Psychosocial Rehabilitation after Moral Injury and Loss with Adaptive Disclosure

道德伤害和损失后的心理康复与适应性披露

• 批准号: 9291960
• 负责人: BRETT T LITZ
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-06-01 至 2021-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9291960
• 关键词: Accidents; Activities of Daily Living; Address; Afghanistan; Aftercare; Aggressive behavior; Alcohol abuse; Anger; Anhedonia; Area; Attention; Behavior; Behavioral; Caring; Chronic; Cognitive; Contracts; Dimensions; Disasters; Disclosure; Elements; Emotional; Emotional Disturbance; Employment; Event; Evidence based treatment; Exposure to; Family; Family Relationship; Family member; Feeling suicidal; Female; Fostering; Friends; Fright; Goals; Guilt; Health Care Costs; Injury; Iraq; Marines; Mental Health; Military Personnel; Morals; Motivation; Occupational; Patients; Post-Traumatic Stress Disorders; Privatization; Productivity; Public Health; Quality of life; Randomized; Randomized Controlled Trials; Recovery; Recruitment Activity; Rehabilitation therapy; Reporting; Research; Resistance; Risk Behaviors; Role; Self Care; Services; Severities; Shame; Site; Symptoms; Testing; Textiles; Trauma; Veterans; Victimization; War; Work; arm; base; clinically significant; depressive symptoms; design; disability; evidence base; experience; functional disability; functional restoration; improved; improved functioning; in vivo; innovation; killings; negative affect; performance site; phenomenological models; physical conditioning; psychologic; psychosocial; psychosocial rehabilitation; reduce symptoms; routine care; service member; sexual assault; skills training; social; stem; stressor; success; treatment response; trial comparing

Relative to most civilian traumas (e.g., sexual assault, car accidents, and disasters), posttraumatic stress disorder (PTSD) from warzone exposure is associated with more chronic and disabling social and occupational functioning problems, as well as poorer response to treatment. Yet, PTSD treatments for war veterans do not target or even systematically assess these functional impairments. Rather, first-line treatments for military- related PTSD focus on symptom change, failing to attend to holistic dimensions of recovery, such as improved work and family functioning and quality of life. The current first-line treatments for PTSD disseminated and mandated in the VA, Prolonged Exposure and Cognitive Processing Therapy, were developed and originally tested on female sexual assault victims. Although strides have been made for these therapies to accommodate veterans traumatized by contexts that are starkly different from most civilian traumas, the therapies still tend to overemphasize victimization from danger-based warzone events as the cause of PTSD and the target for treatment. This is problematic because insufficient attention is paid to the unique phenomenology of warzone experiences within the warrior culture. In particular, existing therapies do not sufficiently address morally compromising war experiences (e.g., killing), termed moral injury (MI), and traumatic loss, neither of which necessarily entail high fear and danger. Yet, these types of experiences are reported by large percentages of veterans as their worst and most currently haunting deployment events. MI and traumatic loss can cause emotional disturbances, such as guilt, shame, low motivation, anhedonia, and anger problems that negatively affect recovery and a variety of functional capacities (e.g., work, self-care, and relationships). The goal of this study is to fill a substantial care-gap in the VA by [testing] an evidence-based treatment for war-related PTSD stemming from MI and traumatic loss focused on improving psychosocial functioning. [We have modified and extended Adaptive Disclosure (AD; Litz et al., 2015), a therapy that was previously tested on deployed Marines, to treat [only] MI and loss (AD-MIL). We have added evidence-based elements to AD designed to foster improvements in functioning and address obstacles to engaging in various functional behaviors in-vivo.] We will conduct a multi-site randomized controlled trial comparing AD-MIL to Present-Centered Therapy (PCT; Frost et al., 2014). We have five hypotheses, grouped into (A) functional change and (B) mental health change. With respect to functional and behavioral change, we hypothesize that post-treatment, 3-, and 6-months post- treatment, Iraq and Afghanistan veterans with PTSD randomized to AD-MIL will have greater: (A.1.) reductions in social, educational, and occupational disability (the primary endpoint); and (A.2.) improvements in quality of life. With respect to change in mental health symptoms, we hypothesize that veterans randomized to AD-MIL will have greater: (B.3.) reductions in PTSD symptom severity and a smaller percentage of PTSD cases; (B.4.) reductions in depressive symptoms; and (B.5.) reductions in shame and guilt. We will also explore the impact of treatment on anger and aggressive behaviors, suicidal ideation, and alcohol abuse. We plan to recruit 93 veterans for each arm of the trial, split equally among the three VA performance sites.

相对于大多数平民创伤（例如，性侵犯，汽车事故和灾难），创伤后压力 Warzone暴露的障碍（PTSD）与更多的慢性和致命社会和职业有关 功能问题以及对治疗的反应较差。然而，《战争退伍军人的PTSD治疗》没有 目标甚至系统地评估这些功能障碍。相反，军事治疗的一线治疗 相关的PTSD专注于症状改变，未能参加恢复的整体维度，例如改善 工作和家庭功能和生活质量。 PTSD的当前一线治疗已散布和 在VA中规定，开发了长时间的暴露和认知处理疗法，最初是 对女性性侵犯受害者进行了测试。尽管已经为这些疗法迈出了进步 退伍军人因与大多数平民创伤截然不同的情况所造成的创伤，这些疗法仍然倾向于 过分强调基于危险的战区事件的受害者，成为PTSD的原因和 治疗。这是有问题的，因为不足以关注Warzone的独特现象学 战士文化中的经验。特别是，现有疗法在道德上没有充分解决 妥协的战争经历（例如杀人）被称为道德伤害（MI）和创伤性损失 一定需要高度恐惧和危险。然而，这些类型的经验报告了很大一部分 退伍军人是他们最糟糕，目前最困扰的部署活动。 MI和创伤性损失可能导致 情绪障碍，例如内gui，羞耻，动力低下，狂热和愤怒问题，而愤怒的问题负面 影响恢复和各种功能能力（例如，工作，自我保健和关系）。目标的目标 研究是通过[测试]对战争相关的PTSD进行基于证据的治疗方法来填补VA的大量护理差距 源于MI和创伤性损失，重点是改善社会心理功能。 [我们已经修改了 扩展自适应披露（AD; Litz等，2015），此前已在已部署的治疗中进行了测试 海军陆战队，仅处理[仅] MI和损失（AD-MIL）。我们为AD添加了基于证据的元素 促进功能的改善和解决障碍在体内从事各种功能行为。] 我们将进行一项多站点随机对照试验，将AD-MIL与以现为中心的治疗进行比较（PCT； Frost等，2014）。我们有五个假设，分组为（a）功能变化和（b）心理健康变化。 关于功能和行为变化，我们假设治疗后，3个月和6个月后 将随机分配给AD-MIL的PTSD的伊拉克和阿富汗退伍军人的治疗将更大：（A.1。）减少 在社会，教育和职业残疾中（主要终点）； （a.2。）提高质量的 生活。关于心理健康症状的变化，我们假设退伍军人随机地将 将具有更大的：（B.3。）减少PTSD症状严重程度和PTSD病例的百分比较小； （B.4。） 减轻抑郁症状的减少； （b.5。）减少羞耻和内gui。我们还将探索影响 愤怒和侵略性行为，自杀念头和酗酒的治疗。我们计划招募93 试验的每个手臂的退伍军人，在三个VA性能站点之间平均分配。