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PTSD affects about 11-20% of veterans that have served in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Symptoms can be grouped into four distinct clusters: recurrent and intrusive reminders of the event, avoidance of things that remind one of the event, negative changes in thoughts and moods, and emotional reactivity. These symptoms can affect ones quality of life. PTSD has been found to contribute to low mental and physical quality of life (Gradus, 2017). It is necessary to improve the quality of life for veterans because they already have to adjust back into civilian life after experiencing war and dealing with additional physical and mental health challenges can cause distress. Generally, people with PTSD have 5.3 times higher rates of death from suicide (Gradus, 2017). These rates are high, and are even higher in veterans who are diagnosed with PTSD. Veterans with PTSD diagnoses have four times higher suicide rates than veterans without (Gradus, 2017). Adjusting to civilian life can add more stressors to veterans who are also struggling with PTSD.
Treatments for PTSD have been focused on two types of cognitive behavioral therapy. Cognitive Processing Therapy (CPT) has been used and shows the strongest evidence for reducing symptoms, better than any other non drug treatment (Reisman, 2016). It focuses specifically on the impact of trauma and identifies negative thoughts. Therapists then work with the patient to replace negative thoughts and work on coping skills. Prolonged Exposure (PE) focuses on repeatedly visiting the trauma in a safe setting to change emotional reaction to the event. It also teaches patients how to overcome stress and fear in situations that may induce these negative emotions. Both techniques take twelve weekly sessions to complete. This time commitment and reexposure to trauma can be potential factors that lead to patient dropout. Dropout rates are as high as 54 percent (Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008) and are even higher for Afghanistan and Iraq veterans with dropout rates being 62 percent (Harpaz-Rotem & Rosenheck, 2011). Some other treatments include Eye Movement Desensitization and Reprocessing therapy and medications. However, these treatments are not used as the first step.
New treatment approaches have been used that focus on mindfulness cognitive behavioral and incorporating exercise. These treatments have been seen as a way to help not only with symptom reduction but also with patient dropout. Mindfulness has been brought into psychology by Langer and Kabat-Zinn (Lang et al., 2012). There has been an increase in using these techniques, which can be used in addition to treatment or as its own intervention (Lang, 2017). Some of these treatments are already being conducted at Veteran Affairs offices (Libby, Pilver, & Desai, 2012). A randomized trial of a certain type of yoga showed reduction in PTSD symptoms, and had a 90 percent rate completion of the veterans in the active group (Seppälä et al., 2014). This suggests that veterans may be interested in trying new methods to helping with PTSD symptom reduction. Mindfulness includes non judgemental acceptance which helps with avoidance and thought suppression, two symptoms that are frequently found in PTSD (Lang, 2017). These two characteristics are often the focus of mindfulness techniques and are strong predictors of outcome (Boden, Bernstein, Walser, Bui, Alvarez, & Bonn-Miller, 2012).
Exercise is also emerging as a new treatment for PTSD. Despite it being a familiar part of their day, individuals with PTSD report exercising less than those without PTSD (Goldstein, Mehling, Metzler, 2017). With being used to exercise as their routine, these treatments might have an appeal to veterans. Previous studies have looked at civilian populations, but have not been generalizable. Even though there have been studies that show there is an improvement in symptoms, they are not generalizable and have limitations. In order to address these concerns, more studies are creating methods that can be replicated. More specifically, they are examining types of exercises, determining which will be most effective in symptom reduction. In the study by Goldstein, Mehling, and Metzler, (2017) they utilized strength training, aerobic exercise, and yoga. All exercises were accessible to participants and could be conducted anywhere. This is also something that can be done whenever is convenient to the individual (Whitworth, Craft, Dunsiger, Ciccolo, 2017). Studies have found that there was a high acceptability rate, meaning that participants were willing to do the treatment as well as finding symptom reduction. Attention and exercise was another factor that was examined. In Fetzner & Asmundson (2015), they found that increasing attention to the changes in body changes made exercise less enjoyable, and that it might be better to not tell the individual to focus on these changes.
These treatments can help with symptom reduction and might appeal to veterans more so. It can be framed as skills to help cope with stressors and done in group settings. This could help with reduction of dropouts. However, more research would need to be done on comparing these treatments with CPT and PE before any claim can be made. It is important to study these treatments side by side because it will help determine if one yields better outcomes than the other. If one technique is proven to be helpful, then it could be used to improve veterans lives and then be researched to see if it has the same effects in civilian PTSD populations. The research will compare mindfulness cognitive behavioral therapy and Integrated Exercise side by side on the effect of symptom reduction. This research proposal hypothesizes that Mindfulness Cognitive Behavioral Therapy will have higher rates of symptom reduction than Integrated Exercise.
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