PTSD AND THE WARFIGHTER: A TECHNOLOGY-BASED APPROACH TO THERAPY

The missions in support of Global War on Terrorism may have concluded throughout the Middle East, but the residual effects of the sustained combat operations remain present and continue to influence the lives of so many combat Veterans. Advances in technology, such as health monitoring and wearable devices, could improve the treatment of the warfighters and the approach adopted by the Defense Health Agency and the U.S. Department of Veterans Affairs. The U.S. Navy and U.S. Marine Corps have policies established to remove their respective Sailors and Marines from their standard deployable status to a Limited Duty (LIMDU) position, which are limited to six-month periods and two concurrent periods before personnel must go before a Medical Review Board, where they are susceptible to medical separation or medical retirement. It is important to explore additional treatment options so the victims can obtain a renewed sense of purpose, eliminate suicidal thoughts and ideations, and if preferred, continue their military service and share their valued experiences with the next generation. This research explores nontraditional methods of PTSD treatment, to include technology, mood tracking, and sleep data, and how these data points influence one another.Approved for public release. Distribution is unlimited.Lieutenant, United States NavyLieutenant, United States Nav

Pharmacotic Wargames:Military Play as Ritual Sacrifice

This article argues that the analytic of pharmacotic war can render visible a logic of ritual sacrifice in the US military’s use of games to attract, produce, and recycle war-fighters. Identifying the ancient framing of the pharmakon – a substance or process that functions as at once drug, poison, and cure – it shows how games function paradoxically to draw in, produce, and rehabilitate military life. The article makes this case by tracing the roots of Kenneth MacLeish’s ‘churn of mobilization and demobilization’ beyond the military’s instrumental calculations of institutional self-perpetuation, showing that this churn functions according to a logic of pharmacotic sacrifice that is not incidental to, but rather built into, their routine operation. It argues that (ex-)war-fighters function as a contemporary equivalent of the ancient pharmakoi, scapegoated and sacrificed figures into whom a polis poured its guilt and dysfunction in an act of ritual purification. Though rejecting any linear genealogy or transhistorical Western way of war, it identifies powerful resonances between the ancient pharmakoi and (ex-)war-fighters today. Drawing on extensive interviews with US military gamers and veterans, the article sheds light on the growing influence of games on the attraction, production, and recycling of (ex-)war-fighters in the 21st century. At the same time, by tracing the purificatory expulsion of war-fighters, it contributes a novel theorization of the pharmacotic logic of the US military’s war-making apparatus

Virtual reality exposure-based therapy for the treatment of post-traumatic stress disorder: a review of its efficacy, the adequacy of the treatment protocol, and its acceptability

Introduction The essential feature of post-traumatic stress disorder (PTSD) is the development of characteristic symptoms following exposure to one or more traumatic events. According to evidence-based intervention guidelines and empirical evidence, one of the most extensively researched and validated treatments for PTSD is prolonged exposure to traumatic events; however, exposure therapy can present some limitations. Virtual reality (VR) can help to improve prolonged exposure because it creates fictitious, safe, and controllable situations that can enhance emotional engagement and acceptance. Objective In addition to carrying out a review to evaluate the efficacy of VR exposure-based therapy (VR-EBT) for the treatment of PTSD, the aim of this study was to contribute to analyzing the use of VR-EBT by: first, evaluating the adequacy of psychological treatment protocols that use VR-EBT to treat PTSD; and second, analyzing the acceptability of VR-EBT. Method We performed a replica search with descriptors and databases used in two previous reviews and updated to April 2015. Next, we carried out an evaluation of the efficacy, adequacy, and acceptability of VR-EBT protocols. Results Results showed that VR-EBT was effective in the treatment of PTSD. The findings related to adequacy showed that not all studies using VR-EBT reported having followed the clinical guidelines for evidence-based interventions in the treatment of PTSD. Regarding acceptability, few studies evaluated this subject. However, the findings are very promising, and patients reported high acceptability and satisfaction with the inclusion of VR in the treatment of PTSD. Conclusion The main weaknesses identified in this review focus on the need for more controlled studies, the need to standardize treatment protocols using VR-EBT, and the need to include assessments of acceptability and related variables. Finally, this paper highlights some directions and future perspectives for using VR-EBT in PTSD treatmen

Virtual reality exposure therapy for armed forces veterans with Post-Traumatic Stress Disorder: a systematic review and focus group

This study aims to determine the guidelines for designing a Virtual Reality - War Scenario program for Armed Forces veterans diagnosed with Post-Traumatic Stress Disorder. This article encompasses two studies: Study 1, a systematic review of eleven articles indexed in the databases B-on, PubMed, Clinical trials and Cochrane Library; Study 2, a focus group of Portuguese armed forces veterans, discussed the outline of such a programme. A set of guidelines were identified as central and consensual, which should be included in the program. This type of program must have a realistic, multisensorial and interactive approach that allows veterans to re-adapt to their past, which is still so present. Virtual reality offers veterans with Post-Traumatic Stress Disorder unlimited opportunities, enhancing a personalized intervention. The results support the use of VRET as an efficacious treatment for combat-related PTSD, but suggest nevertheless, VRET, as a co-creation process, requires more controlled and in-depth research on their clinical applicability

Virtual reality exposure therapy for armed forces veterans with post-traumatic stress disorder: A systematic review and focus group [artigo]

Virtual reality exposure therapy (VRET) is an emerging treatment for people diagnosed with Post-Traumatic Stress Disorder (PTSD) due to the limited accessibility of psychotherapies. This research aims to determine the guidelines for developing a Virtual Reality–War Scenario program for Armed Forces veterans with PTSD and encompasses two studies: Study 1, a systematic electronic database review; Study 2, a focus group of twenty-two Portuguese Armed Forces veterans. Results showed a positive impact of VRET on PTSD; however, there were no group differences in most of the studies. Further, according to veterans, new VRET programs should be combined with the traditional therapy and must consider as requirements the sense of presence, dynamic scenarios, realistic feeling, and multisensorial experience. Regardless, these findings suggest VRET as a co-creation process, which requires more controlled, personalized, and in-depth research on its clinical applicability.info:eu-repo/semantics/publishedVersio

A systematic review of factors associated with outcome of psychological treatments for post-traumatic stress disorder

Objective: Psychological interventions for post-traumatic stress disorder (PTSD) are not always effective and can leave some individuals with enduring symptoms. Little is known about factors that are associated with better or worse treatment outcome. Our objective was to address this gap. Method: We undertook a systematic review following Cochrane Collaboration Guidelines. We included 126 randomized controlled trials (RCTs) of psychological interventions for PTSD and examined factors that were associated with treatment outcome, in terms of severity of PTSD symptoms post-treatment, and recovery or remission. Results: Associations were neither consistent nor strong. Two factors were associated with smaller reductions in severity of PTSD symptoms post-treatment: comorbid diagnosis of depression, and higher PTSD symptom severity at baseline assessment. Higher education, adherence to homework and experience of a more recent trauma were associated with better treatment outcome. Conclusion: Identifying and understanding why certain factors are associated with treatment outcome is vital to determine which individuals are most likely to benefit from particular treatments and to develop more effective treatments in the future. There is an urgent need for consistent and standardized reporting of factors associated with treatment outcome in all clinical trials

Assessing the Effects of Stress Resilience Training on Visual Discrimination Skills: Implications for Perceptual Resilience in U.S. Warfighters

Current military operational environments are highly improvised and constantly evolving, threatening the lives of U.S. warfighters. For instance, since 2001, 60% of all hostile casualties and 65% of hostile injuries in the Middle East theater have been attributed to improvised explosive devices (IEDs). IEDs are powerful physical weapons, and the stressful atmosphere they, and other operational challenges create, can also result in a range of psychological dysfunctions, including anxiety, depression, alcohol abuse, and Post-Traumatic Stress Disorder (PTSD). Not only are these issues concerning for mental health reasons, they are also problematic in terms of combat performance. Extreme arousal (i.e., stress) negatively affects performance through the suppression of cognitive and physiological resources, which inhibits verbal, perceptual, and motor performance. Perceptual abilities are particularly susceptible to the effects of acute hyperarousal, and the degradation of these abilities may limit warfighters’ threat detection skills. Therefore, military researchers are interested in whether and how the visual perceptual field is changed under stress, and the Services are making predeployment training programs a priority, in an attempt to mitigate these concerns. This dissertation first outlines the cognitive processes related to visual perceptual abilities and how these processes are negatively affected by acute arousal. Current training programs in perceptual skills and stress tolerance are then described, along with recommendations for areas of improvement within the status quo. Based on these recommendations, an experimental procedure and five hypotheses were designed to assess training effects on visual perceptual skills and performance under stress. Experimental outcomes suggest that participants who were trained using a novel integrated perceptual skills plus stress resilience (“perceptual resilience”) program performed faster and with higher accuracy during a stressful threat detection task than participants trained using a perceptual skills-only program and participants trained using an existing status-quo knowledge trainer. Participants in this perceptual resilience training group also reported lower feelings of acute stress and anxiety immediately post-task than the two other training groups who did not receive the stress resilience training component. Based on these outcomes, implications for future military-specific training development, study limitations, and recommendations for future research is presented

A Computer-Based Intervention with Elements of Virtual Reality and Limited Therapist Assistance for the Treatment of PTSD : Efficacy, Acceptance and Future Implications

The main objective of this dissertation was to investigate the overall efficacy, acceptance and future implications of the 3MR (Multi Modal Memory Restructuring) intervention for the treatment of PTSD (‘post-traumatic stress disorder’). The 3MR intervention is a computer-based trauma intervention with elements of Virtual Reality (VR) and limited therapist involvement for the treatment of PTSD. To determine the efficacy of the 3MR intervention, we conducted a randomized controlled trial (RCT) amongst traumatized victims of childhood sexual abuse (CSA) and war veterans. In this trial we compared the effects of the 3MR intervention to those of more regular, evidence-based treatment methods (‘treatment as usual’, TAU). A total of 44 patients with PTSD was included in the RCT and results showed that symptoms of PTSD and depression both significantly decreased and that there was no significant difference found between the two treatment conditions (3MR and TAU). This research may form an adequate first step in the direction of future use of this computer-based intervention for the treatment of PTSD. This research is part of the VESP (‘Virtual eCoaching and Storytelling technology for Post-traumatic stress disorder treatment’) project

Psychological and pharmacological interventions for post-traumatic stress disorder and comorbid mental health problems following complex traumatic events: systematic review and component network meta-analysis

Background: Complex traumatic events associated with armed conflict, forcible displacement, childhood sexual abuse and domestic violence are increasingly prevalent. People exposed to complex traumatic events are at not only at risk of post-traumatic stress disorder (PTSD) but also other mental health comorbidities. While evidence-based psychological and pharmacological treatments are effective for single event PTSD it is not known if people who have experienced complex traumatic events can benefit and tolerate these commonly available treatments. Furthermore, it is not known which components of psychological interventions are most effective for managing PTSD in this population. We performed a systematic review and component network meta-analysis to assess the effectiveness of psychological and pharmacological interventions for managing mental health problems in people exposed to complex traumatic events.Methods and Findings: We searched CINAHL, Cochrane Central Register of Controlled Trials, EMBASE, International Pharmaceutical Abstracts, MEDLINE, Published International Literature on Traumatic Stress, PsycINFO, and Science Citation Index for randomised and non-randomised controlled trials of psychological and pharmacological treatments for PTSD symptoms n people exposed to complex traumatic events, published up to 25th October 2019. We adopted a non-diagnostic approach and included studies of adults who have experienced complex trauma. Complex trauma sub-groups were: veterans; childhood sexual abuse; war-affected; refugees; and domestic violence. The primary outcome was reduction in PTSD symptoms. Secondary outcomes were depressive and anxiety symptoms, quality of life, sleep quality, and positive and negative affect. We included 116 studies, of which 50 were conducted in hospital settings, 24 were delivered in community settings, seven were delivered in military clinics for veterans or active military personnel, five were conducted in refugee camps, four used remote delivery via web based or telephone platforms, four were conducted in specialist trauma clinics, two were delivered in home settings, and two were delivered in primary care clinics; clinical setting was not reported in 17 studies. Ninety-four RCTs for a total of 6158 participants were included in meta-analyses across the primary and secondary outcomes; 19 RCTs for a total of 933 participants were included in the component network meta-analysis. The mean age of participants in the included RCTs was 42.6 ±9.3 years, and 42% were male. Nine non-randomised controlled trials were included. The mean age of participants in the non-randomised controlled trials was 40.6 ±9.4 years, and 47% were male. The average length of follow-up across all included studies at post-treatment for the primary outcome was 11.5 weeks. The pair-wise meta-analysis showed that psychological interventions reduce PTSD symptoms more than inactive control (k=46; n=3389; standardised mean difference, SMD=-0.82, 95% CI: -1.02 to -0.63) and active control (k-9; n=662; SMD=-0.35, 95% CI: -0.56 to -0.14) at post-treatment, and also compared with inactive control at 6-month follow-up (k=10; n=738; SMD=-0.45, 95% CI: -0.82 to -0.08). Psychological interventions reduced depressive symptoms (k=31; n=2075; SMD=-0.87, 95% CI: -1.11 to -0.63; I2=82.7%, p=0.000) and anxiety (k=15; n=1395; SMD=-1.03, 95% CI: -1.44 to -0.61; p=0.000) at post-treatment comparted with inactive control. Sleep quality was significantly improved at post-treatment by psychological interventions compared with inactive control (k=3; n=111; SMD=-1.00, 95% CI: -1.49 to-0.51; p=0.245). There were no significant differences between psychological interventions and inactive control group at post-treatment for quality of life (k=6; n=401; SMD=0.33, 95% CI: -0.01 to 0.66; p=0.021). Antipsychotic medicine (k=5; n=364; SMD=–0.45; –0.85 to –0.05; p=0.085) and Prazosin (k=3; n=110; SMD=-0.52; -1.03 to -0.02; p=0.182) were effective in reducing PTSD symptoms. Phase-based psychological interventions that included skills based strategies along with trauma-focused strategies were the most promising interventions for emotional dysregulation and interpersonal problems. Compared with pharmacological interventions we observed that psychological interventions were associated with greater reductions in PTSD and depression symptoms and improved sleep quality. Sensitivity analysis showed that psychological interventions were acceptable with lower drop out, even in studies rated at low risk of attrition bias. Trauma-focused psychological interventions were superior to non-trauma focused interventions across trauma sub-groups for PTSD symptoms, but effects among veterans and war-affected populations were significantly reduced. The network meta-analysis showed that multi-component interventions that included cognitive restructuring and imaginal exposure were the most effective for reducing PTSD symptoms (k=17; n=1077; mean difference=-37.95, 95% CI: -60.84 to -15.16). Our use of a non-diagnostic inclusion strategy may have over-looked certain complex trauma populations with severe and enduring mental comorbidities. Additionally, the relative contribution of skills-based intervention components were not feasibly evaluated in the network meta-analysis.Conclusions: In this systematic review and meta-analysis we observed that trauma-focused psychological interventions are effective for managing mental health problems and comorbidities in people exposed to complex trauma. Multi-component interventions, which can include phase-based approaches, were the most effective treatment package for managing PTSD in complex trauma. Establishing optimal ways to deliver multicomponent psychological interventions for people exposed to complex traumatic events is a research and clinical priority