A behavioral approach to assessing and treating posttraumatic stress disorder in vietnam veterans

Behavioral approaches to the assessment and treatment of psychological problems have received much attention in recent years. The present chapter is among the first to extend the principles of behavioral learning to our understanding of combat-related PTSD. Specifically, this chapter proposes a condW(ming model to help explain the severe symptomatology that accompanies the PTSD diagnosis . From this conceptual model, both assessment ond treatment procedures have been developed and are presented in the chapter. The section on assessment includes a description of the m(litimethod, psychophysiological assessment currently in use in our program. The section on treatment describes the use of both stress management training and imaginal flooding (implosive) therapy. A 33-year-old white male Vietnam combat veteran presented at our Veterans Administration Medical Center for evaluation of psychological distress. The client reported that he was married with two adolescent children and employed on a full-time basis. He served in Vietnam from 1967 to 1968 with the United States Marine Corps. As a machine gunner with the infantry, he was exposed to heavy and direct combat on a routine basis. He reported that his primary duty involved participating in combat patrols or other major military combat operations. During one of these combat operations, the veteran was stranded in the jungle (classified as missing in action) for approximately two-and-a-half months with a five-man combat patrol squad, three of whom were severely injured and totally dependent on him and one other comrade for survival. During this time, their food supplies were depleted; in order to survive, the veteran and the other healthy squad member were forced to kill North Vietnamese soldiers to obtain food supplies for their wounded comrades. They themselves survived on insects, lizards, and any other available source of nourishment. Events that occurred during this time, as well as during other combat experiences, led this individual to present with two primary complaints of disturbed sleep (including nightmares of Vietnam combat experiences) and dissociative-like flashback episodes which he had labeled as "blackouts." The intake interview revealed additional psychological symptoms presenting a clinical picture consistent with post-traumatic stress disorder. Although this veteran had extensive combat experience, and was exposed to many highly stressful situations during the course of his combat duty, he identified four distinct combat events that were distinguishable from other experiences by their particularly traumatic content. Examples of these events include: 1) during a three-day battle (which only three men survived) an already severely wounded comrade was killed as he stood up behind this veteran to protect him from enemy fire from the rear of his position; and 2) while MIA, the client killed an enemy combatant in hand-to-hand combat to obtain food for his wounded comrades. He subsequently discovered that the soldier was a young woman. The client reported that he had nightmares of these specific combat events from one to seven nights per week. He indicated that he often fought in his sleep while dreaming or awoke "in a cold sweat." He estimated that he was getting approximately three to five hours of sleep per night, that he often had difficulty falling asleep, and was also awakening throughout the night. Additionally, this veteran reported that in the presence of certain environmental stimuli which resembled Vietnam (e.g ., smelling odors similar to gun powder), he reacted violently with subsequent amnesia to the episode. For example, he reported that he had physically attacked a man who almost injured his daughter by shooting fireworks at her on the streets of a large city. He had no memory of the attack after it was over. This individual stated that he felt extremely anxious, tense, and depressed during much of the waking day and was easily startled. He indicated that he had begun to worry about his job performance stating that he found it difficult to concentrate on his work and that he often found memories of combat traumas intruding in his thoughts . Although these memories were very disturbing to him, the veteran indicated that he had never talked with anyone about these events or their effect on him. He was especially concerned about the dissociative-like flashback episodes and feared that he might injure his family during one of these episodes. He requested help in understanding and controlling these episodes, as well as assistance in coping with memories of traumatic combat events.

Duke Scholars

Author John A. Fairbank Psychiatry, Child & Family Mental Health & Community Psychia ...