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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 • • • • • • • • 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 • • • • • • • • • • 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 • • • Ancient Chinese medicine/martial arts – Mind-body concept – Human body has energy channels – – 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