2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

The Many Aspects of Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is an anxiety disorder that may develop in individuals who have experienced or witnessed an event that involves threatened death or serious injury, such as military combat, physical or sexual assault, natural disaster, terrorist attack, or motor vehicle accident. When an individual is faced with such an event, the sympathetic nervous system, or “fight or flight” response is activated, which sends adrenaline rushing through the bloodstream and leads to elevated heart rate and increased blood flow to muscle groups to help the individual prepare to fight or flee the danger. Although this system is adaptive and can help the individual survive, the fight or flight response can quickly become associated with cues in the environment, such as sights, sounds, or smells that are present during the trauma. When the individual encounters these same cues at a later point in time, even though the immediate danger has passed, the fight or flight response is triggered again, and the body reacts as though it is in danger. For example, an Iraq war veteran who witnessed a vehicle get hit with an Improvised Explosive Device concealed under garbage on the side of the road may learn to associate piles of garbage with danger, so that later, when he is home, the sight of refuse by the roadside triggers memories of this event and activates his fight or flight response. PTSD symptoms are grouped into three clusters, including re-experiencing symptoms, such as the example described above, where memories of the event come back to the individual in several different ways, avoidance and numbing symptoms, where the individual tries to avoid reminders of the trauma or may feel emotionally numb, and hyperarousal symptoms, such as hypervigilance to potential dangers in the environment, irritability, and difficulties sleeping and concentrating.

Although the diagnosis of PTSD was not officially listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1980, the core features of the disorder have long been evident in soldiers returning from combat, described variously as “shell shock,” “battle fatigue,” or “soldier’s heart.” The inclusion of the disorder in DSM-III led to a burgeoning of research on its etiology, effects, underlying neurobiology, and effective treatment approaches. The return home of over 1.5 million U.S. service members from combat theaters in Iraq and Afghanistan has lent a new urgency to efforts to disseminate effective treatments to a wider number of practitioners, enhance the efficiency of existing treatments, and utilize telemental health applications to reach the broadest number of affected individuals, particularly those constrained by logistical or practical barriers to care. These efforts are particularly important given that current estimates suggest that one in five service members suffers from PTSD following deployment to Iraq or Afghanistan and the considerable costs of PTSD for individuals, families, communities, and society. These costs are not trivial, as studies have found that the development of PTSD following violence exposure (such as combat) is associated with joblessness, homelessness, substance use, and imprisonment.

A large body of research has shown that PTSD is associated with significant occupational, psychosocial, and medical impairments. The disorder negatively impacts functioning across domains, and can lead to absenteeism, lost productivity, inability to work, interpersonal relationship problems, intimate relationship distress, difficulties with emotional and physical intimacy, and increased risk of physical health problems, chronic diseases, and suicide. In addition to the toll PTSD exerts on the individual, one of the most devastating features of the disorder is the toll it takes on families. There are a number of different ways in which PTSD may adversely affect families. First, behavioral avoidance of trauma-related stimuli can make routine daily activities such as driving, shopping, socializing with friends, and participating in children’s activities challenging. Often families attempt to accommodate the individual with PTSD by limiting involvement in activities, which can gradually circumscribe activities to the house. Second, the emotional numbing symptoms of PTSD, such as difficulty experiencing feelings of love or happiness, and feeling distant or cut off from others, can interfere with attachment to partners and children, emotional expression, communication, and intimacy. Finally, hyperarousal symptoms such as irritability are associated with increased conflicts, tension, and stress in close relationships.

Given the deleterious effects PTSD can have on families, it is fortunate that a multitude of studies have shown that cognitive behavioral therapies, particularly exposure therapies, are effective in decreasing PTSD symptoms. Indeed, expert treatment guidelines for PTSD published for the first time in 1999 recommended that cognitive behavioral treatment with exposure therapy should be the first-line therapy for PTSD. The more recent 2008 report on the treatment of PTSD by the Institute of Medicine determined that exposure therapy was the only treatment for PTSD with substantial empirical support to conclude its efficacy. In contrast, the Institute of Medicine report did not find the same level of evidence in support of any other treatment approach, including pharmacotherapy. Exposure therapy involves gradually confronting feared memories and situations that are not realistically dangerous but are avoided because they are associated with the trauma and thus trigger anxiety. Most exposure therapies involve imaginal exposure, in which the patient is guided in repeatedly recounting memories of the trauma in a safe environment in order to facilitate extinction learning, whereby the cued fear response to memories of the trauma is extinguished, and the patient is better able to distinguish between thinking and talking about the trauma and feeling as if it is recurring.

Despite compelling evidence for the efficacy of exposure therapy for PTSD, the nature of imaginal exposure, whereby patients are asked to repeatedly recount their most traumatic event to a therapist, presents a challenge for some patients given that avoidance of trauma related memories, thoughts, and cues are, by definition, part of the diagnostic criteria for the disorder. Thus, the majority of individuals with PTSD fail to seek treatment, some who seek treatment do not engage in the treatment, and others who profess willingness struggle to engage emotionally with the trauma memory. As studies suggest that lack of emotional engagement predicts poor treatment outcome, these patients often do not improve. Finding effective ways to motivate these patients and facilitate emotional engagement in therapy is thus critical.

Fortunately, new developments in Virtual Reality technologies have expanded the range of possible treatment options for PTSD by drawing upon similar principles as imaginal exposure to reach patients who are reluctant or unable to recount their traumatic experiences using traditional imaginal exposure. Virtual Reality exposure therapy for PTSD provides a sensory-rich computer-generated environment in which patients are able to encounter and gain mastery of their trauma. Patients gradually proceed through increasingly detailed virtual simulations of their traumatic event that are closely monitored by the therapist, while recounting details of their experience aloud. By allowing the therapist to program the virtual environment to control what the patient experiences, treatment can be tailored to the needs of the individual patient, and proceed at a pace that it tolerable for that individual. Moreover, Virtual Reality therapy can promote emotional engagement and processing of the trauma memory by offering not only visual, but auditory, olfactory and haptic sensory cues to facilitate immersion in the Virtual World.

Despite the success of Virtual Reality and other exposure therapies for PTSD, a number of barriers to treatment remain. First, misinterpretation of responses to trauma can occur when trauma survivors misattribute difficulties stemming from the trauma to causes that seem more routine or readily apparent. For instance, it may be less emotionally painful for an individual to conclude he is no longer in love with his wife than to remain in a marriage that is a constant reminder of his pre-trauma existence. Alternatively, parents may separate after losing a child partly because remaining together is an ongoing reminder of that loss; in this regard separation may constitute a form of avoidance. Such misattributions of trauma-related problems may be compounded by the failure of survivors and non-psychiatric providers to differentiate between a contextually “normal” level of distress” following a trauma and the development of PTSD symptoms that may benefit from specialist care. Furthermore, even when symptoms of PTSD are recognized and diagnosed, lack of dissemination and implementation of empirically validated treatments among mental health professionals may prevent survivors from receiving appropriate and efficacious treatment. Despite the overwhelming evidence in support of exposure therapy, studies have shown that unfamiliarity with evidence-based treatments, inadequate training, and discomfort using exposure techniques are obstacles to clinicians’ use of exposure therapy. These barriers may prevent individuals with PTSD from receiving optimal care.

In addition to barriers such as these, feelings of shame and concerns about stigma may discourage survivors from seeking treatment. For example, studies among military service members have found that treatment seeking for psychological problems may be inhibited by fears of negative perceptions, being considered weak, or damaging one’s career. Fear of stigma and other treatment barriers may be particularly relevant to those most in need of treatment, as one study found that those Iraq and Afghanistan veterans who met screening criteria for a psychiatric disorder were more likely than those who did not to report such fears. Some studies suggest that perceived stigma may also be a particular concern for certain populations, such as ethnic or minority groups, who may be less likely to enroll in and attend PTSD treatment. Such studies highlight the need for further

psychoeducation and outreach to minimize stigma and promote treatment engagement in military personnel and marginalized populations.

Despite these obstacles, significant strides continue to be made in the refinement, dissemination, and implementation of effective treatments for PTSD. Utilization of innovative technologies such as VR and initiatives by both the Departments of Defense and Veterans Affairs to rollout two evidence-based treatments, prolonged exposure and cognitive processing therapy, represent promising directions in the fight against PTSD. Exciting developments such as these may benefit those who have not responded to traditional treatments and ensure that greater numbers of individuals have access to empirically supported treatments. Such efforts offer new hope of providing relief to the approximately 7% of Americans who suffer from PTSD.

The Program for Anxiety and Traumatic Stress Studies is a specialized program within Weill Cornell Medical College’s Department of Psychiatry. Led by JoAnn Difede, Ph.D., a pioneer in the field of anxiety disorders, the Program for Anxiety and Traumatic Stress Studies offers a state-of-the-art approach to patient care that brings innovation to tried-and-true therapeutic techniques. For many years the program has provided psychological consultation to the New York Presbyterian Hospital Burn Center and has implemented a number of research-based clinical interventions designed specifically for individuals suffering from burn injuries, terrorist attacks, motor vehicle accidents, interpersonal violence, and life-threatening illnesses. Our work with the Burn Center naturally lead to relationships with the FDNY and disaster rescue and recovery workers, because employees of these groups are treated for work related injuries at the NYPH Burn Center. Through our work with these groups, the Program for Anxiety and Traumatic Stress Studies has become recognized as an unparalleled institution in the treatment of anxiety disorders.

The program is currently conducting a national clinical trial for the treatment of combat-related PTSD in Veterans who have served in Iraq or Afghanistan, with funding from the Department of Defense. The study involves the first-line treatment for PTSD, imaginal exposure therapy, and an innovative form of exposure therapy enhanced with virtual reality. Potential participants can enroll in Long Beach, CA, Westchester or New York, NY, or Bethesda, MD, and may be eligible for up to $350 reimbursement. To learn more about this program or to schedule an appointment, call (212) 821-0783.

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