Over the centuries, philosophers, historians, researchers, and clinicians have given many names to the psychological effects of combat. In the fifth century, Herodotus wrote of a brave warrior from the battle of Marathon who was rendered blind “without blow of sword or dart” as he watched a fellow comrade fall in battle.
In the mid-18th century, the term “Swiss disease” was used to describe unexplained physical and psychological symptoms in Swiss villagers who served against their will. During the American Civil War, the Army physician J. M. Da Costa wrote of “irritable heart,” which included symptoms that we now attribute to anxiety and panic.
Other terms such as “shell shock,” “war neurosis,” “battle fatigue,” and “post-Vietnam syndrome” have followed.
It was not until 1980 that the American Psychiatric Association adopted the current term, posttraumatic stress disorder (PTSD), into its third edition of the Diagnostic and Statistical Manual of Mental Disorders. Although the diagnostic criteria have evolved across subsequent iterations of the manual, this is the term we continue to use today.
It is unlikely that any other psychiatric disorder in the last half century has received so much attention. In part, the focus on PTSD arose from political pressures to label and categorize the psychological symptoms that Vietnam veterans were struggling with on their return home. It was also due, in part, to our inability to fully understand the differences in how individuals interpreted and reacted to trauma, as well as the concept of resiliency that has gained prominence in the field today.
More recently, debates about the efficacy and applicability of various psychotherepeutic, pharmacological and complementary and alternative treatments permeate the psychological and medical literature, conferences, and popular media. At times it seems that clinicians either fall into the camps of manualized, evidence-based trauma focused therapies (often times supporting one while criticizing the others), somatic therapies, or “non-traditional” interventions with little clinical trial support but substantial anecdotal and historical support.
Exposure Therapy Gains Support
The reality is that the evidence base for effective treatments for PTSD is lagging behind our knowledge about the mechanisms associated with the development, maintenance, and course, the disorder. In essence, a 2007 report by the Institute of Medicine (IOM) supported this claim.
After being commissioned by the Department of Veterans Affairs, the IOM was asked to review the current efficacy research on psychological and pharmacological treatments for PTSD. The IOM reviewed 90 randomized clinical trials (53 psychotherapeutic interventions and 37 pharmacological interventions) that focused on PTSD outcomes.
The committee concluded that, based on their criteria, there was insufficient evidence to support the efficacy of pharmacological intervention for PTSD. Furthermore, exposure therapy was the only psychotherapeutic treatment modality shown to have sufficient evidence to support its use for PTSD.
Does this mean exposure therapy is the only treatment that works? No, absolutely not. Since 2007, additional research has shown that a variety of psychotherapies and medications can alleviate the burden of PTSD. As revealed in United States Department of Veterans Affairs/Department of Defense (VA/DoD)” Clinical Practice Guidelines for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder,” there is evidence supporting the use of other trauma-focused therapies such as cognitive processing therapy, brief eclectic psychotherapy, and eye movement desensitization and reprocessing.
Non-Trauma Focused Approaches Often Preferred
Evidence also supports the use of non-trauma focused therapies (often preferred by patients) such as stress inoculation training and interpersonal psychotherapy. For those patients who prefer pharmacotherapy, systemic reviews noted in the VA/DoD guidelines support the use of paroxetine, sertraline, fluoxetine, and venlafaxine. Unfortunately, few other medications are noted to have significant support for their use.
Even though the evidence for both pharmacological and psychotherapeutic treatments has grown since the first edition of this book was published, we have a long way to go. Drop out rates for trauma focused therapies are a problem and many veterans prefer complementary and alternative approaches to wellness. Regarding the latter, it is frustrating that little attention and financial resources are expended to explore options other than exposure and cognitive therapies and medication for the treatment of PTSD. At times it seems that we continue to fund the same psychotherapies and pharmaceuticals at the cost of stifling innovation and minimizing the preferences of our combat veterans.
*This article was adapted from Dr. Moore’s latest book, “Treatment of PTSD in Military Personnel: A Clinical Handbook-Second Edition.”