Prolonged Exposure for Combat Veterans with PTSD

Picture Day in the Village, by MSG Martin J. Cervantez, courtesy of the Army Art Collection, US Army Center of Military History.

6.1 Clinical Case

The patient is a 25-year-old service member who sustained a gunshot wound in combat without any immediate psychological sequelae. He underwent approximately 8 months of surgical and rehabilitative care. Around that time frame, he presented with his military commander to the behavior health clinic due to public alcohol intoxication and suicidal ideation. He was diagnosed with alcohol abuse and posttraumatic stress disorder (PTSD) with delayed onset per the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-TR [1].

His predominant symptoms were reexperiencing his trauma through nightmares and flashbacks; avoidance of crowds, driving, and traffic; persistent negative beliefs about the world; persistent negative emotional state; and hyperarousal with insomnia, profuse hyperhidrosis at night, hypervigilance, and panic attacks. This presentation resulted in depressed mood and suicidal ideations secondary to feelings about guilt of being a burden on his family with perceived loss of independence. He reported that drinking alcohol would help him cope with his emotional pain.

Basic laboratory evaluation including thyroid panel, urine drug screens, and markers for heavy alcohol use was assessed and found to be normal, which helped narrow the differential diagnosis. Based on his presentation, several treatments were initiated: psychosocial interventions for alcohol abuse, somatic treatments of sertraline for anxiety and prazosin for nightmares, and prolonged exposure (PE) for PTSD.

Due to his history of index trauma with subsequent symptom development 8 months later, he was diagnosed with delayed-onset PTSD. The most disabling feature of his presentation was noted to be his avoidance behaviors. Premorbidly, the patient was a highly independent and socially engaged individual. After the trauma, he had to rely on others to accomplish his activities of daily living and instrumental activities of daily living. For example, he had to be escorted and chauffeured everywhere due to his fear of driving and inability to go to crowded places like the shopping market. These resulted in overwhelming social isolation. His inability to perform basic activities of daily living also had significant impact on his self-image and sense of self-efficacy.

Since PE gives considerable attention to treating avoidance symptoms through imaginal and in vivo exercises, PE was initiated using standardized techniques per the manual by Foa and colleagues [2]. In vivo exercises are based on PEs theory that the conditioned response (fear and avoidance) to the feared stimulus (avoidance of daily activities, such as driving) will reduce or extinguish through prolonged and repeated habituation-based exercises. It is conceptualized that the reduction or extinction of the fear and avoidance response would result in an increased sense of mastery.

Given the practical limits of a clinic setting and the patient’s preference, the recommended 90 min sessions from the manual were reduced to standard 60 min sessions. Safety assessments were routinely conducted since the patient initially presented with suicidal ideation. Although PE does not directly treat suicidality, it may reduce the psychiatric distress of the patient’s PTSD symptoms, which were conceptualized to be contributory to his suicidality. The clinician was prepared to shift the therapy focus as appropriate to address his suicidality more directly. The PTSD Checklist-Military (PCL-M) was administered at every visit as part of standard practice. In the early sessions of PE, he was educated on the basic concepts and rationale for PE therapy. Relaxation breathing techniques were reviewed.

Despite encouragement from the clinician, the patient declined to use breathing techniques. It was unclear at the time why he was reluctant to use these, but the therapist elected to not emphasize the relaxation skills to avoid endangering or fracturing the therapeutic alliance. It was later revealed that a relaxed state was threatening to the patient. He reported a belief that he may be caught unprepared for potential emergencies if he became too relaxed using such techniques. Since those relaxation skills are a critical component of PE treatment, it was noted as a possible contributor to the slow progression of treatment.

During the next several sessions, he was educated on the subjective units of distress scale (SUDS) and aided in creating an in vivo SUDS hierarchy using standard PE forms. The patient selected activities corresponding to SUDS levels of 40 and 50 as part of his in vivo exposure. The sessions were recorded on his smartphone. The initial in vivo exposure homework exercise was to watch a war-related video that was similar to the patient’s reported trauma memory of gunshot wound sustained during combat.

He successfully accomplished this task, but had more difficulty completing assignments related to imaginal exposure via listening to the recorded session of his index trauma due to significant fear and anxiety. He described that the anticipation of hearing his voice and traumatic experience caused him to feel shortness of breath, chest tightness, racing heart, and fear of losing control. He reported a belief that his hypervigilance was protective because it was what kept him safe. During the third session, he was introduced to in-session imaginal exposure. While initially hesitant, he was able to progress with significant encouragements. He provided data on his SUDS during the detailed description of his trauma, which lessened with repeated exposure (Fig. 6.1).

Fig. 6.1

SUDS scores during imaginal exposure over time demonstrating the gradual initial increase with increasing details in trauma narrative, eventually reaching a peak and then dropping over time

Despite much support from the clinician, he continued to avoid listening to his trauma from the session. Modifications were attempted, such as listening to just the initial 5 min of the tape. However, he reported becoming extremely anxious when attempting to open the recordings on his smartphone. Since imaginal exposure is a critical component of PE, the clinician and patient decided to use a less overwhelming method of exposure. Rather than listening to his trauma, he was asked to write a narrative.

While this seemed like a reasonable alternative to the patient, he still avoided doing this until the ninth session. He did well with in vivo exposure assignments such as going to the mall or watching certain anxiety -provoking videos, although continued to avoid driving. Exploring his avoidance revealed his beliefs that the world is a dangerous place, something bad would happen, and he would die. Over the course of several sessions, he was able to advance to higher level stimuli on his in vivo and imaginal exposure SUDS hierarchy peaking to 100 and demonstrated expected drops during the session.

The PE therapy continued for 12 sessions and then care was terminated due to the anticipated transfer of the clinician. The patient’s goals were discussed, with the dyad agreeing that the patient continued to show much disability and should continue with PE. While the patient demonstrated some success with in vivo exposure, he maintained his fear and avoidance of driving and dependency on family members. However, his mood symptoms had significantly improved. He no longer had thoughts or desire to kill himself. He also maintained his sobriety following brief psychoeducational interventions.

Given his persisting symptoms, he was transferred to another therapist. They continued modified PE with imaginal exposure without in vivo exposure for an additional 20 sessions. Some modifications that were made to help the patient better engage in imaginal exposure included using the past tense, keeping his eyes open, writing the trauma instead of speaking it, and not using audio recordings. Since the patient was hesitant to complete the PE exercises due to these maladaptive beliefs, the clinician modified his approach to include a greater emphasis on cognitive therapy in order to address those beliefs. As the patient was able to increase the intensity of imaginal exposure over time, he progressed to having better tolerance for in vivo exposure.

Initially, he performed these homework exercises with family supervision, but over time, he accomplished assignments by himself. He reported an increased ability to tolerate anxiety, and possessed a sense of accomplishment. At the end of therapy, the patient had significant functional improvement. He had begun to drive, was engaged to be married, and was reporting euthymia. It was hypothesized that the improvement of his PTSD symptoms, particularly avoidance and emotional estrangement from others, contributed to improved socialization and led to his marriage. At that point, he was also medically discharged from military service due to significant physical limitations from his combat-related injury and inability to carry on his duties as an active duty service member.

6.2 Diagnosis and Assessment

When assessing a patient such as in the clinical case example, standardized diagnostic criteria should be used. With the recent update of the Diagnostic Statistical Manual [3], it is important to consider the significant differences between the DSM IV-TR and DSM-5 in the diagnostic criteria of PTSD and how this may impact patient selection for treatment. In DSM-5, PTSD is no longer classified as an anxiety disorder, but as a separate category, trauma-stressor-related disorders. One impetus for this classification was growing research supporting that PTSD is characterized by a range of emotional and behavioral reactions, which are not exclusive to anxiety . Changes in definition and diagnostic criteria, even if minor, do create dilemmas for clinicians with regard to external validity of preceding evidence and its application to the new criteria.

The clinical case described in this chapter illustrates the diagnostic uncertainty that often accompanies diagnosing mental disorders. The differential diagnosis of PTSD can be especially challenging. First of all, the temporal relationship between traumatic event and the development of symptoms can vary. In this case, the patient did not present with immediate psychological sequelae after his trauma. After approximately 8 months of surgical and rehabilitative care, he was evaluated by behavioral health due to alcohol intoxication and suicidal ideation. His presentation was delayed in onset and calls into question whether that patient’s symptoms are attributable to a different disorder.

Delayed-onset PTSD is defined in the DSM-5 as the onset of the symptoms occurring at least 6 months after the traumatic event. It is theorized that many soldiers do not develop symptoms immediately because stress reactions are adaptive in combat [4]. Additionally, one study of soldiers evacuated from combat in Iraq and Afghanistan found some evidence that severe injuries tend to postpone the development of PTSD by several months [5]. Other literature suggests that patients may display milder symptoms initially that are not immediately detected, which become more functionally impairing over time [6]. For example, in the clinical case described, the patient may have been so occupied with surgery and rehabilitation that his symptoms were not readily apparent in such a protective environment.

Another reason that the differential diagnosis can be so challenging is that there is a high comorbidity between PTSD and other psychiatric diagnoses [7]. In this case, the patient’s presentation was also complicated by alcohol use disorder , which can present as anxiety during periods of withdrawal and mimics other mental health disorders. Literature indicates that PTSD often occurs with at least one or more psychiatric diagnoses [8, 9]. Some of the more common comorbid diagnoses are mood, anxiety, and substance use disorders. The co-occurrence of PTSD with traumatic brain injury is also problematic because there is a significant overlap of symptoms to include problems with memory, concentration, irritability, and insomnia [10].

Similarly, PTSD-related symptoms can be shared with or misinterpreted to be secondary to other mental disorders. For example, specific phobia, agoraphobia, and PTSD share a psychological and physiological response to exposure to cues resulting in avoidance behaviors. Anhedonia, social isolation , restricted emotional range, insomnia, difficulty concentrating, and excessive guilt are common symptoms of both PTSD and depression, making it difficult to distinguish the two disorders. PTSD flashbacks may also mimic hallucinations secondary to a psychotic process. Given shared phenotypical presentations and overlap between PTSD and other disorders, it becomes important for the provider to understand the context and motivation for why symptoms emerge. For example, specific phobia and PTSD share an irrational fear of specific objects or situations. Asking patients to explain the reason for their fear helps determine the diagnosis. In PTSD, individuals avoid certain objects or situations because they signify the traumatic event.

6.3 Treatment and Management

6.3.1 Selection Criteria

When selecting patients for PE therapy, specific selection criteria can be applied. Individuals should be chosen who have a diagnosis of PTSD, ideally with a major index trauma as the designated target of imaginal exposure. PE focuses on one event, the index event, even though the patient may have several traumatic events. This criterion appears to serve both cases of rape victims who suffer index sexual trauma and military combat trauma with a singular major violent event.

There are several exclusion criteria for patients who are not ideal candidates for PE therapy. Patients with safety concerns—suicidal or homicidal ideations and behaviors or self-injurious behavior within 3 months prior to treatment—are typically excluded from PE [2, 11]. Presentations characterized by unstabilized risk for harm to self or others may be better served by interventions targeting risk stabilization [12, 13]. Some literature suggests that patients with psychotic disorders are not ideal candidates for PE since there is an absence of intact reality testing and treatment could lead to negative outcomes [11].

There are also some criteria that are not exclusionary, but should be evaluated on a case-by-case basis. For example, patients with substance abuse and dependence could be receiving concurrent treatment with PE, as demonstrated in the case example [2, 14]. Ongoing alcohol use through its sedating properties can chemically inhibit the treatment of anxiety by preventing habituation, which is required to benefit from PE. Depending on the severity of symptoms, dissociation can also be a limiting factor in this form of therapy due to elevated levels of anxiety triggering dissociative symptoms.

6.3.2 Structure of Therapy

The structure of PE therapy averages 10 sessions that are 90 min in duration. The number and length can be modified based on the provider’s or patient’s needs and goals. In our case vignette, the patient participated in 60 min sessions due to practical clinical necessity and patient preference. More sessions were added since the patient’s symptoms did not show a satisfactory response to treatment. However, before adding sessions, it is important to conceptualize the reasons for an unsatisfactory response, and to determine if extending the therapy will address those reasons. In this case, the patient’s nonadherence to imaginal and in vivo assignments due to overarousal and the patient’s lack of adherence to prescribed relaxation strategies may have contributed to the lack of satisfactory response. Given these reasons, modifications were made, such as writing the trauma memory instead of speaking it and revising the in vivo exercises by initially allowing the patient to be in the company of his fiancé. These modifications seemingly promoted greater treatment adherence and a satisfactory treatment response.

The first PE session is focused on understanding the trauma [2]. A detailed history is obtained in which the diagnosis of PTSD is confirmed. It also includes identifying the index trauma, a single distressing event to serve as the basis of symptom inquiry and focal point for PE. A rationale for treatment procedures is introduced, describing the overview of therapy, the time-limited nature of the sessions, and its ultimate long-term goal. The patient is also educated on relaxation techniques to include how the pathophysiology of hyperventilating produces bodily reactions that resemble fear. The patient is instructed that slow breathing, focused on exhalation, can reduce tension and stress. Deep breathing should be performed outside of treatment sessions at least three times a day for 10 min. Finally, a therapeutic alliance is established in the first encounter in order to serve as a basis of trust for future sessions.

Only gold members can continue reading. Log In or Register to continue