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PTSD: The Futile Search for the “Quick Fix”

The views expressed are those of the author and are not necessarily those of Scientific American.


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Preventive measures, like the Violence Against Women Act (VAWA) are the only cure for PTSD

A few weeks ago an article in the Scientific American Twitter stream caught my eye. EMDR (Eye Movement Desensitization and Reprocessing) once again debuted as a “promising new treatment” for PTSD. EMDR, which has been repeatedly called “promising” over the last two decades, works only about as well for PTSD as other psychological treatment modalities with which it competes, primarily cognitive behavioral therapy (CBT) and exposure therapy. These so-called trauma focused treatments (TFT) all garner similar results. TFT have large effects in clinical trials, with two important caveats: 1) the enthusiasm of their various advocates bias the study results towards the treatment the researchers prefer; and, 2) they are effective for a significant number of carefully selected PTSD patients. The sad truth, however, is that current short-term treatments are not the solution for most patients with PTSD. Trial criteria often exclude those with comorbid disorders, multiple traumas, complex PTSD, and suicidal ideation, among others. Even when they are included, comorbid patients drop out of treatment studies at a much higher rate than those with simple PTSD, a problem that has implications for clinical practice.

Data drawn  from Kessler & Sonnega, et al. Arch Gen Psychiatry. 1995;52(12):1048-1060. doi:10.1001/archpsyc.1995.03950240066012.

Data drawn from Kessler & Sonnega, et al. Arch Gen Psychiatry. 1995;52(12):1048-1060. doi:10.1001/archpsyc.1995.03950240066012.

The large majority of those with PTSD also have other psychological disorders (commonly, substance abuse, depression, and anxiety disorders) and many of these patients have complex PTSD, which is both harder to treat, and more prone to relapse (see Fig. 1). Those who suffer from both PTSD and substance abuse (64%-84% of veterans, for example) often perceive the disorders as “functionally correlated.” Similarly, depression and PTSD are mutually reinforcing; each compounds the symptoms of the other. Both substance abuse and depression are notoriously difficult to treat, and harder to treat when comorbid with PTSD. Multiple studies document the long-term failure of PTSD treatment for veterans, but there are fewer on the effectiveness of therapies in treating comorbid PTSD in civilian populations. Existing studies challenge the assumption that PTSD treatments effective for simple PTSD, are also effective for combined PTSD and substance abuse, or PTSD and depression.

Effectiveness in clinical trials is usually measured by the extent to which clinical symptoms of PTSD have diminished, but those may not be the most useful measures for patients. PTSD symptoms are recurrent and even at subclinical levels, reintegration may be difficult for patients and daily functioning may remain impaired. To measure effectiveness accurately, clinical trials should adopt additional outcomes, like daily functioning (also see here and here), if they are intended to cover all dimensions of disorder as described in the DSM. Effective treatment of long term cases is necessary for comprehensive rehabilitation of difficult-to-treat patients: those with comorbid PTSD; those who have been repeatedly re-traumatized; and those whose environments place them at continuing risk of new trauma. Short-term TFTs are regularly prescribed by the VA, and yet, VA studies indicate that the majority of veterans treated for PTSD are still in treatment four years later (see Fig. 2). The military and VA want a quick fix, but that’s not what they’re getting.

Though the military tried to deny the ubiquity of PTSD for many years, prevalence studies made it impossible. Mental illness is the leading cause of hospitalization for active duty troops, and accounts for a larger share of troop indisposal than its next competitor (injury and poisoning). The majority of mental health cases in the military have a PTSD component. Prevalence of the disorder is affirmed in the public sphere, where an endless stream of sympathetic portrayals of veterans with “invisible wounds” can be found in literature, on film and television. The U.S. military spends more money on PTSD research and treatment than any other funder, and with good reason: 8%-20% of veterans suffer from PTSD. Estimates vary widely, as in most claims surrounding PTSD, but that’s a range of between 1.75-4.5 million vets with the disorder, and our continual wars ensure a steady stream of new cases.

The lure of a quick and enduring fix for PTSD is hard for the military to resist since they stand to benefit greatly from a cure. They would surely like to save the $1.5 million per soldier they believe PTSD will ultimately cost them. They are also concerned about troop strength. If PTSD is portrayed as endemic and chronic in soldiers, rather than as a rare and short-term consequence of war, qualified civilians may be reluctant to enlist, and the military will have a hard time convincing their families that it can keep soldiers safe. In the Iraq and Afghanistan wars, the military has lowered the number of troops in combat by increasing tour length and encouraging soldiers to extend and repeat their tours. Fewer soldiers are spending more days in combat than ever before: 20% of the soldiers deployed in Iraq and Afghanistan have served three tours; more than 50,000 have served four or more tours. The math is simple: more combat exposure means that a higher percentage of active duty troops and veterans will get PTSD. Without a cure, there’s no way to stem the tide.

This obsession with a cure seems admirable, until one examines some of the models the military has embraced: virtual reality (a variation on the computer games the military has used to dehumanize the enemy); drugs like propranolol, which erase memory and possibly a soldier’s conscience; and injections that block normal nerve response in physically healthy patients. Compared to these, alternative and poorly validated treatments (e.g., neurofeedback, mind-body medicine, acupuncture, healing touch, loving kindness meditation) for which taxpayers foot the bill look positively benign.

Military and pharmaceutical interests converge: the former wants quick or easy fixes, and the latter wastes no time in peddling the pharmaceutical flavor of the month, whether it’s sertraline, paroxetine, fluoxetine, venlafaxine, risperidone, clonidine, diazepam, lorazepam, alpralozam, duloxetine, propranolol, prazosin, yohimbine, cortisol, quetiapine or gabapentin. In 2012, “the Pentagon spent more on pills, injections and vaccines than it did on Black Hawk helicopters, Abrams tanks, Hercules C-130 cargo planes and Patriot missiles—combined”; drug sales to the military doubled between 2001-2011. The military’s hope is that a combination of drugs and short-term TFT will prove more effective than either alone. Between 2001-2011, the Defense and the VA combined spent $791 million on Risperidone, a drug that turned out to be no more effective than placebo for treating PTSD. Just last year, the Army finally changed its long-standing policy of prescribing benzodiazepines for soldiers with PTSD because the drugs are highly addictive, and they worsen PTSD symptoms. The Army supplements TFTs with pharmaceutical cocktails, often administered seemingly at random.

The pharmaceuticals the military dispenses so freely are often tested by the very companies that produce them, just as treatments that originate in the military are also tested by the military, the VA and other medical arms of the U.S. government. The resources and research of both pharmaceuticals and the government greatly exceeds those of organizations with no conflict of interest. The flood of documentation they generate on PTSD creates the impression that military treatments and pharmaceutical solutions are supported by the weight of evidence, even when they are not. This evidence, in turn, leads civilian institutions to adopt PTSD treatment strategies that originated in the military, and also can determine the decisions made by insurance companies.

Insurance companies, like pharmaceutical companies and the military, have a vested interest in short-term treatments to cure PTSD: the shorter the treatment, the lower the cost. Insurance companies will cut costs even when it means that patients will require more expensive treatments in the long run. Insurance companies place caps on benefits; many will pay for 10-20 mental health visits per year, and no more. Insurance companies will have to cover mental health care under the Affordable Care Act, which singles out behavioral treatments as particularly deserving. But there is no indication that longer-term treatments will receive more support under the ACA than they did previously. Insurance companies will continue to cover TFTs (CBT, exposure and EMDR), and reject longer-term treatments, and they will back up their decisions with evidence from clinical studies supported by the military and the drug industry.

The convergence of pharmaceutical and military interests, and the funding nexus they create, has ensured that the focus of PTSD research and treatment continues to be military veterans, despite the fact that military veterans comprise only 15% (at minimum) or 40% (at maximum) of the approximately 11 million adults and adolescents who suffer from PTSD in the U.S. (No reliable numbers for children exist.) The military medical complex has a history of coming up with psychological theories and treatments, which are transferred to the civilian world, even though treatments for veterans may not meet the needs of survivors of other traumas.

The interests of the majority of those with PTSD have been neglected in comparison. This is unsurprising to those who know the long history of the effort to list PTSD in the DSM. As I wrote over a dozen years ago, in Worlds of Hurt, the efforts of women’s advocates had been rejected, despite the massive amount of evidence they’d assembled and shared with the psychiatric establishment. The long term psychological effect of rape and incest, like the earlier discovery of chronic stress disorder in Holocaust survivors, was not granted the status of a unique psychiatric diagnosis. It was only after returning Vietnam veterans joined together into a massively politicized antiwar faction that the medical establishment and the VA bowed to veteran and public pressure to establish the PTSD diagnosis. In the ensuing decades, although some attention has been paid to other traumatized populations, veterans have continued to get the lion’s share of the attention, funding and treatment, although they are a minority group among survivors.

The Department of Veterans Affairs acknowledges that women are more than twice as likely as men to develop PTSD (10% for women; 4% for men, a number that includes all male veterans). They note that women experience sexual assault more often than men do, and that sexual assault results in higher rates of PTSD than many other traumas. The Justice Department’s Office of Violence Against Women and the CDC have recently published the following statistics (2012-2013):

In contrast, combat in war happens far away from the majority of Americans, in a country most of us will never see. The events that cause PTSD in soldiers and veterans take place of sight and earshot of most of us. Perhaps it is because the psychological costs of combat are paid only a relative few volunteers, who serve in far away lands, and whose actions are condoned by law, by tradition, and by myth, that we can accept (and rationalize) the physical and psychological wounds they receive on our behalf. Except for a few military psychiatrists who think (and quite a few generals who hope) they might be able to use drugs to circumvent PTSD by short-circuiting a soldier’s ability to perceive violence as traumatic, most Americans are resigned to the apparent truth that PTSD is one of the prices many, many soldiers will pay for going to war. At least in theory, we owe them care and support as a debt of gratitude for what they sacrificed to keep us free.

But domestic and sexual violence against women are perpetrated in our own homes and sometimes in our own beds. They affect one in three of women (mothers, daughters, sisters, friends, lovers). Significantly reducing PTSD in the female population would first require us to name the factors that cause violence against women, and then to make rational and radical changes in the legal, social, and economic systems of the country in which we live. The majority of U.S. residents would need to change their beliefs and attitudes, and modify their actions to significantly reduce violence against women. As exhausted feminists are the first to testify, knowledge doesn’t bring about change: the desire and the will to change brings about change.

An excellent example of PTSD prevention born out of effective political change is the Violence Against Women Act (VAWA), first authorized by Congress in 2000, then renewed in 2005. Between 2000-2005, the U.S. government provided $3.2 billion in funds to prevent violence against women. Since then, the government has spent between $500-625 million a year to support a wide variety of prevention programs. A November 2012 Department of Justice Report on intimate partner violence records a steep drop in 1999-2000, when the VAWA was enacted. Since then, the level of domestic violence (while still quite high) has held steady, at a far lower level than it average in the 1990s (see Fig. 3). Its stability between mid-2000 and 2010 demonstrates that the level of domestic violence does not track that of other violent crimes, which dropped, and then peaked sharply, and then dropped again in the same time period.

But the drop may not be permanent. Renewal of the Act was blocked by Republicans in 2011. It is again before the House of Representatives, after passing in the Senate. As I write, the Republicans have just proposed a weaker version of VAWA than the Senate approved. This version strips out the expansions that would offer more protection to lesbian, bisexual and trans women, and to Native American women. If the Act does pass the House, it will be because women constituents have pressured Republican representatives to capitulate to their demands, and their victory will provide aid to hundreds of thousands of American women. VAWA, however, is a holding action rather than a victory, as the statistics and incidents like the recent rape in Steubenville demonstrate: rapes, and their cover-ups and rationalizations, still happen frequently on the community level, with willing participation at the highest and lowest levels of responsibility. More structural intervention is necessary, if we want to see another decline in the rate of domestic abuse and other crimes of violence against women.

Women are not the only population to suffer disproportionately from violence and, hence, from PTSD. Look again at the figures above, and you’ll note that close to half of Native American women have PTSD, as compared to a third of American women in general. Higher rates of PTSD are evident in communities with high rates of violence, low-income communities with poor social support, populations with a high rate of incarceration, and other markers of social and economic disadvantage. Poverty and racial oppression increase the likelihood that an individual will experience one or more traumatic events; PTSD then lowers the life chances of the individual who suffers it. Thus, a seemingly unrelated circumstance, such as unequal sentencing for possession of crack cocaine vs. powder cocaine (especially when it takes place in an environment of unequal policing, prosecution, and sentencing) can have a significant effect on the level of PTSD in a community where a large number of male residents have served time for possession. Much human-caused trauma is systemic, rather than exceptional. Those of us who want to treat PTSD in the U.S. need to ask ourselves how best to treat PTSD in community under siege, where we’re attempting to help patients who were probably traumatized before, and are quite likely to be traumatized again.

The answer is that we may not be able to do so effectively. For many patients, we may only be able practice a form of battlefield medicine as we advocate for structural change and funding for preventive measures. Most short-term therapies require patients to be in a safe environment, as a prerequisite to effective treatment. The safety requirement immediately excludes a large segment of the population with PTSD. Economic barriers are also difficult to surmount, since even after all provisions of the ACA go into effect, many Americans will still be be un- or underinsured. And if they are insured, many cannot afford the required co-payments for therapy, or may not be able to continue therapy beyond the low number of allotted sessions.

Even if a patient gains access to short-term treatment, only a minority will find significant, long-term relief. For the majority, short-term treatment should be considered a bridge into long-term care for a chronic disorder. Claims to treatment effectiveness should not depend primarily on abating clinical symptoms, but on reintegrating the patient, and on improving and maintaining the patient’s ability to function in daily life. The clinical symptoms of survivors may fluctuate, but function is a life-long problem for the majority of them, even when their PTSD symptoms may be subclinical.

If our goal is to lower the burden of PTSD in the long term, we must first of all devote resources to supporting and advocating violence prevention. This means preventing the gun violence that is pervasive in both urban and rural settings; passing and funding more legislation like VAWA, so that all populations that suffer disproportionately from violence are served; and, addressing the inability of the police, the courts, and the prisons to effectively serve victims, ensure their safety, and rehabilitate perpetrators

Finally, we need to look at war trauma from a more comprehensive perspective. We need to assess the effects of long-term psychological trauma on both civilians and soldiers, as well as the social and financial burdens imposed by PTSD even after peace is declared, and weigh them in the decision to commit U.S. troops to battle. If we use the VA’s very reasonable figures for treatment cost ($4,000/year for continuing treatment), and assume that 80% of the 11,00,000 Americans with PTSD have comorbid disorders, we’re talking about $35.2 billion a year, to treat about 8.8 million people (veteran and civilian) on an ongoing basis. This is more than we spent to support the Marine Corps in 2012 ($29 billion). But a 5% cut in the 2012 Department of Defense budget of $707 billion would cover it. Ending even one of our wars would make it possible for the government to fund long-term therapy for those with chronic PTSD, at the same time it would slow the rate at which new cases of PTSD were generated.

There is no quick fix for PTSD. There is only the slow fix: stopping violence before it starts. Whatever treatments you advocate and provide, if you aren’t working to prevent violence, you aren’t working to cure PTSD.

The author gratefully acknowledges the assistance of Jürgen Barth, Ph.D., of Institute for Social and Preventive Medicine, University of Bern, who generously shared his knowledge of clinical treatments and research study design. If there are errors in the essay, they are doubtless mine and not his.

Image sources: Figure 1; Figure 2; Figure 3

Kali Tal About the Author: Kali Tal is Scientific Editor for the Institute of Social and Preventive Medicine at the University of Bern, Switzerland. Her book, Worlds of Hurt, is the seminal text on literatures of trauma, and established that across traumas, survivors have similar drives and use similar strategies to communicate their experiences. Since the 1980s, Tal has participated in and followed the debates within trauma studies, and worked with survivors, including Vietnam veterans, Holocaust, and rape/sexual abuse survivors. She is now writing a book that describes the limits of contemporary PTSD studies, and charts a course for the future of the field. Follow on Twitter @Ktal4.

The views expressed are those of the author and are not necessarily those of Scientific American.






Comments 25 Comments

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  1. 1. Jean 1:43 pm 02/26/2013

    The fix for PTSD is prevention. When you willy-nilly start up wars common sense people everywhere KNOW there is going to be a huge social and financial cost in terms of PTSD disfunctioned survivors, traumatized, abused, broken and impoverished familes, lives forfeited, costs for care increased, and deprivation of potential builders in the community. Shame on us for allowing un-necessary and whimiscal wars to have commenced.

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  2. 2. DrPatti 4:21 pm 02/26/2013

    This is a very important article and the author is to be commended, especially for the statement: ” Whatever treatments you advocate and provide, if you aren’t working to prevent violence, you aren’t working to cure PTSD.”

    My comments are primarily related to the statements about available treatments for PTSD. The author, Kali Tal, states: “… EMDR works only about as well for PTSD as other psychological treatment modalities with which it competes, primarily cognitive behavioral therapy (CBT) and exposure therapy.”

    According to the soon-to-be-released World Health Organization (WHO) Guidelines for the treatment of PTSD (for which I was a peer reviewer): “Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR therapy involves treatment that is conducted without detailed descriptions of the event, without direct challenging of beliefs, and without extended exposure. The mhGAP programme recommends it as a treatment option for PTSD.”

    Much of the following comes directly from the EMDR Institute website in its section on research.

    “As noted in the American Psychiatric Association Practice Guidelines (2004, p.18), in EMDR “traumatic material need not be verbalized; instead, patients are directed to think about their traumatic experiences without having to discuss them.” Given the reluctance of many combat veterans to divulge the details of their experience, this factor is relevant to willingness to initiate treatment, retention and therapeutic gains. It may be one of the factors responsible for the lower remission and higher dropout rate noted in this population when CBT techniques are used.”

    And, unlike CBT or PE, without any homework between sessions. The lack of the necessity for detailed descriptions of memories is a major benefit for survivors or war trauma, as well as survivors of any significant violence.

    Kali Tal goes on to state: “These so-called trauma focused treatments (TFT) all garner similar results. TFT have large effects in clinical trials, with two important caveats: 1) the enthusiasm of their various advocates bias the study results towards the treatment the researchers prefer; and, 2) they are effective for a significant number of carefully selected PTSD patients.”

    The Department of Veterans Affairs & Department of Defense’s 2010 VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress placed EMDR in the category of the most effective PTSD psychotherapies. This “A” category is described as “A strong recommendation that clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.

    The 1998 randomized and controlled research study by Carlson, et al. concluded that twelve sessions of EMDR eliminated post-traumatic stress disorder in 77.7% of the multiply traumatized combat veterans studied. There was 100% retention in the EMDR condition. There were no dropouts and effects were maintained at 3- and 9-month follow-up. In a process analysis, Rogers et al. (1999) compared one session of EMDR and exposure therapy with inpatient veterans, and a different recovery pattern was observed. The EMDR group demonstrated a more rapid decline in self-reported distress (e.g., SUD levels decreased with EMDR and increased with exposure).

    Well controlled research comparing EMDR to other treatments exists for other trauma populations, victims of violence from humans, as well as natural disasters. Results are similar and in some populations, better.

    As stated in the American Psychiatric Practice Guidelines (2004, p. 36), if viewed as an exposure therapy, “EMDR employs techniques that may give the patient more control over the exposure experience (since EMDR is less reliant on a verbal account) and provides techniques to regulate anxiety in the apprehensive circumstance of exposure treatment. Consequently, it may prove advantageous for patients who cannot tolerate prolonged exposure as well as for patients who have difficulty verbalizing their traumatic experiences. Comparisons of EMDR with other treatments in larger samples are needed to clarify such differences.”

    Further, the prevalent somatic and chronic pain problems experienced by combat veterans indicate the need for additional research based upon the reports of Russell (2008), Schneider et al., (2007, 2008) and Wilensky (2007), which demonstrate EMDR’s capacity to successfully treat phantom limb pain (see also Ray & Zbik, 2001). The ability of EMDR to simultaneously address PTSD, depression, and pain can have distinct benefits for DVA/DoD treatment.

    As a psychologist treating and researching the treatment of trauma for over 30 years, I have used many methods of psychotherapy. EMDR therapy is clearly the most effective, as well as the most gentle way of detoxifying traumatic life experiences. That said, I agree with Kali Tal that PTSD, especially of the chronic-complex variety, does not lend itself to an easy fix. Nevertheless, there is hope for, at the least, some relief from suffering, if not significant recovery.

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  3. 3. KTal4 4:45 pm 02/26/2013

    DrPatti, I can’t believe that after reading the article, you were clueless enough to post 13 paragraphs asserting EMDR’s superiority over other treatments. What were you thinking? But I guess I should thank you for demonstrating exactly the problem I describe.

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  4. 4. zstansfi 9:53 pm 02/26/2013

    While I commend the author of this piece for her lucid discussion of both the prevalence and intractability of traumatic stress responses, particularly in individuals exposed to combat or intimate-partner violence, the conclusion that trauma exposure can only be treated adequately by prevention is both impractical and entirely at odds with the apparent thesis of this piece.

    Most of this article is spent arguing that short-term treatments for PTSD are not effective in cases of comorbid disorder, and that PTSD is usually comorbid with either depression or substance abuse. Even this uncontroversial claim may be overstated as it ignores that when treatment of comorbid symptoms is effective that combination treatment for PTSD symptoms improves and also belies the considerable difficulty of treating both substance abuse and depression in the absence of PTSD. I should also mention that some of the figures used in this piece rely upon results from the National Comorbidity Survey (NCS), which is widely regarded to have greatly overestimated the rates of mental illness in the US, which would inflate estimates of comorbidity with PTSD (I have graphed this and related data at the following url http://neuroautomaton.com/?p=175). However, given that the rates of PTSD, substance abuse and depression tend to be greater in at risk groups such as combat soldiers and women who have suffered intimate-partner violence, I can accept that there must still be a very high rate of comorbidity in these groups, even if the rate suggested by the NCS results is inflated. Regardless, it seems commendable—and I believe, entirely reasonable—to advocate more comprehensive and enduring treatment programs for individuals who suffer from chronic illness.

    What I do not understand, and what I believe is inconsistent with most of the content of this otherwise excellent article, is the author’s conclusion that “if you aren’t working to prevent violence, you aren’t working to cure PTSD”. This categorical statement not only discounts the efforts of countless physicians, caretakers, community workers, researchers and others to develop treatments and offer support for those who suffer from this debilitating ailment, but also discards the very same “slow” approach advocated in the first half of this paper–namely, that long-term, intensive treatment and social re-integration is likely more effective than current approaches to reducing the individual and societal burden of personal trauma. Even accepting the outsized costs of such programs, we must recognize that comprehensive violence prevention efforts, while commendable, are inherently infeasible if their aim is to prevent all traumatic experience before it has a chance to occur, given the realities of this world that we live in.

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  5. 5. KTal4 4:39 am 02/27/2013

    zstansfi – you do miss my point. Of course those with PTSD need continuing treatment, but this kind of treatment is case management, not a cure. It’s curious that you dismiss violence prevention because we cannot possibly prevent *all* cases of PTSD, since that was never my contention. Violence prevention, however, is the *only* way to lower the number of new PTSD cases, a large percentage of which will require long-term care. Did you read the section of VAWA, and its strong effect? Violence prevention is cost-effective and feasible, but programs can’t be instituted without political support. I stand by my statement: if you’re not doing the political work of preventing violence, then you’re not curing PTSD.

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  6. 6. geraldvest 9:20 am 02/27/2013

    My experience working with injured warriors identified and labeled with PTSD is a serious part of the problem and often prevents successful treatment that requires ‘working’ all of the systems. Once the soldier identifies his pain and suffering as a disease or disorder for life they are likely to develop the “VA Shuffle”– moving from isolation at home to the clinic to get their meds that suppress, cover over and cover up these injuries. Once the Injured Warrior identifies his injuries with a life-long disorder, health, restoration and resilience become even more hazardous as disillusionment, despair and suicide become issues that must be addressed. It is my experience while working in a comprehensive and intensive Integrative & Holistic Health Center and now in my private practice for several years, we experience improvement with soldiers suffering from these injuries and others. Please visit our website that describes our experience and the opportunities for complete recovery offering health practices & services intensively and extensively for at least a year or more. Thank you for this article. Treating and identifying symptoms with these “quick fixes” may reduce initial pain and suffering, however, for long-term health,recovery and restoration requires much more…including a health care plan, battle buddy, intensive & extensive health services and resources that support the whole family also suffering from PTSI. http://jerryvestinjuredwarrior.com

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  7. 7. DrPatti 1:54 pm 02/27/2013

    Kali, I can’t believe that YOU would call me “clueless” in your response! Hardly professional and frankly rude. After 30+ years of treating PTSD sufferers, I have witnessed many, many cures. And not just symptom relief as you claim, but reintegration into a life that can move on, function at least as well as before the trauma if not better, and not revolve around a diagnosis and/or symptoms (and there’s research behind my anecdotal evidence, likely too for other evidence-based treatments for PTSD). To discredit the work done by so many clients (and therapists) by relegating it to “a bridge into long-term care for a chronic disorder” is frankly demeaning and preposterous. Yes, of course more services are important to support families, and of course working to end violence should be paramount. But down in the “trenches” in private offices or community clinics or VA hospitals, the bottom line is to help people get better, by whatever term THEY feel is the true meaning of better. Talking “cure” is too black/white even though “cure” is the goal, and reached by far more than you can imagine despite your own research.

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  8. 8. KTal4 2:27 pm 02/27/2013

    DrPatti – I said your response was clueless, and I stick by it. Whether that’s your general mode or not, I couldn’t say. Spamming the comments with 13 paragraphs of boilerplate in support of EMDR is not a respectful response to an article. It is quite distinctly rude to use someone else’s essay as a platform for your advertising.

    One of the huge problems I see with the various short-term therapies is that they’re all in financial competition with each other, and their proponents are busy running around and trumpeting that theirs works *best*. Patients improve when they can select the most appropriate therapy from a range of equally effective psychological treatments. You may sing the praises of EMDR because patients don’t have to revisit the trauma in detail, but many patients choose exposure therapy because they want to work that experience through in detail. I am extremely tired of the “EMDR wars” and see not reason to be tolerant of those who continue, beyond reason and sense, to engage in them.

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  9. 9. Future Scientist 8:06 pm 02/27/2013

    I have come to expect much better from “Scientific” American than what I have read in this piece. While the author is correct in making the case that more effort should be put towards the root cause of the PTSD problem in the form of violence prevention and eliminating war as an approach to conflict resolution, she plays fast and loose with a selective presentation of facts at best, and a complete misrepresentation at worst in her effort to make a persuasive case.

    In this piece the blogger commits the same logical crime that she accuses researchers of early on with the statement that the, “…enthusiasm of their various advocates bias the study results towards the treatment the researchers prefer”. (Ever hear of a double-blind randomized controlled trial?). I suppose her “enthusiasm” for presenting a less than balanced view of the good work of many to scientifically and clinically address this horrific challenge is just what one should expect with a blog rather than a peer reviewed critical treatment of the complexity of the issues involved here.

    One such example of this that sticks out early, is in the characterization of virtual reality exposure therapy as, “…a variation on the computer games the military has used to dehumanize the enemy.” While simulation technology is ubiquitous in military training, when someone uses that same technology to create a treatment approach that could draw avoidant digital generation service members into treatment and help them to confront and process traumatic experiences as part of an evidence-based therapeutic approach, there is absolutely no equivalence. There are many such logical gymnastic maneuvers throughout the piece, but I mention the VR one as it represents the kind of low hanging fruit that is easily plucked by a savvy “writer” to spin the point using the good old “evil videogames will steal your soul” archetype that appeals to some.

    Sadly, much of the bile tossed out in this piece is designed to inflame rather than to inform, or it is stuff that we already know. We know that war sucks, we know that co-morbidity, particularly with substance abuse/PTSD is the norm, we know that combat isn’t the only source of trauma and that abused women need help too. These are real problems, that real people suffer with, that demands real effort from the scientific community. To the novice reader of this piece, who might not be aware of the massive efforts that many scientists and clinicians are making to address this challenge, the writer creates the vision of a world of evil Machiavellian players who don’t care and who just don’t “get it” like she does.

    Thus, this pretentious rant…err, I mean blog, while well-written and selectively informed with “facts” in many places, does nothing to advance a realistic scientific agenda for a real problem and instead occupies the category of ankle-biting commentary, worthy of appearance in a personal blog, rather than on the site of “Scientific” American.

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  10. 10. KTal4 4:52 am 02/28/2013

    For a “Future Scientist” you’ve produce a sophomoric piece of rhetoric, backed up by no evidence, bolstered by a wealth of opinion, and peppered with condescending poses. The main point you demonstrate is that you neither read the article thoroughly, nor clicked the links to the supporting papers, since you misrepresent their contents. Though you make sweeping claims about my intent (“fast and loose,” “selective,” “complete misrepresentation”) you provide a single comment (VR therapy) that offends you, and spin that into an “example” of my error… without a single fact or reference to back you up. Could it be that your annoyance at my critique of VR therapy was the heart of your comment? And that the rest was just so much fluff and flurry? In any case, you will need to make a stronger case for your assertions if you want to be taken seriously. And I say this kindly, as a person responsible for training young scientists in the art of writing an argument.

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  11. 11. Future Scientist 12:49 pm 02/28/2013

    No Kali, actually, I DON’T need to waste any more time debating with a “blogger”, who brims with opinion, masquerades as a scientist, and selectively cites only the evidence that supports her pedestrian case. I would debate with someone who produced a balance critical evaluation, but not the work of a hack. You have a talent for writing, but your lack of honest critical analysis of the challenges you write about does not makes you a debate opponent worthy of any more time. I am too busy actually trying to do something about the problems you cite rather than whiling away more time debating a blogger who has a penchant for taking armchair linguistic potshots at those issues.

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  12. 12. KTal4 1:50 pm 02/28/2013

    @Future Scientist: I’m really curious what effect you want to achieve with that rhetorical approach.

    Link to this
  13. 13. aengelflare 2:07 pm 03/5/2013

    Wow, it seems that the comment section has become a mini flame war of treatment proponents and opinions.
    In my humble opinion the article does point out something quite obvious and logical. It would be wishful thinking to believe in a quick fix, specially if PTSDs return to, or continue to live in an environment where PTSD may happen/return/worsen. Basically, in layman terms, just like a recovering alcoholic would do well in avoiding friends/a social environment that promotes/encourages alcohol.
    So… What I am trying to say is that, yes, prevention IS the slow fix.

    Link to this
  14. 14. making it so 9:36 pm 03/11/2013

    Google “behavioral transmission of neurodegeneration”

    At one in three women victimized, surely we are already way into a certifiable pandemic, aren’t we?

    How many books, stories, plays, poems, paintings, or media are there that depict a fully, truly, wonderful future for mankind? Can anyone name even one? I don’t believe there is one. In all futures you or I have ever heard, read, or watched on a video, movie, or video-game screen, humankind’s future is depicted as a ravaged, war-stressed, under attack and often morally bankrupt future is the norm – This is clearly pathological.

    Link to this
  15. 15. Michael Kerrigan 7:35 pm 03/12/2013

    Although treatment and research for Post Traumatic Stress is needed and welcomed, one would expect more from an article in the prestigious Scientific American, namely, that this scholarly journal might make some mention of the equally important research of Post Traumatic Growth (PTG.) Scholars and practitioners are increasingly noting PTG as an antidote fro PTS. We invite Scientific American to provide increasing coverage of research in Post Traumatic Growth.

    Link to this
  16. 16. DanielHaszard 6:20 am 03/13/2013

    PTSD treatment for Veterans found ineffective.

    Eli Lilly made $70 billion on the Zyprexa franchise.Lilly was fined $1.4 billion for Zyprexa fraud!
    The atypical antipsychotics (Zyprexa,Risperdal,Seroquel) are like a ‘synthetic’ Thorazine,only they cost ten times more than the old fashioned typical antipsychotics.
    These newer generation drugs still pack their list of side effects like diabetes for the user.All these drugs work as so called ‘major tranquilizers’.This can be a contradiction with PTSD suffers as we are hyper vigilant and feel uncomfortable with a drug that puts you to sleep and makes you sluggish.
    That’s why drugs like Zyprexa don’t work for PTSD survivors like myself.
    -Daniel Haszard FMI http://www.zyprexa-victims.com
    *Tell the truth don’t be afraid*

    Link to this
  17. 17. KTal4 10:33 am 03/24/2013

    @Michael Kerrigan – Thanks again for making my point and pitching your favorite Trauma Flavor of the Month. But as long as you’re pitching, a few specific citations would be in order, instead of an adjective-laden statement of opinion.

    Link to this
  18. 18. MrBiofeedback 2:14 pm 03/30/2013

    Carmen Russoniello, PhD, LRT, LPC, BCIAC was the President of the Association for Applied Psychophysiology and Biofeedback. He is currently Associate Professor and Director of the Psychophysiology Lab and Biofeedback Clinic at East Carolina University. Dr. Russoniello teaches undergraduate and graduate biofeedback courses through a first of its kind global classroom initiative and directs a biofeedback program for Wounded Warrior Marines at Camp Lejeune. The novel biofeedback intervention involves EEG and heart rate variability feedback and includes the use of virtual reality. Dr. Russoniello is himself a former Marine machine gunner and decorated Vietnam combat veteran.

    The Psychophysiology Lab and Biofeedback Clinic at ECU uses biofeedback and psychophysiology to help Americas wounded warriors heal the emotional wounds of war.
    http://www.youtube.com/watch?v=kDlKRA_vURk&feature=player_embedded

    Link to this
  19. 19. doctorbob 2:18 pm 04/8/2013

    We applaud the intent and the work of these researchers. Nevertheless, there are a few simple but key aspects of this particular review that put its findings into question. As well, we have concerns about your reporting of this research. We feel that the title of your article and your interpretation of the study’s findings gives the public a distorted and even incorrect impression of those findings and of the appropriate conclusions that can be drawn from them. This review makes the excellent point that the vast majority of efforts in treating trauma occur after the development of PTSD, and that more benefits might be obtained through early interventions. Many readers, however, may be misled by your article to believe that there is little evidence for efficacy of treatments once PTSD has developed.

    With regards to the review itself, the fact that only 19 studies met the criteria for inclusion in the review out of 2,563 abstracts reviewed is significant and would warrant a great deal more information and discussion of the reasons for excluding more than 99% of the studies reviewed. It only stands to reason that the methodology of the study has excluded a lot of valid and useful information. Certainly if the International Society for Traumatic Stress Studies found enough evidence to publish a book entitled Effective Treatments for PTSD: Practice Guidelines, one must assume there is evidence to support some satisfactory degree of efficacy in some treatments.

    The authors themselves say “Health professionals should view these findings cautiously, given the limited number of studies that met criteria for this review and the numerous deficiencies in reviewed studies.” We would add to this a caution regarding some deficiencies in this review itself. One of the most important distortions provided by this review is that one of the inclusion criteria was that the research had to take place within three months of the traumatic incident. As researchers note: “Conducting research immediately after a traumatic event poses inherent challenges.” One of these challenges is that most people are not closely followed and posttraumatic stress is only diagnosed a significant time later, as a result of pervasive and persistent problems. When people are followed early on after a traumatic event, clinicians are focusing on helping or treating them. Another distortion, with regards to the “real world” applicability of these findings, is that as the authors say, “few or no studies dealt with victims of terrorism, sexual assault, natural disaster, or combat.”

    Therefore, all treatments that have been found to have some success in actually treating posttraumatic stress disorder are excluded from this review, resulting in the distortion expressed in the headline of your article: Few Effective, Evidence-Based Interventions to Prevent Posttraumatic Stress Disorder, Review Finds. We note, for example, that EMDR, which is now widely regarded in the literature as an effective treatment, is not included at all. Acupoint tapping, for which there is a growing body of very positive research in the treatment of PTSD gets no mention either. (See Feinstein, D. (2010). Rapid Treatment of PTSD: Why Psychological Exposure with Acupoint Tapping May Be Effective. Psychotherapy: Theory, Research, Practice, Training. 47(3), 385-402. Also, Feinstein, D. (2012). Acupoint stimulation in treating psychological disorders: evidence of efficacy. Review of General Psychology. 16 (4), 364-380. doi: 10.1037/a0028602)

    Properly interpreted, the conclusion of the authors of this study was that – based on the approach this study took – the researchers were unable to determine conclusively that specific treatments would help in the prevention of PTSD not that there is insufficient evidence to support current treatments of PTSD. Therefore, your statement that “Only two psychotherapeutic treatments showed possible benefits for adults exposed to trauma” is completely incorrect and misleading to the reader. As noted above, treatments for PTSD have been found effective, and given the scope and gravity of the occurrence of PTSD it is essential that readers are aware of this. With regards to the review itself, it would seem appropriate for the authors to conclude that research should be done providing treatments that are already proving to be effective in treating PTSD – such as EMDR and Acupoint tapping – within a three month timeframe following a traumatic event, to determine whether they are effective in preventing PTSD.

    Robert Schwarz, PsyD
    Executive Director
    Association for Comprehensive Energy Psychology

    Link to this
  20. 20. KTal4 11:17 am 04/12/2013

    Doctor Schwarz… Comprehensive Energy Psychology? Seriously?

    First, you get the headline of my article wrong, which suggests that this is a boiler plate response you post to comments sections of articles that challenge “cures” for PTSD. This impression is bolstered by your repeated reference to “the study,” when, in fact, I mention several studies.

    Second, you ignore the fact that MOST people with PTSD have comorbid disorders and that the very STSS volume you mention describes the difficulty of treating PTSD in patients with comorbid disorders. In fact they devoted a whole final chapter to this problem in the latest edition. This chapter documents both the lack of research on PTSD & comorbid disorders, and the lowered effectiveness (or outright ineffectiveness) of most standard PTSD treatments for these patients.

    Your own evidence contradicts you, and your posting of boilerplate comments that did not directly address the content of the article make it clear that you’re yet another advocate pushing therapies ineffective for the large majority of people with PTSD. One of the nicest things about this comments section is that it has collected a whole range of advocates, and demonstrated how hard they’ll push for their favorite flavor of PTSD treatment.

    Link to this
  21. 21. Macdoodler 12:15 pm 06/6/2013

    Many have a history of few supports and, like me, often hanging off the edge of Maslow’s Hierarchy of Needs. Safety and stability are core requirements for healing, and too many social service agencies and non profits don’t actually provide that, esp if you have “too many special needs” . Many have comorbid physical disability or long term illness +/or a Hx of dysfunctional family and other lack of appropriate supports. In the USA lowest income single disabled adults are the least likely to get even basic shelter assist or proper housing help and are most likely to be the long term homeless or at best inaccessibly housed and helped unless they are Olmstead qualified. Most programs are for healthy families, healthy but for substance rehab and few if any are even willing to help most lowest income single disabled, esp if there is too much need for help and accommodation. All the meds and therapy in the world won’t help if you don’t first have basic safety and stability needs met. IMHO.

    Link to this
  22. 22. jeastman1944 8:11 am 07/24/2013

    “44 veterans attempt and 20 veterans die by suicide every day.”

    PTSDSTRESS.COM is an anonymous, self-directed internet-based computer therapy website that reduces the symptoms of PTSD.

    Developed in part by a National Institute of Health PTSD researcher, the user follows programmed light movements on their computer screen while following easy-to-use instructions. Similar to EMDR, it costs $10 per session and accepts credit cards but does not require a cardholder name for further anonymity and confidentiality. Military and non-military men and women users report results on PTSDSTRESS.COM home page.

    Link to this
  23. 23. JonButler50 1:56 am 07/26/2013

    Personally, what I have read in this article I have seen and lived to be true in my case. I have been diagnosed with chronic PTSD, bipolar depressive, major depression and am a recovering alcoholic.

    By the time that I was ten I had been beaten, tortured, molested and sodomized by a close member of my family. The abuse did not end until I was nineteen. When I found alcohol and drugs at the age of fifteen, I thought that I had found the cure, but it nearly killed me at the age of twenty nine. I have completely blacked out the first twenty years of my life, except for when I am having PTSD flashbacks so intense and real that I do not eat or sleep for days or weeks (which is why I am up now and researching more about PTSD) and have been in three institutions in the last year for suicidal failures or intentions (I don’t personally believe that people attempt suicide, just fail at it). The last ten years have been a drunken blackout filled with violence, fear and nightmares beyond what others can comprehend. At the age of twenty nine, after a series of suicidal overdoses that I kept waking up from, I got tired of all of the psychological torture and almost drank myself to death, literally.

    I started seeing counselors, therapists, psychologists, and psychiatrists at the age of eight because “there was just something wrong with me” as I remember a family member saying while I was supposed to be sleeping (I am now thirty years old, and my sobriety date is May 15, 2012). I have been prescribed a few of the drugs mentioned above, along with most SSRI’s (they make me extremely homicidal or suicidal), SNRI”s, anti-psychotics, a couple benzodiazepines (too addictive), and a few of the new “wonder drugs” for PTSD and/or depression, none of which had any positive and/or long term effect. I have been through CBT therapy, which was too intense and introspective and caused re-occuring nightmares, DBT therapy (By far the best for me, but far from a cure and most insurances don’t cover it), psychotherapy which I almost sent another man at the inpatient trauma center that I admitted myself into to the hospital in a rage, individual and group counselors who have told me that “I’m just not trying hard enough”, EMDR which did almost nothing a few days after the sessions, psychologists who have told me that they could do nothing else for me, and psychiatrist who told me “That medication was a test, I wanted to see how you would react to it”. “I damn well told you that you cant prescribe me those ’cause I’d try to kill myself or someone else!” My alarm just went off for me to take the only pill that I take now, which is Lamotragine, a mood stabilizer, so that I have about a five minute warning before I know that I am going to have a flashback.

    I’m not telling this for pity or self-recognition, and I don’t think that there is anyway that I could make all of this up, I am telling all of this to provide this point: In my experiences of excruciating, intense, decades long trauma, and the lengths that I have taken in my recovery to find a “cure” I can say that there is not any for me yet. The only tools that I have to work with are the ones that I was born with, patience, perseverance, and a strong desire to pursue what it is that I want to in my life, however miserable it may be.

    I would like to reach out to any other PTSD survivors that are reading this. I might not know what you have been through, but I know the feelings: Shame that we could not stop what happened to us; guilt for what we did or did not do because of it; intense self pity for the feelings that we have about ourselves and others; the felling of always being different than everyone and that no one understands what is happening to us and why we act the way that we do; resentments at those who have harmed us, be it the original perpetrator or anyone else that brings back those feelings instilled in us as traumatizing; hopelessness because we cannot see an end of the torture and torment that day-to-day life brings upon waking until the nightmares stop; and the recognition that traumatizing occurrences are happening all around us everyday, that there is always another victim and another life lost because the others could not face this world alone anymore. Please don’t become the other side of the statistic, there are others like us, we can help each other.

    I would also like to say this: from a research-based, professional perspective I can see the validity in all of the above comments and statements, BUT I find the author’s article to be the most accurate to what I have experienced myself. And to belittle someone’s research based on what they have seen for thirty years of personal research and hands-on experience in the field of trauma, working with trauma victims, and the author of a renowned book. If you don’t like the research paper, take what you can and leave the rest for later. It is pure biased, and rude as well, to negatively comment on someone else’s work by showing what you have discovered for yourself, may it me in research alone or hands on experience, at the expense of another’s reputation and wisdom. After all, the highest degree that you can attain in this field is a doctorate of philosophy, philosophy meaning the love of knowledge and/or the critical analysis of fundamental assumptions or beliefs: nothing is proven, everything changes.

    I will close by saying that this comment is only my opinion and the wisdom that I have obtained through first hand experience and research through sleepless nights.

    Thank you for letting me share and for reading this far, aloha.

    Link to this
  24. 24. JonButler50 2:05 am 07/26/2013

    I forgot to thank you, Kali Tal, for your efforts towards trauma victims. I’m sure that it cannot be easy, but I’m sure that you have saved countless lives in your endeavors.

    Thank you.

    Link to this
  25. 25. NeurosciGeek 2:53 am 10/9/2013

    Seriously? This was published in Scientific American? This does great disservice to the public, particularly those who suffer from PTSD. The authors claim to fame seems to be a book she calls “seminal,” but which is ranked lower than 1 millionth on the Amazon best sellers list, meaning that it sells fewer than 4 copies a year. Also one of only two positive reviews she received seems to have thought it was a book on art history.
    I also notice that the author has zero peer reviewed articles on PTSD listed in Pubmed. If this article is any representation, it is clear why it wouldn’t pass such review. The article has logical holes that you could drive a truck through, and when these are pointed out, the author personally goes online to flame the posters.
    A few obvious logical errors:
    1) Assuming equivalence between VR therapy and combat simulation because both use computer simulation. Does this mean that the authors essays are also doing the same thing because it was produced on a computer? (I’ll admit reading it was traumatizing).
    2) Stating that therapy is ineffective because of difficulties establishing the superiority of one trauma focused therapy over another. Considering remission rates in some of these studies are >75%, admittedly it is going to be difficult to show a superior treatment. The same thing by the way applies to comparing cancer treatments or antibiotic interventions, where success rates aren’t as high, but superiority of one intervention has been difficult to prove. Are we to give up on those also?
    3) Assuming that the absence of evidence means the evidence of absence. For example, the risperodone trial did not provide enough evidence to establish this drug as a treatment for PTSD. However, prior correlative evidence (the same type that the author claim proves the value of the VAWA ) was and continues to be very positive. Also, if one actually read the trial, one might notice that the group that received the drug did actually do better than then group that got placebo, in some measures in a statistically significant way. The primary outcome measure was better in the treatment group than in controls, but not to a degree that was statistically significant. The whole risperdal study could be viewed as a failed trial rather than a trial of a drug that failed since depression scores (a condition for which risperodone has proven effectiveness) also didn’t improve. None of this is to defend risperodone as an intervention. I just use this as an example to show that the author is dismissive of clinical observation, while being entirely supportive of a social intervention with the same type of supportive evidence.
    4) The baby with the bathwater problem. I think everyone agrees that trying to end violence and psychological trauma is a good thing. However, just as we know the cause of HIV, type II diabetes, and physical trauma, and theoretically could end them by altering people’s behavior, that doesn’t devalue the scientific work that has created treatments for these conditions. There is no easy solution to remove violence. Laws are imperfect, and completely pacifist approaches to war often result in more people being killed or traumatized over time. Car accidents aren’t going away. etc. Since we seem to be making greater strides in the case of PTSD treatments than we do in prevention perhaps we should continue to make those strides, just as we do for HIV, diabetes, and physical trauma treatments.

    I could go on, but my main point is this: The author seems to make it seem like people with PTSD can’t and don’t get better. I can say from both personal and research experience that they clearly do. Nothing is a perfect solution, but on the whole, therapy works. The author should try it.
    .

    Link to this

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