A Novel Posttraumatic Stress Disorder Treatment for Veterans with Moral Injury

创伤后应激障碍(PTSD)现在是年轻人中最常见的心理健康诊断 一代退伍军人接受退伍军人健康管理局(VHA)的治疗，这使得 需要多种类型的有针对性的护理。虽然有两种循证心理疗法(EBP)来治疗 接受这些治疗的绝大多数退伍军人仍然符合创伤后应激障碍的诊断标准 创伤后应激障碍及其功能继续受到影响。此外，经历过创伤的退伍军人 与杀人相关的人自杀率高，创伤后应激障碍症状更严重。尽管已经很少有 检验EBPS不良结果的预测因素的研究，这一领域最近开始得到越来越多的关注 注意力是精神上的伤害。最近的一项研究发现，创伤后应激障碍和精神伤害是两个截然不同的概念，具有独特的 体征和症状，以及初步证据表明，内疚和愤怒的感觉 与创伤相关的精神伤害，如战争中的杀戮，可能会导致症状的恶化 现有治疗方法的疗程。尽管创伤后应激障碍可能是心理创伤的一种表现， 杀戮，要概念化杀戮的影响，需要一个更广泛的框架。新兴的道德观念 伤害为更好地理解接触杀戮的许多可能后果提供了另一种背景。为 由于这些原因，制定有针对性的精神伤害干预措施至关重要。我们设计并接受了退伍军人管理局 资助进行一项关于杀戮影响的试点随机对照试验(RCT)，该试验可以 在现有的创伤后应激障碍的EBPS之后，无缝添加为一种独立的治疗方法。IOK专注于关键主题 包括杀戮反应的生理学、精神伤害、自我原谅和部署后的改进 重新融入社会。这种疗法是为了很好地适应现有的护理系统而设计的，并已得到证明 以改善EBP后的功能、创伤后应激障碍症状和一般精神症状。鉴于IOK RCT试点最初在旧金山VA医疗系统进行，我们的目标是进行完全- 在两个区域不同的地点进行有动力的多地点疗效试验，样本量更大，并进行主动控制 条件。因此，该项目的目标是测试创伤后应激障碍的个体化治疗效果。 源于精神伤害，称为IOK，与目前中心治疗(PCT)控制条件相比，以及 目的：确定IOK对寻求治疗创伤后应激障碍的退伍军人的康复效用。我们的主要结果是 心理社会功能。目标人群是已经开始或完成认知的退伍军人 加工疗法或长时间暴露疗法，两种针对创伤后应激障碍的循证治疗，并继续患有创伤后应激障碍 与杀人有关的症状和精神伤害。退伍军人将被随机分配到以下其中之一：1)IOK(10 持续60-90分钟的单独治疗)或2)PCT(持续时间与IOK相同的治疗)。我们的首要目标是 是通过测量心理社会功能(主要结果)和创伤后应激障碍来测试IOK的疗效 严重程度(次要结果)。我们的第二个目标是确定退伍军人取得的IOK成果是否 经久耐用。鉴于精神伤害治疗是一个新的和新兴的领域，我们有两个探索性目标 可以帮助推动这一领域向前发展。我们的第一个探索性目标是通过一个 IOK治疗组的子集，以更好地了解如何支持功能的持续改善 在参与者中。我们的第二个探索性目标是评估功能改善的介体，例如 自我宽恕，在退伍军人中完成IOK。如果这笔赠款的目的得以实现，我们将能够 在EBP之后进行精神伤害干预，可以无缝地整合到现有的护理中 退伍军人中最常见的心理健康问题。此外，自杀是国家的优先事项。 对于VHA，扩大对创伤后应激障碍和精神伤害的治疗有可能减少自杀和 改善退伍军人的功能。最后，IOK提供了理解战区经历的技能和方法 随着时间的推移，退伍军人可以掌握并继续实施。

Post-traumatic stress disorder (PTSD) is now the most common mental health diagnosis among the youngest generation of Veterans receiving treatment from the Veterans Health Administration (VHA), necessitating the need for diverse types of targeted care. Although there are two evidence-based psychotherapies (EBP) for PTSD, the vast majority of combat Veterans who receive these treatments still meet diagnostic criteria for PTSD and their functioning continues to be impacted. Furthermore, Veterans that have experienced trauma related to killing have high rates of suicide and more severe PTSD symptoms. Although there have been few studies examining predictors of poor outcomes in EBPs, one area that has recently begun to receive growing attention is moral injury. A recent study found that PTSD and moral injury were distinct constructs with unique signs and symptoms, and preliminary evidence indicates that the feelings of guilt and anger that characterize moral injury associated with trauma such as killing in war may contribute to worsening symptoms over the course of existing treatments. Although PTSD may be one manifestation of psychological trauma related to killing, conceptualization of the impact of killing requires a broader framework. The emerging concept of moral injury offers an alternative context to better understand the many possible outcomes of exposure to killing. For these reasons, the development of targeted moral injury interventions is critical. We designed and received VA funding to conduct a pilot randomized controlled trial (RCT) of the Impact of Killing (IOK) treatment, which can be seamlessly added as a standalone treatment following existing EBPs for PTSD. IOK focuses on key themes including physiology of killing responses, moral injury, self-forgiveness, and improved post-deployment reintegration. The treatment was designed to fit well into already existing systems of care and has been shown to improve functioning, PTSD symptoms, and general psychiatric symptoms following EBP. Whereas the IOK RCT pilot was initially conducted at the San Francisco VA Healthcare System, our goal is to conduct a fully- powered, multi-site efficacy trial at two regionally-diverse sites with a larger sample size and active control condition. Consequently, the objective of this project is to test the efficacy of an individual treatment for PTSD stemming from moral injury called IOK, compared to a present-centered therapy (PCT) control condition, and to determine the rehabilitative utility of IOK for Veterans seeking treatment for PTSD. Our primary outcome is psychosocial functioning. The target population is Veterans who have initiated or completed Cognitive Processing Therapy or Prolonged Exposure Therapy, two EBPs for PTSD, and continue to have PTSD symptoms and moral injury related to killing. Veterans will be randomly assigned to receive either: 1) IOK (10 individual therapy sessions lasting 60-90 minutes) or 2) PCT (sessions of equal duration to IOK). Our first aim is to test the efficacy of IOK through measures of psychosocial functioning (primary outcome) and PTSD severity (secondary outcome). Our second aim is to determine whether IOK gains made by Veterans are durable. Given that moral injury treatment is a new and burgeoning area, we have two exploratory aims that can help move the field forward. Our first exploratory aim is to conduct post-treatment evaluations with a subset of the IOK treatment group to better understand how to support continued improvement in functioning among participants. Our second exploratory aim is to evaluate mediators of functional improvement, such as self-forgiveness, among Veterans completing IOK. If the aims of this grant are achieved, we will be able to have a moral injury intervention following EBP that can be seamlessly integrated into existing care for one of the most commonly occurring mental health problems in Veterans. Furthermore, suicide is a national priority for VHA, and expanding treatment for PTSD and moral injury has the potential to decrease suicide and improve functioning in Veterans. Finally, IOK offers skills and ways of understanding warzone experiences that can be mastered and can continue to be implemented by Veterans over time.