B0038M1ADS EBOK (38 page)

In summary, there have been very few studies of the effectiveness
of combining different psychotherapies or psychotherapy plus medications, particularly in combat veterans, but the presumption is that we can
improve outcomes by combining treatments. Everyone responds differently to treatment, and there is no one-size-fits-all approach. The best
advice is to find someone you're comfortable working with and try whatever method they suggest; if that doesn't work as well as you would like,
then inquire into other options. Explore your options until you find the
formula that works for you.

Psychotherapy

The most common forms of psychotherapy for PTSD that are evidencebased are cognitive behavioral therapy, which includes exposure therapy and
cognitive restructuring (also called "cognitive reframing" or "cognitive processing"); Eye Movement Desensitization and Reprocessing (EMDR); and stress
inoculation training. All of the cognitive behavioral therapies and EMDR involve a combination of exposure therapy (either talking about or writing
your story), analysis of thinking patterns (cognitions), and body relaxation
exercises, along with a supportive connection with the therapist.

Many of the LANDNAV skills in this book are drawn from the techniques used in psychotherapy, which I converted into self-help learning
skills. For instance, the resiliency inoculation training and narration
skills in chapters 6 and 7 contain the key elements of imaginal and invivo exposure therapy. Examples of cognitive restructuring have been
woven throughout the book, such as the exercises to reduce "shoulds,"
the exercises related to control and intolerance of mistakes, the discussion of catch-22s, and the emphasis on viewing yourself in a positive manner. Techniques drawn from stress inoculation training include muscle
relaxation, breathing exercises, and mindfulness meditation, as detailed
in chapter 5, as well as some of the training related to anger in chapter 7.
The material on loss, guilt, complex emotions, and acceptance coming up
in the next chapter also include elements of cognitive restructuring.

Below is a brief description of the most common forms of psychotherapy. Most of these therapies require at least ten to twelve sessions to be
effective (and often many more). They are usually administered individually, although they are sometimes incorporated into group therapy.

A) Exposure Therapy

The elements of exposure therapy have already been extensively discussed
in chapters 6 and 7. The essential elements include talking about your experiences with the therapist in a structured manner, or writing about them and
going over the writing in the therapy session. It also includes various exercises to reduce the tendency to avoid situations that trigger strong reactions.
This form of therapy has the strongest scientific evidence for effectiveness.

B) Cognitive Restructuring / Cognitive Reframing / Cognitive
Processing

This therapy involves analyzing your thoughts and reactions to situations
and combating negative ways of thinking, such as negative beliefs about yourself. Trauma, combined with other experiences you may have had
before and after service, can lead to ways of thinking that can negatively
affect your mood and perception of yourself. Examples include "should"
statements, taking things too personally, all or nothing, leaping to conclusions, focusing only on the negative, oversimplifying things or overgeneralizing, making a mountain out of a molehill, beating up on yourself,
altered perception of safety (viewing relatively safe situations as unsafe),
and excessive guilt. This type of therapy involves analyzing your thought
processes, identifying when you're using some of these negative patterns,
and then identifying new ways of thinking. It's a way of changing programs in your brain that keep you stuck and are affecting your mood and
functioning. The term cognitive processing therapy refers to a therapy that
combines cognitive reframing (processing) with written exposure and
relaxation exercises.

C) Eye Movement Desensitization and Reprocessing (EMDR)

EMDR combines body awareness and relaxation exercises, exposure
therapy, and cognitive restructuring. The exposure component involves
talking about and/or visualizing traumatic experiences while the therapist guides you to move your eyes back and forth horizontally in a rhythmic manner, combined with processing of beliefs or thoughts associated
with the experiences. The eye movements are thought to stimulate both
sides of the brain to help integrate traumatic memories. However, there
is evidence that the eye movements themselves are not necessary, and the
essential element is probably similar to other forms of exposure therapytelling your story to someone who cares, and who can provide feedback in
a supportive way.

D) Stress Inoculation Training

This includes a variety of exercises to reduce anxiety, such as muscle relaxation, diaphragmatic breathing, and "stopping" certain thought patterns.
Again, many of these principles have been incorporated into the training
in this book.

E) Group Therapy

Group therapy doesn't appeal to a lot of warriors who may be uncomfortable speaking about their problems in a group. Group therapy also has
the least amount of research to support its effectiveness. However, this
type of therapy can be a wonderful experience if the group has the right
composition of members and a good facilitator, because it puts you in
contact with other warriors who are going through similar difficulties and
can appreciate your experiences. Many war-related reactions have similarities or common elements, despite vast differences in the actual events. It
can be a tremendous relief to meet other warriors who have gone through
similar difficulties as you. Sharing your experiences in a group or listening
to others can reduce the burden that each individual carries. It can help
to feel less alone and more connected with others.

Most group therapy sessions last sixty to ninety minutes, and the
ideal size is around eight to twelve people. If you're considering group
therapy, find out whether it only includes combat veterans and whether
it's a closed group (one that doesn't change membership over the
course of treatment) or an open group (one that allows new members
in because the group is ongoing). If you can find a group that's geared
specifically for warriors, this may be worth pursuing. Closed groups
offer advantages, but some open groups can work well if there's good
facilitation and a willingness on the part of existing members to allow
in new members.

F) Other Elements of Therapy

There are many other supportive interventions that happen during
psychotherapy sessions, either as part of the above treatments or separately. These can include grief counseling; marital counseling; counseling related to job or financial stressors; alcohol and drug counseling; or
counseling focused on coping with medical problems, pain, or injuries.
Depending on the circumstances and the particular stressors going on at
the moment, these aspects of therapy can take a higher priority than the
other approaches listed above.

Medications

Of all of the available categories of psychiatric medicines, only one, the Selective Serotonin Reuptake Inhibitors (SSRIs) have an acceptable level of evidence to consider them effective for PTSD. There are several other types
of medications that psychiatrists prescribe to alleviate PTSD symptoms, but
their effectiveness is much less certain and less well studied than the SSRIs.

A couple of disclaimers are needed for this section: First, in this brief
overview of medicines I will only touch on relevant information to help you
in your decisions. There's a lot of additional information, particularly on
side effects and risks, which you'll need to consider if your doctor prescribes
one of these. Make sure that you get comprehensive information from your
doctor and read the package insert(s) so you're fully informed on the risks
and side effects, as this chapter doesn't provide complete information. An
easy way to do this for most medications is to simply type www. [name of
medication].com (e.g. www.zoloft.com). Use the brand name (e.g. Zoloft)
rather than the generic name (e.g. "sertraline"). Second, although the FDA
has approved all of these medicines for specific purposes (such as depression), most have not received approval for the treatment of PTSD. This
doesn't mean that they are ineffective, but it does mean that they haven't
gone through as careful a scientific process to weigh the benefits against
the risks. Additional information can be found at the National Institute of
Mental Health (www.nimh.nih.gov) or at www.fda.gov/medwatch.

A) Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs revolutionized the treatment of depression and anxiety disorders,
starting with the introduction of fluoxetine (Prozac) in 1986. Prozac provided a remarkably safe alternative to the tricyclic antidepressants used
since the 1950s that had numerous side effects. Since Prozac was introduced, a number of other SSRIs have followed, including fluvoxamine
(Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and
escitalopram (Lexapro). SSRIs are the only class of medicine shown to
have consistent and reasonable evidence for effectiveness in PTSD. All of
the SSRIs are approved either for depression, one or more anxiety disorders, or both; sertraline (Zoloft) and paroxetine (Paxil) are currently approved by the FDA for PTSD. However, there is no reason to believe that
these two are better than the other SSRIs for PTSD, because they all work
in the same way on serotonin nerve transmission in the brain.

It is commonly stated that depression, anxiety, and PTSD reflect "chemical imbalances" in the brain involving the neurotransmitter serotonin, and
that SSRIs are designed to correct this. The reality is that scientists have very
little understanding of exactly why SSRIs help in these conditions, and what
"chemical imbalance" they are ostensibly treating. However, don't let that
dissuade you from trying out this class of medicine if needed. (The next
time your doctor tells you that you have a "chemical imbalance" in your
brain, tell him what a tremendous relief it is to finally confirm this, because
you've always known you were "imbalanced," that you can't wait to pick up
the magic pill that will correct all this, and that thanks to such a thorough
explanation, you will at last be able to live happily ever after. You'll likely be
rewarded with a perplexed look on your doctor's face.)

Although there are questions of how effective SSRIs are for combatrelated PTSD, SSRIs are almost always the first medicine that a doctor will
select for this condition. One of the advantages of SSRIs is that they are the
leading medicine used to treat depression, and they also may have some
benefit in reducing anger, even if they are relatively less effective for PTSD.
Many warriors benefit from their effect on depression and/or anger. SSRIs
are used routinely in the deployed environment. One recent survey indicated that 5 percent of service members deployed to Iraq and Afghanistan
were taking a psychiatric medicine, with SSRIs being at the top of the list.
Most preparations of SSRIs are taken once a day, and it generally doesn't
matter if it's in the morning or evening.

It's a common misconception that all psychiatric medicines, including SSRIs, "mess with your mind," are addictive, or can impair a person's
judgment or ability to think clearly either from their use or from stopping
them abruptly. There have been concerns among operational leaders that
the widespread use of these medicines in deployed troops could affect their
ability to function in the combat environment, putting lives at risk. There
has also been the concern raised that SSRIs may increase the risk of suicide
because of a "black box" warning issued recently by the FDA. All of these concerns appear to be unfounded. SSRIs do not affect cognitive function-
ing,judgment, or the ability to think clearly. They are not addictive. Abrupt
discontinuation can lead to feeling like you have the flu for several days,
but it's not dangerous. There is no evidence that SSRIs increase the risk of
suicide among adults, although there has been some theoretical concern
about SSRIs increasing suicidal thinking in children and adolescents/young
adults. Most important, many warriors have benefited from taking SSRIs,
either individually or in combination with psychotherapy. Sometimes the
SSRI can take the "edge" off of debilitating symptoms and make it easier to
start the necessary work of talking about your experiences.

SSRIs do have some risks and side effects. One common side effect is
restlessness, jitteriness, or increased anxiety when first started. For this reason, it's wise to take half of the lowest recommended dose for the first week
(by cutting the pills in half) and then increasing it slowly thereafter. Because
there are serotonin nerves in the gastrointestinal track, nausea or diarrhea
may occur. Headaches can also occur. Generally, the nausea, diarrhea, and
headaches will subside after you've taken the medicine for a few days.

The most bothersome side effect, which occurs quite frequently, is sexual difficulties, most commonly in reaching orgasm. This occurs in both
men and women. For men, SSRIs generally don't affect the ability to get an
erection, and some men find the side effect of delayed orgasm beneficial.
However, when it affects the ability to reach orgasm, this can make sexual
experiences frustrating for both partners. If this occurs, don't be embarrassed to speak with your doctor about it. This is one of the most common
reasons for discontinuing this medicine or switching to another medication.

The most important risk associated with SSRIs has to do with their
interactions with other medications. Some of the SSRIs can delay the
speed with which the liver metabolizes and clears other medicines from
the body, sometimes resulting in medicines reaching dangerous levels in
the body. This is more of a problem for fluoxetine (Prozac), fluvoxamine
(Luvox), and paroxetine (Paxil), and less so for sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro). As always, make sure you
speak with your doctor about any other medicines you're taking (including herbals or supplements) and read the package insert so that you are informed of the risks and side effects. This has only been a partial discussion of side effects and risks.