**5.1 Popular treatments for combat related posttraumatic stress disorder**

This section will discuss cognitive processing therapy, prolonged exposure therapy, and the medications that can be used for individuals with posttraumatic stress disorder. An array of therapies exists for treating posttraumatic stress disorder and what is covered below should not be considered an all-inclusive list of the effective treatments.

#### **5.1.1 Cognitive processing therapy**

*Cognitive Processing Therapy* places an emphasis on the meaning that an individual assigns to their traumatic experience (Karlin et. al., 2010; Resick & Schnicke, 1992). The treatment is

Combat Related Posttraumatic Stress Disorder –

**5.2.1 Heart rate variability biofeedback training** 

disorder symptoms from pretest to posttest.

**5.2.2 Virtual reality exposure therapy** 

**5.2 New treatments** 

by person.

History, Prevalence, Etiology, Treatment, and Comorbidity 43

Although there is limited research on novel treatments for posttraumatic stress disorder, some treatments are showing promising results. Two of those treatments include heart rate

As mentioned in previous sections, hyper-arousal is one of the symptoms found in those with posttraumatic stress disorder. Persistent hyperarousal has been linked to physiological abnormalities such as increased blood pressure, exaggerated heart rate response to stressors, and an elevated resting heart rate (Cohen et al. 1997; Pitman et al. 1987). This has led researchers to speculate that posttraumatic stress disorder may alter sympathetic nervous system reactivity. In addition, researcher found that between 80% to 100% of individuals with posttraumatic stress disorder can be distinguished from those without by looking solely at their physiological reactivity (Orr & Roth 2000), which can be indicative of autonomic nervous system dysfunction. Heart rate variability can be used as an indicator of how the autonomic nervous system is functioning (Appelhans & Luecken 2006). Those with posttraumatic stress disorder typically have low heart rate variability (Tan et. al. 2011). Heart rate variability is the mean value of heart rate fluctuations over a period of time and is reflective of the interplay between the sympathetic and parasympathetic nervous system (Akselrod et al. 1981; Cohen et al. 1999). Research has established that by breathing at an ideal resonance frequency (approximately 5.5 breaths per minute), an individual can increase their heart rate variability (Vaschillo et al. 2002). Ideal resonance frequency varies

Clients undergoing *heart rate variability training* are asked to first meet with the therapist to determine what breathing rate will produce their greatest heart rate variability (Lehrer et. al., 2000; Tan et. al., 2011). Clients are then instructed to practice breathing at this rate at home. They may either practice with a CD that guides them through the breathing techniques or they may be given a machine that notifies them when they are not breathing at their ideal rate. In a pilot study by Tan and colleagues (2011), participants who underwent eight, 30 minute training sessions experienced a significant reduction in posttraumatic stress

*Virtual reality exposure therapy* has been used to treat soldiers that served in Vietnam, Operation Enduring Freedom, and Operation Iraqi Freedom. Computer programs were developed for both populations containing scenes that look similar to the surroundings veterans would have experienced during combat. The Vietnam virtual reality environment contains a scene with a virtual jungle and includes sounds of the jungle, gunfire, and nearby helicopters and has a separate scene within a helicopter (Gerardi et. al., 2010). *Virtual Iraq* was developed for veterans of current war. (A. A. Rizzo, et al., 2008). Virtual Iraq contains scenes of a Middle Eastern themed city, where the person is able to travel through the city by foot or in a truck. This environment can be adapted based on the client's therapeutic needs. In addition to the virtual reality scene, the individual is also presented with auditory, tactile, and olfactory stimulation. The client sits on a platform equipped with subwoofers, and the therapist controls which sounds the client hears. Furthermore, the platform vibrates in coordination with the virtual reality environment. The

variability biofeedback training and virtual reality exposure therapy.

divided into three phases and is typically administered over the course of 12 sessions. In addition, the treatment can be used in individual or group therapy. The three phases are comprised of: education, processing, and challenging. During the education phase, clients learn about the symptoms of posttraumatic stress disorder, how treatment will work, and is taught about the interaction between thoughts and feelings. They are also asked to consider how the event has impacted their outlook on the world. More specifically they are asked to examine the changes that may have occurred in their beliefs about themselves, others, and how the world operates. During the processing phase, the client is asked to either write about or discuss the traumatic event and work to identify thinking patterns that may be hindering their recovery. In the final phase of therapy, the challenging phase, the therapist works with the client to help them reframe their distorted beliefs about themselves, others, and the world. In doing this, the client develops a more balanced view of their environment.

#### **5.1.2 Prolonged exposure therapy**

*Prolonged exposure therapy* was designed specifically for individuals with posttraumatic stress disorder. The length of treatment typically ranges from 8 to 15 sessions, although it was initially designed to be 10 sessions (Foa & Kozak, 1986; Foa et al., 2007). This treatment draws from cognitive behavioral theories and it operates on the assumption that exposure to a feared stimulus will eventually extinguish the fear. During the first and second session, the primary focus is to provide psycho-education regarding the techniques that will be used, explain the rationale for using those techniques, and discuss the ways that people typically react to a traumatic event. Subsequent sessions will be dedicated to either imagery exposure or in vivo exposure. *In vivo exposure* is where the client goes out into the real world and encounters the feared object or situation in person with the goal of habituation. The in vivo scenarios that are used during treatment are low risk and are often commonplace experiences. These scenarios are appropriate for treatment because individuals with posttraumatic stress disorder will often avoid an array of low threat situations because they trigger unpleasant memories. *Imagery exposure* involves the person imagining the feared situation. More specifically, the client is prompted to talk about the most disturbing aspects of their trauma with the therapist. This gives them the ability to reprocess what actually happened and the opportunity to reorganize how they reflect on the traumatic event. The length of treatment depends on the client and is terminated when they no longer have symptoms that inhibit them from engaging in every day activities.

#### **5.1.3 Medication**

Due to the biological component of posttraumatic stress disorder, individuals who suffer from the disorder can also receive antidepressants to help ameliorate their symptoms. Medication can be used in conjunction with psychotherapy or can be used alone. Although a number of medications are currently being investigated for the treatment of posttraumatic stress disorder, the Food and Drug Administration has only approved two medications (Friedman & Davidson, 2007). Both of the medications that they approved, Sertraline and Paroxetine, are selective serotonin reuptake inhibitors. As we learn more about the biological mechanisms of the disorder the medications that are recommended for posttraumatic stress disorder will continue to change.
