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、车祸和灾难），创伤后应激障碍 战区暴露造成的精神障碍 (PTSD) 与更慢性和残疾的社会和职业相关 功能问题以及对治疗的较差反应。然而，针对退伍军人的创伤后应激障碍 (PTSD) 治疗并没有 针对甚至系统地评估这些功能障碍。相反，军事治疗的一线治疗 相关的创伤后应激障碍（PTSD）关注症状变化，未能关注康复的整体维度，例如改善 工作和家庭功能以及生活质量。目前针对 PTSD 的一线治疗方法已得到广泛应用 VA 强制规定的延长暴露和认知处理疗法是开发出来的，最初是 对女性性侵犯受害者进行了测试。尽管这些疗法已经取得了长足的进步，以适应 对于因与大多数平民创伤截然不同的环境而遭受创伤的退伍军人来说，治疗方法仍然倾向于 过分强调基于危险的战区事件的受害者是 PTSD 的原因和目标 治疗。这是有问题的，因为对战区独特现象的关注不够 武士文化中的体验。特别是，现有的疗法不能充分解决道德问题 损害战争经历（例如杀戮），称为精神伤害（MI）和创伤性损失，这两者都不是 必然会带来高度的恐惧和危险。然而，很大比例的人报告了这些类型的经历 退伍军人是他们最糟糕、目前最令人难以忘怀的部署事件。心肌梗死和创伤性损失可能会导致 情绪障碍，例如内疚、羞耻、积极性低下、快感缺失和愤怒问题，这些问题会产生负面影响 影响康复和各种功能能力（例如工作、自我护理和人际关系）。此举的目标 研究旨在通过[测试]针对战争相关创伤后应激障碍的循证治疗来填补退伍军人管理局的巨大护理空白 源于心肌梗死和创伤性损失，重点是改善心理社会功能。 [我们已修改并 扩展自适应披露（AD；Litz 等人，2015），这是一种先前在部署上进行过测试的疗法 海军陆战队，[仅]治疗 MI 和损失 (AD-MIL)。我们在 AD 中添加了基于证据的元素，旨在 促进功能的改善并解决体内参与各种功能行为的障碍。] 我们将进行一项多中心随机对照试验，比较 AD-MIL 与以现在为中心的疗法 (PCT； 弗罗斯特等人，2014）。我们有五个假设，分为 (A) 功能变化和 (B) 心理健康变化。 关于功能和行为改变，我们假设治疗后 3 个月和 6 个月 治疗后，患有 PTSD 的伊拉克和阿富汗退伍军人随机接受 AD-MIL 将获得更大的：(A.1.) 减少 社交、教育和职业残疾（主要终点）； (A.2.) 质量的提高 生活。关于心理健康症状的变化，我们假设退伍军人随机分配到 AD-MIL 将有更大的： (B.3.) PTSD 症状严重程度的降低和 PTSD 病例比例的降低； （B.4。） 减少抑郁症状； (B.5.) 减少羞耻感和内疚感。我们还将探讨影响 对愤怒和攻击行为、自杀意念和酗酒的治疗。我们计划招募93名 试验各部分的退伍军人在三个退伍军人事务部表演地点平均分配。