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Treating trauma in women veterans

By Matthew C. Wiencke

There's good news for women veterans suffering from post-traumatic stress disorder (PTSD). A team led by DMS's Paula Schnurr, Ph.D., has demonstrated in a five-year national study that "prolonged exposure," a form of cognitive behavioral therapy, is more effective in treating women veterans with PTSD than the more common "present-centered" therapy. PTSD is an anxiety disorder that can result from experiencing trauma such as combat stress, assault, or rape. The symptoms range from flashbacks to emotional numbness to hyperarousal. "Lifetime prevalence in U.S. adults is higher in women (9.7%) than in men (3.6%) and is especially high among women who have served in the military," the authors wrote in the study, which was published in the Journal of the American Medical Association.

Believed to be the first randomized controlled trial of military women and PTSD, it included 284 women: 277 veterans and 7 activeduty personnel, ranging in age from 22 to 78. The women were recruited from VA medical centers

and counseling centers and a military hospital. Most identified sexual trauma as the worst kind of trauma they'd experienced; over 70% experienced it in the military.

Women were randomly assigned to receive either prolonged exposure or present-centered therapy in 10 weekly 90-minute sessions. Present-centered therapy, commonly used to treat women with PTSD, focuses on current life problems that may be a result of PTSD. In prolonged exposure, patients recount the event repeatedly to gain mastery over it. It remains "a painful memory, but it's not one that dominates them anymore," says Schnurr, who is deputy director of the VA National Center for PTSD in White River Junction, Vt.

The team found that women in the prolonged exposure group were more likely than those in the present-centered group to no longer meet criteria for a diagnosis of PTSD (41.0% versus 27.8%) and over twice as likely to reach total remission (15.2% versus 6.9%).

Real world: The average time from experiencing trauma to receiving treatment was 23 years, suggesting that patients with chronic PTSD can truly benefit from the treatment, says Schnurr. And, she adds, "we showed it can work in the real world." The study used a range of practice settings; most of the therapists were not expert in the two therapies and had to be trained in them. "We didn't discover prolonged exposure," says Schnurr, and "we didn't show that the treatment works. What we showed is that it works well in a range of settings that are much more similar to the way therapy is done in practice."

Her team had hoped the women's comorbidities (depression, anxiety, and diminished quality of life) would also improve with prolonged exposure. They showed some improvement, but it seems more treatment is needed for patients with chronic PTSD. A minor disappointment was that they had few active-duty subjects, possibly because of the "stigmatizing effects of PTSD treatment," the authors wrote—something their findings may help to change.

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