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: 9920599
• 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 2021-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9920599
• 关键词: 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; Rehabilitation therapy; Reporting; Research; Resistance; Risk Behaviors; Role; Self Care; Services; Severities; Shame; Site; Symptoms; Testing; Textiles; Trauma; Veterans; Victimization; War; Work; arm; automobile accident; base; clinically significant; comorbidity; depressive symptoms; design; disability; evidence base; experience; functional disability; functional restoration; improved; improved functioning; in vivo; innovation; negative affect; performance site; phenomenological models; physical conditioning; primary endpoint; psychologic; psychosocial; psychosocial rehabilitation; recruit; 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 战区暴露引起的精神障碍(PTSD)与更多的慢性和致残的社会和职业相关 功能问题，以及对治疗的反应较差。然而，退伍军人的创伤后应激障碍治疗却没有 针对或甚至系统地评估这些功能障碍。相反，军队的一线治疗- 相关的创伤后应激障碍侧重于症状的变化，而没有注意到康复的整体层面，如改善 工作和家庭功能以及生活质量。目前创伤后应激障碍的一线治疗弥漫性和 在退伍军人事务部的授权下，长时间暴露和认知加工疗法被开发出来，最初 在女性性侵受害者身上进行了测试。尽管这些疗法已经取得了长足的进步，以适应 退伍军人受到与大多数平民创伤截然不同的环境的创伤，治疗仍然倾向于 过分强调基于危险的战区事件的受害者是创伤后应激障碍的原因和目标 治疗。这是有问题的，因为对战区独特的现象学重视不够 勇士文化中的经历。特别是，现有的治疗方法在道德上还不够 妥协的战争经历(例如，杀戮)，称为精神伤害(MI)，以及创伤性损失，这两者都不是 必然会带来高度的恐惧和危险。然而，有很大比例的人报告了这类经历 退伍军人是他们最糟糕和目前困扰最深的部署事件。心肌梗死和创伤损失可能会导致 情绪困扰，如负罪感、羞耻感、动力不足、快感缺乏和愤怒等消极问题 影响康复和各种功能能力(例如，工作、自我照顾和人际关系)。这样做的目的是 这项研究旨在通过[测试]战争相关创伤后应激障碍的循证治疗来填补退伍军人事务部的重大护理缺口 源于心肌梗死和创伤性损失，侧重于改善心理社会功能。[我们已修改和 扩展自适应披露(AD；Litz等人，2015)，这是一种先前在Deploed上进行测试的疗法 海军陆战队，治疗心肌梗死和损失(AD-MIL)。我们在广告中添加了基于证据的元素，旨在 促进体内功能的改善，解决参与体内各种功能行为的障碍。] 我们将进行一项多点随机对照试验，比较AD-MIL和以呈现为中心的治疗(PCT； Frost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。 关于功能和行为的变化，我们假设治疗后、3个月和6个月后- 治疗后，患有创伤后应激障碍的伊拉克和阿富汗退伍军人随机进入AD-MIL将有更大的：(A.1)。减量 社会、教育和职业残疾(主要终点)；和(A.2.)质量的提高 生活。关于精神健康症状的变化，我们假设退伍军人随机进入AD-MIL 将有更大的：(B.3.)创伤后应激障碍症状严重程度的降低和创伤后应激障碍病例的较小比例； 减少抑郁症状；和(B.5.)减少羞耻和负罪感。我们还将探讨其影响 治疗愤怒和攻击性行为、自杀意念和酗酒。我们计划招聘93人 试验的每一支队伍都有退伍军人，在退伍军人管理局的三个表演地点平分。