Firefighter-Paramedic With Posttraumatic Stress Disorder, Horrific Images, And Depression: A Clinical Case Study

Despite the existence of evidence-based treatments for posttraumatic stress disorder (PTSD), no identifiable study reported delivery of exposure therapy for a first responder with PTSD, as well as horrific images that generalized beyond the index trauma to loved ones. Horrific images have been defined as strongly aversive intrusive thoughts such as images of dismembered bodies or disgusting scenes. This clinical case describes the assessment and treatment of Ryan, a 41-year-old, firefighter-paramedic who completed a multifaceted intervention that included imaginal exposure therapy, behavioral activation, and cognitive therapy for depression. PTSD symptoms as measured by the PTSD Checklist for DSM-5 (PCL-5) displayed a clinically significant decrease from 25 at pretreatment to 3 at 2-month-follow-up, indicating Ryan no longer met diagnostic criteria for PTSD. In addition, Ryan endorsed a clinically significant reduction in horrific images from 21 per week at pretreatment to 0 at 2-month-follow-up. Depressive symptoms as measured by the Beck Depression Inventory–Second Edition (BDI-II) demonstrated a clinically significant decrease from 18 at pretreatment to 1 at 2-month-follow-up, indicating Ryan no longer met diagnostic criteria for depression. This clinical case study provides evidence for the feasibility and effectiveness of delivering a multifaceted intervention for a first responder with multiple psychiatric disorders

Comprehensive Treatment: Intensive Exposure Therapy For Combat-Related Ptsd And Comorbid Conversion Disorder

This clinical case describes the assessment and treatment of Roger, a 31-year-old veteran who served in Operation Iraqi Freedom. In addition to combat-related post-traumatic stress disorder (PTSD), Roger presented with a conversion disorder (globus pharyngeus) and avoidance of consuming solid food without also consuming alcohol. A multicomponent treatment program for PTSD, trauma management therapy (TMT), was provided 5 times per week over a 3-week period. TMT included daily-exposure therapy (EXP) as well as daily social and emotion regulation (SER) group therapy to target anger, social withdrawal, and depression. In addition to TMT, exposure to food consumption in the absence of alcohol was provided in the final week. PTSD symptoms were assessed via semi-structured interview and self-report measures, while food intake was assessed via behavioral observation. PTSD symptoms as measured by the Clinician-Administered PTSD Scale (CAPS) decreased from 63 at pre-treatment to 17 at post-treatment, indicating that Roger no longer met criteria for PTSD. Exposure to food intake was equally successful with Roger consuming full meals (e.g., hamburger and french fries) without consuming alcohol. This case study exemplifies the successful use of intensive exposure therapy to target comorbid anxiety-based disorders in a short period

Olfactory Stimuli Increase Presence In Virtual Environments

Background Exposure therapy (EXP) is the most empirically supported treatment for anxiety and trauma-related disorders. EXP consists of repeated exposure to a feared object or situation in the absence of the feared outcome in order to extinguish associated anxiety. Key to the success of EXP is the need to present the feared object/event/situation in as much detail and utilizing as many sensory modalities as possible, in order to augment the sense of presence during exposure sessions. Various technologies used to augment the exposure therapy process by presenting multi-sensory cues (e.g., sights, smells, sounds). Studies have shown that scents can elicit emotionally charged memories, but no prior research has examined the effect of olfactory stimuli upon the patient\u27s sense of presence during simulated exposure tasks. Methods 60 adult participants navigated a mildly anxiety-producing virtual environment (VE) similar to those used in the treatment of anxiety disorders. Participants had no autobiographical memory associated with the VE. State anxiety, Presence ratings, and electrodermal (EDA) activity were collected throughout the experiment. Results Utilizing a Bonferroni corrected Linear Mixed Model, our results showed statistically significant relationships between olfactory stimuli and presence as assessed by both the Igroup Presence Questionnaire (IPQ: R2 = 0.85, (F(3,52) = 6.625, p = 0.0007) and a single item visual-analogue scale (R2 = 0.85, (F(3,52) = 5.382, p = 0.0027). State anxiety was unaffected by the presence or absence of olfactory cues. EDA was unaffected by experimental condition. Conclusion Olfactory stimuli increase presence in virtual environments that approximate those typical in exposure therapy, but did not increase EDA. Additionally, once administered, the removal of scents resulted in a disproportionate decrease in presence. Implications for incorporating the use of scents to increase the efficacy of exposure therapy is discussed

Combat-Related Guilt And The Mechanisms Of Exposure Therapy

Exposure therapy (EXP) is one of the most widely used and empirically supported treatments for PTSD; however, some researchers have questioned its efficacy with specific populations and in targeting specific symptoms. One such symptom, guilt, has garnered increased attention in the PTSD treatment literature, as it is associated with worse symptomatology and outcomes. The current study examined cognitive changes in guilt in response to Intensive (3-week) and Standard (17-week) Trauma Management Therapy (TMT), and the potential mechanisms underlying TMT treatment. TMT is an exposure based intervention that does not include an emotional processing component after the imaginal exposure session. A portion of the sample completed measures of guilt. As a result, sample size for these analyses ranged from 39 to 102 and varied by the domain and measure. Of the 102 individuals that completed the PTSD Checklist- Military Version, 42 completed the Trauma Related Guilt Inventory, and 39 completed the Clinician Administered PTSD Scale supplemental guilt items. Participants reported significant reductions in trauma-related guilt symptoms over the course of the TMT interventions. Greater reductions in avoidance and prior session general arousal predicted the reduction of guilt symptoms. Exposure therapy may be effective in reducing trauma-related guilt even in the absence of the emotional processing component of treatment

The Efficacy Of Trauma Management Therapy: A Controlled Pilot Investigation Of A Three-Week Intensive Outpatient Program For Combat-Related Ptsd

Despite the 8–18.5% of returning Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn (OND) veterans who are suffering from posttraumatic stress disorder (PTSD), few receive empirically supported treatments. Among those that do, the dropout rate is high and more than 50% retain their diagnosis after treatment. This study evaluated the efficacy of Trauma Management Therapy (TMT), delivered in a 3-week intensive outpatient (IOP) format. TMT combines virtual-reality augmented individual exposure therapy with a group intervention to address social isolation, anger, and depression. One hundred twelve (112) OIF/OEF/OND veterans and active duty personnel participated. Assessment included measures of PTSD, sleep, depression, anger, guilt, and social isolation, administered at post-treatment, 3-month, and 6-month follow-up. The effect size for TMT delivered in an IOP format was 2.06, with 65.9% no longer meeting diagnostic criteria for PTSD. There were similar positive effects in other domains and treatment gains were maintained at 6-month follow-up. The results are discussed regarding the need for efficacious, multi-component interventions that can be delivered safely and rapidly, and the potential of this approach towards that end

Maladaptive Cardiac Autonomic Control During A Stress Reactivity Assessment Among Primary Care Patients With Metabolic Syndrome

Metabolic syndrome (MetS) comprises a constellation of metabolic abnormalities that substantially increase risk for chronic illnesses. Autonomic dysregulation is closely linked to MetS, and while pathophysiological models often address chronic stress exposure, none have examined how such physiological contributions operate situationally, in a clinical setting. We used ambulatory impedance cardiography to examine indicators of cardiac autonomic control (CAC) in a sample of 50 adult primary care patients with and without MetS. Indices of independent sympathetic and parasympathetic cardiovascular control in primary care outpatients were measured during a brief stress reactivity assessment. We compared interdependent CAC features, including cardiac autonomic balance (i.e., sympathovagal reciprocity) and cardiac autonomic regulation (i.e., sympathovagal coactivation) and found significant differences among MetS participants as compared to healthy controls. In particular, cardiac autonomic regulation scores were higher among MetS patients when discussing medication concerns, and cardiac autonomic balance scores were lower among MetS patients when discussing daily stressors. These results suggest that patients meeting criteria for MetS demonstrate momentary variations in CAC depending on personally relevant health topics. The potential for future research is discussed with a focus on prospective data collection to enhance diagnostic procedures and treatment monitoring

An Intensive Outpatient Treatment Program For Combat-Related Ptsd: Trauma Management Therapy

An estimated 18.5% of veterans returning from Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn are suffering from posttraumatic stress or posttraumatic stress disorder (PTSD). The number of veterans and service duty personnel requesting VA health care services is increasing, and the VA\u27s ability to handle requests is dwindling. Thus, both the content of interventions and the format by which these services are delivered need to be reconceptualized. The authors present a multicomponent intervention program known as Trauma Management Therapy (TMT), a comprehensive, empirically supported treatment that can be delivered in an intensive, 3-week outpatient format. TMT combines individual exposure therapy with group social and emotional rehabilitation skills training to address specific aspects of the combat-related PTSD syndrome. The authors present the format of this novel intensive outpatient program, describe the components, and address implementation factors such as treatment compliance, dropout rates, and administrative considerations

Evidence-Based Practice For Posttraumatic Stress Disorder

This chapter briefly reviews the evidence for other posttraumatic stress disorder (PTSD) interventions so as to provide a comprehensive summary of treatment options for the disorder. The appropriate use of evidence-based practices, administered as soon as possible after return from deployment, may offer the best hope for alleviating PTSD and preventing subsequent occupational, social, and familial impairments. A number of etiological pathways and causal mechanisms have been implicated in the development of PTSD. PTSD is a severe psychiatric disorder resulting from a history of exposure to a traumatic event that results in a minimum threshold of symptoms across four symptom clusters namely: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. Additional criteria relate to duration of symptoms, functioning, and differential diagnosis due to a substance or other co-occurring condition

Neurophysiological Response To Olfactory Stimuli In Combat Veterans With Posttraumatic Stress Disorder

There is a need for a better understanding of underlying pathology in posttraumatic stress disorder (PTSD) to develop more effective treatments. The late positive potential (LPP) amplitude fromelectroencephalogram has been used to assess individual differences in emotional reactivity. There is evidence that olfaction is particularly important in emotional processing in PTSD. The current study examined LPP amplitudes in response to olfactory stimuli in 24 combat veterans with PTSD and 24 nonmilitary/non-PTSD controls. An olfactometer delivered three negatively valenced odorants, with 12 trials of each delivered in a random order. The groups did not differ in LPP amplitude across odorants. However, within the PTSD group, higher Clinician-Administered PTSD Scale scores related to an increased LPP amplitude after diesel fuel and rotten egg, but not n-butanol, odorants. Results provide specific targets and theory for further research into clinical applications such as selection of idiographic odorants for use in virtual-reality exposure therapy

A Functional Near-Infrared Spectroscopy Study Of Trauma-Related Auditory And Olfactory Cues: Posttraumatic Stress Disorder Or Combat Experience?

The prevalence of posttraumatic stress disorder (PTSD) among U.S. veterans deployed to Iraq or Afghanistan necessitates the need for comprehensive assessment and treatment strategies. This study investigated the utility of a combat-related PTSD symptom provocation paradigm to elicit unique neurological responses across three groups: combat veterans with PTSD, combat veterans without PTSD, and nonmilitary participants without PTSD. Using functional near-infrared spectroscopy (fNIRS) the results indicated that combat veterans with PTSD demonstrated significant activation to a trauma-related sound compared with nonmilitary personnel, channel 14: d = 1.03, 95% confidence interval (CI) [0.28, 1.76]; channel 15: d = 1.30, 95% CI [0.53, 2.06]; and combat veterans without PTSD, channel 14: d = 0.87, 95% CI [0.14, 1.59]. Specifically, this increased neural activation was approximately located in the right medial superior prefrontal cortex (Brodmann areas 9/10), an area associated with experiencing negative or threatening stimuli and emotional detachment. There were no differences across the groups for nontrauma-related sounds. Results were less clear with respect to a combat-related odor. These results suggest a specific neurophysiological response to trauma-related cues and, if replicated, may offer a biomarker for combat-related PTSD. Such a response could provide incremental validity over diagnostic assessments alone and assist in planning and monitoring of treatment outcome