Curing invisible wounds

Psychologist’s military experience leads to national PTSD research networks

While deployed as an Air Force clinical psychologist in Iraq, Lt. Col. Alan Peterson, Ph.D., experienced firsthand the toll war can take on the mental health of service members.

Serving in 2004 during the bloody Battle of Fallujah, Dr. Peterson’s mission, with his military medical colleagues from San Antonio, was to establish an Air Force Hospital in Balad. His seven-member team was responsible for providing mental health services.

“When the helicopters came in with mass casualties it was ‘all hands on deck.’ We unloaded the victims, brought them to the ER and stayed to help the doctors and nurses caring for them,” said Dr. Peterson, who is now a professor of psychiatry and chief of the Division of Behavioral Medicine in the School of Medicine.

Lt. Col. Alan Peterson, Ph.D. (right), experienced firsthand the toll war can take on mental health. He was deployed as an Air Force clinical psychologist in Iraq in 2004.

Lt. Col. Alan Peterson, Ph.D. (right), experienced firsthand the toll war can take on mental health. He was deployed as an Air Force clinical psychologist in Iraq in 2004.

“Blasts are the most common type of trauma and there is a lot of carnage,” he said. Besides the fear of ambushes, roadside bombs and mortar attacks, service members frequently see their buddies suffering from gruesome injuries.

“Emotions can range from fear to anger, depression and remorse,” he said. And when they come home, some experience flashbacks and other serious symptoms, making it difficult to adapt to normal life.

Post-traumatic stress disorder, which affects about 14 percent of Iraq and Afghanistan war veterans, is one of the most well-known mental injuries of war. Because published studies have all been conducted with civilians or Vietnam War veterans, there are no research-based guidelines for treating combat-related PTSD among active-duty military.

So Dr. Peterson relied on his background as a clinical practitioner and researcher to use proven therapies for civilians with PTSD. Two types of cognitive behavioral therapy, prolonged exposure and cognitive processing therapy, have been shown in research studies to treat 80 percent of civilians to the point of remission.
Prolonged exposure helps patients confront and process traumatic memories through education about normal reactions to traumatic events, relaxation techniques, repeated retelling of the traumatic event and homework that involves confronting reminders of the trauma in a safe environment.

Cognitive processing therapy helps patients understand how their thoughts about a traumatic event influence their feelings and reactions. The therapy helps them develop new ways of thinking about the event that alleviate their distress and show them how to regain control over their lives.

Dr. Peterson and his colleagues found that these methods worked well, but they needed to be adapted for the military.

“[Both therapies] typically require eight to 12 sessions of 90 minutes each. With the homework they do between sessions, the whole series usually lasts several weeks. This is not realistic for a war zone and can even be difficult with demanding military schedules back home,” he said.

And the type of trauma experienced in the military is different.

“Civilians with PTSD usually have one traumatic event that severely affects them, such as a rape, major accident or natural disaster. Deployed military members may experience graphic and highly stressful events daily—and they are deployed numerous times,” Dr. Peterson said.

Another consideration is that military training for survival in a war zone, such as being on constant alert for danger, can conflict with PTSD therapy. Therapy tries to alleviate the symptom of hypervigilance, or that feeling of always being “on edge.” So the appropriate application of that training may need to be addressed in therapy.

Dr. Peterson, who had been trained in prolonged exposure therapy, began adapting it to fit the military environment.

“After a few sessions I had people telling me, ‘I’m good to go. I’m ready to go back on convoys with my unit,’” he said.

After retiring from the military, Dr. Peterson joined the Health Science Center in 2006 and wanted to continue helping military members suffering from PTSD. He gained an unprecedented opportunity in 2008 when he and his collaborators received approximately $35 million from the Department of Defense through its Congressionally Directed Medical Research Programs to form STRONG STAR.

STRONG STAR, which stands for the South Texas Research Organizational Network Guiding Studies on Trauma And Resilience, is a multidisciplinary, multi-institutional research consortium designed to understand, prevent and treat combat-related PTSD. Under Dr. Peterson’s direction and the leadership of the UT Health Science Center San Antonio, the consortium brings together more than 100 of the world’s top research investigators from over 20 collaborating civilian, military and Veterans Affairs institutions.

The consortium is conducting 25 clinical trials in Central and South Texas evaluating both prolonged exposure therapy and cognitive processing therapy, as well as similar therapies in active-duty military and recently discharged veterans who served in Afghanistan and Iraq. Genetic, epidemiological and biological studies also are underway to learn more about biological influences on PTSD and related conditions to develop new and improved prevention and treatment methods.

The studies are being conducted at four San Antonio locations: San Antonio Military Medical Center, Wilford Hall Ambulatory Surgical Center, Joint Base San Antonio-Randolph and the South Texas Veterans Health Care System, Audie L. Murphy Division. Other locations include Fort Hood’s Carl R. Darnall Army Medical Center, the Central Texas Veterans Health Care System in Waco and locations in Afghanistan.

STRONG STAR also has received $27 million in supplemental funding for new studies investigating PTSD and related conditions, such as insomnia, suicide risk and traumatic brain injury.

The biggest affirmation of STRONG STAR’s success came in August 2013, when the group received $45 million from the Department of Defense and VA for the Consortium to Alleviate PTSD. President Barack Obama announced the award as part of a National Research Action Plan for improving access to mental health services for veterans, service members and military families.

The consortium, called CAP, involves STRONG STAR’s original collaborators plus some new ones, including all seven divisions of the VA’s National Center for PTSD. Dr. Peterson directs the CAP and its coordinating center, based at the Health Science Center. Dr. Terence Keane of the National Center for PTSD at the Boston VA is co-director.

Guided by a government steering committee, the CAP is charged with addressing research gaps and developing and evaluating new diagnostics, therapeutics and preventions for PTSD and conditions associated with it, emphasizing genetic and biological markers.

In the future, Dr. Peterson would like to expand the Health Science Center’s work through a PTSD-related residency program and large clinical practice in this specialty.

“We are formulating ideas for these programs but will need funding to move forward,” he said.

Dr. Peterson said the work his consortia are doing will have far-reaching effects that could significantly improve PTSD treatment not only for military personnel, but also for the general public.

“I feel like I’m doing the most important work of my career,” Dr. Peterson added. “I’ve helped hundreds of people through what I’ve learned and done as a clinician and researcher, but now we have the potential through STRONG STAR and CAP to help thousands of military members and families. We plan to test lots of theories over the next seven years and have the opportunity to develop the standard of care for military members and veterans who deserve our help. My overall goal is that one day we will not only know how to prevent and treat PTSD, but also how to cure it.”

How to enroll in research studies

STRONG STAR and affiliated studies are located in San Antonio, Fort Hood and Waco, where there is a large concentration of active-duty, retired and former military members.

San Antonio-area studies include:

  • Individual PTSD treatment compared with couples therapy that addresses PTSD and relationship issues with active-duty military
  • PTSD and alcoholism in veterans
  • In-home treatment compared with in-office treatment of PTSD for active-duty military and veterans
  • PTSD treatment delivered in the primary-care doctor’s office for active-duty military
  • Dog adoption in veterans with PTSD

If you or someone you know needs help with service-related post-traumatic stress disorder, visit STRONG STAR and click on the red “Get Treatment” button in the upper right corner to learn more.

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