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PTSD & Veterans: Finding Hope
and Supporting Healing
Susanne Fogger DNP, PMHNP-BC, CARN-AP, FAANP
Randy Moore DNP, RN
Leah Picket DNP, PMHNP-BC
Disclosure statement
• The speaker has no conflict of
interest to disclose
Objectives
• Briefly discuss traditional PTSD therapies such as
Cognitive Behavioral therapy, Prolonged Exposure
therapy and medications useful to decrease
symptoms in Veterans
• Discuss evidence supporting non-pharmacological
therapies for Veterans with Post-Traumatic Stress
Disorder (PTSD)
• Highlight recommendations for use of eye movement
desensitization and reprocessing (EMDR), yoga, tai
chi, breathing based meditation, and logotherapy for
adjunctive PTSD therapy
What makes PTSD different for
individuals who have been in the
military?
Stressors in Theater
• Stress of climate/diet/living
arrangements
• Stress of living in crowded,
confined, highly structured
environment
• Stress of combat. Personal
danger, danger to others,
danger of accidents
• Difficult to determine who is
the enemy.
– Who is the threat? Who are your
friends?
Stressors in Theater
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Biochemical exposures
Dehydration
Never truly “off duty” (constant vigilance)
Broken contact with family
Seeing things one can never “un-see”
Heat/cold
Nagging injuries
Political decisions vs. chain of command decisions
vs. personal decisions
Redeployment (Returning home)
Stress
• Missing that sense of
belonging
• Separation anxiety –
weapon, unit, buddies
• Sense of things undone
• Rationalizing what you
have done. Need to
validate acts of war.
• Leaving your military
family to return home.
Transition to Civilian Life
• Coming home from combat and resuming a “normal”
life.
• Going back to work and daily routines
• Trying to be the person you were before the
deployment.
• Looking forward to the happy fantasy
• Briefings, Briefings, Briefings….
• Reverse separation anxiety –weapon, unit, buddies
• Leaving native people/friends… “I made promises, will
they be OK when I’ve gone home.”
Differential Diagnoses for PTSD
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Adjustment disorder
Acute stress disorder
Anxiety disorder
Obsessive-compulsive disorder
Major depressive disorder
Personality disorder
Dissociative disorder
Conversion disorder
Psychotic disorder
Traumatic brain injury
* Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Cognitive Processing therapy(CPT)
• Targets putatively maladaptive ways of
thinking about the trauma that are posited to
maintain PTSD symptoms
– 12 one hour sessions with homework
Review of Exposure Therapy: A Gold
Standard for PTSD Treatment
Prolonged exposure (PE) is an effective first-line
treatment for PTSD, regardless of the type of
trauma, of Veterans and military personnel
PE has demonstrated efficacy in reducing comorbid
issues such as anger, guilt, negative health
perceptions, and depression
The PE protocol includes four main therapeutic
components: psychoeducation, in vivo exposure,
imaginal exposure, and emotional processing)
Medications
• SSRIs – Paroxetine, venlafaxine, fluoxetine &
Sertraline
– Significantly more effective than placebo
– May take up to 6 weeks to reach therapeutic
blood level
– Side effects – wt gain, security clearance issues
and sexual side effects and stigma
– Pharmacological interventions can be effective but
the magnitude of effect is small⁸
CPT and PE
• Treatment of choice within DoD and VA
• 2/3rds of patients receiving CPT or PE retain
their PTSD dx after the treatment
• Non-response rates are high
– Many patients continue to have symptoms⁷
Additional therapy may be required to bring about
symptom improvement
EMDR
• Treatment with EMDR encourages distancing
effects which are considered effective
memory processing rather than cognitive
avoidance.
• The EMDR therapist accesses only brief details
of the traumatic memory then encourages
distancing⁴
EMDR
• EMDR asks patients to recall an image
representing the traumatic event as well as
any associated negative cognition and bodily
sensations.
• Patients are asked to follow alternating eye
movements which have been shown to lower
the emotional arousal and tax the working
memory so that the trauma can be worked to
resolution⁵
EMDR
• Two meta-analysis findings:
• EMDR significantly reduced symptoms of PTSD
such as anxiety, depression, and subjective
distress (Chen et al., 2014) [Taiwan]
• EMDR is effective in decreasing the severity of
arousal and intrusive thoughts (Chen et al.,
2015) [China]
Logotherapy
• Created by Viktor Frankl (1905-1997)
• Considered the “Third Viennese School of
Psychotherapy”
• Today Logotherapy is blended with CBT to
help decrease anxiety through paradoxical
intention.
• Central tenets include
Logotherapy
• Logotherapy is a meaning-centered
psychotherapy that literally means “healing
through meaning”
• The therapy is future-oriented, focused on
personal strengths, and places responsibility for
changes succinctly on the patient.
• Logotherapy is a collaborative therapy which
helps the individual reframe what is perceived as
broken into human achievement and meaningful
action (Ameli & Dattilio, 2013; Southwich,
Gilmartin, McDonough, & Morrissey, 2006)
Guilt, Depression, & Altered World View
• Logotherapy employs specific techniques
including self-distancing, Socratic dialogue,
and dereflection.
• This is used to supplement PE, CPT, EMDR, &
pharmacotherapy.
• Focuses on problematic symptoms such as a
sense of foreshortened future, external loss of
control, guilt & survivor’s guilt, and existential
loss of meaning.
Tai Chi
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Ancient Chinese medicine/martial arts
– Mind-body concept
– Human body has energy channels –
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Taiji or tai chi
• Taiji and Qigong are meditative exercises in which
breathing and physical movements are combined
• a form of martial art practice that incorporates a
series of movements that are both graceful and
strengthening
• Taiji has produced statistically significant
improvements in areas individuals with PTSD
often struggle and do not respond well to other
forms of treatment due to poor overall wellbeing, self-esteem, and interpersonal
relationship.
Yoga
• Yoga based interventions
– Decrease autonomic nervous system function
• Decreases blood pressure and heart rate
• Participants experience a sense of relaxation
• Post yoga improves GABA levels
– Decrease PTSD hyper-arousal system
• Disturbed sleep and anger
• Promotes psychological flexibility and emotional
regulation ₆
Yoga
• Yoga is a mind-body practice
• considered a popular complementary and
alternative medicine (CAM) therapy
• offers guided, focused movement, controlled
breathing and meditation that supports
relaxation
Yoga
• Breathing exercises activates both
sympathetic and parasympathetic
systems
–Elucidating both alertness and calm
–Increased optimism and general
wellbeing
• Individuals who engage in yoga therapy
–Are more open to begin traditional
therapy ₉
Breathing Based Meditation
• Mindfulness practice can help address dissociative
symptoms as the person focuses on their inner self
• training also facilitates neurological changes
responsible for the regulation of emotion and
positively correlates to anxiety symptom improvement
• Consistent mindfulness decreases amygdala reactivity
and fosters greater functional connectivity between
amygdala and prefrontal cortex regions, as evidenced
by lower anxiety scores on the Beck Anxiety Inventory
(Hölzel et al, 2013).
Summary
Traditional therapies for PTSD do not provide complete
symptom relief, alternative therapies can supplement
traditional therapy to help decrease symptoms in Veterans
EMDR have very strong bodies of evidence supporting use for
those who suffer from PTSD
Other adjunctive therapies such as yoga, logotherapy, tai chi
and breathing based meditation have a growing evidence
base and can provide a sense of improved symptom
management, purpose and internal locus of control
awareness of these options may assist individuals to have a
better understanding of effective choices
offering individualized patient centered care includes nonpharmacological treatment to augment traditional therapy