Transcript Slide 1

Enhancing Outcomes for Military
Personnel and Their Families
Deborah C. Beidel, Ph.D., ABPP
University of Central Florida
Date
What is Trauma?
• An event that involves
– actual or threatened death
– serious injury or threat to
physical integrity
• Types of events
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Natural disasters
Terrorism
Physical or Sexual Assault
Motor Vehicle Accidents
Combat
Traumatic Events are Common
• Up to 90% of Americans report exposure to a
traumatic event during their lifetime
• “Expected” reactions to trauma include:
– Fear or anxiety
– Difficulty sleeping
– Difficulty eating
– Re-experiencing the event
– Urges to avoid situations
associated with the event
– Hyperarousal
• Symptoms will gradually decrease over time for
many people
Who Is Most Likely to Experience The
Effects of Trauma?
• Direct exposure to the
sights and sounds of the
event
• Direct injury or threat of
injury
• Socioeconomic status
• Female
• Prior mental health
difficulties
Typical Reaction to Trauma
• There is no one typical
reaction
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Resilience
Recovery
Acute Stress Disorder
Post-Traumatic Stress
Disorder
Bonanno (2004)
 On October 2, 2006
Charles Carl Roberts
entered a one-room
schoolhouse in the
Amish community of
Nickel Mines, PA.
 He lined up ten young
girls and shot them each
at point blank range.
 5 dead and 5 wounded
Effects on Central PA community
• Horrific nature of the injuries
• Affected
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–
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–
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Families
First Responders and Medical Personnel
County Coroner and Deputy County Coroner
ER Personnel
Radiology
• Affected more than trained medical personnel
– Chaplains
– Environmental Services staff
Amish Community Response
 The Amish community
forgave Mr. Roberts and
went to the house of his
widow that evening,
bringing food and comfort
 More that 50% of those
at Mr. Roberts’ funeral
were from the Nickel
Mines Community
 How did they do it? –
“With God’s help”
What Types of Trauma Remit With Time?
• Any traumatic reaction
can remit but most
commonly
– Motor vehicle accidents
– Natural disasters
– Medical diagnoses such
as cancer
• When reactions do not
remit, the result may be
Post-Traumatic Stress
Disorder (PTSD)
Historical Perspective
• Combat reactions noted
throughout literature
(Homer, Shakespeare)
• Soldier’s Heart (Civil War)
• Shell Shock (World War I)
• Combat Fatigue (World
War II)
• “PTSD included in DSM-III
(1980), post-Vietnam
Diagnostic (DSM5) criteria for PTSD
(1) Alterations in arousal and
reactivity
• Nightmares, distressing thoughts,
flashbacks
(2) Avoidance of Stimuli
• Avoidance of people, places, feelings
(3) Negative Alterations in
Cognition and Mood
• Numbing of interests and positive
emotions
(4) Increased Arousal
• Sleep/concentration difficulties, anger
outbursts, exaggerated startle
response
Epidemiology of PTSD
• Combat PTSD prevalence = 6 – 9%
• Front line troops with combat exposure have higher rates
than support personnel
• Epidemiological data from community samples show the
prevalence of PTSD drops by 50 -60% over time
• Recent, more rigorous estimates of PTSD rates among
Vietnam veterans are 40% to 65% lower than original
estimates, and there are few cases of severe functional
impairment
• Studies of non-US forces/veterans typically find lower rates of
PTSD
Richardson, Frueh, Acierno. Prevalence estimates of combat-related posttraumatic stress disorder: critical
review. Australian and New Zealand Journal of Psychiatry 2010; 44:4-19
So Why Not Just Go and Get Treatment?
Rosenheck R A , Fontana A F Health Aff 2007;26:1720-1727
©2007 by Project HOPE - The People-to-People Health Foundation, Inc.
Current Status of Available Treatments
• Several SSRIs have FDA approval
• According to the IOM (2007), there is insufficient
data to support efficacy of medications alone for
treating PTSD
• Excellent efficacy data for exposure therapy in
civilians, even some for veterans
• Support for cognitive processing therapy in
civilians, even some for veterans
• According to the IOM (2007), exposure is the only
empirically supported treatment for PTSD
What is the Core Element of Effective
Treatment for PTSD
• Exposure Therapy
– How do you get over
your fear of a dog?
– You have to be around a
dog
• So how does exposure
therapy work?
“Typical” Anxious Response
to a Feared Stimulus
7
6
SUDS
5
4
Anxiety
3
2
1
0
Base
5
10
TIME
15
SUDS
Within Session Habituation
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
SUDS
0
10
20
30
40
50
60
Time of Session
70
80
90
SUDS
Between Session Habituation
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
1
4
7
10
0
10
20
30
40
50
60
Time of Session
70
80
90
What is the Core Element of Effective
Treatment for PTSD
• Exposure Therapy
– How do you get over
your fear of a dog?
– You have to be around a
dog
• But the dog has to look
like the dog that
created the trauma
Challenges for Exposure Therapy for
OEF/OIF Veterans
•How do you
recreate this?
Challenges for Exposure Therapy for
OEF/OIF Veterans
•Virtual reality (VR) as a means of augmenting
EXP has been introduced into many treatment
settings.1-4
•VR is a promising treatment augmentation
– Allows presentation of relevant cues, overcoming
reluctance of some warriors to imagine these events
– Overcomes a significant hurdle: an inability to engage
in imagery of sufficient detail and affective magnitude
to re-create essential aspects of the traumatic event.
OEF = Operation Enduring Freedom; OIF = Operation Iraqi Freedom. 1Anderson P et al. Behav Ther. 2006;37(1):91-7; 2Klinger E et al.
Cyberpsychol Behav. 2005;8(1):76-88; 3Ready DJ et al. Cyberpsychol Behav Soc Netw. 2010;13(1):49-54; 4Rothbaum BO et al. Behav Ther.
2006;37(1):80-90.
Virtual Reality Therapy
Why Include Olfaction in VR?
• Olfactory cues, paired with aversive stimuli, produce
conditioned fearful behavior to both the odor and the
context in which the odor is presented (Kroon et al.,
2008).
• In the clinical setting, patients with PTSD associate
odors with their traumatic events and described
specific olfactory cues as primary precipitants of PTSD
flashbacks (Kline & Rausch, 1985; Vermetten &
Bremner, 2003).
• This is particularly so for veterans of OIF/OEF who
frequently report memories of the novel smell of the
desert, smells from IEDs, garbage and related smells
such as Middle Eastern spices
What is the efficacy of exposure for PTSD?
• EXP is specifically focused on anxiety and fear
but does not specifically address the
“negative” symptoms
– avoidance
– social withdrawal
– interpersonal difficulties
– occupational maladjustment
– emotional numbing
– anger
Trauma Management Therapy
• A multi-component intervention consisting of
– Exposure therapy (individual)
– Skills training and behavioral activation (group)
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Social and assertive skills
Anger management
Problem Solving
Behavioral activation
Beidel et al. (2011); Turner et al. (1998)
Trauma Management Therapy
for OEF and OIF Combat Veterans
Award Number: 08214003
Award Date: 11/15/10 – 11/14/15
Contract Officer: Susan Dellinger, Ph.D.
Science/Grants Off: Officer: Dwayne L. Talliaferro, PhD.
Portfolio Manager: Ronald Hoover, Ph.D.
Study Design
17 week program
EXP: 3x/wk for 5
weeks
SER
Psychoed
& Rap
3 week intensive
program
TMT: EXP in am
Group in pm
Design and Methodology
• At study’s end, 180 participants (3 arms)- randomized (when
possible) to:
– 17 week TMT (EXP + SER)
– 17 week EXP +TAU
– 3 week TMT (tests the rapid delivery of TMT and allows participants
from outside of Orlando to participate in the program)
• Treatment
– 17 week arms - 5 weeks individual VR assisted EXP (3x/week)
followed by 12 weeks group tx (either SER or TAU)
– 3 week arm – daily individual VR assisted EXP (am) and group SER
(pm) (housing and most meals paid by the grant).
Preliminary Outcome 17 weeks
Preliminary Outcome 3 weeks
Is VR a useful augmentation?
VR Combination
No VR
Used visuals only
Used sounds only
Used smells only
Used visuals and sounds
Used visuals and smells
Used sounds and smells
Used visuals, sounds and smells
n=56
% using that combination
21.4%
1.8%
7.1%
0.0%
1.8%
0.0%
55.4%
12.7%
Does exposure produce side-effects in combatPTSD?
CGI-Improvement, p<.001; suicidal thoughts and alcoholic drinks p=ns
Military Families
Age Distribution of Children
Effects of Deployment on Children
• Unique factors of
OIF/OEF/OND
– Multiple and prolonged
deployment
– Reliance on guard and
reserve members
– Returning service
members with serious
wounds/injuries
– Continuous family
communication
Adjustment to Deployment Based on
Spousal Report
Office of the Deputy Undersecretary of Defense for Military Community and Family Policy (2009)
Limitations of Current Data
• Primarily based on spousal report
• Primarily used one parental measure – Child
Behavior Checklist
• Most results indicate statistically significant
differences when compared to control group –
but outcome is not always clinically significant
• Minimal use of objective measures or
measures of resilience
Statistical vs Clinical Significance
When Parents Go to War:
Psychosocial adjustment among the children of
deployed OEF/OIF service members
Award Number: 11356008
Award Date: 1/15/13 – 1/14/17
Contract Officer: Susan Dellinger, Ph.D.
Science/Grants Off: Officer: Dwayne L. Talliaferro, PhD.
Portfolio Manager: Kate Nassaur, Ph.D.
Design and Methodology
• 600 families
– Military – one parent currently deployed
– Military – no parent deployed
– Civilian – parents are separated or divorced
– Civilian – parent “deployed” for work
– Civilian - intact families with children of civilian
parents who are currently living in the same
household.
• All children ages 7 to 17 years may participate
Measures
• Diagnostic interviews
with parent and child
• Measures of stress, and
family environment
• Measures of parenting
behaviors and spousal
report of marital
satisfaction
• Measures of resilience
• Academic, school
behavior, and social
adjustment
• Objective measures of
stress
Objective Measures of Stress
• Neuroendocrine
measure - cortisol
(saliva) samples of
children
• Assessed each morning
for 5 days (week days)
Objective Measures of Stress
• Physiological
measure - sleep
as measured by
actigraphy
– Assessed for
one week
Military Families Program
• 3 sites (Orlando,
Houston,
Hilo/Honolulu)
• Study is set up so that it
could be done by
internet and email if
necessary
• Anyone is welcome to
participate
• Recruitment has just
begun
Thank you
• US Army Military Operational Medicine
Research Program
• Co- Principal Investigators
– Trauma Management Therapy Project – Drs.
Christopher Frueh, Thomas Uhde and Sandra Neer
– Military Families Project – Drs. Candice Alfano,
Christopher Frueh, and Charmaine Higa-McMillan