Dr Robert London

For Vets With PTSD, Try Behavior Modification

Clinical Psychiatry News - Volume 35, Issue 11, Page 23 (November 2007)

Some years ago, an Army war veteran was referred to me by an orthopedic surgeon for help in dealing with pain secondary to a war injury. The patient had a prosthetic limb, and he complained of pain during our first meeting. From an orthopedic standpoint, his care appeared excellent.

The patient, who was depressed, made it clear during that first session that he was having nightmares and flashbacks over the events of the injury. He described himself as irritable most of the time, full of anxiety, and as a person who saw the world as doomed. He thought that he would be better off dead.

I learned that this young officer had been part of an armored vehicle crew that was blown up in a war-related incident. All of his fellow soldiers had been killed.

The patient was not eager to see yet “another” psychiatrist. He was tired of exploring his past life experiences as a cause for his current distress. Too many times, those explorations omitted the actual stressor that was at the root of his current psychological problems: the death of his buddies in the explosion.

My thought was that this veteran suffered from chronic intractable benign pain syndrome, a disorder that I coined and wrote about around that time (Foot Ankle 1986;7:133-7).

A few years earlier, in 1980, the American Psychiatric Association had recognized posttraumatic stress disorder (PTSD) as an illness in which emotional trauma such as a life-threatening event could trigger a constellations of symptoms.

PTSD was first included in the DSM-III. Before, we referred to the symptoms of PTSD as shell shock, soldier's heart, combat fatigue, or neurocirculatory asthenia, and sometimes as Da Costa syndrome. After DSM-III, for the first time, the mental health professions had a better understanding of this type of acute and chronic stress. And now additional changes to the DSM definition of PTSD could be on the horizon. (See related article, p. 1.)

Current studies report that 1%-3% of the U.S. population is affected by PTSD. Among Vietnam veterans, 30% of veterans were affected, with at least 25% more experiencing subclinical levels (“Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry,” Baltimore: Lippincott Williams and Wilkins, 2002, p. 624). In the current Iraqi and Afghanistan conflicts, I would bet that PTSD is occurring at the same or greater levels as during the Vietnam War.

We know all too well that the comorbidities associated with PTSD can be deadly. One recent study analyzing of 1,946 veterans with symptoms of PTSD showed an increase in both fatal and nonfatal heart attacks among 255 veterans who otherwise had no pre-existing heart disease (Arch. Gen. Psychiatry 2007;64:109-16). The authors indicated that those with more stress were at higher risk. It's clear, then, that the military should make a concerted effort to treat these mental disorders.

One positive sign that the military finally recognizes that mental illness among veterans and soldiers must be addressed is the Department of Defense's new report, “An Achievable Vision: Report of the Department of Defense Task Force on Mental Health.” It emphasizes the importance of allocating sufficient and appropriate resources to prevention, early intervention, and treatment in active duty and military personnel/dependent network systems (“Military to Focus on Improving Mental Health Care,” CLINICAL PSYCHIATRY NEWS, October 2007, p. 1). In addition, I understand that an Institute of Medicine committee recently released a report on PTSD. This panel's findings on what works in treating PTSD–and what does not–are consistent with my own experience. (See related article, p. 3.)

Now back to my veteran, with his severe guilt about being alive, depression, physical pain, and PTSD, plus his resistance to seeing a psychiatrist. My approach was to take a good history during the first interview and then assure him that I would teach techniques to control his flashbacks, insomnia, nightmares, irritability, and anxiety–not just sit around asking questions that were not relevant to the problem at hand. My focus was on those PTSD symptoms because, as I learned about his problems, I began to think that the depression and chronic pain were extensions of what I saw as clear manifestations of the disorder. The orthopedist and neurosurgeon thought that the patient's pain patterns were out of proportion to his injury and the good physical recovery he had made.

I taught the patient some relaxation exercises, and then, when he felt good about using those techniques, I added a reciprocal inhibition/systematic desensitization strategy to the process.

By teaching a 5- to 10-minute self-induced relaxation/hypnosis technique, the first step of the treatment is underway. That is, the relaxation begins the reciprocal inhibition process. As relaxation increases, the anxiety and emotional stressor decrease as the emotional stressors get overwhelmed as relaxation/hypnosis progresses. The patient was well motivated and task oriented, and he took to this technique quickly.

All this fits very nicely into my learning, philosophizing, and action (LPA) technique. We have already learned what happened in the history. Philosophizing about the incident leading to the PTSD might be useful briefly, but the real test is a treatment that gives relief, so I worked mainly with the action part of the LPA technique.

As relaxation and reciprocal inhibition reduce some of the problems, the next step is systematic desensitization. Here, the good history and the patient's willingness to work in the system are essential. A hierarchy of events leading up to the PTSD is developed. I go slowly, attempting to avoid any more emotional trauma by flooding the patient with too much stimuli as the treatment method develops. Using a split-screen technique, I explore with the patient some of the events leading up to the PTSD experience before actually getting to the experience itself. All of this is projected onto the left side of the screen.

Slowly, we move toward the PTSD event or events. As I progress in this, two things occur: 1) the patient learns how to do this himself again and again in the desensitization process, and 2) as the patient adjusts to the hierarchy of anxieties, he becomes less stressed. These traumatic memories that are being projected are always introduced at a slow pace and, as painful as the memories are, it is explained clearly to the patient that they cause no danger to life or limb–they are being seen on the screen, not experienced.

We then link this PTSD visualization on the left side of the imagined movie screen with the right side of the screen, where the patient can develop skills to see himself in any type of pleasant scene. Both the left and right sides of the split screen become linked, and the process completes the desensitization technique.

The veteran and I spent about 3 months together, first biweekly and then more or less weekly for about eight visits. In the end, his flashbacks and nightmares stopped, and he also became less anxious.

Besides my method of treating PTSD, the military's use of virtual reality for veterans returning from Iraq and Afghanistan also holds promise (New York Times, Aug. 28, 2007). With the virtual reality technique, the patient puts on a headset and is taken back through contemporary technology visually and audibly to the PTSD event using flooding/desensitization/in vitro exposure. This is not unlike my split-screen systematic desensitization systematic technique, in which the patient is relieved of the emotional charge in overcoming the PTSD.

What I find most troubling is that, when I speak with young psychiatrists or psychologists, few of them have the slightest idea of how to use behavior modification techniques, let alone have any experience using virtual reality. As newer, more efficient techniques like virtual reality are developed through advances in technology, you would think that every training program in psychiatry or psychology and every hospital/psychiatric outpatient program would be on board in offering these modalities to patients–not only for PTSD, but for many other disorders.

Let me know your thoughts on treating PTSD, including behavior modification and virtual reality, and I'll try to pass them along to my readers.

PII: S0270-6644(07)70714-2