Validating new ways to help troubled veterans

The last thing many women who have been sexually assaulted while serving in the military want to do is go to a Veterans Administration hospital where, as Ron Acierno, Ph.D., puts it, “Everybody seems to look like the perpetrator.”

Acierno, professor and associate dean for research in the College of Nursing at the Medical University of South Carolina, says there may be a better option when it comes to mental health treatment for effects of military sexual trauma, and it’s newly available through a study he’s conducting. “We are offering evidence-based psychological interventions through home-based telemedicine.”

It’s part of a larger body of research designed to help military veterans that MUSC is conducting with the Ralph H. Johnson VA Medical Center. It’s funded by the Department of Defense.

Military sexual trauma study

In Acierno’s study, instead of having to travel to Charleston for appointments, military sexual trauma patients communicate with psychologists by video. “Basically, it’s an encrypted version of a program like Skype,” Acierno says.

Previous research out of MUSC, detailed in The Lancet and the Journal of Depression and Anxiety, suggests that it’s likely to work as well as in-person visits would.

Acierno is a senior clinical researcher with a strong interest in finding innovative ways to help people in distress. “We offer more home based telepsychology here in Charleston than any other VA in the country. By far.”

Military sexual trauma involves psychological harm from “sexual assault or repeated, threatening sexual harassment that a veteran experienced during his or her military service,” according to the U.S. Department of Veterans Affairs website.

One in 4 women and 1 in 100 men tell VA clinicians that they’ve been victims of military sexual trauma.

The treatment Acierno is studying is called prolonged exposure therapy, a method used to help people recover from PTSD. It has two parts.

The first part is called imaginal exposure, and it’s grueling but important, Acierno says. “You have the person recount the most horrible trauma they’ve been through in dramatic detail, in all 5 senses, in the first person, like they’re on a cell phone telling you what’s happening right then and there for about 40 to 50 minutes.”

They audiotape the whole thing, then have patients listen to the recording twice a day. “The idea is to move people from being overwhelmed by these memories to being very disturbed by them. We don’t make people forget, but we help them get used to the memories, and by repeated imaginal exposure, they begin to have the memories on their terms,” Acierno says.

The second part of the treatment involves in vivo exposure. “That’s real world exposure,” Acierno says. “For combat veterans, it’s hard to be in crowded places such as Walmart. For rape victims, it’s maybe a bus stop similar to the bus stop where they were attacked.”

The person is gradually exposed to the site, using relaxation techniques to try to stay calm, and over time, gets used to being there and stops avoiding it.

“If every time you feel stress you leave the situation, you’ve trained yourself to avoid it,” Acierno says. “Avoidance works to reduce anxiety. You can also take pills or alcohol to avoid anxiety.  The problem is, you also end up avoiding life, and you become imprisoned by anxiety. It’s not fair that those who fought to preserve our freedom lose their own.”

He says the study not only allows victims to speak with counselors in the privacy of their homes but also allows those experts to reach victims who live in other cities and would otherwise have to drive a long way for appointments. 

“We’re treating people in Georgia and rural parts of South Carolina,” Acierno says. “We’ve also treated people in other states across the country when they had to travel for work and would have missed their appointment if we didn’t have the ability to use home-based or hotel-based telemedicine.”

Subclinical PTSD 

Acierno’s research has also tested new treatments for veterans with symptoms of PTSD who don’t have the full disorder. In an article in the March 2016 issue of the Journal of Anxiety Disorders, investigators in the Department of Psychiatry and Behavioral Sciences at MUSC working with Acierno reported that veterans who fall just below the threshold for a diagnosis of PTSD respond to a psychotherapy regimen better than those with full PTSD. 

Investigator Kristina Korte, Ph.D., says it highlights the need to recognize veterans suffering from an overlooked condition called subclinical PTSD. “The study shows not only that we can treat those experiencing subclinical presentations of PTSD, but also that those with subclinical PTSD may actually respond better to treatment than those with more severe forms of the disease.”

Just like patients with full PTSD, those with subclinical PTSD have experienced a traumatic event and are regularly re-experiencing it, often in nightmares or flashbacks. Patients with full PTSD also experience hyperarousal, meaning they’re easily startled and avoid reminders of the event. For example, they may withdraw from social interaction or turn to substance abuse. Patients with subclinical PTSD may exhibit either hyperarousal or avoidance, but not both.

Psychologists began noticing this pattern in the 1990s in veterans returning from the Gulf War, and even more frequently in veterans returning from Iraq and Afghanistan in the last decade. As researchers have learned more about these patients over time, varying and sometimes conflicting symptoms have provided an incomplete picture of the disorder and how to treat it. 

Further confounding the issue is the fact that people with subclinical PTSD are often excluded from clinical trials testing treatments for PTSD. Patients with only some symptoms of PTSD commonly aren’t included in the healthy control group or in the group with full PTSD. As a result, there is still no standard psychotherapy for treating subclinical PTSD.

The researchers devised an intuitive approach: Why not treat subclinical PTSD patients with one of the standard evidence-based psychotherapy tools already being used in PTSD patients? They enrolled 200 patients from the Ralph H. Johnson VA Medical Center, located adjacent to MUSC, who suffer with combat-related PTSD symptoms identifying those with either subclinical or full PTSD. 

For eight weeks, patients received intensive weekly sessions of behavioral activation and therapeutic exposure therapy designed to lessen their PTSD symptoms by helping them safely re-experience and resolve elements of the original trauma. Psychologists rated the patients’ PTSD symptoms and had patients rate their own symptoms before, during and after the eight weeks.

The results were encouraging. People with subclinical or full PTSD each experienced a real drop in PTSD symptoms after treatment. The striking results showed symptoms dropped 29 percent in those with subclinical PTSD as compared to 14 percent with full PTSD.

It may seem obvious that patients with a less severe form of PTSD would respond better to standard psychotherapy, but the implications for treatment extend beyond that. PTSD symptoms often worsen over time. As they do, treatments become less effective at reducing symptoms. In this context, subclinical PTSD could also be seen as “early-stage” PTSD, in that treatment might be more effective when the disorder is caught early.

Korte’s group hopes these early studies can move beyond men in combat to civilians of both sexes. “It is our hope that providing treatment for subclinical PTSD could have a significant impact on the cost-effectiveness of treating this common disorder,” says Korte. “It could lead to the prevention of more intractable forms of PTSD that can occur when subclinical PTSD goes untreated.”