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Posttraumatic stress disorder: a treatable public health problem.

Clinical social workers need to be aware of the growing problem of untreated and undertreated trauma in society. This is an especially important issue affecting our veteran population. According to the U.S. Department of Veterans Affairs, posttraumatic stress disorder (PTSD) affects 6.8 percent of the general population (Kessler, Sonnega, & Bromet, 1995; Kulka et al., 1990). There are reports of Iraq and Afghanistan veterans returning with PTSD rates as high as 50 percent (Helmer et al., 2007). The emotional and financial costs of this diagnosis to society are staggering. Affected veterans can have difficulty functioning in both the home and the job environment, so they may receive disability payments for life. Those seeking help face additional expenses for mental health treatment and medications; others who self-medicate risk alcohol and drug abuse. There may be additional costs for treatment of family members living with someone affected by PTSD.

Why is the rate of PTSD now so much higher than in previous conflicts? The higher rate may be due to several factors, including the following:

* Our troops have been engaged in cities and towns where they cannot easily distinguish enemy combatants from civilians. The enemy combatants do not wear uniforms, and any typically dressed citizen could be a suicide bomber.

* The length and number of tours of duty has increased. During the Vietnam War, a tour was one year, and soldiers knew their service was complete at the end of that time. Further tours came only if one volunteered. In our current wars, tours last 12 to 15 months, and some units have been redeployed four times.

* Due to medical advances, more vets are surviving their wounds, although they may be missing limbs or have survived other severe physical injuries.

* Many of our soldiers are National Guards, not full-time career military. They have full-time jobs and families here at home. When their deployment ends, they return to civilian life.

The military has worked hard to inform returning veterans about what they might experience emotionally and how it may affect their families. However, most veterans do not ask for help with PTSD symptoms out of shame or fear that it will negatively affect their career advancement. Newly returned National Guards are given medical insurance that expires in three months. The "post" in PTSD means that symptoms begin months or years later. Some veterans are so traumatized that they are unable to leave their homes, and their insurance has run out. In my practice, I see older veterans from the Gulf War and the Vietnam War who are experiencing an increase in PTSD symptoms--memories, flashbacks, and nightmares--triggered by watching television news about the current conflicts.

Fortunately, we have a highly effective psychotherapeutic treatment called eye movement desensitization and reprocessing (EMDR) that works very quickly to end PTSD in clients (Shapiro, 1989). Numerous randomized studies attest to its efficacy as an evidence-based treatment for PTSD (Bisson & Andrew, 2007; Bradley, Greene, Russ, Dutra, & Westen, 2005). It is recommended by many organizations and insurance companies, including the American Psychiatric Association (2004) and the Department of Veteran Affairs and Department of Defense (2004). In studies comparing EMDR to cognitive therapy, exposure, desensitization, and Prozac, the effectiveness of EMDR equals or exceeds other PTSD treatments, and it is generally faster (Van der Kolk et al., 2007). A Veterans Affairs study also demonstrated that EMDR successfully relieves phantom limb pain, which may be a common problem for the many veteran amputees (Russell, 2008; Schneider, Hofmann, Rost, & Shapiro, 2008). In one study of multiply traumatized veterans, 12 sessions of EMDR relieved the symptoms in 77 percent of the veterans (Carlson, Chemtob, Rusnak, Hedlund, & Muraoka, 1998).

Veterans typically dislike talking to nonveterans about their combat experience. One of the benefits of using EMDR (for patients and therapists) is that they do not have to talk about the details of their trauma for the EMDR process to work. During EMDR, the patient's brain heals itself and the therapist just needs to adhere to the EMDR protocol. Talking too much actually gets in the way and takes the patient out of the healing process. EMDR also works well with PTSD caused by traumas other than war that most clinicians see daily--that is, sexual abuse (Edmond, Rubin, & Wambach, 1999; Rothbaum, 1997), accidents (Hogberg et al., 2007), natural disasters (Konuk et al., 2006), and grief (Sprang, 2001).

At a time when we face rising incidences of PTSD and increased budget and health care costs, it concerns me--a practicing clinician with more than 30 years of frontline experience treating trauma--that many clinical social workers and other health care professionals are unfamiliar with the effectiveness of EMDR for PTSD and other disorders.

I have treated hundreds of PTSD patients using EMDR, and the vast majority of them improved completely. Every combat veteran that I have treated recovered within one to eight sessions of EMDR. I have also used EMDR successfully with patients who had smaller traumas, phobias, performance anxiety, and diagnoses other than PTSD. If a patient has any memories or thoughts that cause him or her distress, no matter how minor, EMDR can usually resolve it quickly.

In light of its effectiveness, it makes sense that all social workers should familiarize themselves with EMDR. The relevant studies can be viewed on the home page of EMDR.com. I also believe that most clinical social workers should be trained in EMDR, as most of our clients have trauma histories. If the estimates of PTSD in veterans are accurate, we could save them and their families from years of suffering. We could save taxpayers hundreds of millions of dollars in disability payments and medical costs, which could accrue for the next 60 or more years to assist Iraqi and Afghanistan veterans. And equally important from a professional standpoint, thanks to EMDR, PTSD is now one of the easiest and most rewarding psychiatric diagnoses to treat.

Accepted February 23, 2009

REFERENCES

American Psychiatric Association. (2004). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: American Psychiatric Association Practice Guidelines.

Bisson, J., & Andrew, M. (2007). Psychological treatment of post-traumatic stress disorder (PTSD). Retrieved February 26, 2009 from http://www.cochrane.org/ reviews/en/ab003388.html

Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227.

Carlson, J., Chemtob, C. M., Rusnak, K., Hedlund, N. L., & Muraoka, M. Y. (1998). Eye movement desensitization and reprocessing (EMDR): Treatment for combat-related post-traumatic stress disorder. Journal of Traumatic Stress, 11, 3-24.

Department of Veterans Affairs & Department of Defense. (2004). VA/DoD Clinical practice guideline for the management of post-traumatic stress [Publication No. 10Q-CPG/PTSD-04]. Washington, DC: U.S. Department of Defense, Department of Veterans Affairs and Health Affairs, Veterans Health Administration.

Edmond, T., Rubin, A., & Wambach, K. (1999). The effectiveness of EMDR with adult female survivors of childhood sexual abuse. Social Work Research, 23, 103-116.

Helmer, D. A., Rossignol, M., Blatt, M., Agarwal, R., Teichman, R., & Lange, G. (2007). Health and exposure concerns of veterans deployed to Iraq and Afghanistan. Journal of Occupational and Environmental Medicine, 49, 475-480.

Hogberg, G., Pagani, M., Sundin, O., Soares, J., Aberg-Wistedt, A., Tarnell, B., & Hallstrom, T. (2007). On treatment with eye movement desensitization and reprocessing of chronic post-traumatic stress disorder in public transportation workers: A randomized controlled study. Nordic Journal of Psychiatry, 61, 54-61.

Kessler, R. C., Sonnega, A., & Bromet, E. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.

Konuk, E., Knipe, J., Eke, I., Yuksek, H., Yurtsever, A., & Ostep, S. (2006). The effects of EMDR therapy on post-traumatic stress disorder in survivors of the 1999 Marmara, Turkey, earthquake. International Journal of Stress Management, 13, 291-308.

Kulka, R. A. Schlenger, W. E., Fairbank, J.A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.

Rothbaum, B. (1997). A controlled study of eye movement desensitization and reprocessing in the treatment of post-traumatic stress disordered sexual assault victims. Bulletin of the Menninger Clinic, 61, 317-334.

Russell, M. C. (2008). Treating traumatic amputation-related phantom limb pain: A case study utilizing eye movement desensitization and reprocessing within the armed services. Clinical Case Studies, 7, 136-153.

Schneider, J., Hofmann, A., Rost, C., & Shapiro, F. (2008). EMDR in the treatment of chronic phantom limb pain. Pain Medicine, 9(1), 76-82.

Shapiro, F. (1989). Efficacy of the eye movement desensitization procedure in the treatment of traumatic memories. Journal of Traumatic Stress Studies, 2, 199-223.

Sprang, G. (2001). The use of eye movement desensitization and reprocessing (EMDR) in the treatment of traumatic stress and complicated mourning: Psychological and behavioral outcomes. Research on Social Work Practice, 11, 300-320.

Van der Kolk, B., Spinazzola, J., Blaustein, M., Hopper, J., Hopper, E., Korn, D., & Simpson, W. (2007). A randomized clinical trial of EMDR, fluoxetine and pill placebo in the treatment of PTSD: Treatment effects and long-term maintenance. Journal of Clinical Psychiatry, 68, 37-46.

Robert P. Salvatore, ACSW, LICSW, is a licensed clinical social worker, LaMora Psychological Associates, 29 Simon Street, Unit 5, Nashua, NH 03060; e-mail: salvatore@lamorapsych.com.
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Title Annotation:VIEWPOINT
Author:Salvatore, Robert P.
Publication:Health and Social Work
Geographic Code:1USA
Date:May 1, 2009
Words:1533
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