ATrain Education

 

Continuing Education for Health Professionals

WV: Sexual Trauma in the Military

Module 5

Health Diagnoses and Treatment Options

Survivors of MST are at high risk for a variety of physical and mental health disorders that often co-occur. Recent work has suggested the positive value of fully integrated treatment plans for veterans who may be suffering both physical and mental effects related to military sexual trauma (Johnson et al., 2015).

Mental Health Disorders

Post traumatic stress disorder (PTSD), depression and major depressive disorder (MDD), other mood disorders, and substance use disorders are common diagnoses in veterans who experienced sexual trauma. The severity and duration of symptoms varies among survivors for many reasons, and the best treatments consider the individual and those variations.

Posttraumatic Stress Disorder (PTSD)

Post traumatic stress disorder . . . can occur after you have experienced a traumatic event. PTSD symptoms usually start soon after the traumatic event, but may be delayed several months or years. Symptoms also may come and go over many years.

 

If the symptoms last longer than 4 weeks, cause you great distress, or interfere with your work/home life, you probably have PTSD. Symptoms of PTSD include reliving the event, avoiding places or things that remind you of the event, a shift to more negative thoughts and feelings, feeling numb, and feeling keyed up (also called hyper arousal).

 

VA, 2016

Rates of PTSD are high in both civilian and military victims of sexual assault, and PTSD is the psychiatric disorder most highly associated with MST (Anderson & Surís, 2013). The rates of PTSD associated with military sexual assault victimization are 65% in men and 45.9% in women. It is notable that the rate reported by men following combat exposure is significantly lower (38.8%) (VA, 2017a).

Clinicians in VA and DoD facilities are guided by the VA/DoD Clinical Practice Guideline and by the VA’s Uniform Mental Health Services handbook, which requires that any veteran with PTSD have access to cognitive processing therapy (CPT) or prolonged exposure therapy (PE), the evidence-based treatments of choice for PTSD (Anderson & Surís, 2013; VA, 2017c; VA, 2015a/2008).

Cognitive Processing Therapy (CPT) works by giving patients skills to handle distressing thoughts and memories that may leave them feeling stuck and unable to make sense of the trauma they experienced. CPT helps patients come to terms with how the trauma changed the way they view themselves, the world, and others. By becoming aware of thoughts and feelings, and then changing the thoughts, one can change the feelings.

Prolonged Exposure Therapy (PE) involves repeated exposure to thoughts, feelings, and situations that the patient has been avoiding. PE includes four parts: education, breathing retraining, real world practice (in vivo exposure), and talking through the trauma (imaginal exposure).

These two treatments continue to be found effective for treating PTSD (Cook & Wiltsey Stirman, 2015) but another therapy, EMDR—is now being used as well.

Eye Movement Desensitization and Reprocessing (EMDR), which has four parts: identification of a target memory, image and belief about the trauma; desensitization and reprocessing; installing positive thoughts and images; and body scan to change how the patient reacts to memories of the trauma.

The use of medication, especially selective serotonin reuptake inhibitors (SSRIs) has proven effective for veterans with PTSD. A number of other therapies have been or are being tested. As with the ones in use now, some treatments involve active confrontation of the traumatic experiences while others deal with the effects of the experiences. Not all treatments work equally well for all survivors and there are clinicians who feel the VA and DoD should consider other approaches altogether (Zaleski, 2015).

A critical element in the treatment of PTSD is the issue of avoidance, especially when employing trauma-focused therapies. Survivors may try to avoid the distress they feel over the memory of the sexual trauma. The temporary reduction of distress and anxiety may seem like a reward for that behavior, thus fueling the temporary sense of control they feel over the anxiety. However, in reality, that continued behavior reinforces the negative situation and makes the distress worse (Anderson & Surís, 2013).

Treatment can be very difficult for many, and the fear of reliving the event is a very real concern. Missing appointments or dropping out of a treatment program are not uncommon, and positive results from treatment depend on well trained and highly aware clinicians. Official guidelines call for VA facilities to provide same-sex counselors for MST treatment whenever indicated, although male MST survivors do not usually want male therapists (Anderson & Surís, 2013).

Healthcare providers can learn more about PTSD in Veterans by taking an interactive course, PTSD 101: PTSD Overview, available at the National Center for PTSD.

The website includes a professional section for those who work with people who have experienced trauma or who have PTSD.

Afterdeployment.org offers trainings for healthcare providers on the topic of PTSD and special populations, including PTSD and aging; African American, Hispanic, Asian American and Pacific Islander veterans; and cross cultural considerations (http://afterdeployment.dcoe.mil/providers/continuing-education).

Other Mental Health Diagnoses

Depression and major depressive disorder (MDD) are also highly associated with MST and research suggests that almost one-third of sexual assault victims experience at least one period of MDD in their lifetimes. Other mood disorders and substance use disorders are also associated with having survived MST. As with PTSD, guidelines for treatment of each of these disorders have been established for use in VA and DoD facilities. While there is considerable research and guidance available for assessing and treating sexual and other trauma, there is little available yet that is focused specifically on military sexual trauma (Anderson & Surís, 2013).

Physical Health Disorders

Male and female active duty personnel and veterans who have experienced MST report more physical health problems than those who have not. The most critical issue for veterans may be encouragement and support in understanding and making use of the healthcare services available to them. Recent research emphasizing a holistic approach to physical and mental health treatment for those who have survived MST makes a great deal of sense (Johnson et al., 2015).

For both men and women, liver disease and chronic pulmonary disease are shown to have a moderate association with MST. AIDS is significantly associated in men (Anderson & Surís, 2013).

For women, physical health issues include obesity, weight loss, and hypothyroidism. Sleep disturbances and chronic pain also are mentioned frequently by female veterans (Johnson et al., 2015). When compared with female veterans who did not experience MST, those who did have more physical symptoms that include headaches, chronic fatigue, pelvic pain, menstrual problems, and gastrointestinal symptoms (Anderson & Surís, 2013). The connection between MST and eating disorders was noted earlier.

Understanding that a patient has experienced MST informs the clinician and allows him or her to check for known frequent co-morbidities, address known risk factors and behavioral components, and offer referrals or suggestions for other possible treatments.

Although confidentiality is a critical part of healthcare today, victims of MST often have special concerns about it and a healthcare provider may want to consider how they broach certain topics and what assurances they give to patients.

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