Healing Combat Trauma

Mind Body Medicine: Healing the Wounds of War

When I started this blog over two years ago now, I was hoping that somehow James S. Gordon, M.D., and the Center for Mind-Body Medicine which he founded in Washington, DC, would somehow get involved in the prospect of bringing mind-body medicine to the troops.  Gordon is a Harvard-trained psychiatrist, with impeccable credentials, who has a lifetime interest in expanding patient care into new areas, particularly Complementary and Alternative Medicine (CAM), and mind-body medicine in particular.  (Mind-body medicine is a shorthand way of re-combining the two "halves" of medicine perhaps unjustly sundered in an arbitrary Cartesian mind-body split.  Much of Eastern thought, rather than Western, never saw them divided at all.)  In a previous lifetime, where I interviewed luminaries in the natural medicine field, Gordon was a favorite interviewee - smart, genial and with a very forward-thinking grasp of what mind-body medicine could accomplish.  Gordon, who was featured in the Bill Moyers series on PBS, Healing and the Mind, was a frequent lecturer at the Smithsonian Institution in Washington, DC, and for years had served as the head of the White House Commission on Complementary and Alternative Medicine.  He is also a Clinical Professor in the Departments of Psychiatry and Family Medicine at Georgetown University Medical School.

But more to our purposes, when war broke out in Kosovo, he and the Center for Mind-Body Medicine (CMBM) took their methods into the region, creating a program called "Healing the Wounds of War," to help war-torn schoolchildren and their caregivers manage the trauma they had undergone, through a sustained, devastating conflict.  What I was hoping -- and I kept checking the CMBM website periodically to find out -- was that they would leapfrog off their successes with PTSD in Bosnia and Kosovo, and Israel and the Middle East, and develop something geared to PTSD in servicemembers, and the conflicts in Afghanistan and Iraq.  For years, nothing was obvious (yet), but here's some of their success with children in Kosovo.  Notice what symptoms the program helped with, how impressive the statistics are, and make the conceptual leap to how this might help with combat veterans and/or their families:

The clinical efficacy of the CMBM program with traumatized children has been repeatedly demonstrated. In a pilot study in which high school teachers in the Suhareka region of Kosovo used the CMBM model, levels of posttraumatic stress disorder in high school students were reduced from an average of 88% to 38% in only six weeks (read the research, published in Journal of Traumatic Stress, April 2004, linked here). Participants have also reported the following documented effects of CMBM trainings, including: the alleviation of their own stress and trauma; decreases in anxiety and depression; increased optimism; decreased anger; and increased capacity to help others.

You can read more about the program's specific successes, here.  Or, you can read a general overview of the program and what's involved, here.  You can also read Dr. Gordon's bio, here.

Similarities Explored in How Cops and Troops Experience Trauma Cumulatively, Develop PTSD

Lately we've been taking a look at crucial concept in the linkage between combat trauma and PTSD -- the "dose-response relationship," which is apparently a more or less linear relationship between more combat trauma experienced and greater chance of developing PTSD.  (Earlier blog entries on that topic are linked here and here.)

On the Web, every once in a while you find a gem -- some good and useful material -- in its entirety, and one such "find" is Mary Elizabeth Claire's Ph.D. thesis at Drexel University, available online, called "The Relationship between Critical Incidents, Hostility, and PTSD Symptoms in Police Officers."  (The thesis is linked here.)

While we might prefer her thesis to be about combat veterans and PTSD (heh), the reality is, there's quite a bit of overlap or similarity in how police and veterans experience the events that contribute to PTSD, a fact she explains early on, when she writes:

...Although police officers are usually identified with emergency responders, the context in which police officers experience critical incidents is similar to situations experienced by military veterans. Violanti (1996a) identified six areas of police work that are comparable to the experiences of those that served in the Vietnam War: guerilla warfare at home, the identity of the enemy, a continual sense of insecurity, lack of support, witnessing abusive violence, and depersonalization. The first area, guerilla warfare, is similar to the current plight of many police officers. Violanti (1996a) describes police officers as serving in "peacetime combat."

In a segment entitled, Cumulative Effects of Exposure to Critical Incidents, she writes that:

Learning theory suggests that when an individual is exposed to a repeated stimulus, the person either habituates to the stimuli or becomes sensitized to it. When habituation occurs, the individual reduces their responsiveness to the stimuli while sensitization increases and heightens an individual’s responsiveness. Both behaviors are normal responses but how one reacts to a repetitive stimulus often depends on the intensity of the stimulus. A high intensity stimulus generally tends to sensitize a person to the stimulus while habituation occurs when a person is repeatedly exposed to low to moderate stimuli (Barker, 2001).

It is commonly assumed that individuals that encounter traumatic stressors frequently (e.g., police officers, firefighters) habituate to the stimuli, and therefore they are more resistant to the psychological effects of traumatic incidents. However, the opposing view, that the cumulative effect of critical incidents results in more posttraumatic stress symptoms, has become more empirically supported in recent years (Violanti, 1996b). These findings are congruent with the theories of learning since police officers experience high intensity stimuli on a routine basis thus becoming sensitized, not habituated, to the stimuli.

Several studies have investigated the cumulative effect of critical incidents and the development of PTSD symptoms. For example, Stephens and Miller (1998) conducted a study of 527 New Zealand police officers and found a positive relationship between the number of traumatic events and more PTSD symptoms. Trauma experienced prior to joining the police force was not related to PTSD symptoms while trauma experienced after joining the police force was related to more PTSD symptoms.

Martin et al. (1986) reported that 26% of the 56 police officers attending a sensitive crime seminar met criteria for PTSD. Moreover, the authors found PTSD was related to the number of incidents experienced by the officers. The most frequently endorsed symptom "Recurrent and intrusive recollection of the event" was endorsed by 47 % of the police officers. Martin et al. (1986) indicated it is not surprising that this symptom was endorsed most frequently since police officers continually place themselves in situations similar to previous traumatic incidents and have little opportunity to distance themselves from the incident. Likewise, only 11% of the officers reported in engaging in active avoidance of activities. Moreover, sensitization to the repetitive trauma appeared to occur for these police officers as evidenced by the frequent endorsement of hyperarousal and exaggerated startle response.

Mitchell (1999) reported on the qualitative descriptions of 426 officers above the rank of probationer in the United Kingdom. The officers were asked to describe the most memorable critical incident they experienced during their police career. Almost 75% of the descriptions involved death, and almost 33% of the deaths described involved traffic accidents. Although the Lockerbie Disaster and the crash of the RAF Chinook helicopter were frequently reported, traffic accidents were the largest category of memorable critical incidents described. Different occupational groups within the police department participated, however, 60% of the traffic incidents described as memorable and distressing were reported by current members of the traffic division. Thus, it appears that these officers did not habituate to the incidents in which they were commonly exposed, but instead became sensitized to such incidents. Additionally, the length of time since the accident ranged from two weeks to 25 years with a mean of 5.6 years, indicating that time did not ameliorate the impact of critical incidents in this sample.

Neylan et al. (2002) investigated the impact of critical incident exposure on the quality of sleep in 747 police officers from New York, New York, and Oakland and San Jose, California. The investigators found that cumulative critical incident exposure was associated with nightmares, a symptom of PTSD. Furthermore, sleep disturbances were strongly related to PTSD symptomatology and general psychopathology.

Sleep disturbances and how they contribute to PTSD is another well-deserved treatment that we'll have to leave, though, for another time...

The Dose-Response Relationship with PTSD: More Combat = More PTSD, Earlier Study Shows

"If you aim for simplicity, you must first master complexity" -- said the 17th century Chinese painter, Wang Kai. Almost 400 posts in on this blog, I still enjoy the moments when something profoundly complex like combat trauma is nevertheless reduced to something quite simple to understand.  Here's one such observation: the more combat one is exposed to, the greater the chances of experiencing PTSD.  Makes sense, doesn't it?  Although we've talked about that concept recently on this blog -- with a great graphic that shows the linear relationship quite profoundly, that entry linked here -- here's another, earlier study that says the same thing, in an article linked here.

Researchers who went back and analyzed two conflicting, large-scale studies of PTSD -- one done by the Centers for Disease Control (CDC), the other the National Vietnam Veterans' Readjustment Study -- found, among other things, that although "most veterans who experienced very highly traumatic events did not develop PTSD," still, the more war trauma a veteran experienced, the higher a veteran's odds of developing PTSD.  Researchers called this the "dose-response relationship," and said their work, going back over the two major studies and attempting to reconcile their findings, found that it was "even stronger than previously reported."

SOURCES: Dohrenwend, B.P. Science, Aug. 18, 2006; Vol. 313: pp. 979-982. McNally, R.J. Science, Aug. 18, 2006; Vol. 313: pp. 923-924.

Not Specific to Combat, Research Project Studies Use of Tibetan Meditation to Treat PTSD

Although not specifically directed towards combat veterans and PTSD, a research study is currently evaluating whether Tibetan meditation has benefit for PTSD sufferers. Miami and Ohio State university researchers will use an ancient technique to address a modern problem. With a $98,000 grant from the Ohio Department of Mental Health, Deborah Akers, Miami visiting assistant professor of anthropology, will work with co-researchers from Ohio State on a project titled "Treatment of Trauma Survivors: Effects of Meditation Practice on Clients' Mental Health Outcomes."  (For more information about the department conducting the study, click here.) Akers and co-researchers Moyee Lee, professor of social work, and Amy Zaharlick, professor of anthropology, will investigate the impact of Tibetan meditation on victims of post-traumatic stress disorder (PTSD). The project began this month and will continue for two years.

Researchers will work with a group of women diagnosed with PTSD who live in Amethyst House, a women's treatment program for alcohol and drug addiction in Columbus. Tibetan monk Geshe Kalsang Damdhul of the Institute of Higher Buddhist Dialectics in Dharamsala, India, will assist as a meditation instructor. "Participants will be taught specialized meditation techniques and will be guided through meditation for a period of six weeks," said Akers. Results could then provide a new option for treating other victims of PTSD, such as combat soldiers returning from war or victims of natural disasters such as Hurricane Katrina. "This project charts new ground, bringing a holistic perspective to the treatment of PTSD," said Akers. She added that though meditation has been used in a variety of therapeutic settings in the West, such as reducing stress and coping with pain,its application in the treatment of mental illness, including PTSD, has not been extensively explored.

 

"Whereas in the West treatment of PTSD may require years of prescription medicine and counseling, the Tibetan approach has been successful within one to two years by focusing on the spiritual connection between the mind and the body that seems to allow the patient to process the trauma more effectively," said Akers. "Moreover, unlike Western medical therapies, meditation is free and can benefit individuals who cannot afford extensive therapy or medicine over long periods of time. The Tibetan approach is empowering, as it offers PTSD patients an alternative and less invasive form of therapy and enables them to participate in their own treatment." The project grew from a Miami summer field school program, "Peoples and Cultures of Tibet," conducted in Dharamsala, the residence of the spiritual leader of the Tibetans, the Dalai Lama, and location of the Tibetan government in exile. During the field school, Akers and Miami students learned about how Tibetan monks minister to political prisoners and victims of torture who suffer from PTSD. For more information about the program, click here.) Several Miami pre-med and anthropology students will assist in the Columbus project, gaining hands-on research experience.

"The PTSD research project and the summer field program in Dharamsala exemplify Miami University's continuing interest in South Asia," said Akers.

More Combat = More Trauma, and More Chance of Developing PTSD, Study Shows

For anyone who's every wondered about whether troops' increased exposure to combat trauma results in greater chances of their developing PTSD, the answer is a definite "yes," according to a study released in the February issue of the Psychiatric Times, linked here.  The article from which excellent graphic (left) is taken is entitled, "Posttraumatic Stress Disorder in Veterans," and it makes the point that cumulative exposure to combat trauma predicts PTSD in a linear fashion.  Less exposure (fewer firefights) -- lower rates of PTSD; higher exposure (greater number of firefights) -- higher rates of PTSD.  According to the article, it really is that simple.

The article's authors cite an earlier published report of OIF (Iraq) and OEF (Afghanistan) servicemembers, and found high rates of exposure to both "traumatic situations and combat."  "According to the study, about 33% of soldiers in Afghanistan and 71% to 86% of soldiers in Iraq experienced a firefight. PTSD rates ranged from 6.2% for veterans of Afghanistan's OEF to more than 12% for OIF veterans. The risk of PTSD was found to increase linearly with the number of firefights (see graphic, above). Having been wounded, a condition previously found to be predictive of PTSD, was also significantly associated with PTSD. As is commonly found in patients with PTSD, rates of depression and alcohol use also increased following combat exposure."

When we think of tragic stories of what we can only assume to be PTSD-fueled incidents in the news -- the recent suicide of Marine SSgt. Travis Twiggs, the arrest of Marine LCpl. Eric Acevedo for murder, and others like them -- we should really stop to pause and wonder, how many times have these servicemembers been deployed, for how long have they been in combat, and to what have they been exposed (meaning, how many firefights)?  Twiggs, it turns out, had done four(!) tours of Iraq, and one of Afghanistan (earlier reports mentioned four total, but they were wrong); Acevedo had done three tours of Iraq by the time he was 22, including one that involved a horrific battle, where 10 members of his battalion died on a single day, and several others were wounded.  To not take the effects of their cumulative exposure -- what they saw, did, were witness to -- is just unconscionable.  We have a very love-hate relationship with the glory of serving in this country: we glorify our military heroes for their astounding feats of endurance (Brad Kasal, the Marlboro Marine, etc.), but we also equally unreasonably vilify them when they crack under the all-too-obvious strain.  It seems like what we need most of all is just the sober estimation: the more servicemembers have gone through -- and suffered -- the more we can expect them to have problems later on, with developing PTSD.  As noted Australian Vietnam War researcher Hedley Peach said in a slightly different context, what we're really looking at here is not something unusual -- it's the generic effects of combat.

Making Art from War: Art Therapy as a Treatment for Combat Veterans

A recent article entitled, "Art Therapy for Combat-Related PTSD: Recommendations for Research and Practice," make the heavily-referenced case that we shouldn't overlook art therapy's potential for treating PTSD in combat veterans -- particularly because of its nonverbal nature, and its ability to integrate and express experience trapped below the level of conscious thought.  Typically, art therapy has been under-studied, or studied with victims of trauma who are children, not combat veterans -- but over time, those facts are changing.  The article, linked here, and referenced in a previous blog post linked here, is well worth reading.

They introduce their argument by saying (citations are everywhere in the original article, I'm leaving them out of this summary) that PTSD is difficult to treat in part because no single treatment has emerged as the clear leader, with effectiveness across the board.  Similarly, PTSD can be somewhat intractable to treat because any trauma severe enough to cause PTSD seems to affect the brain's underlying physiology.  Pharmaceutical drugs and talk therapy, among other treatments, are commonly-used approaches for treating PTSD, but the attractiveness of art therapy as a treatment is expressly because of its non-verbal nature.  It has the potential to allow combat veterans to process and integrate what has happened to them, without specifically requiring them to talk about it -- something many veterans are reluctant to do.

Some interesting points from the article:

PTSD is thought to be caused in part by the nature of traumatic memories, which are encoded in implicit as well as declarative memory systems and are likely to exist primarily as dissociated emotional, perceptual, or sensory fragments with no coherent verbal, symbolic, or temporal basis (O’Kearney & Perrott, 2006; Reisberg & Hertel, 2004).

Furthermore, implicit and declarative memories of an event can become disconnected due to trauma. These qualities of traumatic memory make it hard to describe traumatic experiences in words or to “integrate” them as part of one’s life story (Christianson, 1992; van der Kolk,Hostetler, Herron, & Fisler, 1994). The failure to process information symbolically (verbally or otherwise) after a trauma is thought to be a core element of PTSD (van der Kolk & Fisler, 1995). Indeed, brain imaging research has demonstrated hypoactivity in Broca’s area, which is involved in the motoric aspects of speech, and hyperactivity in the amygdala (fear, anger), hippocampus (memory), and occipital cortex (visual processing), among veterans with PTSD (Rauch & Shin, 1997).

By their nature, traumatic memories are difficult to express in words alone. Non-verbal expression, as is used in art therapy, can facilitate both the shift to declarative memory and the creation of a coherent narrative. The narrative can be pictorial rather than verbal. Indeed, visual imagery may be necessary for the symbolic processing involved in constructing a trauma narrative (van der Kolk & Fisler, 1995).

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Additionally,

Although art therapy has not been extensively researched, a number of small studies of art therapy for veterans with PTSD have yielded promising results. In a study designed to identify which components of a specialized inpatient PTSD program (SIPU) were most effective, Johnson and colleagues (1997) found that art therapy was the only component among 15 standard SIPU components, such as group therapy, drama therapy, community service, anger management, and journaling, that produced the greatest benefits for veterans with the most severe PTSD symptoms. (The other 14 components were most effective for those with the least severe symptoms.) They also found art therapy to be exceptional in that the veterans could tolerate war-zone content during art therapy and could not do so during other activities. The authors surmise that art therapy was more effective than other therapies because it provided pleasurable distraction in conjunction with exposure to difficult content and thus allowed traumatic material to be processed without the negative short-term side effects of verbal introspective interventions. Other studies also have found art therapy to be more effective than verbal therapy for veterans with PTSD. Morgan and Johnson (1995) assessed a drawing task for treating nightmares in combat-related PTSD and found that those who did the drawing task when they were awakened by nightmares had fewer and less intense nightmares than those who did a writing task.

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Editor's Note: To learn more about art therapy, or to find an art therapy practitioner who may have some experience with PTSD (and there could be very few who do), contact the American Art Therapy Association, Inc., 11160-C1 South Lakes Drive, Suite 813, Reston, VA 20191.  Tel.: (888) 290-0878 or
(703) 212-2238.  Their website is linked here.

Acupuncture May Help PTSD Sufferers

Acupuncture May Help Symptoms of Posttraumatic Stress Disorder

A pilot study by researchers at the University of Arizona's Department of Psychiatry shows that acupuncture may help people with posttraumatic stress disorder. Posttraumatic stress disorder (PTSD) is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat.

Michael Hollifield, M.D., and colleagues conducted a clinical trial examining the effect of acupuncture on the symptoms of PTSD. The researchers analyzed depression, anxiety, and impairment in 73 people with a diagnosis of PTSD. The participants were assigned to receive either acupuncture or group cognitive-behavioral therapy over 12 weeks, or were assigned to a wait-list as part of the control group. The people in the control group were offered treatment or referral for treatment at the end of their participation.

The researchers found that acupuncture provided treatment effects similar to group cognitive-behavioral therapy; both interventions were superior to the control group. Additionally, treatment effects of both the acupuncture and the group therapy were maintained for 3 months after the end of treatment.

The limitations of the study are consistent with preliminary research. For example, this study had a small group of participants that lacked diversity, and the results do not account for outside factors that may have affected the treatments' results.

Michael Hollifield, Nityamo Sinclair-Lian, Teddy D. Warner, and Richard Hammerschlag, "Acupuncture for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial." The Journal of Nervous and Mental Disease, June 2007.

PTSD Elevates Risk of Other, Chronic Health Problems

Geisinger research finds that veterans suffering from posttraumatic stress disorder (PTSD) are as likely to have long-term health problems as people with chronic disease risk factors such as an elevated white blood cell counts and biological signs and symptoms.

However, few healthcare providers screen for PTSD in the same way as they screen for other chronic disease risk factors. “Exposure to trauma has not only psychological effects, but can take a serious toll on a person’s health status and biological functions as well,” Geisinger Senior Investigator Joseph Boscarino, PhD, MPH says. “PTSD is a risk factor for disease that doctors should put on their radar screens.”  (Click here to listen to a podcast of Dr. Boscarino discussing the study.)

For this study, Dr. Boscarino examined the health status of 4,462 male Vietnam-era veterans 30 years after their military service. Results are being published in the current edition of the Journal of Nervous and Mental Disease. The study finds that having PTSD was just as good an indicator of a person’s long-term health status as having an elevated white blood cell count. An elevated white blood cell count can indicate a major infection or a serious blood disorder such as leukemia.

The study also found that veterans with high erythrocyte sedimentation rate (ESR), which indicates inflammation, were also at risk. There was a similar finding for a possible indicator of serious neuroendocrine problems. While these disease markers are measured with a blood test, PTSD is commonly measured with a psychological test or a mental health examination.

This research comes as Geisinger is organizing a national conference on May 13 to address PTSD in combat veterans from rural parts of the country. Boscarino says that almost anyone who experiences a traumatic event can experience PTSD, meaning accident and disaster victims are also predisposed to the biological risk factors associated with PTSD. (Click here for the link to that conference.)

Although therapy doesn't necessarily have to be extensive, Boscarino says it should occur shortly after a person has experienced a traumatic event. Early treatment may be critical to avoiding depression, PTSD and substance abuse-related problems following trauma. “As the conflicts in the Middle East continue, we’re seeing a new wave of our service members who have posttraumatic stress,” says Boscarino, a Vietnam veteran. “If we don’t get these personnel help earlier, our research shows that they may experience more serious health problems down the road.”

Dr. Boscarino is one of the country’s leading authorities on PTSD and has published extensively on the topic. His prior research has established links between PTSD and the increased likelihood of death by unnatural causes and between PTSD and individual soldiers’ dexterity levels.

Founded in 1915, Geisinger Health System (Danville, PA) is one of the nation’s largest integrated health services organizations. Serving more than two million residents throughout central and northeastern Pennsylvania, the physician-led organization is at the forefront of the country's rapidly emerging electronic health records movement. Geisinger is comprised of three medical center campuses, a 700-member group practice, a not-for-profit health insurance company and the Center for Health Research—dedicated to creating innovative new models for patient care, satisfaction and clinical outcomes.

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Editor's Note: the figured featured in the statue is Asclepius, the ancient demi-god of medicine and healing.

PTSD Articles in English and Spanish

aContinuing our series of posts on how to find out more about PTSD and combat trauma, in terms of current medical and psychological research being done, here's what a search for "PTSD" on MedLinePlus came up with, as of today: 219 hits, on topics as varied as the following.  (Spanish speakers can find a Spanish-speaking version of MedlinePlus en Espanol here.)  "Hits" from the English language search referenced above included:

• What Can I Do If I Think I Have PTSD;
• How Common is PTSD?
• How is PTSD Measured?
• Discussing Trauma and PTSD with Your Doctor;
• Women, Trauma and PTSD;
• Treatment of PTSD;
• FAQs about PTSD Assessment;
• VA Programs for Veterans with PTSD;
• Coping with PTSD and Lifestyle Changes;
• PTSD and Older Veterans;
• PTSD and Physical Health;
• PTSD and the Family;
• PTSD and Problems with Alcohol Use;
• PTSD and Suicide;
• Sleep and PTSD;

Clearly, these online databases, provided free by the Federal government -- our tax dollars at work! ;-) -- can be invaluable, "one stop shopping" type places to learn more information and to share the information with others (family members, friends, co-workers, healthcare workers, social workers, combat veterans, etc.) who want to learn more about combat trauma and PTSD.  And don't forget this website, where we're trying to keep as current as possible about everything worth knowing on the topic of combat trauma and PTSD, in particular what resources are available for and about healing it.

Where to Find Recent Medical Studies on PTSD and Combat Trauma

Well, the Inner Librarian got a little, er hem, carried away in that last blog post on how to search online databases effectively for articles on PTSD and combat trauma -- and where those articles are to be found -- but, we didn't really get around to telling you WHAT you could find in those searches.  Of course, it's better to do them yourself, but here's just a taste of what you can find by doing a search at the ...

In PubMed, if you do a search for "PTSD combat trauma" -- to pull in articles that talk about both -- important because not all PTSD is combat-related, as of today's date you can find ar