Literature Review on "Veterans of Our Armed Forces Need Cognitive"

Literature Review 6 pages (1905 words) Sources: 6

[EXCERPT] . . . .

Veterans of Our Armed Forces Need Cognitive Behavioral Therapy to Treat Post Traumatic Stress Disorder

Defining PTSD

Clinical features of posttraumatic stress disorder are related in the work of Steven Taylor (2006) entitled 'Clinicians Guide to PTSD: A Cognitive-Behavioral Approach' and it is related that oftentimes patients present with "what might look like relatively simple anxiety or depressive problems or anger management issues. But as we engage with these patients and families, a more complex pattern emerges and we recognize the problems they present with as both intransigent and multilayered." (p.3) the method used to differentiate PTSD from other clinical problems is examined by Taylor who states that in diagnosing PTSD there is a requirement for "a sufficient number of symptoms" and these must be present for at least one month. Acute stress disorder, "defined by the development of dissociative and PTSD symptoms within a month following exposure to a traumatic stressor" is different although dissociative symptoms overlap PTSD symptoms and may occur during, or after exposure to the stressor." (Taylor, 2006, p.4) Dissociation refers to the breakdown in the normally integrated functions of consciousness, identity, memory, or perception of one's self or surrounding and is manifested by symptoms such as depersonalization, derealization or psychogenic amnesia. (Taylor, 2006, p.4) Dissociative symptoms include: (1) subjective sense of numbing; (2) detachment, or absence of emotional responsiveness; (3) reduction in awareness of surroundings; (4) drealization; (5) depersonalization; or (6) dissociative amnesia. (Taylor, 2006, p.4) When symptoms last at least 2 days and more than four weeks, then the diagnosis is acute stress disorder however symptoms persisting beyond four weeks result in a diagnosis of PTSD. (Taylor, 2006, p.4)

Cognitive Behavioral Therapy

Tanielian (2008) reports that data demonstrates that "mental health and cognitive conditions are widespread" due to the increase of the "invisible wounds of war." (p.xxvii) a study reported in the work of Schnurr, et al. (2007) reports that PTSD is "elevated among women who have served in the military" and that previous research indicates, "cognitive behavioral therapy is a particularly effective treatment for PTSD. The study reported by Schnurr states the objective of comparison of "prolonged exposure, a type of cognitive behavioral therapy, with present-centered therapy, a supportive intervention, for the treatment of PTSD." (Schnurr, 2007) the study reports a randomized controlled of female veterans (n=277) and active-duty personnel (m=7) with PTSD recruited from 9 VA medical centers, 2 VA readjustment counseling centers, and 1 military hospital from August 2002 through 2005. (Schnurr, 2007) it is reported that participants were randomly assigned to receive prolonged exposure (n=141) or present-centered therapy (n-143) delivered according to standard protocols in 10 weekly 90-minute sessions. (Schnurr, 2007) the primary outcome measures state include that "comorbid symptoms, functioning and quality of life were secondary outcomes. Blinded assessors collected data before and after treatment and at 3- and 6-month follow-up." (Schnurr, 2007) the study reports that women receiving prolonged exposure "experienced greater reduction of PTSD symptoms relative to women who received present-centered therapy (effect size, 0.27; P = .03). The prolonged exposure group was more likely than the present-centered therapy group to no longer meet PTSD diagnostic criteria (41.0% vs. 27.8%; odds ratio, 1.80; 95% confidence interval, 1.10-2.96; P = .01) and achieve total remission (15.2% vs. 6.9%; odds ratio, 2.43; 95% confidence interval, 1.10-5.37; P = .01). Effects were consistent over time in longitudinal analyses, although in cross-sectional analyses most differences occurred immediately after treatment." (Schnurr, 2007) the study reported by Schnurr et al. reports that prolonged exposure "is an effective treatment for PTSD in female veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings." (Schnurr, 2007)

Long-Term Efficacy of PTSD

David W. Foy writes that cognitive restructuring methods are utilized in coping with issues that are troublesome and "related to patients' appraisals of their traumatic experiences. Cognitive distortions can affect an individual's ability to evaluate both external factors and personal factors. Cognitive restructuring can be applied under either or both of two conditions." (1992, p.63) Cognitive restructuring is sued to "correct misattributions of causality and responsibility associated with remembered traumatic scenes" and "independently in individual therapy sessions devoted primarily to that task." (Foy, 1992, p.64) Foy states that interventions that have their focus on cognitive factors and skill building needs can be initiated during a period of inpatient clinical care." (1992, p.64) However, aftercare is stated to be that which determines the "long-term efficacy of treatment for PTSD…" (p.64-5) Treatment planning is reported as best conceptualized "as a long-term process that will include short-term intensive treatment of acute symptoms and long-term follow-up and rehabilitation. (Foy, 1992, p.65) Stated as predictors of treatment success are: (1) motivation of patient to engage in rehabilitation that is long-term; (2) clinical resource availability. (Foy, 1992, p.65)

Everly and Lating (1995) report that behavioral scientists have "in recent years, attempted to identify and measure the cognitive and behavioral strategies that individuals use to adapt to a variety of conditions. Recent significant advances in the measurement of cognitive coping have give rise to controlled investigations of the effects of specific coping strategies on adaptation to extreme stress." (p.370)

Adaptive Cognitive Coping Strategies

Fairbank, Hensen and Fitterling (1985) examined "cognitive coping in 30 veterans of World War II: 10 former prisoners of war (POWs) with a diagnosis of PTSD; 10 former POWs who were well adjusted and did not meet DSM-III criteria for a diagnosis of PTSD; and 10 well-adjusted non-combat veterans who were not exposed to traumatic wartime stressors." (Everly and Lating, 1995, p.371) Participants are reported to have completed a standardized inventory of coping strategies under two experimental conditions stated as follows:

(1) induction of a distressing memory of military service during World War II; and (2) induction of thoughts about a recent stressor (Everly and Lating, 1995, p.371)

Researchers state findings that POWs with PTSD "under both experimental conditions…reported using a wider repertoire of coping responses than the two comparison groups." (Everly and Lating, 1995, p.371) POWs who were formerly well-adjusted were found to be more likely to "use adaptive cognitive coping strategies than the veterans with PTSD." (Everly and Lating, 1995, p.371) Several studies show that seeking social support when experiencing distress "has been recognized as a prevalent and adaptive coping strategy" and in fact there have been a great many studies that have validated a direct link between such as social network size and psychological adjustment with empirical studies describing "low levels of social support and dysfunctional patterns of social interaction in Vietnam veterans with PTSD" including those reported in the work of Carroll, Rueger, Foy & Donahue (1985); Escobar et al. (1983); Keane, Scott, Chavoya, Lamparski & Fairbank (1985). (Everly and Lating, 1995, p.371) it is additionally reported that is "clear that data from multiple response systems (cognitive, behavioral, and psychophysiological) would provide the most comprehensive assessment of treatment efficacy." (Everly and Lating, 1995, p.373) the multi-method assessment package developed at the Jackson VA Medical Center and reported in the work of Malloy et al. (1983) could be used to make the provision of 'behavioral, subjective/cognitive, and psychophysiological indices of anxiety in response to visual and auditory stimuli associated with the traumatic event." (Everly and Lating, 1995, p.373) the work of Jakupcak, et al. (2006) reports a pilot study that was conducted for investigating the feasibility and effectiveness of behavioral activation therapy for veterans with PTSD. The study included 11 veterans who sought treatment at a Veterans Administration outpatient PTSD clinic who were enrolled in the study, which was comprised by 16 weekly individual sessions of behavioral activation therapy. Nine veterans completed the 16 weekly sessions and one veteran complete 15 sessions while one veteran dropped out follow one session. Findings of the study report that several participants improved on measures of depression and quality of life although changes were not statistically significant. The study concluded that behavioral activation therapy is "a well-tolerated, potentially beneficial intervention for veterans with chronic symptoms of PTSD." (Jakupcak, et al., 2006, p.391) it is reported in the PTSD Research Quarterly, Volume 20, No. 1, Winter (2009) that a great deal of the Center's OEF/OIF research emphasizes the development and dissemination of treatments for combat-related mental health problems. Presently the Behavioral Science Division is reported to be conducting an examination of the efficacy of the combination of "D-cycloserine (a medication to enhance extinction) and exposure therapy to treat PTSD (Litz); the Clinical Neurosciences Division is examining the use of propranolol to block reconsolidation of combat memories (Deane Aikins); and the Women's Division is testing relationship enhancement therapy (Taft and Candice Monson). Several researchers across divisions are participating in the "STRONG STAR" multidisciplinary PTSD research consortium, which includes projects on assessment (Litz and Alan Peterson, Behavioral Science Division); cognitive behavioral conjoint therapy for PTSD (Monson, Women's Division); and individual vs. group cognitive processing therapy (Patty Resick, Women's Division). The Dissemination Division has launched longitudinal survey predicting treatment utilization and clinical outcomes over 2 to 3 years among VA patients with PTSD (Craig Rosen)." (PTSD… READ MORE

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