Treating PTSD Resulting from Military Sexual Trauma
The current criteria for a diagnosis of Post-Traumatic Stress Disorder can be found detailed in the DSM-5 (APA, 2013) on pages 271 through 274. This is the most likely mental disorder to develop as a result of Military sexual trauma. The list of criterion and associated symptoms describes the presentation for PTSD as outlined by the APA and in turn the VA (U.S. Dept. of Veterans Affairs, 2014). Three to Thirty days after the trauma a diagnosis of Acute Stress Disorder (pages 280 & 281) can be made with a provisional diagnosis for PTSD once thirty days has elapsed (APA, 2013). Each individual criterion must be met to make a diagnosis that qualifies for treatment that is covered by most third-party health insurers.
A major shift from DSM-IV-TR to DSM-5 has to do with the subsequent affective reaction to the precipitating traumatic event outlined in criterion A. In the DSM-IV a reaction to the event involving, “fear, helplessness, or horror,” is listed as a necessary affective state for diagnosis (APA, 2000). To accommodate the highly mixed presentation of PTSD this has been dropped. With the DSM-5, merely the occurrence of a traumatic event without a specified emotional reaction satisfies criterion A. Because cultural and sub-cultural reactions to traumatic events can vary greatly this shows a greater sensitivity to the atypical reactions that may result as a consequence of Military sexual assault.
Despite the many problems with the DSM-5 the substitution of, “Exposure to actual or threatened death, serious injury, or sexual violence,“ (APA, 2013) for, “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” (APA, 2000) is a semantic improvement. Even if only a pedantic distinction, the inclusion of specifically named sexual violence reflects a changing perception of PTSD as not merely a condition that results from war or the immediate threat of loss of life.
Symptomology and Conceptualization of PTSD
Criteria B, C, and D have changed very little in either letter or spirit from DSM-IV-TR to DSM-5 (Cluster C in the DSM-4-TR has simply been separated into two separate clusters; negative cognitive symptoms is covered by cluster D in the DSM-5 and arousal and reactivity symptoms have been placed in cluster E). In both manuals criterion B pertains to the reliving of the traumatic experience through, “flashbacks,” dreams, and trauma associated stimuli. Criterion C deals with avoidance of such stimuli and emotional numbing. This can cause a problematic resumption of sexual and emotionally intimate relationships even with trusted loved ones. Criteria D is associated with negative cognitive distortions and negative effect marked by anhedonia, dissociation, and dysphoria. Criteria E is attendant to hyper-vigilance and increased arousal including panic symptoms, exaggerated startle response and problems with sleep. These symptoms might undergo a, “delayed expression,” of months or years but typically appear within three months of the trauma.
Cognitive distortions involving amnesia, self-blame, and dichotomous thinking are often present following the precipitating event. Emotional volatility and mercurial affect along with pervasive feelings of, “fear, horror, anger, guilt, shame,” (APA, 2013) are also characteristic of PTSD. Self-destructive or reckless behavior may worsen in the after math of the traumatic event.
A posttraumatic factor that should be of special concern in the military is environmental reminders of the assault including working alongside the perpetrator(s) and stimuli that are reminiscent of the assault. This repeated posttraumatic exposure can have a negative effect on PTSD prognosis (APA, 2013) and makes Military sexual assault especially pernicious.
Symptoms clusters B, C, D, and E comprise the most troubling and debilitating aspects of PTSD. These symptom clusters are directly culpable in comorbid substance abuse, suicidality, and anxiety/depressive symptoms that make a return to normal life all but untenable without treatment. What’s more, avoidance and a pervasive reticence about the event(s) are characteristic of the symptomology of the disorder thus resulting in an immediate obstacle to therapeutic interventions.
Criterion F specifies that these symptom clusters must be present for at least one month and Criterion G specifies that they must interfere in major areas of life function. Given the gravity and diversity of symptom presentations, criteria G is all but axiomatic. It is relevant to note that rape survivors are among the trauma survivor sub-groups most likely to develop PTSD and that most sub-threshold PTSD cases are among older adults (American Psychiatric Association, 2013). This means that the nearly half of active duty service members between the ages of 22 and 30 that are most at risk for Military sexual trauma are at an age of high prevalence for the development of PTSD.
Treatment; Best Practices
Two of the main modalities used to treat these symptoms are prolonged exposure therapy (PE) and cognitive processing therapy (CPT). The former to primarily address symptoms from cluster B and C and the latter to remediate symptoms from cluster D and E.
First PE; Nightmares and intrusive flashbacks are a direct result of repression. Helping a client to confront and become more habituated to the precipitating sexual trauma will reassure them that exploring the events will not lead to a loss of control and will mollify fears that reliving the trauma will result in re-traumatization. If the reality of what happened is faced, assessed, and affectively integrated into the client’s world schema then the event is made real in a much more tangible way. This shift of memory processing from the subconscious to the conscious should help ameliorate stimuli avoidance, and cause unwanted memory recurrences to abate and become more manageable.
Avoidance behaviors are a result of overgeneralization. The evolutionary responses to danger that aid in survival are conflated with situations that resemble the traumatizing event. Innocuous stimuli become associated with danger and a, “flight or fight,“ response in otherwise mundane and safe situations that may contain similar environmental characteristics with the initial trauma. Through imaginal and in vivo routine exposure this response to harmless stimuli can be adjusted and dissociated from danger through a process of systematic acclimation and desensitization.
After building rapport with the client and explaining the rationale behind PE, the clinician should begin teaching breathing and other stress tolerance techniques as well as building a hierarchy of stressors for use in imaginal and in vivo exposure therapy. Consistent telling and retelling of the trauma will bring the event back into the realm of consciousness decreasing the subconscious need for reenactment of the trauma manifested in dreams and flashbacks. Focusing on, “hot spots,” or areas particularly difficult to process or verbalize is important in maximizing the therapeutic effect of PE. Acclimation to the sights, sounds, scents, and sensations associated with the sexual trauma through structured imaginal and in vivo excises and homework will greatly decrease avoidance and increase the client’s general tolerance of associated stimuli.
Now CPT; Cognitive distortions resulting in dichotomous thinking about the safety of the world and a victim’s self-worth (cluster D symptoms) can be clearly linked as causal to the irritability and reckless behavior exhibited by PTSD diagnosed clients as well as the hyper-arousal symptoms found in cluster E. The genesis of these two sets of symptom clusters is cognitive in nature. CPT (much like REBT) challenges the distorted cognitive patterns about the world and about one’s self that result in self-deprecation and hyper-arousal. Traumatic events leave a residue of faulty cognitions and beliefs in both areas of agency and over-accommodation. Problems related to agency are thoughts resulting in problems with esteem and intimacy. The internalization of these unchallenged thoughts can often lead to emotional distress, estrangement, and anhedonia.
Over-accommodation (adjustment of prior positive beliefs) and assimilation (confirmation of prior negative beliefs) are both attempts to make a traumatic event fit with one’s world schema and thus assure a more predictable future. The logical leaps one must make to achieve this involves regarding the world as ubiquitously dangerous, unpredictable, and threatening. When these assumptions are taken as true, the natural response is hyper-arousal, reckless behavior, and self-destructive coping mechanisms (Cluster E symptoms).
Therapeutically working through the cognitive, “stuck points,” that can result from trauma can provide a more grounded, realistic, and optimistic view of the world and one’s place within it that will facilitate the integration of the traumatic event. By encouraging realistic accommodation through the challenging of cognitive distortions and the use of A-B-C worksheets, the client’s outlook will become more sensible. Inner-dialogue will come to more truly reflect the reality of the world and the client’s role in the trauma thus reducing negative affect and detachment (symptom cluster D) and hyper-arousal (symptom cluster E).
Both modalities have undergone numerous randomized clinical trials with victims of sexual assault and show high degrees of efficacy in PTSD symptom reduction or total remission. PE has been studied on civilian traumas such as sexual assault and been proven highly beneficial. Conversely, there is a relative dearth of PE RCT’s for combat related trauma. CPT pilot study populations were comprised of survivors of sexual assault and more studies are emerging demonstrating its effectiveness with military populations suffering from various forms of trauma.
Supportive and Ancillary Services
An obstacle in particular to Military sexual trauma is the increased sense of betrayal that comes with an assault from one’s “brothers (and sisters) in arms.” For this reason victims of Military sexual assault are made to feel like outsiders in an environment in which they were presumably hoping to find trust, acceptance, and comradery. Victims need to know that they are not alone in this experience nor are their symptoms a sign of weakness or, “craziness.” A support group will offer unconditional support and acceptance of the client and of what happened to them as well as affirmation of their feelings and symptoms as normal reactions to the sexual trauma. A support group might be particularly important for men who are questioning their masculinity, self-concept, or dealing with subsequent sexual issues. Understanding and support can lower the risk of developing PTSD.
Additionally, Couples and/or family counseling might be a necessary ancillary treatment modality. Psycho-education can take place in this setting thus informing the victim’s family about PTSD and its symptoms. Also issues involving communication, family conflict, and sexual issues between partners can be addressed and placed into perspective within the expectations and prognosis regarding sexual trauma, Acute Stress Disorder, and PTSD.
Finally, since substance abuse has high comorbidity with PTSD. Substance abuse rehabilitation along with continuing twelve step maintenance care may be called for as part of a multi-pronged treatment approach.