Succinctly, in 1–2 pages, address the following:

  • Briefly explain the neurobiological basis for PTSD illness.
  • Discuss the DSM-5 diagnostic criteria for PTSD and relate these criteria to the symptomology presented in the case study. Does the video case presentation provide sufficient information to derive a PTSD diagnosis? Justify your reasoning. Do you agree with the other diagnoses in the case presentation? Why or why not?
  • Discuss one other psychotherapy treatment option for the client in this case study. Explain whether your treatment option is considered a “gold standard treatment” from a clinical practice guideline perspective, and why using gold standard, evidence-based treatments from clinical practice guidelines is important for psychiatric-mental health nurse practitioners.

Support your Assignment with specific examples from this week’s media and at least three peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.


Post Traumatic Stress Disorder

Jeffrey Audette

Psych 630

February 10th 2020

Professor Stephanie Fernandez




Post Traumatic Stress Disorder Introduction

Throughout the history of armed conflict, service members have been subjected to

combat-related posttraumatic stress disorder (PTSD). It has been referred to by many names

throughout time, the side effects have remained fairly constant, and often times the effects last

far beyond the battlefield. Veterans often return from deployments with symptoms or the

symptoms develop once the veteran is at home. At times, it can take months or even years before

symptoms develop. In the past several decades, advances in neuroscience, pharmacology,

psychiatry, and alternative therapy have provided victims of this disorder hope of a brighter

future. When left untreated, these symptoms can develop into chronic and debilitating

conditions, which can have long lasting and even a fatal effect on the veteran, as well as their

loved ones. The Veterans Health Administration has been incorporating different treatment

approaches to help their veterans cope with and heal from these debilitating conditions. Experts

have recently begun to challenge the effectiveness of current standard treatment methods, opting

more for Virtual Reality Exposure Therapy (VRET) and Accelerated Resolution Therapy (ART)

instead. Often, veteran’s symptoms can be depression, anxiety, traumatic brain injuries,

insomnia, and physical pain. Along with technological therapy advancements, more studies have

been conducted to help determine and clarify the comorbid relationship PTSD has with major

depression and anxiety disorders. We will study three different treatment options that veterans

can receive that are both traditional or non traditional, Cognitive Processing Therapy (CPT),

Prolonged Exposure (PE) to the nontraditional treatments of Component of healing touch,

Pharmacological and Virtual Reality Exposure Therapy. We will study which of these traditional

or non-traditional treatments have more effectiveness, treat symptoms better behavior manage

and recidivism is better traditional or non-traditional? Lastly, while still too early to say




definitively, advances in pharmacology and other alternative treatment options such as therapy

dogs have also shown potential to reduce or possibly prevent PTSD completely.

Stigma and Early Treatment

PTSD is a relative new diagnosis. Medical professionals in the early to mid 1900s were

uncertain as to which new treatment would do better. A majority of mental health providers at

that time were not military members, but rather civilian psychiatrists. (Jones 2005) noted that

these civilian doctors faced moral and ethical dilemmas when treating military patients because

finding the military member fit for duty, would most likely be signing their death certificate.

Advancements in the mental health field, as well as more detailed data analysis have helped

mental health providers better recognize and treat combat-related PTSD. As long as there is

trauma and traumatic events, posttraumatic stress disorder (PTSD) may exist. The name has

changed throughout time, from “shellshock” to PSTD as well as ways of treating the disorder.

Regardless of the name or treatment, the effect it has on people has remained constant. The

actual number of people who suffer from this disorder is most certainly higher than any numbers

reported this is due to many people being either scared or ashamed to admit they have a problem.

Advancements in treatments, have provided victims of this disorder hope of a brighter future. To

fully understand the benefits and direction of treatments, we first look at the history of the

disorder, and understand of how we got to where we are today with treatment. As of December

2012, over 131,000 active duty service members are diagnosed with PTSD. Additionally, nearly

30% of Veterans receiving care at VA medical centers were treated for PTSD (Rizzo et al., 2014).

The most current statistics from the Veterans Affairs website more accurately depict the size and

scope of this disorder. According to the website, PTSD affects 7-8% of the population, or nearly

8 million adults annually (U.S. Department of Veterans Affairs, n.d.). The statistics are further




broken down for military members by the conflict in which they served. Between 11 and 20% of

Veterans who served in Operation Enduring Freedom/Operation Iraqi Freedom have PTSD.

Veterans who served in the Gulf War were affected at nearly 12%, while 15% of Vietnam

Veterans are affected annually, even now, more than 40 years later (U.S. Department of Veterans

Affairs, n.d.). Studies of combat-related PTSD have increased substantially within the last two

decades, creating more reliable data for determining risk factors, comorbidity rates, and possible

prevention of the disorder in the future. These are the people that are included in studies and

trying to find treatments that are able to assist them to live a more comfortable life when

returning from combat with the sights that have reoccurring visions within themselves.

We need to study whether it is traditional or nontraditional treatments that work best for

the veteran, also whether it be on an individual, one on one basis, or in support groups or if it just

needs to be a pharmacology. Currently, the de facto VA approved PTSD therapy consists of

Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), or a combination of the two

(Kip et al., 2013). While better than previous treatment methods, these two are not without

significant disadvantages. Both are lengthy, expensive and have variable rates of completion.

As well as the possibility of the patient to backslide while in the program making the treatment

continue to be long.

Accelerated Resolution Therapy

In a limited sample size, Accelerated Resolution Therapy (ART) has proven to produce

more positive results and a much higher completion rate among patients (Kip et al., 2013). This

PE is more advanced for of CPT combined with PE. consists of 10 sessions of 90 minutes each,

and homework assignments. The drop out rate for PE is nearly 50%, with nonresponse rates as

high as 67%. CPT is even longer, consisting of 12 sessions of 60-90 minutes. The drop out and




nonresponse rates for CPT is much lower compared to PE, but still quite high. In contrast, ART

is completed 80% faster, consisting of only 2-5 sessions over 2 weeks, and showed significantly

higher reductions of symptoms over PE or CPT.

ART combines portions of PE and CPT along with methods not covered in the other two,

in significantly less time. As stated above, where PE and CPT take anywhere from 10-12

sessions at up to 90 minuets per session and additional homework assignments, ART is

completed in 2-5 sessions over a 2 week period (Kip et al., 2013). Shorter treatment time has

shown to produce a significantly lower dropout rate than the other two as well. ART is still

relatively new, having only been used since 2008. More studies will have to be completed to

verify the early results, but if the initial trends continue, it would be wise for the VA to declare

this the new standard.

Virtual Reality Exposure Therapy

Aside from time, cost, and completion rates, the current methods also have shown

significant drawbacks regarding overall effectiveness as well. (Nelson 2012) believes there are a

couple main reasons for this ineffectiveness. He proposes that in many cases, service members

especially, have completely blocked out the memories of the traumatic events, rendering CPT

essentially ineffective. Another identified cause for the ineffectiveness of current methods is the

difficulty of imagining these horrific real-life events while in a quiet, calm, safe therapist’s office

environment. This is where Virtual Reality Exposure Therapy (VRET) can be an effective


VRET creates experiences that stimulate more of the patient’s senses, allowing them to

feel like they are really there, while in reality they are still in a safe, controlled environment.

VRET allows for precise control of exposure intensity and can be gradually increased as patients




become more comfortable (Nelson, 2012). Patients wear headsets that allow them to move

through virtual landscapes as if they were actually there. Sounds and even smells are also

tailored to provide the most realistic experience possible. As the video platform continues to

improve, these experiences will become more effective, and will continue to prove helpful for a

wider demographic of patients.

The current VRET system is being upgraded and expanded in order to provide care not

only for service members who experienced direct enemy combat, but also to medics and

corpsmen (Rizzo et al., 2014). Expanding the exposure scenarios to include this demographic of

combat medics is extremely important. Although they may not participate directly in combat,

they do see the devastation caused by war arguably more than anyone else in the unit. (Rizzo et

al. 2014) emphasizes the importance of expanding VRET treatment to medics due to the fact that

they are permanently assigned to a unit, so they have close personal relationships with those they

have to treat, as opposed to traditional civilian hospital doctors who rarely know their patients.

As with ART, this type of therapy is also relatively new, but initial reports have shown this could

also be a viable, and more effective course of treatment for service members suffering from

combat-related PTSD over standard treatment methods today.


Medical cannabis is becoming a more prevalent treatment option for certain diagnosed

conditions. It is a topic of discussion that elicits passionate debate from advocates and

opposition alike. As of 2014, at least 21 states had passed laws allowing the use of medical

marijuana, although it was, and still is illegal at the federal level (Bohnert et al., 2014). In

addition, three states had included PTSD as one of the medical conditions that qualified for

medical cannabis use. It is still too early to determine if there are any long-term benefits or risks




to this potential alternative treatment method. However, it is worth noting that nearly 25% of

first time applicants for medical cannabis had also been diagnosed with PTSD (Bohnert et al.,


An article written one year later challenged the hypothesis above that marijuana use

improved PTSD symptoms. (Wilkinson 2015) stated that nearly 13,000 patients with diagnosed

PTSD participated in a study to determine the effects of increased marijuana use and severity of

PTSD symptoms. The study found that while patients subjectively felt marijuana use improved

symptoms, it actually made them worse in the long run. Patients were split into 4 categories

based on past, current and continued use. Those who had not used before the study but started

after showed significant increases in violent behavior (Wilkinson, 2015). The article did

however say that the use of purely cannabinoid products (the actual part of the marijuana plant

that has proven to have medicinal value) has proven to have positive results. Other studies

indicate positive results to several pharmacological treatments targeted at regulating naturally

occurring chemicals and conditions in the brain related to arousal in response to fear, anxiety,

startle response, depression, and so on. (Searcy, Bobadilla, Gordon, Jacques, & Elliot, 2012 )

suggest that these medicines could have extremely positive, and cost effective, results as

secondary preventive measures for PTSD. Primary preventive measures should continue to

focus on psychosocial interventions conducted immediately upon returning from deployments


As more veterans are seeking out the non-traditional approach of treating PTSD, it would

be beneficial to create a treatment approach that incorporates both the traditional evidence-based

treatment approach and the complementary and alternative approach. An Army Base in El Paso

Texas used to have such a program that was offered through the Warrior Resilience Center where




service members with combat related PTSD attended a four-week intensive treatment program

that incorporated both the evidence-based as well as the alternative approach. By incorporating

both treatment approaches, veterans are able to learn to cope with the disorder, relearn to feel

safe in their environment, as well as learn different tools to help them when they feel anxious or

are in a stressful situation. Using a rather holistic approach would be more beneficial to veterans

than using only one or the other.

Overall, these studies have shown the efforts to help veterans who have been suffering

from PTSD to find relief of their debilitating conditions. None of these approaches are either

good nor bad, they all work in their own way but the most important piece is that the veterans

who receive the treatment must be willing to get better. No treatment method will bring results if

the veteran who received the treatment does not believe in the treatment, doesn’t think it’s

working for them, or are not willing to do the work necessary to get better. The licensed

professionals can only do so much to help the veterans but the real work has to be done by the

veteran themselves. Many studies have been documented over the years regarding PTSD

treatment, but there has been little to no research regarding prevention. PTSD diagnoses in the

military are nearly 4 times higher than in the civilian population with hundreds of thousands of

people affected (Searcy, Bobadilla, Gordon, Jacques, & Elliot, 2012). Post trauma treatment is

crucial, and new techniques should continue to be developed, but if there is a way to prevent the

disorder ahead of time, that should be the primary focus.

Results from the causality category of hypothesis were that even if the relationship did

exist, it would be impossible to determine the direction of causality (Stander et al., 2014).




Results from the common factors hypothesis category determined that there are common risks

and vulnerabilities, but (Stander et al. 2014) could not conclusively prove a relationship between

risk factors, in particular combat exposure, or vulnerabilities of PTSD and depression.

The most definitive findings were from the confounding factors hypothesis category. These

results most accurately determined that it is unlikely these two disorders are completely

coincidental. However, factors such as medical provider bias, patient expectations, self-reporting

subjectivity, and indistinct diagnostic criteria create artificial associations between the two

(Stander et al., 2014).





Bohnert, K. M., Perron, B. E., Ashrafioun, L., Kleinberg, F., Jannausch, M., & Ilgen, M. A.

(2014). Positive posttraumatic stress disorder screens among first-time medical cannabis

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Foa, E. B. (2011, 1 December). Prolonged exposure therapy: past, present and future. Depression

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depression on quality of life in male combat veterans with posttraumatic stress disorder.

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Stander, V. A., Thomsen, C. J., & Highfill-McRoy, R. M. (2014). Etiology of depression

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and violent behavior in patients with posttraumatic stress disorder. The Journal of

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