National Nurses United

Registered Nurse October 2006

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PTSD 10/11/06 1:11 AM Page 18 In the early days of PTSD management, MDs treated patients with common antianxiety and antipsychotic medications, mainly tricyclic antidepressants and benzodiazepines. In the last decade, SSRIs became the mainstay of treatment. And more recently, beta-blockers have been used to calm symptoms of episodic panic. But these drugs' effectiveness in treating PTSD symptoms varies greatly with the individual: very helpful for certain patients, not so with others. Nor do they cure the disorder. Currently, official PTSD treatment guidelines call for psychotherapy along with medication. While one-on-one therapy is the cornerstone of psychological care for PTSD, many MDs and RNs maintain that group therapy for survivors—from war veterans, to brutalized refugees, to rape victims—is most effective in lessening long-term symptoms. Newer psychotherapeutic techniques gaining favor in PTSD treatment include EMDR (Eye Movement Desensitization and Reprocessing), with the patient recalling traumatic memories while the therapist elicits eye movements similar to those which occur naturally in REM sleep. As PTSD incidence among GIs grows, the Department of Veterans Affairs, too, has begun treatment trials with atypical forms of psychotherapy. Project DE-STRESS, coordinated by RN Victoria Bruner, uses "virtual reality-based exposure therapy" with PTSD-diagnosed vets at Walter Reed Army Medical Center in Washington, D.C. In interactive computer-generated environments, vets are exposed to controlled, anxiety-provoking stimuli with the aim of becoming desensitized to traumatic memories. Clinical supervision reportedly occurs along the way. Proponents of virtual reality therapy (VRT) claim it is safer than "vivo exposure" (live therapists) and better suited for vets who live in remote locales, or are reluctant to seek care. They say VRT also relies less on patients' ability to visualize traumatic memories, making it harder to resist processing them. But not all experts are thrilled by VRT. Social isolation—perhaps a PTSD survivor's worst enemy—is consolidated by "solo" therapies like VRT. So while the military forges ahead with experiments in high-tech PTSD cures, other institutions have expanded their own treatment plans to include "no-tech" options such as stress reduction and meditation, often with notable success. Lloyd Burton, today a University of Colorado environmental law professor, served as a medic in Vietnam. Home from the battlefield in 1967, Burton believed he'd left the worst behind. Not so. For the next seven years, Burton lived with PTSD symptoms—chronic insomnia, flashbacks, and uncontrollable outbursts of anger—without a diagnosis or treatment. Once diagnosed, Burton tried nearly every standard therapy available. While Burton attests to the value of antianxiety drugs and other programs in treating PTSD, he credits insight meditation—a few steps removed from its Buddhist roots—as the technique that finally helped him face his ghosts and, ultimately, to eliminate flashbacks. The Boulder professor is not alone. Currently, institutions from the Mayo Clinic to Harvard to the Stanford University School of Medicine advocate meditation and stress-reduction techniques as an integral part of treatment offered to traumatic stress survivors. "To truly treat PTSD," Burton said, "we need not only to treat the symptoms, but also the root cause"—what Burton and mental health experts refer to as "triggering moments." To do so, healthcare centers must create a safe, calm environment where trauma-associated 18 REGISTERED NURSE memories and emotions can be acknowledged. Burton and a group of fellow vets have done this with Vets4Vets, a therapy group that has been a haven for many vets too full of shame to seek care with psychiatric professionals. Today, Burton sees a small but growing number of clinics, hospitals, and VA programs considering not just the GI's physical injury, but the social, spiritual, and community contexts to which patients are returning. Because RNs are often providing much of the day-today, long-term care for vets, Burton says that their role in creating integrative healthcare environments for vets with PTSD is crucial. RN Laura Berg agrees that RNs, and particularly clinical specialists, offer a particularly useful combination of skills for the task. "We're not just on a 'track' looking at physical symptoms," she said. "We're looking at the whole person, every aspect: psychic, spiritual, physical, self-esteem, family life. RN clinical specialists can really get the job done. Social workers are great, but they have to call for medications. Psych workers working within the system may only be able to offer a psych appointment in two months, not knowing, say, as we do, that there's a vet center downtown where a patient can get help the day they walk in. A nurse can look at a patient with chronic pain and ask, 'Is this person on tramadol? Is that all he's been given?'" RNs today are also serving PTSD survivors with a profile distinct from veterans of former wars. According to Defense Department statistics, 11 percent of those who have served in Afghanistan and Iraq are female. While most have no formal combat assignment, no real front line exists in Iraq, so consequently many female personnel end up there anyway. Twenty years ago, 2 percent of the VA's patients were female; now they constitute 14 percent. Though treatment options for PTSD are expanding, that doesn't mean returning soldiers will be able to access them. One reason is that the White House and Congress are not adequately budgeting for the long-term healthcare needs of Iraq War veterans. In July 2002, White House budget advisor Larry Lindsey was ousted for suggesting that the Iraq War might end up costing $200 million. Today, the tab, according to Bush administration figures, is nearly $400 billion dollars. And these are simply the initial costs of the war. In September 2004, Congress' Government Accountability Office declared that six out of seven Veterans Affairs hospitals it monitored "may not be able to meet" the increasing need for PTSD treatment. Economists, including Nobel laureate John Stiglitz, who recently drew up an independent estimate, also project that the costs are much higher than stated. Stiglitz calculates that at the current rate of injury, the government may be compelled to pay out between $1 to 2 trillion in lifetime healthcare and disability to Iraq War vets. As an example, a recorded 161,000 Vietnam veterans were still receiving disability compensation in 2004 for PTSD, the Veteran's Adjustment Survey revealed. Today, a returning vet must wait an average of 165 days for a VA decision on initial disability benefits. An appeal can take up to three years—and in the last decade more than 13,000 veterans have died awaiting a decision. Several of the deaths have been suicides, as in the 2005 case of Alabama Specialist Doug Barber, an Operation Iraqi W W W. C A L N U R S E S . O R G OCTOBER 2006

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