Prolonged exposure (PE) therapy has been found efficient in reducing posttraumatic stress disorder (PTSD) symptoms mostly among rape victims, but has not been explored in combat-related PTSD. Five patients with severe chronic PTSD, unresponsive to previous treatment (medication and supportive therapy) are described. Patients were evaluated with the PTSD Symptom Scale–Interview, and Beck Depression Inventory, before and after 10–15 sessions of PE therapy. All five patients showed marked improvement with PE, with a mean decrease of 48% in PTSD Symptom Scale–Interview score and 69% in Beck Depression Inventory score. Moreover, four patients maintained treatment gains or kept improving 6–18 months after the treatment. The results suggest that PE was effective in reducing combat-related chronic PTSD symptoms.
The conceptualization of posttraumatic stress disorder (PTSD) as a conditioned fear (phobia) has led to the employment of exposure therapy procedures, which have been found efficacious with other types of anxiety disorders, to PTSD sufferers.1
Exposure therapy comprises a set of techniques designed to help patients confront frightening objects, situations, memories, and images. With PTSD, the core components of exposure therapy are repeated recounting of the traumatic memory (imaginal exposure) and gradual exposure to fear-evoking trauma-related situations or objects (in vivo exposure). In the treatment guidelines developed under the auspices of the International Society for Traumatic Stress Studies, exposure therapy emerged as the most empirically supported intervention for PTSD. Several exposure therapy programs have been developed and studied with PTSD.
One such program, prolonged exposure (PE), has been extensively studied in recent years.2,3
PE is a structured treatment protocol which includes a series of 10–15 individual sessions. In theses sessions, patients undergo breathing retaining, education about common reactions to trauma, imaginal exposure to the trauma memory and in vivo exposure. PE therapy has been found to be quite successful in ameliorating assault-related PTSD in female assault victims3,4
but its efficacy with combat-related PTSD has not been examined.
Other exposure therapy programs have been partially efficacious among Vietnam War veterans with PTSD.5
For example, 14–16 sessions of implosive therapy, or flooding, combined with relaxation training produced 26% reduction in total symptom checklist and 17% reduction in PTSD subscale of the Minnesota Multiphasic Personality Inventory.1
Exposure, along with cognitive structuring and relapse prevention in group therapy was found to have a modest effect on PTSD symptoms.6
In addition, a meta-analysis held by Bradley and colleagues7
found a statistically lower overall effect size in studies focusing on combat veterans in comparison to effect sizes found in other trauma groups. Results from these and other studies led clinical researchers to conclude that combat veterans are treatment resistant relative to other traumatized populations.7
It is unclear, however, whether the limited success of exposure therapy found with male veterans relative to female sexual assault victims is due to differences in the populations or to differences in the exposure programs employed (eg, PE vs implosive therapy).
This article reports on the efficacy of PE in reducing PTSD symptoms in five Israeli veterans. All five patients had persistent PTSD since their war experiences and, prior to entering the PE program, had been receiving ongoing treatment with medication and supportive therapy. All five patients were offered PE because they did not respond to their treatments. Their PE treatment and its outcome are described below.
Five Israeli veterans with chronic PTSD are described in this paper. Three veterans participated in the Yom-Kippur war (1973), one in the Lebanon war (1982), and one in the first Intifada (1991). All patients were diagnosed with chronic PTSD according to Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition criteria by a senior psychiatrist (NN). Comorbidity of obsessive-compulsive disorder was found in two patients and major depressive disorder (MDD) in all five patients. Clinical characteristics of the participants are described in Table 1. All patients have agreed to participate in the PE treatment, and were treated in the Chaim Sheba Medical Center Ministry of Defense clinic in Israel, a specialized clinic for veterans suffering from chronic combat-related PTSD. These five patients were selected to be presented in this article because they were the first to be treated with PE although exhibiting long chronic PTSD (10–30 years), with severe symptoms and low functioning. These patients were part of about 20 patients who were treated with PE for combat and terror-related PTSD. Significant improvement in symptoms was evident in this group of patients, with dropout rate of about 14%.
PTSD symptoms were assessed pre- and posttreatment and followed-up at 6–12 months by the therapist. PTSD symptoms were assessed both in a semi-structured interview, by the PTSD Symptom Scale–Interview (PSS-I). The PSS-I comprised of 17 items that assesses the 17 PTSD symptoms included in sections B, C, and D of the DSM-IV
criteria. The interviewer rates how often each of the symptoms has bothered the patient during the two past weeks (0=not at all or only one time, 1=once a week or less/once in a while, 2=2–4 times a week/half the time, and 3=>5 times a week/almost always). The PSS-I has a range of scores of 0–51, and was reported to have excellent psychometric properties.8
In addition, as depressive symptoms are common in PTSD patients, depression was assessed by the Beck Depression Inventory (BDI), a 21-item self-report scale. BDI has good to excellent psychometric properties.9
PE therapy was conducted by two therapists who delivered the treatment in individual weekly sessions lasting ~90 minutes. All sessions were videotaped (for use in supervision) and audio-taped (to be reviewed by the participants as part of their homework). The treatment was conducted according to the PE therapy protocol by Foa and Rothbaum2
and consisted of 10–15 sessions. Patients admitted all sessions and were cooperative in doing their home assignments. During the course of the treatment and the follow-up, patients did not receive any other psychological treatment and remained on the same psychotropic medications they received at least 3 months prior to the beginning of the PE. Psychotropic medication included fluoxetine, paroxetine, sertraline, venlafaxine, and benzodiazepines.
During the treatment, all five patients showed marked improvement in their posttraumatic and depressive symptoms, including decrease of the intrusive memories and diminished anxiety associated with these memories. Importantly, a significant improvement was seen in the participants’ avoidance behavior. Assessment revealed a mean decrease of 48% in PSS-I score and 64% in BDI score. Moreover, four out of the five patients maintained treatment gains or kept improving 6–18 months after the treatment. Table 2 presents the scores of PSS-I and BDI pre-, post-treatment, and in follow-up for each patient.
Case Report 1
Mr. A was severely injured and was almost ran over by friendly tanks during the war. He was hospitalized for 2 years and his physical condition gradually improved. However, his PTSD symptoms did not remit. He became withdrawn at home and could not maintain a job. Despite his PTSD symptoms and his inability to function, Mr. A did not seek psychological treatment for 17 years (January 2000). He was then diagnosed with severe PTSD, major depressive disorder (MDD), and panic disorder, and was treated with both medications and psychotherapy. Although his depressive and panic symptoms improved, there was no significant improvement in his PTSD symptom severity as was reflected in recurring thoughts about the event, flashbacks, nightmares, severe sleep disturbances, and avoidance of crowded places. Three years later (2003), Mr. A was offered PE, which included gradual exposure to various activities he had avoided for 30 years and imaginal exposure to the traumatic memory. The memory elicited high anxiety in the first few sessions, but over the course of treatment the anxiety decreased. There was an overall decrease in intrusion and avoidance but he still suffered from sleep disturbances. At the 6-month follow-up assessment, Mr. A stopped shutting himself in his room and became socially active, started to study, flew abroad, and met with his daughter for the first time in 7 years.
Case Report 2
Mr. R experienced his major trauma during the war when he saw two missiles approaching him. He remembered freezing to his spot and thinking he was going to die. Immediately after this event, Mr. R began to suffer from tension and sleep disturbances. Over the years, his PTSD symptoms became more severe but he did not seek psychiatric treatment and continued doing army reserve duty. Ten years ago, when on reserve duty, he had a severe worsening of his mental state and was referred to treatment, where he was diagnosed with PTSD. He was treated with medications and psychotherapy for 2 years. As a result of the treatment, Mr. R’s functioning, but not his PTSD symptoms, improved. Two years later, after witnessing his neighbor commit suicide, Mr. R exhibited further deterioration of PTSD symptoms, along with severe depression, obsessive symptoms, and panic attacks. He sought psychiatric help again and was treated with sertraline 150 mg/day and psychodynamic therapy, which resulted in a slight reduction of the anxiety and depression, but not in the PTSD symptoms. After 8 months of this treatment (and 20 years after his initial trauma occurred), Mr. R was offered PE therapy. During the treatment his avoidance diminished and in the imaginary exposure led him to remember important details from the trauma. At 30-months follow-up, Mr. R is employed while completing a Masters degree. There is a remission in his depressive symptoms, his ability to concentrate has improved, and he has renewed relationships with old friends from the army.
Case Report 3
Mr. S was exposed to several traumatic experiences during the war. The event that continued to haunt him most was the image of rows of soldiers lying covered with blankets and realizing that they were all dead. After this experience, Mr. S returned to the battlefield, but began to experience dissociative episodes, severe nightmares, sleep disruptions, and severe tremor. He was diagnosed with acute stress reaction and was treated with injections of thiopental sodium and abreaction for 6 months; his symptoms further increased during this treatment. For almost 28 years, Mr. S suffered from severe PTSD but did not seek treatment. In 2001, he began psychiatric treatment, but his PTSD and depression symptoms persisted, as was reflected in recurrent memories of the traumatic events, flashbacks, nightmares, sleep disruptions, avoidance of crowded places (such as shopping centers, supermarkets, movie theaters, and coffee shops), and social contacts. In 2003, Mr. S began 15 sessions of PE. After the first imaginal exposure, Mr. S questioned the therapy method and was afraid to continue because of his negative experiences with thiopental treatment. Gradually, Mr. S’ avoidance and intrusive symptoms diminished. Twelve months after treatment, Mr. S’ feelings of numbness were reduced and for the first time he not only started to have feelings of love and warmth toward his family, but he was also capable of hugging them. He stopped avoiding crowded places and reported decreased frequency of intrusive thoughts and nightmares.
Case Report 4
Mr. Y witnessed his friends under missile attack, calling him for help while he was unable to respond and watched them die. In the next weeks he had difficulty functioning and following orders. After the war he began to experience PTSD symptoms. He refused psychiatric help with the exception of an occasional dose of diazepam. Several years ago, under continuous pressure from his family, Mr. Y sought psychiatric help. He was diagnosed with PTSD and MDD, and was treated with both medications and psychotherapy, with no improvement, as was reflected in continuous intrusive thoughts and images about the war, flashbacks and nightmares, avoiding situations that reminded him the trauma, social withdrawn and motor restlessness, startle response, hypervigilance, and irritability. Two years later, he was offered 15 sessions of PE. As would be expected, in the first sessions of the exposures, Mr. Y reported high levels of anxiety, but was very diligent with homework assignments. He started visited places he had avoided for 30 years, and at the end of treatment, he went back with his therapist to the place of his combat and visited the memorial monument. However, at follow up there was a slight decrease in his symptomatology that was reflected in re-adaptation of some of the avoidance pattern, although there was still a vast improvement compared to the beginning of his treatment.
Case Report 5
Mr. G’s major trauma was an attack by hundred of locals, who stoned him, stole his weapon, and threatened his life, while he was alone in his jeep. His major trauma occurred during the first Intifada in 1991, in which he was attacked by hundreds of locals, who stoned him, stole his weapon, and threatened his life, while he was alone in his jeep. Immediately after the trauma, Mr. G began to experience severe PTSD symptoms. Despite his severe symptoms he did not seek treatment until 13 years later when his wife became pregnant with their third child. He received medication, but with no response as was reflected in intrusive thoughts, flashback, sleep disturbances, panic attack, avoidance of crowded places and social situations. He was then offered 12 sessions of PE which resulted in significant improvement of his PTSD and depression symptoms. According to Mr. G, the most significant aspect of his improvement was his ability to feel love toward his family in general and especially for his new born baby.
The results from these series of five patients suggest that PE therapy, a treatment program that was originally developed for female survivors of sexual and non-sexual assault, might be effective in PTSD in male veterans, even more than a decade after the onset of symptoms. Moreover, treatment gains were maintained at follow-up for four out of the five patients, and two patients even continued to improve. The 48% mean reduction in the PSS-I score for the five patients is superior to the outcome found in other studies that utilized other exposure therapy programs with veterans.6,10-12
Moreover, the PTSD symptoms in the five patients were chronic for 10–30 years and failed to respond to other treatments that included medication, supportive psychodynamic psychotherapy, or their combinations.
Few controlled studies have examined the efficacy of cognitive-behavioral therapies with veterans suffering from chronic, combat-related PTSD, most of which reported limited impact on relieving PTSD symptoms and comorbid depression. Cooper and Clum11
have employed imaginal exposure therapy combined with psycho-educational and group therapy in Vietnam veterans with chronic PTSD. Although significant improvements were evident on several self report measures, no effect was found on other PTSD symptoms such as physiological hyper-arousal, trait anxiety and depression. Frueh and colleagues12
have also employed a cognitive-behavioral therapy program called Trauma Management Therapy in combat-related PTSD. Yet again, improvements were limited to several PTSD symptoms, with no significant improvement in depression, anxiety and expression and experience of anger. In a study examining the efficacy of group therapy combining cognitive-behavioral elements, a trauma-focused group psychotherapy was employed and compared to present centered group therapy that avoided trauma focus, with only modest improvement found in the trauma-focused group psychotherapy patients in symptoms of avoidance and numbing.6
Three important issues are worth attention. First, all five patients had experienced multiple traumas during their military service. However, the therapists focused on the traumatic event that most frequently came to their mind in the form of intrusive thoughts, flashbacks, or nightmares. According to patients’ reports, the processing of that event decreased the intrusive symptoms of other traumatic events as well. Second, the PE treatment was conducted during the second Intifada (2002–2005), a period with ongoing combat and terrorist attacks in Israel. These events served as trauma reminders, as well as further traumatizations for the patients. Moreover, the occurrence of attacks on civilians inside Israel presented a challenge for the in vivo exposures, as many Israelis tended to avoid crowded places at that time. One of the problems in PTSD is that they perceive the world as extremely dangerous and over-estimate probability for danger. One of the therapists’ challenges in treating a PTSD patient is to change their cognition and perception about danger throughout cognitive restructuring and exposure. However, this is especially challenging in time of ongoing terrorism and war. Although the probability of danger is higher, people with no PTSD tend to continue with their routine with some adjustments, rather than adapting avoidance. This goal was accomplished even with the patients with most severe avoidance.
The five patients completed their in vivo assignments despite this mitigating environment. Third, one of the patients was treated with abreaction shortly after the traumatic event, a treatment that was associated with some exacerbation of his symptoms. While PE and abreaction therapy both confront the patients with the traumatic memory, we hypothesize that the important aspect that differentiate the PE is that this confrontation is conducted in a manner that promotes a sense of control during the confrontation. Indeed, during PE the therapist’s role is to regulate the degree of anxiety such that the patient is both anxious, and feels control over their emotions.
While the results described here are encouraging, the small number of patients and the absent of a randomized comparison condition limit the ability to draw firm conclusions from the results. The patients presented in the current manuscript were selected to show a beneficial outcome for veterans with chronic PTSD after being treated with PE. However, these results cannot be generalized but to give the idea of PE as a possible good treatment for veterans with chronic PTSD. At present we are conducting a randomized, single-blind study that compares PE to treatment as usual with patients who have chronic PTSD related to combat and terror attacks.
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