Prolonged Exposure Therapy

Prolonged Exposure Therapy

Abstract

Combat exposure has been linked to an array of negative health consequences, most notably posttraumatic stress disorder (PTSD). The disorder can manifest with dozens of different symptoms, and each can appear on a continuum of complexity, level of seriousness, and co-morbidity with other symptoms, which may or may not be PTSD related. Quickly becoming one of the most highly presented disorders within the U.S. military, combat-related PTSD is presenting in alarming proportions. Despite barriers to reporting, assessment, and treatment in the military, prolonged exposure (PE) therapy has proven to be a highly effective intervention for combat-related PTSD, as research has shown that PE significantly decreases symptoms related to the disorder.

        Keywords: prolonged exposure therapy, combat-related, PTSD

Prolonged Exposure Therapy for Combat-Related PTSD

Life can be difficult, and uncontrollable things happen at one point or another. Cancer strikes, and suddenly an otherwise healthy family member is terminal. An earthquake destroys an entire region, killing hundreds of thousands and leaving millions more homeless without basic necessities. A woman is violently raped on her way home from work. A soldier deploys and sees combat for the first time. He takes a life in battle, something that he was trained to do but unprepared to deal with psychologically. All of these situations can bring with them a wealth of negative feelings, including desperation, hopelessness, depression, deeply rooted anxiety, guilt, or shame. Kaplan and Tolin (2011) report that over a quarter of the U.S. population will at some point in their lives develop an anxiety disorder, and a good portion of this number will be related in one way or another to trauma.

PTSD

Sharpless and Barber (2011) describes PTSD as a consequence of both natural and manmade occurrences that distresses the psychological system, violating core assumptions about a safe and predictable life. PTSD can manifest with dozens of different symptoms, and each can appear on a continuum of complexity, level of seriousness, and co-morbidity with other symptoms, which may or may not be PTSD related (Bliese et al., 2008; Bryant et al., 2008; DSM-IV-TR, 2000; Smith et al., 2009).  

Combat-related PTSD

        The physical and psychological consequences of war have been documented since the beginning of time. The brutality of war is likely to have an unsettling effect on anyone that witnesses or participates in it. For U.S. soldiers, the impact can be measured on a large scale. The National Center for PTSD (www.ptsd.va.gov) reports that up to 18% of soldiers returning from deployment in OIF/OEF (Operation Iraqi Freedom and Operation Enduring Freedom) will develop PTSD. Combat exposure has been linked to an array of negative health consequences, most notably posttraumatic stress disorder (PTSD). As noted by Garske (2011), PTSD can be a chronic and disabling psychiatric disorder that is rapidly becoming one of the biggest presenting issues within the military. Because of the sheer number of people who are or will be affected by combat related PTSD, social workers will have an enormous job in identifying effective treatment options that are both utilized and accepted by clients (Yarvis, 2011).  

        Any event that is life-threatening or that severely compromises the physical or emotional well-being of an individual or causes intense fear may cause PTSD. Combat seems to be a leading factor in the development of PTSD in soldiers; this has been well documented (Keane, Marshall, & Taft, 2006; McClean & Foa, 2011; Nacasch et al., 2011; Tuerk et al., 2011; Yarvis, 2011).  A recent review of the literature found a wide range of PTSD rates among those serving in OIF/OEF; estimates ranged from 4% to 45%, depending on the samples and how PTSD was measured (Garske, 2011; Tanielian & Jaycox, 2008). Unfortunately, there is a significant deficiency in empirical data collected on PTSD as it relates to the current wars.  Although there is a body of documented research from Vietnam era veterans, research is in the infancy stages regarding OIF/OEF.   The literature that does exist is varied and includes a wide range of methodologies.

Prevalence of combat-related PTSD 

Accurate prevalence rates for combat-related PTSD are difficult to validate (Smith et al., 2009; Tanielian & Jaycox, 2008). Garske (2011) discusses the difficulty in doing so as an effect of the nature of the disorder itself. We can count the dead, we can categorize physical injuries, but we cannot see into the minds of our soldiers. We cannot estimate or accurately measure the horrors they have seen, nor can we, without relying on self-reporting and the honesty with which soldiers choose to describe their symptoms, define the extent to which they have been psychologically damaged. It has been documented that soldiers serving in combat zones like OIF/OEF have reported greater incidence and severity rates of PTSD symptoms than civilians and non-combat military personnel (Hoge, Auchterlonie, & Milliken, 2006; Hoge, Terhakopian, Castro, Messner, & Engel., 2007) and that rates of PTSD are increased by multiple deployments, exposure to fire fights, and the extent of wartime experiences (Garske, 2011; Yarvis, 2011).

DSM-IV-TR Diagnosis

        There has been much debate over changing the diagnosis model to a continuum, especially since traumatic events that spur PTSD can differ so wildly and can have substantially different effects from one individual to another, even when experiencing the same occurrence (Benish, Imel, & Wampold, 2007; Smith et al., 2009; Pols & Oak, 2007).  In addition to the differences in presenting indicators, the duration of PTSD can last for varied amounts of time, also dependent on the individual and often times his or her innate ability at self-efficacy.  Because of the differences inherent to each individual, effects can be as varied as the manifested symptoms (Hoge et al., 2007; Pols & Oak, 2007; Smith et al., 2009). For a full list of diagnostic criteria for PTSD, please refer to Appendix A.

Because of the differences in symptoms, duration, and severity, PTSD  can be difficult to differentiate from other traumatic illnesses and mental health issues, and is often misdiagnosed as Acute Stress Disorder (ASD), anxiety, and depression; the latter two are often co-morbid with PTSD (Smith et al., 2009; Pols & Oak, 2007).  The difficulty in diagnosis can also be at least partially blamed on its black-and-white medical model definition in the DSM-IV-TR (2000).  

Barriers to Treatment

        Tuerk, Yoder, Ruggiero, Gros, and Acierno (2010) report that there are several factors that contributes to the non-treatment of mental health issues in the military. Person-based barriers include a tendency to dodge stigma as well as avoidance issues related to examining the source of the trauma and mental health issues themselves. Other factors are more institutionally based and center on geographic barriers, inefficient or inaccessible services, and issues with the military health care referral system.