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The Effects of Relaxation Plus Imaginal Flooding Versus Relaxation Only on Panic Attacks in Veterans with Post-Traumatic Stress Disorder

Jan E . Bachman Western Michigan University

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Recommended Citation Bachman, Jan E ., "The Effects of Relaxation Plus Imaginal Flooding Versus Relaxation Only on Panic Attacks in Veterans with Post-Traumatic Stress Disorder" (1991). Dissertations. 2032. https://scholarworks.wmich.edu/dissertations/2032

This Dissertation-Open Access is brought to you for free and open access by the Graduate College at ScholarWorks at WMU. It has been accepted for inclusion in Dissertations by an authorized administrator of ScholarWorks at WMU. For more information, please contact [email protected]. THE EFFECTS OF RELAXATION PLUS IMAGINAL FLOODING VERSUS RELAXATION ONLY ON PANIC ATTACKS IN VETERANS WITH POST-TRAUMATIC STRESS DISORDER

by

Jan E . Bachman

A Dissertation Submitted to the Faculty of The Graduate College in partial fulfillment of the requirements for the Degree of Doctor of Philosophy Department of Psychology

Western Michigan University Kalamazoo, Michigan December 1991

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. THE EFFECTS OF RELAXATION PLUS IMAGINAL FLOODING VERSUS RELAXATION ONLY ON PANIC ATTACKS IN VETERANS WITH POST-TRAUMATIC STRESS DISORDER

Jan E. Bachman, Ph.D.

Western Michigan University, 1991

Many Vietnam veterans experience intrusive recollec­

tions of combat-related events in the form of nightmares

and flashbacks, a primary symptom of Post-traumatic Stress

Disorder (PTSD). Imaginai flooding has shown some promise

in reducing the frequency and intensity of these. Cogni­

tive-behavioral therapies have also been used, but their

effectiveness has not been studied. Experiment 1 attempted

to determine whether a self-imposed version of imaginai

flooding (called Self-Imaginai Flooding) could be used

rather than the usual therapist-led procedure, and whether

treatment effects could generalize from the treated to un­

treated intrusive memories. In a between groups design,

with six Vietnam veteran subjects in each group, the ef­

fects of Self-Imaginai Flooding were compared with Relax­

ation Only. Following relaxation training for both groups,

three intrusive memories were presented for treatment to

the Flooding Group in a multiple baseline fashion. The Re­

laxation Group received extended relaxation training.

Probes, in which subjective and physiological measures were

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. obtained, were conducted prior to treatment, after relax­

ation training, and following treatment of each of the

three intrusive memories. Results indicated that Self-

Imaginal Flooding was more effective than Relaxation Only

in reducing the frequency and intensity of intrusive memo­

ries outside of treatment, neither anxiety nor depression

were decreased, generalization of treatment effects did not

occur, and EDG was the only physiological measure which

changed significantly as a result of the Self-Imaginai

Flooding treatment. In Experiment 2, six subjects were

taught the Self-Imaginai Flooding technique and four cogni­

tive-behavioral coping strategies. Subjects received

training for each of these techniques and selected one

strategy for extended practice. Probes, similar to those

in Experiment 1, were conducted before and after training.

The results showed that strategy preferences were related

to the amount of discomfort reduction. In addition, there

were significant within-group decreases in the frequency of

intrusive memories and measures of anxiety and depression.

As measured in the probes, self-selected coping strategies

were more effective than previously used coping methods in

reducing subjective discomfort and heart rates. The impli­

cations of the results of both experiments are discussed.

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The effects of relaxation plus imaginai flooding versus relaxation only on panic attacks in veterans with post-traumatic stress disorder

Bachman, Jan E., Ph.D.

Western Michigan University, 1991

UMI 300 N. ZeebRd. Ann Arbor, MI 48106

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGEMENTS

I wish to express a special acknowledgement and sin­

cere appreciation to the individuals who were instrumental

in supporting this work in a variety of ways. They include

my committee, R. Wayne Fuqua, Ph.D., Michele Burnette,

Ph.D., Malcolm Robertson, Ph.D., and David Sluyter, Ed.D.,

who provided valuable guidance and comments during the

course of the research and/or development of this document;

the staff at the Battle Creek Veterans Administration Medi­

cal Center, particularly Dharm Bains, Ph.D., Pat Munley,

Ph.D., Gordon Hare, Ph.D., Larry Schwartz, Ph.D., Lynn

Becker, Ph.D., and Jim Frazee, who provided access to the

subjects, the equipment, and the environment in which to

conduct the research; my wife, Cheryl Bachman, who sacri­

ficed much, tolerated my extended involvement in higher ed­

ucation, and gave me the strength to complete it; and our

children, Andrea and Aaron, who have been most forgiving

about my spending more time with the Macintosh than with

Hungry Hippos.

Jan E . Bachman

11

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS

ACKNOWLEDGEMENTS ...... ii

LIST OF TABLES ...... vii

LIST OF FIGURES ...... viii

CHAPTER

I. INTRODUCTION ...... 1

Statement of the Problem...... 1

Review of Related Literature ...... 4

Purposes of Experiment 1 ...... 10

II. EXPERIMENT 1 ...... 13

Method ...... 13

Sub] ects...... 13

Approval of Study...... 14

Setting...... 16

Equipment...... 16

Treatment Conditions...... 17

Stress Recovery Treatment Program 17

Experimental Treatments...... 17

Procedure...... 18

General Procedure ...... 18

Baseline...... 18

Relaxation Training...... 19

Self - Imaginai Flooding Training...... 20

Probes...... 21

iii

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table of Contents--Continued

CHAPTER

Dependent Measures...... 22

Subjective Units of Discomfort (SUDS) Levels...... 22

Physiological Measures...... 22

Self-Report Data...... 24

Design and Data Analysis...... 24

Results of Experiment 1 ...... 26

Symptom Reduction...... 26

STAI...... 26

BDI ...... 26

Intrusive Recollections...... 28

Probe D a t a ...... 29

SUDS Levels...... 29

Physiological Measures...... 30

Generalization Across CEs ...... 35

Discussion of Experiment 1 ...... 36

III. EXPERIMENT 2 ...... 43

Introduction ...... 43

Purposes of Experiment 2 ...... 45

Method ...... 46

Subjects...... 46

Setting...... 47

Procedure...... 48

General Procedure...... 48

iv

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CHAPTER

Coping Strategies...... 48

Coping Strategy Training...... 50

Coping Strategy Selection and Practice . 50

Dependent Measures ...... 52

Probes...... 52

Design...... 53

Results ...... 53

Coping Strategy Training and Selection .... 53

Self-Report D a t a ...... 56

BDI and STAI...... 56

Intrusive Recollections...... 57

Symptom Severity Checklist...... 58

Probes...... 58

SUDS Levels...... 58

Physiological Measures...... 60

IV. DISCUSSION ...... 63

APPENDICES

A. Notification of Approval From VA Medical Center ...... 74

B. Notification of Approval From WMU' S HSIRB ...... 76

C. VA-Form 10-1086 Informed Consent ...... 78

D. "Information About PTSD Study": Informed Consent...... 80

E. Example of Critical Events Description ...... 82

V

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APPENDICES

F. Pleasant Scene Description ...... 84

G. Additional Graphs ...... 86

H. Weekly Symptom Rating Questionnaire ...... 96

BIBLIOGRAPHY...... 98

VI

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF TABLES

1. Sub]ect, Characteristics (Experiment l) ...... 14

2. Mean Self-Report Data (Experiment 1) ...... 27

3. Mean EDG and Standard Deviation Values During Exposure and Relaxation Components in Each P r o b e ...... 31

4. Mean EMG and Standard Deviation Values During the Relaxation Components in Each P r o b e ...... 33

5. Mean TMP and Standard Deviation Values During Exposure Component in Each P r o b e ...... 34

6. Subject Characteristics (Experiment 2)...... 47

7. Mean SUDS Levels Reported During Training for Each Coping Technique...... 54

8. Self-Report Data (Experiment 2) ...... 56

V I 1

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF FIGURES

1. Design Configuration...... 25

2. Mean SUDS Levels of All Events in Exposure and Relaxation Components in Each Probe ...... 29

3. Mean EDG Levels of All Events in Exposure and Relaxation Components in Each P r o b e ...... 30

4. Mean EMG Levels of All Events in Exposure and Relaxation Components in Each P r o b e ...... 32

5. Mean Temperature Levels of All Events in Exposure and Relaxation Components in Each P r o b e ...... 34

6. Mean SUDS Levels During Exposure Component for Each Event in Each P r o b e ...... 37

7. Pre- and Posttreatment Probe SUDS Levels During Exposure and Coping Components ...... 59

8. Mean SUDS Levels for All Subjects Within Consecutive Components of Each Probe ...... 59

9. Mean HR Levels in Pre- and Posttreatment Probe Sessions...... 60

10. Mean HR Levels for All Subjects Within Consecutive Components of Each Probe ...... 61

V l l l

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER I

INTRODUCTION

Statement of the Problem

Post-traumatic Stress Disorder (PTSD) is characterized

by reexperiencing a "traumatic event, avoidance of stimuli

associated with the event or numbing of general responsive­

ness, and increased arousal" (American Psychiatric

Association, 1987, p. 247). The critical feature is that

the symptoms follow a traumatic event that is an uncommon

human experience (American Psychiatric Association, 1987).

For veterans with PTSD the traumatic event(s) typically re­

late to killing or maiming during combat activities or wit­

nessing or experiencing physical brutality. These events

are "reexperienced" at later points in time as intrusive

recollections (nightmares and/or flashbacks) when the vet­

eran is exposed to stimuli similar to those during the

original event (American Psychiatric Association, 1987).

The emergence of symptoms may be delayed for many

years. Thus, it had been assumed that veterans adjusted

well upon leaving Vietnam, and PTSD was not widespread

(Horowitz & Solomon, 1978). However, the recent National

Vietnam Veterans Readjustment Study (see Keane, Fairbank,

Caddell, & Zimering, 19 89), reported 36% of "high combat

1

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 exposed" males experienced psychological problems. Other

estimates differ somewhat due to sampling methods and diag­

nostic criteria (Foy, Resnick, Sipprelle, & Carroll, 1987),

with the prevalence of PTSD projected from 30% in the low

combat exposed subjects (Foy et al., 1987) to 60% in high

combat exposed veterans (Helzer, Robins, & McEvoy, 1987).

Regardless, it is generally accepted that in excess of

500,000 Vietnam veterans need intensive treatment for PTSD-

related problems (Egendorf, Kadushin, Laufer, Rothbart, &

Sloan, 1981; Figley, 1978; Jelinek & Williams, 1984;

Wilson, 197 8) .

As the magnitude of PTSD in Vietnam veterans became

apparent over the last 10 years, treatment professionals

responded with the development of improved diagnostic meth­

ods (Blanchard, Gerardi, Kolb, & Barlow, 1986; Brett,

Spitzer, & Williams, 1988; Keane, Caddell, & Taylor, 1988;

Lund, Foy, Sipprelle, & Strachan, 1984) and specialty

treatment programs at Veterans Administration (VA) medical

centers (Bains, Frazee, Amidon, Hare, & Munley, 19 88;

Berman, Rice, & Gusman, 1982; Schwartz & Doherty, 1987;

Starkey & Ashlock, 1984) . A National Center for Post-trau­

matic Stress Disorder was developed that, according to

Lehman (1990), treated 3,485 combat veterans between Octo­

ber 1, 1989 and March 30, 1990. Of these veterans 2,307

had never been treated before.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3 Psychology has played a key role in the treatment of

PTSD. Among psychological techniques that have been ap­

plied to PTSD are the following: narcosynthesis (e.g.,

Kolb & Mutalipassi, 1982), hypnosis (Balson & Dempster,

1980; Brende & Benedict, 1980; Eichelman, 1985; Parson,

1984, 1988; Spiegel, 1981), imagery (Grigsby, 1987), relax­

ation (e.g., Hickling, Sison, & Vanderpleog, 1986; Parson,

1984), desensitization (Brodsky, Doerman, Palmer, Slade, &

Munasifi, 1987; Peniston, 1986; Schindler, 1980), imaginai

flooding (e.g., Fairbank, Gross, & Keane, 1983; Fairbank &

Keane, 1982; Keane & Kaloupek, 1982; Lyons & Keane, 1989),

cognitive-behavioral therapy (e.g., Alford, Mahone, &

Fielstein, 1988; Besyner, 1985; McCormack, 1985; Nezu &

Carnevale, 1987), and psychotherapy (e.g., Hendin, 1983;

Hendin, Pollinger, Singer, & Ulman, 1981; Ulman & Brothers,

1987 ; Wilmer, 1986) . These methods are generally used in

conjunction with other psychological treatment and/or with

pharmacotherapy.

While attempts to assess the efficacy of each of these

modalities continue to be made, increasing emphasis has

been given to those therapies, particularly imaginai flood­

ing, in which the veterans are required to "relive" the

traumatic event(s) first experienced in combat (e.g.,

Fairbank & Nicholson, 1987; Keane et al., 1989). In fact,

the inclusion of the "reliving" experience is fast becoming

a common ingredient across therapies supported by diverse

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4 theoretical biases. Another common ingredient is the use

of cognitively oriented techniques, but studies on these

have yet to be done. These two treatment modalities are

the focus of the following research.

Review of Related Literature

The defining feature of imaginai flooding is the pro­

grammed "reliving" of traumatic event(s) through verbal and

imaginary processes. It is a derivative of flooding

(Malleson, 1959) , a procedure that directly exposes p a ­

tients to anxiety-provoking conditioned stimuli for pro­

longed periods in an effort to reduce or extinguish anxi­

ety-related responses. Imaginai flooding is used when di­

rect exposure to the conditioned stimuli thought to elicit

symptoms is difficult or impossible to arrange. Instead of

being directly exposed to stimuli, patients are asked to

imagine them, often with the help of verbal directions from

a therapist.

The use of imaginai flooding in the treatment of com­

bat-related PTSD was first reported in 1982 (Black & Keane,

1982). The typical procedure requires an initial period of

relaxation, following which the therapist provides a series

of "hypnotic-like" statements suggesting that the patient

will be able to "relive" a combat experience as though he

were actually there (Lyons & Keane, 1989). The patient is

asked to imagine himself engaging in a specific combat-re­

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 5 lated scene as it is described by the therapist (Shielkh,

1983). The patient is prompted to interact with the thera­

pist (e.g., stating what he is experiencing as though it

were happening now) to intensify the effects of the stimu­

li and to keep him from attending to other stimuli during

the process (Rainey et al, 1986). The patient is encour­

aged to hold onto these images until the anxiety diminish­

es. A detailed description of the way in which imaginai

flooding treatment with Vietnam veterans is conducted has

been presented by Lyons and Keane (1989) .

Several case studies on the efficacy of flooding tech­

niques exist. Keane and Kaloupek (1982) and Fairbank and

Keane (1982) reported significant improvements in self-re­

ported sleep measures, anxiety levels, nightmares, and

flashbacks as a function of flooding. Significant decreas­

es in depression, the number of endorsed items on a symptom

rating scale, symptom intensity (Fairbank, Gross, & Keane,

1983), and frequencies (Fairbank & Keane, 1982) and inten­

sities (Fairbank, Gross, & Keane, 1983) of intrusive recol­

lections have also been noted. Gains have been maintained

at 3 and 12 (Keane & Kaloupek, 1982) and 6 months

(Fairbank, Gross, & Keane, 1983) posttreatment. While

these case study results appear promising, they suffer lim­

itations which have been addressed by more recent between

group designs.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6 Compared with no treatment, imaginai flooding is more

effective in reducing depression, state anxiety, and fear

(Keane et al., 1989). Sleep disturbances and physiological

responses (heart rate) to traumatic stimuli decrease more

significantly when flooding is used adjunctively with a

combination of group and individual treatment (Cooper &

Clum, in press) than when flooding is not included; and

self-reported measures of adjustment (Boudewyns & Hyer,

1990) and depression, state anxiety, and fear (Keane et

al., 1989) were significantly better at posttreatment for

those treated with imaginai flooding than for those receiv­

ing only individualized counseling (Boudewyns & Hyer, 1990)

or no treatment (Keane et al., 1989). These studies demon­

strate the superiority of flooding over no treatment con­

trols cind a variety of alternative psychotherapeutic inter­

ventions.

Because many veterans report the occurrences of multi­

ple traumatic memories, a concern in treatment is the ex­

tent to which treatment effects generalize to untreated

traumatic memories. Keane and Kaloupek (1982) noticed

that, for one subject, pulse rates for an untreated trau­

matic memory decreased across successive assessment ses­

sions. It is possible that either the successive assess­

ments of that scene constituted a form of treatment, or,

due to some similarities with the treated scenes, there was

a generalization of treatment effects to the untreated

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7 scene. Following the latter line of thinking Fairbank and

Keane (1982) attempted to determine whether treatment of

one traumatic memory could result in diminished reactions

to untreated memories. Using imaginai flooding to treat

two subjects, they found that extinction of anxiety gener­

alized only to an untreated scene that had similar charac­

teristics (common "stimulus and response cues") with the

traumatic events presented during earlier flooding ses­

sions. Unfortunately, these results must be interpreted

cautiously as replications have not been reported, and cri­

teria for determining common characteristics were not

cited. The studies using imaginai flooding contain some

critical methodological problems. In Fairbank and Keane

(1982), for example, probe phases, in which subjects were

exposed to evocative stimuli, immediately preceded treat­

ment phases of a session. This confounds the results as

the scenes treated later were presented more times than the

earlier treated scenes. Probe and treatment session

lengths each varied across the study, criteria for session

termination were unclear, and subjective units of discom­

fort (SUDS) ratings were "periodic." Some treatment com­

parison groups have not been exposed to probe sessions

(e.g., Keane et al., 1989). Exposing both groups in a be­

tween groups design to an equal number and quality of probe

sessions would help to limit arguments regarding confound­

ing and uncontrolled treatment variables.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8 Many studies have not obtained subjective (e.g.,

Boudewyns & Hyer, 1990; Keane & Kaloupek, 1982) or physio­

logical (e.g., Keane et al., 1989) data, or have collected

and not reported them (e.g.. Cooper & Clum, in press; Keane

& Kaloupek, 1982). The absence of measures of the intensi­

ty of the traumatic stimuli during the flooding or assess­

ment procedure (e.g., Boudewyns & Hyer, 1990; Bowen &

Lambert, 1986; Cooper & Clum, in press; Keane et al., 1989)

weakens the support for any functional relationship between

the procedure and outcome. SUDS scores may be an indica­

tion of the extent to which a veteran feels he has been

positively affected, regardless of other behavioral or

physiological measures, and these measures are important to

substantiate clinical significance for the consumer. The

lack of these also disallows the confirmation of the acqui­

sition of the relaxation skills (e.g., Boudewyns & Hyer,

1990; Bowen & Lambert, 1986; Keane & Kaloupek, 1982; Keane

et al., 1989) which are an integral part of the treatment.

There is variation of the length of treatment sessions

(e.g., Boudewyns & Hyer, 1990; Cooper &, Clum, in press;

Fairbank & Keane, 1982; Keane & Kaloupek, 1982; Keane et

al., 1989) and in the number of sessions (e.g., Boudewyns &

Hyer, 1990; Cooper & Clum, in press; Keane et al., 1989)

within studies (from subject to subject). This is particu­

larly critical, as there is evidence that length (Chaplin &

Levine, 1981; Foa & Chambless, 197 8; Stern & Marks, 197 3)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 9 and repetition (Chaplin & Levine, 1981) of exposure affect

outcome. This may have contributed to inconsistencies in

some earlier studies.

In addition to the above methodological limitations,

the clinical application of imaginai flooding is limited by

the need for individualized intervention, a time consuming

and cost intensive procedure. Improved treatment efficien­

cy would be possible if symptom reduction were obtained by

using similar procedures with a group of subjects. Such a

technique would require that the patient repetitively ex­

pose himself (rather than being exposed during an interac­

tion with the therapist) to the personal, evocative stimuli

(Dowd & Govaerts, 1985) . There already exists a foundation

for the effective use of self-desensitization (frequently

referred to as "self-control desensitization") (e.g..

Baker, Cohen, & Saunders, 1973; Rosen, Glasgow, & Barrera,

1976) and in self-flooding (e.g., McDonald et al, 1979) for

the treatment of anxiety disorders unrelated to combat ex­

periences. It is believed that such self-exposure tech­

niques facilitate learning of a coping strategy (Dowd &

Govaerts, 1985; Williams, Dooseman, & Kleifield, 1984) that

can be applied outside of treatment. These techniques have

yet to be evaluated for the treatment of Vietnam veterans

with symptoms of PTSD.

In summary, imaginai flooding has more empirical sup­

port than other treatments for PTSD. Limitations include

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 10 the lack of comparative research, methodological problems,

and efficiency of its application in treatment.

Purposes of Experiment 1

In Experiment 1 the effects of relaxation and relax­

ation plus self - imaginai flooding on PTSD symptoms were

compared. One purpose was to determine if the imaginai

flooding procedure typically used with individuals could be

conducted in a group format with similar clinical benefits

as reported with traditional 1:1 procedures. (This modi­

fied procedure is referred to as Self-Imaginai Flooding

throughout the remainder of the paper.) A successful ap­

plication in this format would be more cost efficient for

the treatment facility and less demanding in time and ef­

fort and less anxiety arousing for the therapist.

Other purposes were related to the questions, "Does

relaxation alone reduce symptomatology?" and "Does the com­

bination of Relaxation and Self-Imaginai Flooding produce a

greater effect than Relaxation alone?" Relaxation was cho­

sen for a comparison treatment because it is frequently

used as a component of PTSD treatment (e.g., Lyons & Keane,

1989), and there is a precedence for comparing two current­

ly used clinical treatment procedures (e.g.. Miller &

DiPilato, 1983). It is also known to affect some PTSD symp­

toms such as sleep latency (Keane, Fairbank, Caddell,

Zimering, & Bender, 1985) and sleep disruptions (Figley &

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 11 Southerly, 1977; Keane et al., 1985), nightmares (Miller &

DiPilato, 1983), anxiety following intrusive thoughts

(Zimering, Caddell, Fairbank, & Keane, 1984), irritability

and anger (McDermott, 1981) , and the probability of aggres­

sive episodes accompanying anger (Keane et al., 1985).

A final purpose was to determine whether the effects

of treatment following Self-Imaginai Flooding of one trau­

matic event would generalize to another traumatic event.

This study phenomenon has been reported but not replicated

in other studies.

In seeking to answer the above questions several meth­

odological improvements over other studies were incorporat­

ed. The VA treatment program in which subjects were in­

volved remained consistent across groups. Similarly, re­

laxation training and probe sessions were identical for

both groups. These restrictions were necessary to rule out

major confounding treatment variables.

Improvements were also made in the data collection

procedures and in the probe format. Probe data following

relaxation training can demonstrate the extent to which re­

laxation alone affected the dependent measures in the probe

sessions. The probe session format differed from previous

studies. For instance, the order of presentation of the

critical events was selected randomly in order to limit the

possible effects which may be related to intentional se­

quencing. The length of exposure to traumatic imagery in

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 12 each probe was held constant across critical events, sub­

jects and groups. This provided consistency of procedures

and the recording of dependent measures absent in much of

the prior research.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER II

EXPERIMENT 1

Method

Subj ects

Volunteers were solicited from a group of 20 Vietnam

veterans in an inpatient PTSD Stress Recovery Treatment

Program at a VA medical center. Of these 20, four veterans

elected not to participate, two elected to leave the pro­

gram before completion, and two were dismissed from the

program for rules infringements. The remaining 12 served

as subjects, six in each of two groups.

A psychologist and a social worker, who were not in­

volved in the study, conducted the assessments and deter­

mined whether veterans were to be admitted to the Stress

Recovery Treatment Program. The experimenter was not in­

volved in either of the assessment or admission processes.

Diagnoses and decisions to admit veterans were based upon

information gathered from structured interviews, DSM-III-R

(American Psychiatric Association, 1987) criteria, and re­

sults of several assessment instruments including the MMPI-

PTSD Scale (Keane, Malloy, & Fairbank, 1984), the

Mississippi Scale for PTSD (Keane et al., 1988), impact of

13

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 14 Events Scale (Horowitz, Wilner, & Alverez, 1979), and Expo­

sure to Combat Scale (Lund et al., 1984). The Beck De­

pression Inventory (EDI) (Beck, Ward, Mendelson, Mock, &

Erbaugh, 1961) and the Speilberger State-Trait Anxiety In­

ventory (STAI) (Speilberger, Gorsuch, & Lushene, 197 0) were

also administered.

Prior to the inception of the study, the first group

of veterans was arbitrarily designated as the Relaxation

Group, and veterans in the second group constituted the

Self-Imaginai Flooding Group, here after referred to as the

Flooding Group.

The data in Table l indicate that the groups were es­

sentially equivalent in all non-PTSD measures. Statisti­

cally significant differences were found on two of the four

PTSD measures, the Mississippi Scale (t[l0]=-2.72, p=.022)

and the Avoidance (t[10]=-2.63, p=.025) and Intrusion

(t [10]=-3.85 , p = .003) subscales of the Impact of Events

Scale. This may be an indication that the Flooding Group

was more severely affected. However, no significant dif­

ferences were found on the MMPI-PTSD scale and the Exposure

to Combat Scale.

Approval of Study

This dissertation study was approved by the Research

and Development Committee and the Director of the Battle

Creek Michigan Veterans Administration Medical Center (Ap­

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 15 pendix A) and by the Human Subjects Institutional Review

Board (HSIRB) of Western Michigan University, Kalamazoo

(Appendix B).

Table 1

Subject Characteristics (Experiment l)

Relaxation Flooding Group Group

Mean SD Mean sn

IQ 99.67 13.02 102.00 11.15 BDI 23.83 12.61 28.83 12.97 STAI

State 46.32 8.87 50.3 11.99 Trait 50.17 12.80 56.00 14.10 PTSD Scale 12.77 33.83 7.41 (MMPI) 26.17 Mississippi 101.5 17.36 127.2 12.24** Scale Exposure to 23.17 12.77 31.67 2.73 Combat Scale Impact of Events Scale Avoidance 14.83 6.88 26.50 8.43*

Intrusion 16.67 6.35 29.67 5.32** Intrusions (Week 1) Frequency 11.1 7.64 7.17 5.98 SUDS 6.11 3.39 8.00 1.64

*D=.025 (t[10]=- 2.63. **p=.022 (t[10]=-2.72). ***E=.003 (t[10] =-3.85.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 16 S.e.t.tlng

All introductory and relaxation training sessions were

held in a group therapy room. The room was equipped with

two exhaust fans that were used to maintain a comfortable

temperature and to block out extraneous noise. Chairs for

the veterans were arranged in a U-shape with a chair for

the experimenter at the top. A licensed staff psychologist

was available for assistance during the training and probe

sessions.

Probes were conducted in a room that contained a re­

clining chair, physiological monitoring equipment on a mov­

able table, a dim light, and a desk. Windows were covered

with blinds that were adjusted to maintain a relatively

subdued level of light.

Equipment

Equipment for electrodermography (EDG), electromyogra­

phy (EMG), and digital skin temperature (TMP) was manufac­

tured by J&J Equipment (Models R-7 3, M-53, and D-200, re­

spectively) , and the heart rate (h r ) monitoring instrument

was a Cardiotach Series 4600 (Applied Sciences Laboratory).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 17 Treatment Conditions

Stress Recovery Treatment Program

All subjects participated in an ongoing Stress Recov­

ery Treatment Program five days per week. Components con­

sisted of self-development, leisure education, occupational

and social skills development, physical conditioning, group

planning, anger management and assertiveness training,

group therapy, and discharge planning. This program has

been described elsewhere in more detail (Bains et al.,

1988) .

E3g>grJ.m.en.tal_Tr.ea.tments

Relaxation Group. Following the initial relaxation

training, this group received additional relaxation train­

ing on two consecutive days during each of the last three

experimental phases.

Flooding Group. Participants also received the same

initial relaxation training as the Relaxation Group. In

addition, during the treatment sessions in the last three

experimental phases, subjects practiced the Self-imaginai

Flooding technique.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 18 Procedure

General Procedure

Group treatment sessions occurred on the first two

days of the week and lasted approximately l .5 hours. Each

subject attended one individually conducted, weekly probe

session during one of the last three days of each week.

When not attending a session as a part of this study, sub­

jects attended the regularly scheduled Stress Recovery

Treatment Program sessions.

Baseline

Introduction. During the first two sessions veterans

in both groups were introduced to the study and its ratio­

nale as a part of the Stress Recovery Treatment Program.

They were informed that participation was voluntary. Vol­

unteers signed the VA Form 10-1086, "Agreement to Partici­

pate in Research by or under the Direction of the Veterans

Administration," (Appendix C) and an information sheet (Ap­

pendix D) which served as the informed consent.

Development of Critical Events (CES) and. Pleasant.

Imagery. Subjects in both groups wrote descriptions of the

three most anxiety producing CEs that were experienced as

intrusive memories. Descriptions for each CE included five

progressive scenes. The first three scenes consisted of

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 19 sequential events leading to the fourth scene, which was

the one during which the veterans experienced the most dis­

comfort. This was referred to as the Vital Scene (VS) .

The fifth scene was the event(s) which followed the VS and

during which arousal and discomfort were diminished. The

scene descriptions were reviewed and discussed privately

with each subject. A sentence representing each scene was

written on a 3" x 5" index card (see example in Appendix

E), and cards were placed in order within each CE.

A description of a pleasant scene, which would be used

as a part of relaxation training, was also developed. Sub­

jects completed a form (Appendix F) detailing specific sen­

sual modalities, physiological responses, and covert verbal

behavior. This form was also reviewed with each subject to

ensure that a pleasant scene was developed.

Relaxation Training

Subjects in both groups were taught progressive deep

muscle relaxation during four group sessions on successive

treatment days. The relaxation instructions were essen­

tially the same as Bernstein and Borkovec's (1973) with the

addition of a breathing component (Poppen, 1988, p. 66).

When subjects reached a relaxed state in the third and

fourth sessions, they were prompted to recall their person­

alized pleasant scene, and the experimenter provided gener­

al cues relating to the sensual, physiological, and covert

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 20 verbal details to enhance the imagery. It has been sug­

gested that the addition of guided imagery to relaxation

training is useful in cases where attentional control is

particularly difficult (Poppen, 1988). The focus on senso­

ry events provides alternative stimuli in place of the anx­

iety arousing ones. Subjects were instructed to practice

the relaxation technique at least once each day throughout

the study.

Self-Imaginai Flooding Training

Following 15 minutes of relaxation, each subject was

instructed to view a 3" x 5" card on which was written the

sentence describing the first scene of a CE. Cues (Lang,

1977) were given throughout a five minute period by the ex­

perimenter to enhance the imagery, and subjects were in­

structed to retain the image regardless of its intensity.

The sentence describing the second scene was then viewed,

and cues were presented as before. This procedure contin­

ued until each of the five scenes was imaged, and the fifth

scene was followed by 10 minutes of relaxation. A differ­

ent CE was presented in each of the three weeks of treat­

ment. The Flooding procedure was presented twice in each

session, resulting in four presentations of each CE.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 21 Probes

Probes were conducted at the end of phases to obtain

measures of baseline responses (Probe l) and to determine

the acquisition of relaxation training (Probe 2). A series

of probes was used to ascertain the combined effect of re­

laxation plus Self-Imaginai Flooding (for the Flooding

Group) or continued relaxation training (for the Relaxation

Group).

Subjects sat in a recliner in a semi-recumbent posi­

tion, and sensors for physiological monitors were attached.

In Probe l subjects were told to relax using any method

they could. After 10 minutes the five scenes for a CE were

sequentially presented by the therapist at one minute in­

tervals. (The portion of each probe during which CEs are

imaged is referred to as the exposure component.) Subjects

were told to see the scenes as if they were really there

and the events were happening now. Cues like those used to

evoke imagery relating to sensual, physiological, and co­

vert verbal details of the pleasant image were given con­

tinuously to enhance the imagery. Subjects were prompted

to verbally respond to the cues. Àt the end of each of the

three imaged CEs the subjects were told to relax in any way

they could for a five minute period (referred to as the re­

laxation component). Following their own attempt to relax

after exposure to the third CE, subjects were assisted in

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 22 therapist-led relaxation. Procedures for the remaining

probes (2-5) were identical, except in the relaxation com­

ponents, during which subjects used the relaxation tech­

nique taught as a part of the study. The order of presen­

tation of CEs was randomly determined, but identical for

each probe. The total length of each probe session was ap­

proximately 1.5 hours.

Dependent Measures

Subjective Units of Discomfort (SUDS). .■.Levels

On one minute intervals during probe sessions subjects

were prompted to indicate on an 11 point (0-10) Subjective

Units of Discomfort Scale (SUDS) (Foa & Chambless, 197 8)

the extent to which they felt anxious or disturbed by the

imaged CE during the exposure component and an amount of

discomfort during the relaxation component.

Physiological Measures

Physiological measures obtained during probe sessions

consisted of EDG, EMG, TMP, and HR. While evidence is

mixed, previous studies have shown that there is a rela­

tionship between levels of autonomic arousal and a diagno­

sis of PTSD, and that these measures may detect fluctua­

tions in arousal when veterans are presented with stressful

imagery (Boudewyns & Hyer, 1990; Pitman, Orr, Forgue, de

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 23 Jong, & Claiborn, 1987) . All data were recorded on one

minute intervals during both exposure and relaxation compo­

nents .

EDG. EDG levels provide an indirect measure of sweat

gland activity (Beck, 1987). Electrodes, with electrode

gel, were placed on the second most distal phalange of the

index and ring fingers of the left hand.

EMG. EMG levels, which indicate the extent to which

muscles are contracted (Beck, 1987), were obtained from two

Ag/AgCl electrodes, with electrode gel, placed approximate­

ly 2.5 cm above the center of the eyebrows with the ground

electrode at a midpoint between them. The forehead was

cleansed with isopropyl alcohol and a mild abrasive.

TMP. The measure of peripheral temperature is a cor­

relate of peripheral vasoconstriction (Beck, 1987). TMP was

recorded by attaching the sensor to the index finger of the

left hand.

HR . Heart rates are directly influenced by changes in

the autonomic nervous system (Olton & Noonberg, 1980). HR

was recorded via a sensor attached to the index finger of

the right hand.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 24 Self-Report Data

Pre- and posttreatment measures were obtained on the

BDI (Beck et al., 1961) and the STAI (Speilberger et al.,

197 0). The frequencies and associated SUDS levels of

intrusive recollections were reported by the subjects dur­

ing the first and last weeks of the study.

Design .and^Data Analysis

A between groups design was used to compare the depen­

dent variables between the two treatment groups. A three-

way ANOVA (Group X Probe x CE) was used to examine the

groups' physiological responses to the presentation of the

CEs during the exposure and subsequent relaxation compo­

nents. This analysis provided the basis for discriminating

the effects of Self -Imaginai Flooding apart from relax­

ation. Within group treatment effects across probes and be­

tween components were analyzed with one-way AMOVAs. Tukey

HSD analyses were used to determine interprobe differences

when ANOVAs yielded significant values. For purposes of

examining the generalization of treatment in the Flooding

Group, a multiple baseline across CEs design was used (see

Figure l).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 25

CE 1

Self-Imaginai Flooding

a

I CE 2 ü S' ■o o o k

CE 3

C §H U 11 Ü L 1 2 3 4 5 Probe Figure 1. Design Configuration.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 26 Results of Experiment l

Symptom Reduction

Pre- and posttest self-report data for the STAI, BDI,

and intrusive memories are shown in Table 2. The extent to

which each of these variables was reduced within a group is

support for the efficacy of the associated treatment, and

significant differences between groups indicates superiori­

ty of one treatment over the other.

STAI

Mean pretest scores for the State and Trait tests were

46.32 and 50.17, respectively, for the Relaxation Group and

50.3 and 56.00, respectively, for the Flooding Group prior

to treatment. Reductions in anxiety, as measured by the

STAI, did not occur, as posttest scores were higher than

pretest scores. Differences within and between groups for

pre- to posttreatment were not statistically significant.

BDI

Mean scores on the BDI were indicative of moderate

levels of depression at pretest and posttest for the Relax­

ation Group (23.83 and 21.50) and the Flooding Group (28.83

and 26.83), and slight decreases occurred in both groups at

the end of treatment. There were no statistically signifi­

cant differences within or between groups from pretest to

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 27

Table 2

Mean Self-Report Data (Experiment l)

Relaxation Flooding Group Group

Pretest Posttest Pretest Posttest (SD) (SD) (SE) (SE) STAI

State 46.32 54.67 50.30 59.00 (8.87) (4.27) (11.99) (13.08)

Trait 50.17 56.00 56.00 56.33

(12.8) (8.79) (14.10) (9.67)

BDI 23.83 21.50 28.83 26.83 (12.61) (7.09) (12.97) (12.16) Intrusions

Frequency per Subject 11.00 3.83* 7.17 0.67** (7.64) (6.11) (5.98) (1.03)

SUDS per 4.83 8.00 6.50*** Intrusion 6.11 (3.39 (2.80) (1.64) (3.49)

*D=.036 (t[5]=2. 84). **E=.036 (t[5]=2 .84). ***D=.032 ( t[5] =2.95) .

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 28 posttest.

intrusive.-Racpllections

There were pre- to posttreatment reductions in the

frequencies of intrusive memories for both groups. For the

Relaxation Group frequencies were reduced to 3.83 from 11.0

per week. The Flooding Group experienced decreases from

7.17 to 0.67 per week. These reductions were statistically

significant for the Relaxation Group {(t[5]=2.84, p=.036)

and for the Flooding Group (t[5]=2.84, p = .036). Pre- to

posttreatment reductions in the SUDS levels associated with

these memories for the Relaxation Group (6.11 to 4.83) and

the Flooding Group (8.00 to 6.50) were also evident. Only

the reduction for the Flooding Group was significant

(t[5]=2.95, ef.032). (Note that these SUDS levels are cal­

culated per intrusion and not per subject, the latter of

which would result in artificially low values, particularly

at posttreatment.)

The mean percentage of reduction in frequencies of in­

trusions and associated SUDS offers a measure of clinical

significance. The Flooding Group had greater mean reduc­

tions in both frequencies and SUDS levels (87.03% [SD=26.7]

and 64.58% [61.25], respectively) than the Relaxation Group

(60.5% [43.36] and 39.26% [43.67], respectively). Another

measure of clinical significance is the number of individu­

al subjects who experienced significant improvement. Five

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 29 of the Flooding Group experienced reductions of more than

7 5% in frequencies, while only two in the Relaxation Group

did.

Probe Data

SUD.S_L.eze.la

Figure 2 shows the mean SUDS levels for all CEs in

each probe for the exposure and relaxation components.

SUDS levels decreased slightly for both groups across the

probes in each component. An examination of the mean val-

8 Exposu^re Component

6 Relaxation I Group 4 Ui s 53- Flooding 2 Group ■0 a _ . — Relaxation Component 0 1 2 3 54 Probe Figure 2. Mean SUDS Levels of All Events in Exposure and Relaxation Components in Each Probe.

ues of the SUDS levels shows there were no significant dif­

ferences between groups in either component. For the Re­

laxation Group significant differences in SUDS levels

during the exposure component were found across the probes

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 30 (E[4,72]=3.104, e =.0205), yet no two probes differed sig­

nificantly from each other. Significant differences for

both the exposure (£[4,851=7.2083, p=^.000l) and relax­

ation (£[4,851=5.43, p=.0119) components were found for the

Flooding Group. Significant SUDS level differences (Tukey

HSD, p3.05) in the exposure component existed between Probe

1 and Probes 3, 4, and 5, suggesting subjective improve­

ment. A significant difference also existed between Probes

2 and 5. For the SUDS levels during the relaxation compo­

nent, significant differences were found between Probes 1

and 5 and between Probes 2 and 5.

Physiological Measures

EDG. Figure 3 shows the mean EDG levels in each probe

for the exposure and relaxation components. Decreases from

Probe 1 to Probe 2 in EDG levels were similar for both

10 -1 Relaxation ^ Group

Exposure f— I I Component o s

Flooding Group

1 32 4 5 Probe Figure 3. Mean EDG Levels of All Events in Exposure and Relaxation Components in Each Probe.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 31 groups in each component following relaxation training.

However, in the subsequent three probes, EDG levels for the

Relaxation Group increased to Probe 1 levels while the lev­

els for the Flooding Group remained low and stable. Dif­

ferences between groups were statistically significant in

both the exposure (E[1,29]=43.616, p=<.001) and relaxation

(E[l,29]=39.973, p=<.00l) components. Statistically sig­

nificant main effects were also found for probes in the ex­

posure (E[4 , 29]=3.061, E=^.001) and relaxation

(E[4,29]=2.987, p = .021) components, with differences in

Probes 3,4, and 5 (see Table 3).

Table 3

Mean EDG and Standard Deviation Values During Exposure and Relaxation Components in Each Probe

Probe

Component Group 1 2 3 4 5

Relax­ 9.31 6.04 7 .51 8.38 9.21 ation (4.17) (4.15) (3.98) (4.83) (3.79) Exposure 6.87 4.63 4 .30* 3.93** 4.09** Flooding (3.70) (0.83) (1.47) (1.68) (0.94)

Relax­ 9.34 6.23 7.11 8.67 9.27 ation (3.89) (4.42) (3.87) (4.94) (3.76) Relaxation 6.89 4.27 4.40* 3.93** 4.44** Flooding (3.84) (0.97) (1.50) (1.72) (2.11)

Note. Comparisons between groups for probe by probe differences within each component. *E<.01. **p3.001.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 32 As may be seen in Figure 3, EDG levels differed little

between the components within groups. Positive within

group differences across the probes were found only for the

Flooding Group in both the exposure (E [4,85] =6.803,

2=^.0001) and relaxation ( E[4,85]=5.06, p=3.001) com­

ponents. The Tukey HSD analyses indicated that baseline

levels differed significantly (^.05) from each of the sub­

sequent probes in both relaxation and exposure components.

EMG. Figure 4 shows the mean EMG levels across the

1.4 Exposure

1.2

Relaxation 1.0 Q) Group

o 0.8 — , Flooding 0.6 Relaxation Group

* - 0.4 1 2 3 4 5 Probe Figure 4. Mean EMG Levels of All Events in Exposure and Relaxation Components in Each Probe.

probes for the exposure and relaxation components. Except

for Probe 2, EMG levels for both groups in the exposure

component were similar. Levels during the relaxation

component were consistently lower for the Relaxation Group

than the Flooding Group (E[1/29]=31.290, p=3.001). Those

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 33 which differed were Probes 2,3, and 4 (see Table 4).

Table 4

Mean EMG and Standard Deviation Values During the Relaxation Components in Each Probe

Probe

Group 1 2 3 4 5

0.51* 0.47** 0.44*** Relaxation 0.58* 0.50 (.022) (0.25) (0.23) (0.18) (0.23)

0.90 Flooding 0.83 0.80 0.74 0.71 (0.36) (0.38) (0.37) (0.26) (0.49)

*E<.05. **p<.01.

Each group had lower EMG levels in the relaxation component

compared to the exposure component. However, this between

component difference was only significant for the Relax­

ation Group (E[4,72]=6.5374, p=.0002).

TMP. Figure 5 shows the mean TMP levels in each probe

for the exposure and relaxation components. The Relaxation

Group had consistently higher TMP levels than the Flooding

Group in both components. Significant between group main

effects were found for Group (£[1,291=29.232, p=<.001) and

Probe (E[4,29]=2.65,p=.036) only during the exposure compo­

nent. t tests comparing TMP at each probe (see Table 5)

show that differences existed at baseline and Probes 2, 4,

and 5.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 34

96 n Relaxation Group 94 - 0) Exposure 5 92 - Component 5 ■ t 90 - Relaxation Q) 6 Component

88 - Flooding Group

85 1 2 3 4 5 Probe Figure 5. Mean Temperature Levels of All Events in Exposure and Relaxation Components in Each Probe.

Table 5

Mean TMP and Standard Deviation Values During Exposure Component in Each Probe

Probe

Group 1 2 3 4 5

91.76* 92.87* 91.25 93.38*** 93.88** Relaxation (2.09) (2.08) (1.38) (1.8) (1.12)

88.14 91.26 90.98 88.80 90.42 Flooding (2.08) (1.81) (1.45) (3.52) (1.00)

*E<.05. **p<.002. ***E<.001.

Within each group the TMP levels show no consistent pattern

across probes. The differences between components are min­

imal. The only significant within group change was in the

exposure component for the Relaxation Group

(E[4,72]=7.0916, p=3.001). Further analysis (Tukey HSD)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 35 yielded differences from the baseline with Probe 5 and

from Probe 3 with Probes 4 and 5.

These results must be interpreted cautiously, since

the validity of the TMP levels is questionable. Aber-

rantTMP levels may be produced by allowing the TMP sensor

to have contact with other parts of the body (particularly

the thigh area) or chair. The experimenter prompted the

subjects to move the hand when contact was noticed. Howev­

er, it cannot be assumed that all contacts were of short

duration without causing an increase or decrease in TMP

levels. Anecdotally, it appeared that contact was more

frequently with the thighs during the relaxation component

(producing artificially high temperatures) and with the

chair during the exposure component (producing lower TMP

levels) .

HR. No between or within group differences were found

for HR in either component nor in the differences between

components.

Sgogralization Across-CEs.

Generalization may be said to’ have occurred if changes

in a dependent variable for an untreated CE correspond with

changes in the treated CE. Employing an examination of the

SUDS data similar to that of Fairbank and Keane (19 82)

(i.e., ignoring data for the Relaxation Group while consid­

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 36 ering only those for the Flooding Group), Figure 6 minimal­

ly suggests such a relationship, as decreased SUDS levels

during the exposure components for untreated scenes (CEs 2

and 3) in Probe 3 correspond with decreased SUDS levels

following treatment of CE 1. However, support for gener­

alization is lost when Relaxation Group data are also exam­

ined, as a similar relationship between treated and un­

treated CEs is apparent. Comparable relationships within

and between groups were evident during the relaxation com­

ponent (see Appendix G). Generalization is also not sup­

ported by other physiological measures (see Appendix G) .

Discussion of Experiment 1

The first purpose of Experiment 1 was to determine

whether the Self-Imaginai Flooding procedure could reduce

subjective and physiological responding in probes of trau­

matic memories. Only one physiological measure, EDG, was

significantly affected. Reasons for the lack of signifi­

cant changes in the other measures are not clear. However,

these results are not unlike those reported previously

(e.g., Boudewyns & Hyer, 1990), that have suggested that

the lack of change in physiological responding following

repeated exposure indicates that PTSD may be associated

with neurological changes that will remain unaffected by

repeated exposure. There have been no studies to determine

this yet. Although the reductions in the associated SUDS

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 37 Relaxation Baseline Training Self-Imaginai Flooding

CE 1

5- Relaxation Group Flooding Group

CE 2

§m

1 2 3 4 5 Probe Figure 6. Mean SUDS Levels During Exposure Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comparison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 38 levels were statistically significant, the lowest SUDS

level continued to remain elevated as compared to others'

reports of posttreatment responding (e.g., Fairbank &

Keane, 1982). As stated earlier, calculating SUDS levels

per subject, as done in most studies, results in artifi­

cially low values. Values here were calculated per intru­

sion.

This study also aimed to determine the effect of Self-

Imaginal Flooding on the general levels of depression and

anxiety. The fact that STAI State scores did not change,

particularly when compared to results in other studies,

could be due to several reasons. The posttreatment mea­

sures were completed immediately prior to leaving the

Stress Recovery Treatment Program. At that time several

subjects reported being quite anxious about leaving, b e ­

cause they felt unprepared to return to environments which

were associated with numerous problems and included stimuli

affiliated with intrusive memories. It is unlikely that

scores on the BDI would decrease as a result of flooding

alone. Decreases reported in other studies could have been

due to adjunctive treatments. Since no part of the Stress

Recovery Treatment Program directly targeted the treatment

of depression, and since subjects used the extra-treatment

setting as the frame of reference for which to answer the

items on the BDI, the lack of changes in BDI scores is not

surprising.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 39 The lack of generalization of effects from treated to

untreated CEs does not support the findings of Fairbank and

Keane (1982). Their case study failed to account for the

effects of relaxation, and were that done with the data in

this study (by ignoring Probe 2 data and between group com­

parisons) , similar conclusions might be suggested.

Fairbank and Keane (1982) suggested that generalization oc­

curred when events shared common features. A review of the

scene descriptions in this study revealed many common fea­

tures, yet the data did not fit the pattern of that

presented by Keane and Fairbank (1982).

It appears that the initial decrease in EDG levels for

both groups could have been due to relaxation training.

Further between group comparison shows that maintenance of

this decrease was related to the Self-Imaginai Flooding

procedure rather than continued relaxation practice alone.

For the Flooding Group, the decreases in EDG levels were

accompanied by similar decreases in associated SUDS levels.

This was not true for the Relaxation Group. Lack of corre­

spondence between subjective and physiological measures has

been reported in other studies (e.g., Burish & Horn, 1979),

suggesting that some measures of anxiety vary independently

from subjects' self-reports. In this experiment, for exam­

ple, SUDS reports in probe sessions may have been based

upon those physiological responses which did not change

across probes or on some other unknown variable.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 40 The data in this study favor the Self-Imaginai Flood­

ing treatment over Relaxation Only for several reasons. One

measure of effectiveness is the extent to which subjects'

subjective and physiological responses diminished across

the probes when confronted with imaged intrusive memories.

In the exposure component, SUDS levels were reduced across

the study for both groups, more significantly for the

Flooding Group. Also across the probes, EDG levels were

reduced for the Flooding Group and TMP levels improved for

the Relaxation Group. However, TMP levels may be suspect

as mentioned earlier. Another measure of effectiveness is

the extent to which the relaxation response following expo­

sure improves across the study. Only the Flooding Group

showed such improvement, with decreased SUDS and EDG lev­

els. Perhaps the strongest support for Self-Imaginai Flood­

ing is the fact that those in the Flooding Group had more

positive extra-treatment gains. Both the frequency and in­

tensity of intrusive memories outside of the treatment ses­

sions decreased significantly. These measures are likely

to be the critical determinants of treatment success from

the veteran's perspective, as they are most concerned with

their responses in the extra-treatment environment. It is

unlikely that differences between groups could be attribut­

ed to differences in expectancies, as both groups were

given identical instructions, and the Relaxation Group un­

derstood that the probes were a part of the treatment.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 41 Sub]ects also did not have the opportunity to share infor­

mation between groups, as there was a one week lapse b e ­

tween their treatment. Unfortunately, there were no reli­

ability data for self-report measures, but it is unlikely

that subjects could have benefited by reporting decreases.

Reported decreases were also not reinforced by the experi­

menter. In addition, it is unlikely that subjects reported

decreases in order to avoid the flooding training and probe

procedures, as they could have accomplished this by merely

refusing to continue in the study.

More veterans were positively affected to a greater

degree in the extra-treatment environment. In the last

week of treatment when compared to the Relaxation Group,

the Flooding Group had one fourth the number of men report

intrusions. The improvement for the Flooding Group was two

times better for intrusions and 1.6 times better for asso­

ciated SUDS levels than that experienced by the Relaxation

Group.

In summary. Self-Imaginai Flooding is a procedure

which can be used to reduce some symptoms of PTSD, particu­

larly the frequency and intensity of intrusive memories

which occur outside of treatment. This procedure was more

effective than Relaxation Only in reducing the impact of

the intrusive stimuli and in improving the subjects' abili­

ty to relax following exposure to these stimuli. As has

been found in some other recent studies, this experiment

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 42 also shows that positive physiological changes for each

measure did not result from an exposure-based treatment, in

spite of subjective reports which suggest otherwise.

In the absence of treatment, veterans have some abili­

ty to control the effects of the traumatic memories. Some

subjects in Experiment 1 indicated they were able to

respond constructively to intrusive memories for a while

after the traumatic experiences in Vietnam. It is also

known that many veterans with similar experiences report

occurrences of intrusive memories, but are not negatively

affected by them (e.g., Foy et al., 1987). In Experiment 1

an ability to cope was seen during Probe 1, as between-com­

ponent responses for the physiological measures and associ­

ated SUDS levels were reduced following each CE. Anecdotal

data gathered during the course of the study indicated that

veterans, when confronted with intrusive memories, "block

them out." For the most part, the veterans' descriptions

of this included cognitive activities like talking to one­

self, thinking about something else, or making "my mind go

blank." These descriptions of self-imposed methods sug­

gested the subsequent study, in which several cognitively

oriented coping strategies were taught, and veterans were

given the option to choose among them. The efficacy of

this technique was evaluated.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER III

EXPERIMENT 2

Introduction

The use of cognitive-behavioral techniques, in which a

patient's cognitions, feelings and behaviors are modified

with behavior therapy procedures (Turk, Meichenbaum &

Genest, 1983), is mentioned in many PTSD treatment program

descriptions (e.g., Alford et al., 1988; Besyner, 1985;

Nezu Sc Carnevale, 1987). They are used because it is

thought that relationships between environmental stimuli

and anxiety are modified with cognitive responses (Keane et

al., 1985). Among the techniques are irrational thought

(Green, Lindy, & Grace, 1988; McCormack, 1985; Parson,

1988) and irrational behavior (Keane et. al, 1985) replace­

ment, cognitive restructuring (McCormack, 1985; Parson,

1984, 1988; Williams, 1987), and problem-solving (Keane et

al., 1985). Unfortunately, while cognitive techniques are

frequently used, they are seldom described in the detail

required for replication or application, and since they

have been generally viewed as adjunctive modalities, their

influence on treatment outcome has been largely ignored.

McCormack (1985) reported a case study in which a vet­

eran was taught to recognize the environmental stimuli

43

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 44 reminiscent of Vietnam and to reduce the impact of these

stimuli by replacing irrational covert thoughts with ratio­

nal ones. At the end of five months of treatment the fre­

quency and severity of intrusive recollections decreased,

the veteran had more control of angry outbursts, and the

frequency and severity of depressive episodes decreased.

Gains in relationships with his family, quite likely as a

result of the attenuation of PTSD symptoms, were also no­

ticed. While impressive, these results must be interpreted

as merely suggestive, because of the well known limits of

uncontrolled case studies.

An additional self-control, cognitive-behavioral tech­

nique, thought stopping, has been used to eliminate covert

verbal behaviors and the undesirable overt behaviors which

typically follow (Wisocki, 1985; Wolpe, 1969), particularly

with symptoms similar to those exhibited during intrusive

memories (e.g., Anthony & Edelstein, 1975; Cox & Klinge,

197 6; Rimm, 197 3). It has been found to be equally as ef­

fective as imaginai flooding in nonveteran populations

(Emmelkamp & Kwee, 1977; Hackman & McLean, 197 5). Thought

stopping, while sometimes used alone, is more frequently

used with other cognitive and behavioral techniques (e.g.,

Cautela & Baron, 197 3; Cox & Klinge, 197 6; Holmes,

Delprato, & Aleh, 1979).

In addition to the above, pleasant imagery, time pro­

jection, and attention diversion may also be useful in

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 45 treating some PTSD symptoms. "Pleasant imagery," a form of

"imaginative inattention" (Turk et al., 1983), incorporates

the use of an incompatible image and is accompanied by

pleasantly arousing subjective changes. "Covert assertion"

(Rimm & Masters, 1979) or "time projection" (Beck & Emery,

1985) procedures are similar, but the image is of some fu­

ture behavior. Another technique, attention diversion

(Hanson & Gerber, 1990; Meichenbaum, 1985), requires that

attention be focused on actual, rather than imagined, stim­

uli in the environment (Turk et al., 1983). Each of these

techniques serves to replace the unwanted image (in this

case, a combat-related memory) with an incompatible one.

No attempts to apply these techniques to the treatment

of PTSD in combat veterans have been reported in the treat­

ment literature, although it is possible that veterans have

used similar, "common sense" techniques themselves (e.g.,

"blocking it out"). The assessment of their efficacy in

reducing symptoms would be desirable, as they are coping

strategies which are easily learned and which do not re­

quire intensive exposure to aversive stimuli as in flooding

techniques.

Purposes of Experiment 2

In addition to the notion that cognitive coping strat­

egies may effectively reduce some PTSD symptoms, it is pos­

sible that veterans may have individual preferences for

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 46 them. Once taught several of them, veterans could select,

practice, and use one to respond to intrusive memories.

Therefore, a primary purpose of Experiment 2 was to deter­

mine whether significant symptom reductions could be ob­

tained using a variety of self-imposed coping strategies,

including Self-Imaginai Flooding and several cognitively-

based ones. Given the variety of these self-directed

strategies, another purpose was to determine if there were

preferences for any of these. The final purpose was to de­

termine whether self-selected coping strategies were as ef­

fective as program-imposed treatments of relaxation and

Self -Imaginai Flooding used in Experiment 1.

Method

Subj.e.c.t.s.

Ten Vietnam combat veterans from the Stress Recovery

Treatment Program volunteered as subjects. Prior to the

first probe four veterans elected not to participate in the

probes but did attend most of the relaxation training and

coping strategy training sessions. The remaining six

served as subjects. They ranged in age from 39-49

(x=41.8), and in IQ from 83-115 (x=101.2). Additional sub­

ject characteristics are included in Table 6.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 47

Table 6

Subject Characteristics (Experiment 2)

Mean sn

IQ 101.17 3.71

BDI 29.00 9.08

STAI

State 67.00 11.03

Trait 61.17 10.72

PTSD Scale (MMPI) 32.67 10.63 Mississippi Scale 120.83 16.43 Exposure to Combat Scale 20.33 4.23 Intact of Events Scale

Avoidance 19.67 7 .77

Intrusion 19.33 9.31

Intrusions (1st week)

Frequency 12.83 6.31

SUDS 6.54 1.15

Setting

The setting was identical to that described in the

first study. Coping strategy training sessions were held

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 48 in the same room as relaxation training.

Procedure

General Procedure

Group training sessions for this study occurred as the

first daily session of the Stress Recovery Treatment Pro­

gram and lasted approximately 1.5 hours. Baseline and re­

laxation training conditions were identical to those in Ex­

periment 1. During the introduction session, subjects

identified one scene from each CE as the "crucial scene."

This scene was the one which was most frequently experi­

enced at the onset of the intrusive recollection of the CE.

Following coping strategy training, subjects selected a

coping strategy to practice outside of sessions and to use

when confronted with intrusive recollections. Each subject

attended an individually conducted Pretest Probe before re­

laxation training and subsequent coping strategy training

and a Posttest Probe after the last coping strategy prac­

tice session.

Coping Strategies

Self-Imaginai Flooding. This strategy was taught

using the same procedure as described for the Flooding

Group in Experiment 1.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 49 Thought Stopping. Subjects read the crucial scene

card and imaged the event. When all signaled an associated

heightened SUDS level, the therapist shouted "STOP." Sub­

jects had earlier been instructed to also covertly shout

the same to themselves. For the remainder of a five minute

coping period they could use any strategy they wished

(e.g., relaxation) and were to covertly shout "stop" at any

time they began to image any part of that or another un­

pleasant scene.

Pleasant Imagery. On the back of each crucial scene

card was the statement, "I would rather think about (scene

used in relaxation training or some other self-selected

pleasant scene)." After viewing the crucial scene card and

experiencing heightened arousal, subjects turned the card

over, read the sentence, and imaged the pleasant scene.

They were also instructed to reread the prompt if the

pleasant scene was replaced by an unpleasant image.

Projection. This strategy used a similar prompt pro­

cedure as in Pleasant Imagery. The prompt of the back of

the crucial scene card was read when arousal was height­

ened. It stated, "That happened to me a long time ago, and

it is behind me now. Because I practice coping strategies,

next month at this time I will be much improved. I see my­

self (personal objective, positive message about function­

ing in the future)."

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 50

Diversion. This procedure was also referred to as

"distraction." Upon experiencing heightened arousal while

imaging the crucial scene, subjects opened their eyes and

looked around the room and out the windows, allowing them­

selves to become distracted by the sights and sounds. They

were also instructed to enhance the distraction by making

covert statements about these stimuli.

.CQPihg.-Stm t.egy--Tm i ning,

One coping strategy training session was conducted for

each of the five coping strategies. Each session began

with an explanation of and rationale for the coping strate­

gy presented. Ten minutes of therapist-prompted relaxation

with pleasant imagery was included immediately prior to and

following the training segment. Relaxation between the

presentations of each event was self-directed by the sub­

jects. CEs were presented during these sessions in random

order within each group of three events, and each was pre­

sented twice per session. Sessions ended with a discussion

of the strategy and a prompt to practice it outside of the

session.

Coping Stratecrv Selection and Practice

Three, therapist-led coping strategy practice sessions

were conducted on consecutive days following coping

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 51 Strategy training. At the beginning of the first practice

session subjects selected a preferred coping strategy.

They were also given personalized SUDS data collected by

the experimenter during the training sessions. These data

included the highest level of subjective discomfort while

imaging the crucial scene, the discomfort level five min­

utes after initiating a coping response, and the mean level

of discomfort during the coping response. Subjects were

told that a lower "Mean Coping" value was an indication of

getting rid of the anxiety more quickly; a lower "Final

Coping" value meant they had less anxiety after 5 minutes

than when using other strategies; higher values of "% Re­

duced" indicated a better overall strategy in reducing anx­

iety levels; and if "% Reduced" and "Final Coping" were

each about equal across strategies, a selection based upon

the lower "Mean Coping" value may be preferred. They were

also told that they could ignore these data and select a

strategy by any method they desired. In each session the

selected coping strategy was practiced following each of

three presentations of each CE.

Except for Self -Imaginai Flooding, the selected coping

strategies were practiced in a procedure similar to train­

ing. Those who chose Self-Imaginai Flooding were instruct­

ed to image the crucial scene and those following, using

self-provided cues as presented in training. After imaging

the last scene of the CE, a relaxation response was to be

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 52 initiated.

Subjects were given copies of the CE cards. They re­

ceived instructions on practicing the coping strategy out­

side of sessions, on coping with actual intrusive memories,

and on using these procedures for coping with intrusive

recollections that were not targeted in treatment.

Dependent Measures

The pre- and posttreatment, within probe self-report

measures, and physiological measures used in Experiment 1

were also used in Experiment 2. Subjects also reported oc­

currences of intrusive recollections, the associated SUDS

levels, and SUDS levels five minutes later during their

attempt to "cope" (coping SUDS). A locally designed Symp­

tom Severity Checklist (Appendix H) was completed at the

beginning and end of the study. During coping strategy

training sessions, maximum SUDS levels associated with cru­

cial scenes during exposure and SUDS levels during the cop­

ing component were also recorded.

Probes

Two probes were conducted, the first (Pretest Probe)

as a baseline measure prior to relaxation and coping strat­

egy training and the second (Posttest Probe) as a post­

treatment measure at the end of the study. For the most

part the probe procedures were identical to Experiment 1.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 53 Differences were as follows: at the end of the exposure

component for each CE, subjects were told to cope (coping

component) with the anxiety in any way they could for five

minutes (relaxation was not suggested); after the five

minute coping period following the third CE, therapist-led

relaxation was conducted; and during the Posttest Probe,

subjects were told to cope with the anxiety using the

strategy they elected to use in training.

Design

A within-subjects, pre- and posttest design (Johnson &

Solso, 1971) was used to evaluate changes in outcome mea­

sures as a result of using a selected treatment. £, tests

(paired comparisons) were employed to examine the statisti­

cal significance of the within group changes.

Results

Coping Strategy Training and Selection

Table 7 shows the data for the SUDS levels recorded

during training sessions for each coping technique. Reduc­

tions in SUDS levels were noticed for each technique. In

the order of the most to least effective strategies, the

percentage reductions in reported SUDS levels were 93.54%

for Diversion (range=85.6-100%), 91.47% for Pleasant Imag­

ery (59.7-100%), 81.92% for Thought Stopping (62.5-100%),

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 54

Table 7

Mean SUDS Levels Reported During Training for Each Coping Technique

Coping Technique

Self- s# Pleasant Thought Pro- Phase Imaginal Diversion Imagery Stopping j ection Flooding 1 Imagery 10 9 8.7 9 9 Final Coping 1.7 0.3 1.7 2.7 1.3 Mean Coping 4.4 2.9 4.1 4.8 3.2 % Reduced 83.0 96.7* 80.5 70.0 85.6 2 Imagery - 7 8 9 8.7 Final Coping - 0.3 3 2.3 1 Mean Coping - 3 5.9 4.9 4.6 % Reduced - 95.7* 62.5 74.4 88.5 3 Imagery 6.7 6.7 7 6 - Pinal Coping 0.3 2.7 1.7 3 - Mean Coping 1.8 4.7 5.7 4.3 - % Reduced 95.5* 59.7 75.7 50.0 - 4 Imagery 1.7 3.7 - - 5.5 Final Coping 0.7 0 - - 0 Mean Coping 1.1 1.1 - - 1.7 % Reduced 58.8 100.0* - - 100.0* 5 Imagery 8.5 9 7 .7 - 7 Final Coping 2.5 0.3 0.7 - 0 Mean Coping 3.8 1.8 3.5 - 1.3 % Reduced 70.6 96.7 90.9 - 100.0* 6 Imagery 9.3 5.7 8 6.7 4.7 Final Coping 0.3 0 0 0.3 0.3 Mean Coping 1.7 1.7 1 1.2 1.9 % Reduced 96.7 100.0* 100.0* 95.5 93.6 Mean % Reduced 80.92 91.47 81.92 72.55 93.54

Notfi■ Imagery = maximum SUDS level associated with crucial scene; Final Coping = SUDS level at end of five minute coping phases; Mean Coping = mean of all SUDS during coping phases. Asterisked numbers indicate maximal reductions. Larger bold numbers are the percentage reductions associated with the subject-selected coping strategy.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 55 80.92% for Self-Imaginai Flooding (58.8-95.5%), and 72.55%

for Projection (50.0-95.5%). The rank order of the strate­

gies by the number of subjects receiving maximal benefit

from the strategies was Pleasant Imagery (4), Diversion

(2), Self-Imaginai Flooding (1), Thought Stopping (1), and

Projection (0). (Note that 2 subjects each had equal re­

ductions in 2 strategies.)

Following training and prior to practicing a selected

technique, subjects were asked to rank order the strategies

according to their preference using any criteria they

wished. Using Spearman Rho (nonparametric, two-tailed) to

calculate the correlation between ranked levels and SUDS

data, the strongest relationship was found between final

coping SUDS and rank level (£=.666, p<.001).

Personalized SUDS data (those which appear in Table 7)

were provided in order to assist in the selection of a cop­

ing strategy. Subjects 2, 4, 5, and 6 selected techniques

which appeared to give them greatest relief during training

(Pleasant Imagery for Subj ects 2, 5, & 6, and Diversion for

Subject 4) . In spite of the data Subject l chose Self-

Imaginal Flooding, and Subject 3 chose Pleasant Imagery,

strategies which did not produce maximum reductions in

their SUDS ratings.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 56 Sel £.-Rep.or.t_Pat a

BDJ.-and STAI

Self-report data appear in Table 8. Pretreatment BDI

scores (x=29.00) were significantly reduced (x=16.17,

Table 8

Self-report Data (Experiment #2)

Week 1 Week 5

Mean SD Mean SD

BDI 29.00 9.08 16.17* 11.16

STAI

State 67.00 11.03 51.67*** 6.92

Trait 61.17 10.72 53.83** 13.53

Intrusions

Frequency 12.83 6.31 6.33* 4.32

SUDS 6.54 1.15 7.64 1.52

Coping SUDS 5.52 1.67 4.42 0.68 Symptom Checklist Score 156.50 46.18 135.33 44 . 86

*p3.05. **p<.005. ***p<.ooi

t,[5]=2.68, p=.044). Reductions also occurred for both

state (67.0 to 51.67) and trait (61.17 to 53.83) measures

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 57 of the STAI. These reductions were found to be statisti­

cally significant (i;[5]=6.92, e =.001, for state, and

t[5]=5.13, e =,004, for trait); however, the posttreatment

scores indicated the continued presence of anxiety.

Intrusive Recollections

The mean frequency of intrusive recollections declined

from 12.83 to 6.33 per week, a reduction of 50.7%

(t[5]=3.26, p=.023). Reductions were reported by 5 of the

6 subjects. Five subjects experienced an increase

(x=16.8%) in SUDS levels associated with these recollec­

tions. Five minutes into the coping period, subjects re­

ported decreases (x=2 3.1%) from Week 1 to Week 5 in SUDS

levels, and for the five subjects who showed improvement,

decreases ranged from 6.3%-56.5%. When intrusive recollec­

tion SUDS levels were compared to coping SUDS levels within

Weeks 1 and 5, mean reductions of 16.3% and 4 0.7% were

found (Weeks 1 and 5, respectively). Only the reduction in

Week 5 was significant (t[5]=4.03, p=^.01). In addition it

should be noted that intrusion SUDS levels in Week 5

(x=7.6) were higher than Week 1 (x=6.5), yet SUDS levels

five minutes into coping in Week 5 (x=4.24) were lower than

Week 1 (x=5.52).

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 58 aanp.tQin_S.ey.er.i.ty— Checkl ist

To obtain a score on this checklist the ratings of

each symptom were summed, with a maximum possible score of

230. The mean score (with associated ranges) was reduced

from 156.5 (89-212) to 135.3 (65-183) for a mean improve­

ment of 13.5% (7%-32.5%). Two subjects reported increases

of 5% and 7% in severity ratings.

Probes

To examine the differences between the probes, indi­

vidual comparisons (t tests) were conducted between the re­

spective exposure and coping components in the two probes,

t tests were also used to examine the significance of

reductions between components within each probe.

SUDS Levels

Figure 7 shows the SUDS levels reported by each

subject during the exposure and coping components of the

Pre- and Posttest probes. The reductions in SUDS from the

exposure to coping components were significant within both

pretest (t[5]=7.20, p=<. 001) and posttest (t[5]=5.36,

E=.003) probes. Between-probe reductions in coping compo­

nent SUDS levels were reported for 5 of the 6 subjects;

however, these were not statistically significant. Lack of

significance was also found for between-probe differences

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 59

10 H Pretest Exposure 8 - 0 Pretest Coping m Posttest Exposure 0 Posttest Coping aI w i 4 -

2 - I 2 3 4 5 6 Subject Figure 7. Pre- and Posttreatment Probe SUDS Levels During Exposure and Coping Components.

in the SUDS levels experienced during the exposure com­

ponents. Figure 8 shows the mean SUDS levels during each of

the successive components within each of the probes. Fol­

lowing training (Posttest Probe) subjects reported lower

8

6 I w 4 i 2 Pretest Posttest

0 Relax A Exposure 1 Coping 1 Exposure 2 Coping 2 Exposure 3 Coping 3 Relax B Component Figure 8. Mean SUDS Levels for All Subjects within Consecutive Components of Each Probe.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 60 SUDS levels in the initial relaxation phase (Relax A) than

before training (Pretest Probe). They also reported lower

SUDS levels during the coping components (Coping 1, 2, & 3)

in the Posttest Probe, even though the SUDS levels in the

associated exposure components were at least as high prior

to training. There is an ordered increase in SUDS levels

during flooding and coping components of successive scenes

in both probes. It is undiscernible whether the increase

in SUDS levels during the coping components is a function

of increased intensity during the exposure component or due

to successive presentations or related to both.

Physiological Measures

Figure 9 shows the HR for subjects during both expo­

sure and coping components of each probe. There were no

150 0 Pretest Exposure

0) S Pretest Coping I I □ Posttest Exposure S 100 - 0 Posttest Coping y ft M 4J(ti m 50 m I II

Subj ect Figure 9. Mean HR Levels in Pre- and Posttreatment Probe Sessions.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 61 statistical differences between exposure and coping compo­

nent HR levels in the Pretest Probe, indicating that sub­

jects' own coping responses were insufficient to produce a

reduction. Only two subjects were able to decrease their

HR more than one beat per minute with their coping strate­

gies. Subjects 5 and 6 experienced an increase in HR dur­

ing the coping component and Subject 3's HR remained equal­

ly elevated. The learned coping strategies appeared to be

more effective, as statistically significant decreases were

found between coping components (t[5]=2.82, p=.037) in the

Pre- and Posttest Probes and between the exposure and cop­

ing components in the Posttest Probe (t[5]=l3.25, p<.00l).

Figure 10 shows the mean HR for all subjects across the

components of each probe. HR in the Posttest components

110 -1 0) JJa •H ^ 100 - S ft cn 4J fÜ m 90-

Pretest Posttest 80 Relax A Exposure 1 Coping 1 Exposure 2 Coping 2 Exposure 3 Coping 3 Relax B Component Figure 10. Mean HR Levels for All Subjects within Consecutive Components of Each Probe.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 62 was much less than the respective Pretest components. The

reductions from exposure to coping components during Post­

test Probe are not evident in the Pretest Probe. It is

clear that heart rates were accelerated during the Posttest

Probe but never reached the lowest levels of the Pretest

Probe.

No other statistically significant differences existed

between the exposure components and the coping components

in the two probes nor between the exposure and coping com­

ponents within each probe for EMG, EDG, and TMP measures.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER IV

DISCUSSION

In Experiment 2 subjects were taught Self-Imaginai

Flooding and several cognitive-behavioral techniques, and

each subject selected and practiced one as a coping strate­

gy for intrusive recollections. These strategies were ef­

fective in reducing subjective discomfort between 72.6% to

93.5% in the training sessions. More specifically, indi­

vidual subjects experienced SUDS reductions ranging from

50.0% to 100%. SUDS level reductions were also evident in

the Posttest Probe. Three subjects had significant reduc­

tions by the end of treatment during the exposure compo­

nent, indicating they were not affected as greatly by in­

trusive memory presentations. The significant decreases in

SUDS levels during the relaxation component for five sub­

jects indicate they had acquired an improved coping strate­

gy over their own original one.

HR was the only physiological measure which modulated.

The way in which it did, with lower rates in both compo­

nents during the Posttest Probe, offers support for the ef­

fectiveness of the coping strategies. Subjects could more

quickly attenuate the discomfort related to the traumatic

memory.

63

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 64 Finally, similar to some other studies (e.g., Fairbank

Sc Keane, 1982) , subjects experienced a decrease in the fre­

quency of intrusive memories and an increase in associated

SUDS levels in the extra-treatment environment. It is im­

portant to note, however, that these SUDS levels could be

more quickly reduced after coping strategies training than

during the first week of treatment.

Whether any of the noted improvements would have oc­

curred in the Stress Recovery Treatment Program without the

added experimental component or would have occurred in the

absence of any treatment is unknown. The constraints im­

posed within the research setting prevented a design which

could have controlled for this. However, anecdotal obser­

vations by Stress Recovery Treatment Program staff suggest

that similar improvements had not been noticed in earlier

treatment groups.

The extent to which the subjective and self-reported

data were valid and reliable may be questioned since con­

firmation of the subjects' reports was not obtained. It is

difficult to obtain independent data on the occurrences of

intrusive memories and impossible to confirm subjective ex­

periences. However, the importance of these data is not

diminished for two reasons. First, there were no obvious

incentives for subjects to report decreases in intrusions

or SUDS levels. On the contrary, report of maintenance or

worsening of these levels would have been to the advantage

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 65 of the subjects, as benefits (continued absence from work

and family, more financial support, continued hospitaliza­

tion on another ward, etc.) could have continued or im­

proved. In light of this, these self-reports may be ade­

quate for measuring the effects of treatment.

Second, changes in the HR mirrored the reported chang­

es in subjective measures. Because HR has been found to be

a sensitive measure of the effects of traumatic stimuli

(e.g., Blanchard, Kolb, Gerardi, Ryan, & Pallmeyer, 1986;

Boudewyns & Hyer, 1990; Cooper & Clum, in press; Keane &

Kaloupek, 1982), this adds validity to the results based on

subjective measures. Similar covariation between subjec­

tive measures and HR has been reported by others (e.g.,

Boudewyns & Hyer, 1990; Pitman et al., 1987).

One purpose of the experiment was to determine the

preferences for coping strategies. Pleasant Imagery (cho­

sen by four of six subjects) was the most preferred tech­

nique, although Diversion produced slightly better overall

effects. The superiority of Diversion, however, may be

misleading, as the one subject, who more consistently had

lower percentages of improvement in coping phases, was not

present during the training of this technique. The scores

from those present may have produced a higher mean than if

all subjects were present. The effectiveness of Pleasant

Imagery could be related to the fact that it was incorpo­

rated into the relaxation portion of the training sessions

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 66 and practiced in each session.

Pleasant Imagery was chosen by four of the six sub­

jects. The correlational analyses and anecdotal reports

suggest that four subjects selected a strategy based prima­

rily upon the extent to which discomfort was reduced within

the coping period and secondarily on the rapidity with

which SUDS levels decreased. Preferences did not consis­

tently coincide with the strategies that produced maximal

effects during coping strategy training sessions. Subject

1 preferred Self-Imaginai Flooding over Pleasant Imagery

and Diversion because "it seemed like a more logical treat­

ment for treating flashbacks," Subject 3 chose Pleasant

Imagery because "it was more pleasant to do." He chose

this over Thought Stopping, which "didn't reduce any dis­

comfort" (SUDS levels indicate a 75.7% reduction compared

to 59.7% for his preferred strategy) and Self-Imaginai

Flooding, because "it doesn't make any sense to treat in­

trusive memories this way" (in spite of the fact that SUDS

levels were about 35% better with the Self-Imaginai Flood­

ing technique). That four subjects did choose the predict­

ed strategy may be coincidental and independent of the fact

that it produced maximal reductions.

It is appropriate to briefly compare the outcome of

these two experiments. Based upon the percentage of reduc­

tion of intrusions reported. Self-Imaginai Flooding was 20%

and 45% better than Relaxation and cognitive coping strate­

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 67 gies, respectively. Considering SUDS levels associated

with the intrusions, most to least effective treatments

were Relaxation, Self-Imaginai Flooding, and cognitive cop­

ing strategies. The fact that Relaxation SUDS levels were

reduced more than those for the Self-Imaginai Flooding

group may be insignificant, since, as discussed earlier,

fewer posttreatment intrusions were experienced by fewer

subjects in the Flooding Group.

The reasons for superiority of relaxation-only over

cognitive coping strategies in reducing the frequency and

intensity of intrusions are not clear, as the latter treat­

ment included relaxation training plus the coping strategy.

One reason may be that to be maximally effective, coping

strategies should occur simultaneously with deep muscle re­

laxation rather than be taught separately. Another possi­

bility is that in Experiment 1, the Relaxation Group par­

ticipated in three more probes than the group in Experiment

2. These probes could have contributed to treatment ef­

fects, particularly because they were essentially exposure-

based trials. It is also possible that in Experiment 2,

subjects used one or more different coping strategies, yet

reported using only one.

Significant decreases in depression and anxiety (mea­

sured by the BDI and STAI, respectively) were seen only in

Experiment 2. This might be attributed to the addition of

cognitive components to the treatment. Reductions in

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 68 anxiety (e.g., Barlow et al., 1984) and depression (e.g..

Beck, Rush, Shaw, & Emory, 197 9) have both been enhanced

when cognitive therapies are combined with behavioral pro­

cedures .

While these experiments produced intrusion frequency

and SUDS level reductions similar to those in other stud­

ies, physiological response reductions were not as dramat­

ic. This may be due in part to treatment or unknown sub­

ject differences, but other reasons may also be offered.

In these two experiments statistical analyses of the probe

data were based upon mean values from each of the compo­

nents. This is likely to produce a much more conservative

outcome than methods used in other studies in which compar­

isons are made between extreme values. For example,

Boudewyns and Hyer (1990) used the lowest value for physio­

logical measures during baseline components and highest

values during components, and Fairbank and Keane (19 82)

compared mean values of the first and last minute during

flooding with the values during the last minute of the re­

laxation component. These methods are more likely to re­

sult in statistical differences.

Another reason for differences may be due to the dura­

tion of exposure to stimuli. Subjects in the Flooding

Group of Experiment 1 were exposed to each CE four times

for approximately 25 minutes each during training, with ad­

ditional exposure during structured and self-practice ses­

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 69 sions. This differs from most exposure-based treatments

which report session durations of up to 12 0 minutes. There

is some evidence that longer sessions produce more pro­

nounced subjective (Foa & Chambless, 197 8) and physiologi­

cal changes than shorter ones (Stern & Marks, 197 3) , with

physiological (McCutcheon & Adams, 1975; Orenstein & Carr,

197 5) and subjective (Foa & Chambless, 197 8) responses di­

minishing only after a period of about 50 minutes. Perhaps

the Self-Imaginai Flooding sessions were too short to pro­

duce optimal results.

Still, an additional reason is offered. Unlike most

other studies the probes were not identical to treatment

sessions, particularly in the length of exposure during the

probes, nor were probes conducted within the same session

as treatment. This was intentional, as probes were de­

signed to gather data on the effects of the treatment at

various stages, and contributions of exposure in the probes

to treatment outcome were to be minimized. The fact that

probes contribute significantly to outcome (i.e., they are

capable of producing treatment effects themselves) has been

the criticism of some other studies (e.g., Keane &

Kaloupek, 1982). Thus, exposure to CEs in this study was

intentionally kept at five minutes, a duration which may be

more like the duration of "naturally occurring" intrusive

memories. Had the length of the exposure in the probes

been increased, results approximating those of other stud-

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 70 les may have been obtained.

In conclusion, these experiments contributed to the

current state of knowledge about the treatment of PTSD.

The usefulness of a self-exposure technique was demonstrat­

ed. Such a technique may prove to be cost efficient, as

compared to current treatment methods. In addition the

preference for cognitive oriented treatments was deter­

mined. While the results of these techniques were not as

drastic as Self-Imaginai Flooding, significant decreases in

the frequency of intrusive memories were also evident.

The results of these experiments provide additional

considerations for future treatment of PTSD. Professionals

may want to consider that veterans may have preferences for

the type of treatment they receive. While it is not known

whether this preference would improve the compliance, at­

trition rates, and outcome with this population, treatment

preferences have improved outcome in other areas (e.g., al­

cohol treatment). Therefore, treatment/patient-preference

matching research and treatment may be useful. Some con­

cern related to this is apparently being shown, as guide­

lines for the selective use of exposure-based treatment are

being suggested (Litz, Blake, Gerardi, & Keane, 1990).

The Self-Imaginai Flooding procedure reported herein

may provide some benefits over existing flooding treat­

ments. It is a procedure that once taught can be imple­

mented without the aid of a therapist, and the procedure

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 71 could be used to treat intrusive memories not presented in

the formal treatment setting. It also allows the veteran

to take a more active, rather than passive, role in the ex­

posure procedure. There is a potential benefit for the

therapist as well. An often discussed, yet not studied,

topic among those who lead flooding treatment is that the

stimuli presented to the veteran also heighten the anxiety

of the therapist. The Self-Imaginai Flooding procedure

would prevent that from happening. Because the procedure

is self-imposed and private, this allows for group training

and treatment, a benefit over current procedures which re­

quire one-to-one involvement.

Future treatment should also take into account the re­

sults of Experiment 2, in which gains were made by using

cognitive techniques. Similar to the Self-Imaginai Flood­

ing procedure, these were active, covert, and easily imple­

mented coping strategies. The possibility exists that the

effectiveness of these strategies could be further enhanced

with concurrent exposure-based treatment, and that other

cognitive techniques not studied here might be equally or

more effective.

The interpretations of the results of these experi­

ments and suggestions for future application based upon

them must be done while keeping in mind the problems inher­

ent in the studies. While both studies were an improvement

over the case study format of most prior flooding research,

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 72 each used a small number of subjects. The selection of the

subj ects may also be questioned, as no clear selection cri­

teria were used (e.g., for baseline physiological respond­

ing, scores on specific PTSD assessment instruments, previ­

ous treatment history, frequency of intrusions), and sub­

jects were volunteers from those attending three consecu­

tive treatment programs.

A second problem was the lack of reliability data for

the implementation of intersession practice for relaxation

and coping strategies. Such data would be difficult to ob­

tain. More difficult to obtain would be reliability data

for the implementation of the coping strategy at the time

intrusive recollections are experienced. As well, during

treatment using the Self -Imaginai Flooding and cognitive

strategies, there was no certainty that subjects were imag­

ing the events and initiating the coping strategy or relax­

ation responses as directed.

A third major problem is one which has plagued all

similar exposure-based studies with this population to

date. Because the probe session procedures are nearly

identical to the treatment procedures, the extent to which

the probes constitute additional treatment is not clear.

While this study attempted to control this problem, there

is still no assurance that outcome was not affected by the

exposure in the probes.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 73 These experiments have answered a few questions re­

garding the treatment of PTSD in Vietnam veterans, yet many

remain to be answered. In spite of what remains to be

done, there is ample evidence for the use of exposure-based

and cognitive coping techniques in PTSD treatment programs.

Treatment programs may improve their cost effectiveness by

using group taught, self-exposure techniques, they may pro­

vide a more consumer-acceptable treatment by allowing pref­

erences among effective modalities, and they may offer pa­

tients more useful and easily applied coping strategies by

teaching those which have been shown here to have more pos­

itive effects than the veterans' current strategies.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix A

Notification of Approval From VA Medical Center

74

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 75

Veterans Administration Memorandum Date; April 6, 1989 .

Pfom; Coordinator, Research and Development

Sub| Approval of Research Proposal, "The Effects of Relaxation Plus Imaginai Flooding VS Relaxation Only On Panic Attacks in Veterans with PTSD" Medical Center Director (00) Thru: Chief of Staff (Itf

1. The Research and Development Committee and the Subcommittee for Human Studies both met on 4/5/89 and gave a recommendation for your approval of the above study.

2. Jan Bachman, H.A., will be completing this study for his Doctoral Dissertation at Western Michigan University.

3. Mr. Bachman, in order to complete this study before his V.A. appointment expires in August, will be beginning his study on April 10, 1989.

4. The Subcommittee on Human Studies received assurances from Hr. Bachman that his use of flooding and imagery will be supervised by professional staff psychologists at all times. He has revised his informed cgnsent forms to communicate thi^-to^ study participants.

LAWRENCE T. SCHWARTZ, Ph.D. Coordinator, Research and Development

C/i Recommend approval ( ) Recommend disapproval

■wi fliiM iM SPENCER F&LCOHr M.D. Acting Chief of Staff

44lApproved ( ) Disapproved

STEPHEN J. HUSSER Medical Center Director

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix B

Notification of Approval from WMU's HSIRB

76

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 77

Human Subjects Institutional Review Board Kalamazoo. Michigan 49008-3899

W estern M ic h ig a n U n iv e r s it y

TO: Jan E. Bachman FROM: Ellen Page-Robin, Chair RE: Research Protocol DATE: March 17, 1989

This letter will serve as confirmation that your research protocol, "The Effects of Relaxation plus Imaginai Flooding versus Relaxation Only on Panic Attacks in Veterans with Posttraumatic Stress Disorder" is now complete and has been signed off by the HSIRB. If you have any further questions, please contact me at 387-2647.

Reproduced witli permission of the copyright owner. Further reproduction prohibited without permission. Appendix C

VA-Form 10-1086 Informed Consent

78

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 79

PART I-AGREEMENT TO PARTICIPATE IN RESEARCH BY OR UNDER THE DIRECTION OF THE VETERANS ADMINISTRATION

I. I, voluntarily conoent to participate aas subject (Typo or print subjoct'a nemo)

in the investigation entitled (Title ol study)

2. I have signed one or more information sheets with this title to show that 1 have read the description including the purpose and nature of the investigation, the procedures to be used, the nsks, inconveniences, side effects and benefit* to be expected, as well as other courses of action open to me and my nght to withdraw from the investigation at any.time. Each of these items has been explained to me by the investigator in the presence of a witness. The invesiigutor has answered my questions concerning the investigation and 1 believe I understand what is intended.

3. I understand that no guarantees or assurances have been given me since the result* and risk* o f an investigation are not always known beforehand. I have been w ld that this investigation has been carefully planned, that the plan has been reviewed by knowledgeable people, and that every reasonable precaution will be taken to protect my well being. '

4. In the event I sustain physical injury as a result of participation in this investigation, if 1 am eligible for medical care as a veteran, all necessary and appropriate care will be provided. If I am not eligible for medical care as a veteran, humanitarian emergency care will nevertheless be provided.

5. 1 realize I have not released this institution from liability for negligence. Compensation may or may not be payable, in the event of physical injury arising from such research, under applicable federal laws.

6. I understand that all information obtained about me during the course of this study will be made available only to doctors who are taking care of me and to qualified investigators and their assistants where their access to this information is appropriate and authonzed. They will be bound by the same requirement* to maintain my pnvacy and anonymity as apply to all medical personnel within the veterans Administration.

7. I further understand that, where reouized by law, the appropriate federal officer or agency will have free access to information obtained In this study should it become necessary. Generally, I may expect the same respect for my pnvacy and anonymity from these agencies as is afforded by the Veterans Administration and it* employees. The provisions of the Privacy Act apply to all agencies.

8. In the event that research in which I participa*^ involves certain new drugs, information concerning my response to the drug(s) w ill be supplied to the sponsoring pharmaceutical nouse(s) that made the drug(s) available. This information will be given to them in such a way that I cannot be identified.

NAME OF VO LUN TEER

HAVE READ THIS CONSENT FORM. ALL MY QUESTIONS HAVE BEEN ANSWERED. AND I FREELY AND VOLUNTARILY CHOOSE TO PARTICIPATE. I UNDERSTAND THAT MY RIGHTS AND PRIVACY WILL BE MAINTAINED. I AGREE TO PARTICIPATE AS A VOLUNTEER IN THIS PROGRAM.

9. Nevertheless. I wish to lim it my participation in the investigation as follows:

VA FACILITY SUBJECT'S SIGNATURE

WITNESS'S NAME AND ADDRESS fPrtft» Of typ 9 ) WITNESS'S SIGNATURE

INVESTIGATOR'S NAME (Print or trpo) INVESTIGATOR'S SIGNATURE

—- Signed information P— Signed information I I sheets attached. I I sheets available at:

SUBJECT'S IDENTIFICATION (1,0. plot» Of *IV9 nan# - loot, lirot, mifklto) SUBJECT'S I.D. NO.

AGREEMENT TO PARTICIPATE IN RESEARCH BY OR UNDER THE DIRECTION OF THE VETERANS ADMINISTRATION SUPERSEDES VA FORM 10-I0M JUN m s . WHICH WILL NOT BE USED.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix D

"Information about PTSD Study": Informed Consent

80

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 81

Information about PTSD Study: “The effects of relaxation plus imaginai flooding versus relaxation only on panic attacks in veterans with posttraumatic stress disorder*

THIS STUDY HAS BEEN REVIEHED AND APPROVED BY THE VETERANS ADMINISTRATION MEDICAL CENTER, BATTLE CREEK. MICHIGAN.

This study is being done to examine the effectiveness of a treatment on on some symptoms which combat veterans notice while experiencing flashbacks and nightmares. Some of these symptoms include increased heart rate, sweating, and increased muscle tension. This treatment has been used successfully in other VA Medical Centers, and the veterans noticed significant decreases in the amount of discomfort associated with flashbacks and panic attacks. The purpose of this study is to determine whether the treatment previously used for individuals can be used to treat groups of veterans. A successful outcome of this study may result in more effective treatment for combat veterans with PTSD. Veterans will receive this treatment as a part of the Stress Recovery Treatment Program. During treatment sessions veterans may be asked to imagine and talk about scenes which relate to traumatic combat events and which are the subjects of flashbacks and nightmares. Veterans will maintain daily records about flashbacks and nightmares^ including their levels of discomfort with certain thoughts and feelings. - During several sessions external sensors, which will be placed on the skin (eg., hand, forehead), will be used to measure pulse rate, skin conductance, skin temperature, and muscle tension. This will indicate the progress the veteran will have made in treatment. This study will begin and end on the same days' as the Stress Recovery Treatment Program. This study has been carefully planned and has been reviewed andapproved by the VA Medical Center. The only known risk is the possibility of a temporary increase in the frequency or intensity of flashbacks. This is a possible occurrence in any PTSD program, regardless of the type of treatment. Should such such an incident occur, additional professional staff will be immediately available for support. The results of your participation in this study will be confidential. Your identity will not be revealed, and your name will be removed from any data sheets after the study is completed. If you participate in this treatment study and for some reason elect at a later date to withdraw, you may do so. Withdrawal from the study will involve no penalty or loss of benefits to which you are otherwise entitled. At the time of withdrawal you may continue to receive treatment, including relaxation training, at the Battle Creek. VAMC. The principal investigator of this study is Jan E. Bachman, M.A., a psychology student and Ph.D. candidate at Western Michigan University. He is also an employee at the Battle Creek VA)iC in Psychology Service. Any questions about the study should be directed to Mr. Bachman, who will be available each morning during the study. His office is in Building 13, Room 218. If you are willing to participate, please sign this statement and the following statement (VA Form 10-1066), which further outlines your rights and the responsibilities of the VA and its staff.

( ) I am willing to participate in this treatment study.

Veteran's:______]______Date:______

Witness' signature:______Date:

Investigator's signature______Date:______

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix E

Example of Critical Events Description

82

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Bailey 1-A 83

I am coming in towards the airport on the plane.

Bailey 1-B

Out the plane window I see a fire fight - Charlie is trying to get on base

Bailey 1-C

On final search and seizure - shooting enemy - stomping on heads until dead.

Bailey l-D

Throwing bodies into the hole, covering with lime. I'm crying, throwing up.

Bailey 1-E

I'm in the bar with some other guys.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix F

Pleasant Scene Description

84

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 85

PLEASANT SCENE DESCRIPTION

Describe as clearly as possible the details about a pleasant scene which fit the categories below. The pleasant scene may be one you recall be­ cause you experienced it, or it may be one that you would like to imagine because doing so makes you feel good.

I. General Description:

II. Details A. Describe what you see:

B. Describe what you hear:

C. Describe what you smell:

D. Describe what you taste:

E. Describe the sensations you feel against the outside of your body:

F. Describe any movement you see:

G. Describe the movements you are making:

H. Describe your emotions and feelings:

I . What are you saying to yourself :

J. What are you feeling inside of your body? (Also think about heart rate, sensations in your throat, stomach, chest, and back; how relaxed or alert you are):

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix G

Additional Graphs

86

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 87 Relaxation Baseline Training Self-Imaginai Flooding

5- CE 1

4- Relaxation Group Flooding Group

2 -

6-1

CE 2 5-

I 4- HP

CO 3- wB

2 -

6-1

CE 3 5-

4-

3-

2 -

-O

1 2 3 4 5 Probe

Figure 11. Mean SUDS Levels During Relaxation Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comparison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 88

Relaxation Baseline Training Self-Imaginai Flooding 12 -1

10 - CE 1

Relaxation Group Flooding Group

4-

12 -1

10 -

CE 2 I 4-

12 -, CE 3

10 -

4-

1 2 3 4 5 Probe Figure 12. Mean BDG Levels During Exposure Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comparison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 89 Relaxation Baseline Training Self-Imaginai Flooding

10 -1

CE 1

Relaxation Group Flooding Group

10

CE 2 r4I i

10 -1 CE 3

Probe Figure 13. Mean EDG Levels During Relaxation Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comparison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 90 Relaxation Baseline Training Self-Imaginai Flooding

CE 1

Relaxation Group Flooding Group

CE 2

? S

w

0.4

CE 3

1.2

0.4 1 2 34 5 Probe Figure 14. Mean EMG Levels During Exposure Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comparison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 91 Relaxation Self-Imaginai Flooding Baseline Training i i I T CE 1

Relaxation Group Flooding Group

CE 2

CE 3

0.7

1 2 34 5 Probe Figure 15. Mean EMG Levels During Relaxation Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comoarison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 92 Relaxation Baseline Training Self-Imaginai Flooding 96 -1 CE 1 94 -

92 -

90 -

88 - Relaxation Group Flooding Group 86

96 -, CE 2

94 -

92 .

90 -

88 _

86

96 _

94 .

92 -

90 -

88 _

86

1 2 3 4 5 Probe Figure 16. Mean TMP Levels During Exposure Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comoarison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 93 Relaxation Baseline Training Self-Imaginai Flooding 96 -1 CE

94 -

92 -

90 -

Relaxation Group 88 - Flooding Group

86

96 -, CE 2

94 -

92 -

88 -

86

96

94 _

92 .

90 -

88 .

86

1 2 3 4 5 Probe Figure 17. Mean TMP Levels During Relaxation Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comoarison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 94

Baseline Relaxation Self-Imaginai Flooding Tr ain in g90 -, Training90 CE 1

80 -

Relaxation Group Flooding Group

60

90 -, CE 2 0)

80 - a CO a m

60

90

80 -

60

1 2 3 4 5 Probe Figure 18. Mean HR Levels During Exposure Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comparison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 95 Relaxation Baseline Training Self-Imaginai Flooding 96 -, CE 1 94 -

92 -

90 -

Relaxation Group 88 - Flooding Group

86

96 -, CE 2

0) 94 - I 92 -

a CO 90 - Ü

m 88 -

86

96 -, CE 3

94 _

92 .

90 .

88 -

86

1 2 3 4 5 Probe Figure 19. Mean HR Levels During Relaxation Component for Each Event in Each Probe. (Although not subjected to a multiple baseline design, Relaxation Group data are included for comparison.)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Appendix H

Weekly Syitptom Rating Questionnaire

96

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 97

Weekly Symptom Rating Questionnaire Name: SS#: Date: fiease answer eacn o£ che rollowing gueecione as they apply Co you in the past week. For each symptom you experienced, circle the number on the scale to indicate how disturbed you were by the symptom. If the symptom was

Example for symptom which did I I How much were you disturbed? not occur: I I Not at all Moderately Extremely ...NO 0 -- 1 ---2 ---3" — 4""“5 — - II NO 0 - -1 — 2 — 3"~4““5""6 — 7 — 9 — 9--10

In the past week did you: 1 . feel as if a traumatic event were actually occurring NO 0--1--2--3--4--5--6--7--8--9--10 2. feel distressed when you saw, heard, tasted, felt, or otherwise came into contact with something that symbolized or resembled an aspect of a traumatic event NO 0--1--2--3--4--5--6--7--8--9--10 3. try to avoid thoughts or feelings associated with a traumatic event NO 0--1--2--3--4--5--6--7--8--9--10 4 . try to avoid activities or situ- ations that aroused traumatic recollections NO 0--1--2--3--4--5--6--7--8--9--10 5 . notice any inability to recall an important aspect of a traumatic event NO 0--1--2--3 --4 - - 5--6--7 - - 8--9 - -10 6. notice that you were not interested in any significant activities NO 0--1--2--3--4--5--6--7--8--9--10 7 . feel detached or estranged from others...... NO 0 — 1 — 2 — 3--4--S — 6 — 7 — 8 — 9 - -10 8. notice an inability to experience certain kinds of feelings NO 0--1--2--3--4--5--6--7--8--9--10 9 . think you may not have a long life or not be able to accomplish some things you would like t o ...NO 0""1 — 2 — 3 - - 4 ■ “ 5 “ ” 6 ■ “7 - “ 0 “ “ 9 - •* 10 10. become easily irritated...... NO 0--1--2--3--4--5--6--7--8--9--10 1 1 . have outbursts due to being angr*y ...... NO 0--1--2--3--4--5 — 6"“7 ”“0""9““1O 12. have difficulty concentrating...... NO 0--1--2--3- - 4--5--5--7- -8--9- -10 1 3 . notice that you were extra watchful or cautions about what was going on around you ...... NO 0--1--2--3--4--5--6--7--8--9--10 1 4 . notice that you were easily startled ...NO O--1--2 --3 --4 --5--6--7 --8--9 --10 15. notice increased heart rate, muscle tension, difficulty with breathing, sweating, or heartburn when something reminded you of a traumatic event...... NO 0--1--2--3--4--5--6--7--8--9--10 1^' experience forgetfulness...... NO 0--1--2--3--4--5--6--7--8--9--10 1^ ' feel sad ...... NO 0--1--2 --3 --4 - - 5-- 6--7 - - 8--9 - - 10 16. feel overwhelmed...... NO O--1--2--3--4--5--6--7 --8--9--10 1 9 . have any noncombat-related nightmares...... NO 0 — 1 - - 2 — 3 - - 4 — 5 — G--7--8--9- -10 20' have any thoughts about combat. ...NO o--1--2--3--4--5--6--7--8--9--10 2 1 . have troubling thoughts other than those related to combat...... NO O--1--2--3--4--5--6--7--8--9--10 22. think about killing yourself...... NO 0--1--2--3--4--5--6--7--B--9--10 2 3 . think about killing or harming others...... NO 0--1--2--3--4--5--6--7--8--9- - 10

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