal at the beginning of the PTSD program is to provide patients with a number of tools they can use to help them calm down when feeling overwhelmed, especially before more intense therapy begins in the latter weeks. Cognitive processing therapy is used throughout the program. EMDR and prolonged exposure therapy are also available on an individual basis at the Soldier's request. All three techniques are research-based treatments.

When life-changing events occur, Brown said perceptions about the world may change. For example, before Soldiers experience combat trauma they may think the world is safe. Following combat, a Soldier's perceptions may change - a majority of the world may now seem unsafe. Cognitive processing therapy attempts to re-address experiences and reshift a Soldier's perceptions.

Prolonged exposure therapy is behaviorally based and addresses a Soldier's fears, which are seen as reflex reactions to a stimulus. To decondition the reactions, a patient is continually exposed to the stimulus by retelling the story repeatedly, minus the negative outcome. Brown compared it to riding a roller coaster over and over again to overcome a fear of roller coasters.

"So they're getting EMDR, they're getting cognitive processing therapy, they're getting individual therapy, they're getting group therapy, they're getting education, anger management, self-esteem, relationship issues, grief and loss, yoga, meditation exercise, skill building -- a little bit of everything across the board," said Brown. "Not everything's going to resonate with everyone who comes through, but something's going to resonate for everyone who comes through."

In addition to the overall core curriculum, Brown and her staff have programs such as pain management, relationship enrichment and tobacco cessation to help individualize treatment.

"The core of the group and individual education is consistent for everyone," said Brown. "But we recognize that every patient is different, and we have to tailor-make it to give an individualized treatment plan. We don't keep people in pain management if they're not in pain. We don't give them tobacco cessation if they're not smoking. So we do try and tailor as much of it as we can."

Spirituality, relationship enrichment and gender-specific issues are also areas of focus.
"The program is holistic," said Pehm. "It looks at people from different spheres, not just the medical model, because everything is impacted when someone has combat stress or PTSD - not just the individual Soldier, but everybody who comes in contact with them."

The intensity, length and "kitchen sink" qualities are not the only aspects that make this program unique, said Brown. It is a joint military and civilian effort accomplished entirely by volunteers. The staff is as diverse as the therapy options, and includes chaplains, social workers, Red Cross volunteers, psychiatrists, a nurse practitioner, enlisted psychiatric technicians, and graduate students. Brown said having a sundry of personnel keeps the program fresh and the staff excited.

"The patients get perspectives from people from a number of different backgrounds," said Brown.

Thus far, the staff outnumbers the program's participants.

"By design we started out small, and we were able to establish a really good working relationship with the local Warrior Transition Unit people ... It's been a wonderful working relationship with them," said Pehm.

Evolution is currently on it second eight-week course, with five patients enrolled. The first class had four. The goal is to keep the class size small in order to benefit from the program's intensity. Thinking small also helps keep the impact large by successfully returning Soldiers to their units, while also expanding access outside the WTUs. However, Pehm said they would like to expand the program to include patients from throughout the European Command.

"Ideally, we'd like to max it at about 10 because it is so intensive," said Brown. "These are folks we hope to remediate and return to the Army to be functional members again. Also, if they go back to their communities and their providers or spouses see the changes that have come about, that will increase the willingness or desire of more people to be here."

Though few have completed this young program, signs of success have already started to surface.

"With the last group, the shift from 'I have to be here' to 'I'm so glad I came' was really phenomenal," said Pehm.

"One of them said that he didn't think he was getting anything out of the program," Brown said. "It was about week six until he saw himself react differently to a situation that came up, and watched himself do it differently using skills that he didn't know he learned. He went 'Wow,' maybe I am getting something out of this."

It is too early, and the numbers are too small, to generalize the early trends, but self-completed PTSD checklists showed a significant decrease in reported symptoms for three of the four patients in the first cohort. Additionally, anxiety and depression symptom measures decreased.

"The whole idea is that we know all the changes aren't going to take place here," said Brown. "But we hope we give them enough learning to send them in a different direction. My hope is that we can build a program to provide valid, effective treatment to folks who have put themselves in harm's way at the request of their country, and help them live happier and better lives."

Invisible Injuries

Not all wounds are visible.

Invisible injuries can remain long after the battle is over: depression, post-traumatic stress disorder, and traumatic brain injuries among them. The symptoms aren’t always clear, and may not be what you think. Like any wound, they can fester and worsen if ignored. They can get in the way of being a parent, sibling, soldier, friend and co-worker.

If untreated, invisible injuries can lead to an onslaught of problems including domestic violence, alcoholism and even suicide. Rates of each run high among vets compared to the civilian population.

It doesn’t have to be this way. Seeking help sooner rather than later can spare you and those around you a lot of pain.

Many vets learn to cope with these wounds, and come away stronger. One Iraq vet who fought to get his life back on track describes a renewed sense of purpose. “You know, I almost died, so I figured there’s a lot of stuff I need to do.” He went on to start a nonprofit outdoor adventure group for disabled people.

Get help.

• Contact your health care professional
• Find your nearest VA hospital by calling 877-222-VETS
• Check out the Vet Center Readjustment Services
• Call the VFW or American Legion for soldier support services

Soldiers in Colorado slayings tell of Iraq horrors

COLORADO SPRINGS, Colo. – Soldiers from an Army unit that had 10 infantrymen accused of murder, attempted murder or manslaughter after returning to civilian life described a breakdown in discipline during their Iraq deployment in which troops murdered civilians, a newspaper reported Sunday.

Some Fort Carson, Colo.-based soldiers have had trouble adjusting to life back in the United States, saying they refused to seek help, or were belittled or punished for seeking help. Others say they were ignored by their commanders, or coped through drug and alcohol abuse before they allegedly committed crimes, The Gazette of Colorado Springs said.

The Gazette based its report on months of interviews with soldiers and their families, medical and military records, court documents and photographs.

Several soldiers said unit discipline deteriorated while in Iraq.

"Toward the end, we were so mad and tired and frustrated," said Daniel Freeman. "You came too close, we lit you up. You didn't stop, we ran your car over with the Bradley," an armored fighting vehicle.

With each roadside bombing, soldiers would fire in all directions "and just light the whole area up," said Anthony Marquez, a friend of Freeman in the 1st Battalion, 9th Infantry Regiment. "If anyone was around, that was their fault. We smoked 'em."

Taxi drivers got shot for no reason, and others were dropped off bridges after interrogations, said Marcus Mifflin, who was eventually discharged with post traumatic stress syndrome.

"You didn't get blamed unless someone could be absolutely sure you did something wrong," he said

Soldiers interviewed by The Gazette cited lengthy deployments, being sent back into battle after surviving war injuries that would have been fatal in previous conflicts, and engaging in some of the bloodiest combat in Iraq. The soldiers describing those experiences were part of the 3,500-soldier unit now called the 4th Infantry Division's 4th Brigade Combat Team.

Since 2005, some brigade soldiers also have been involved in brawls, beatings, rapes, DUIs, drug deals, domestic violence, shootings, stabbings, kidnapping and suicides.

The unit was deployed for a year to Iraq's Sunni Triangle in September 2004. Sixty-four unit soldiers were killed and more than 400 wounded — about double the average for Army brigades in Iraq, according to Fort Carson. In 2007, the unit served a bloody 15-month mission in Baghdad. It's currently deployed to the Khyber Pass region in Afghanistan.

Marquez was the first in his brigade to kill someone after an Iraq tour. In 2006, he used a stun gun to shock a drug dealer in Widefield, Colo., in a dispute over a marijuana sale, then shot and killed him.

Marquez's mother, Teresa Hernandez, warned Marquez's sergeant at Fort Carson her son was showing signs of violent behavior, abusing alcohol and pain pills and carrying a gun. "I told them he was a walking time bomb," she said.

Hernandez said the sergeant later taunted Marquez about her phone call.

"If I was just a guy off the street, I might have hesitated to shoot," Marquez told The Gazette in the Bent County Correctional Facility, where he is serving a 30-year prison term. "But after Iraq, it was just natural."

The Army trains soldiers to be that way, said Kenneth Eastridge, an infantry specialist serving 10 years for accessory to murder.

"The Army pounds it into your head until it is instinct: Kill everybody, kill everybody," he said. "And you do. Then they just think you can just come home and turn it off."

Both soldiers were wounded, sent back into action and saw friends and officers killed in their first deployment. On numerous occasions, explosions shredded the bodies of civilians, others were slain in sectarian violence — and the unit had to bag the bodies.

"Guys with drill bits in their eyes," Eastridge said. "Guys with nails in their heads."

Last week, the Army released a study of soldiers at Fort Carson that found that the trauma of fierce combat and soldier refusals or obstacles to seeking mental health care may have helped drive some to violence at home. It said more study is needed.

While most unit soldiers coped post-deployment, a handful went on to kill back home in Colorado.

Many returning soldiers did seek counseling.

"We're used to seeing people who are depressed and want to hurt themselves. We're trained to deal with that," said Davida Hoffman, director of the privately operated First Choice Counseling Center in Colorado Springs. "But these soldiers were depressed and saying, 'I've got this anger, I want to hurt somebody.' We weren't accustomed to that."

At Fort Carson, Eastridge and other soldiers said they lied during an army screening about their deployment that was designed to detect potential behavioral problems.

Sergeants sometimes refused to let soldiers get PTSD help or taunted them, said Andrew Pogany, a former Fort Carson special forces sergeant who investigates complaints for the advocacy group Veterans for America.

Soldier John Needham described a number of alleged crimes in a December 2007 letter to the Inspector General's Office of Fort Carson. In the letter, obtained by The Gazette, Needham said that a sergeant shot a boy riding a bicycle down the street for no reason.

Another sergeant shot a man in the head while questioning him, lashed the man's body to his Humvee and drove around the neighborhood. Needham also claimed sergeants removed victims' brains.

The Army's criminal investigation division interviewed unit soldiers and said it couldn't substantiate the allegations.

The Army has declared soldiers' mental health a top priority.

"When we see a problem, we try to identify it and really learn what we can do about it. That is what we are trying to do here," said Maj. Gen. Mark Graham, Fort Carson's commander. "There is a culture and a stigma that needs to change."

Fort Carson officers are trained to help troops showing stress signs, and the base has doubled its number of behavioral-health counselors. Soldiers seeing an Army doctor for any reason undergo a mental health evaluation.

___

On the Net:

Colorado Springs Gazette: http://www.gazette.com