Enhancing Outcomes for Military Personnel and Their

Families

Deborah C. Beidel, Ph.D., ABPPUniversity 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 – 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– 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

– 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

• 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

Epidemiology of PTSD

Rosenheck R A , Fontana A F Health Aff 2007;26:1720-1727

©2007 by Project HOPE - The People-to-People Health Foundation, Inc.

So Why Not Just Go and Get Treatment?

• 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

Current Status of Available Treatments

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

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Within Session Habituation

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Between Session Habituation

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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

• 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

Why Include Olfaction in VR?

• 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

What is the efficacy of exposure for PTSD?

Trauma Management Therapy• A multi-component intervention consisting of

– Exposure therapy (individual)– Skills training and behavioral activation (group)

• 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: 08214003Award Date: 11/15/10 – 11/14/15Contract Officer: Susan Dellinger, Ph.D.Science/Grants Off: Officer: Dwayne L. Talliaferro, PhD.Portfolio Manager: Ronald Hoover, Ph.D.

Study Design

17 week program17 week program 3 week intensive program

3 week intensive program

TMT: EXP in am Group in pm

TMT: EXP in am Group in pm

EXP: 3x/wk for 5 weeks

EXP: 3x/wk for 5 weeks

SERSERPsychoed

& Rap Psychoed

& Rap

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 % using that combination

No VR 21.4%Used visuals only 1.8%Used sounds only 7.1%Used smells only 0.0%

Used visuals and sounds 1.8%Used visuals and smells 0.0%Used sounds and smells 55.4%

Used visuals, sounds and smells 12.7%

n=56

Does exposure produce side-effects in combat-PTSD?

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: 11356008Award Date: 1/15/13 – 1/14/17Contract 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