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Lafortune D, Dubé S, Lapointe V, Bonneau J, Champoux C, Sigouin N. Virtual Reality Could Help Assess Sexual Aversion Disorder. JOURNAL OF SEX RESEARCH 2024; 61:588-602. [PMID: 37556729 DOI: 10.1080/00224499.2023.2241860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Virtual reality (VR) may improve our understanding of sexual dysfunctions' manifestations, although research in this area remains limited. This study assessed the potential use of a VR Behavior Avoidance Test (VR-BAT) as a tool for examining the clinical features of Sexual Aversion Disorder (SAD): the experience of fear, disgust, and avoidance when facing sexual cues/contexts. A sample of 55 adults (≥ 18y) with (n = 27) and without SAD (n = 28) completed a self-report measure of sexual avoidance. Their anxiety, disgust, electrodermal activity, heart rate, and visual and behavioral avoidance were then examined during two VR-BATs involving sexual or non-sexual stimuli. Mixed repeated measures ANOVAs, t-tests, and correlational analyses were performed. Results showed that individuals in the SAD group reported greater anxiety and disgust compared to their non-SAD counterparts during the sexual stimuli condition. Sexual avoidance scores were largely positively related to anxiety and disgust during the VR sexual condition, and moderately negatively related to the time spent touching the virtual character's genitals. This study is important given the prevalence of sexual difficulties, such as SAD, and the new research avenues offered by emerging technologies, like VR.
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Affiliation(s)
- D Lafortune
- Department of Sexology, Université du Québec à Montréal
| | - S Dubé
- Department of Psychology, Concordia University
| | - V Lapointe
- Department of Psychology, Université du Québec à Montréal
| | - J Bonneau
- School of Media, Université du Québec à Montréal
| | - C Champoux
- School of Media, Université du Québec à Montréal
| | - N Sigouin
- School of Media, Université du Québec à Montréal
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Lewis MW, Bradford DE, Akman E, Frederiks K, Rauch SL, Rosso IM. Unconditioned response to a naturally aversive stimulus is associated with sensitized defensive responding and self-reported fearful traits in a PTSD sample. Psychophysiology 2024; 61:e14473. [PMID: 37919832 DOI: 10.1111/psyp.14473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 09/10/2023] [Accepted: 09/18/2023] [Indexed: 11/04/2023]
Abstract
Unconditioned responding (UCR) to a naturally aversive stimulus is associated with defensive responding to a conditioned threat cue (CS+) and a conditioned safety cue (CS-) in trauma-exposed individuals during fear acquisition. However, the relationships of UCR with defensive responses during extinction training, posttraumatic stress disorder (PTSD) symptom severity, and fearful traits in trauma-exposed individuals are not known. In a sample of 100 trauma-exposed adults with a continuum of PTSD severity, we recorded startle responses and skin conductance responses (SCR) during fear acquisition and extinction training using a 140 psi, 250-ms air blast to the larynx as the unconditioned stimulus. We explored dimensional associations of two different measures of UCR (unconditioned startle and unconditioned SCR) with conditioned defensive responding to CS+ and CS-, conditioned fear (CS+ minus CS-), PTSD symptom severity, and a measure of fearful traits (composite of fear survey schedule, anxiety sensitivity index, and Connor-Davidson resilience scale). Unconditioned startle was positively associated with startle potentiation to the threat cue and the safety cue across both learning phases (CS+ Acquisition, CS- Acquisition, CS+ Extinction Training, CS- Extinction Training) and with fearful traits. Unconditioned SCR was positively associated with SCR to the CS+ and CS- and SCR difference score during Acquisition. Neither type of UCR was associated with PTSD symptom severity. Our findings suggest that UCR, particularly unconditioned startle to a naturally aversive stimulus, may inform research on biomarkers and treatment targets for symptoms of pervasive and persistent fear in trauma-exposed individuals.
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Affiliation(s)
- Michael W Lewis
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel E Bradford
- School of Psychological Science, Oregon State University, Oregon, USA
| | - Eylül Akman
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, Massachusetts, USA
| | - Kevin Frederiks
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, Massachusetts, USA
| | - Scott L Rauch
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Isabelle M Rosso
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, Massachusetts, USA
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
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3
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Grasser LR, Erjo T, Goodwin MS, Naim R, German RE, White J, Cullins L, Tseng WL, Stoddard J, Brotman MA. Can peripheral psychophysiological markers predict response to exposure-based cognitive behavioral therapy in youth with severely impairing irritability? A study protocol. BMC Psychiatry 2023; 23:926. [PMID: 38082431 PMCID: PMC10712194 DOI: 10.1186/s12888-023-05421-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Irritability, an increased proneness to anger, is a primary reason youth present for psychiatric care. While initial evidence supports the efficacy of exposure-based cognitive behavioral therapy (CBT) for youth with clinically impairing irritability, treatment mechanisms remain unclear. Here, we propose to measure peripheral psychophysiological indicators of arousal-heart rate (HR)/electrodermal activity (EDA)-and regulation-heart rate variability (HRV)-during exposures to anger-inducing stimuli as potential predictors of treatment efficacy. The objective of this study is to evaluate whether in-situ biosensing data provides peripheral physiological indicators of in-session response to exposures. METHODS Blood volume pulse (BVP; from which HR and HRV canl be derived) and EDA will be collected ambulatorily using the Empatica EmbracePlus from 40 youth (all genders; ages 8-17) undergoing six in-person exposure treatment sessions, as part of a multiple-baseline trial of exposure-based CBT for clinically impairing irritability. Clinical ratings of irritability will be conducted at baseline, weekly throughout treatment, and at 3-month and 6-month follow-ups via the Clinical Global Impressions Scale (CGI) and the Affective Reactivity Index (ARI; clinician-, parent-, and child-report). Multilevel modeling will be used to assess within- and between-person changes in physiological arousal and regulation throughout exposure-based CBT and to determine whether individual differences are predictive of treatment response. DISCUSSION This study protocol leverages a wearable biosensor (Empatica) to continuously record HR/HRV (derived from BVP) and EDA during in-person exposure sessions for youth with clinically impairing irritability. Here, the goal is to identify changes in physiological arousal (EDA, HR) and regulation (HRV) over the course of treatment in tandem with changes in clinical symptoms. TRIAL REGISTRATION The participants in this study come from an overarching clinical trial (trial registration numbers: NCT02531893 first registered on 8/25/2015; last updated on 8/25/2023). The research project and all related materials were submitted and approved by the appropriate Institutional Review Board of the National Institute of Mental Health (NIMH).
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Affiliation(s)
- Lana Ruvolo Grasser
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Trinity Erjo
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Matthew S Goodwin
- Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Reut Naim
- School of Psychological Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Ramaris E German
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Jamell White
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Lisa Cullins
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Wan-Ling Tseng
- Yale Child Study Center, Yale School of Medicine, New Haven, CT, USA
| | - Joel Stoddard
- Department of Psychiatry and Biomedical Informatics, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Melissa A Brotman
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Brown DG, Jarnecke AM, Saraiya TC, Santa-Ana E, Acierno R, Reese M, Adams R, Harley W, Back SE. Clinician perspectives on technology-enhanced in vivo exposures during prolonged exposure therapy for PTSD. J Clin Psychol 2023; 79:2947-2958. [PMID: 37702428 PMCID: PMC10840959 DOI: 10.1002/jclp.23591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE To investigate clinicians' perceptions regarding the use of mobile technology tools during prolonged exposure (PE) therapy to allow for monitoring and enhancing in-vivo exposures (IVEs). METHODS Clinicians with training in PE therapy (N = 32; average of 9 years of practice) completed surveys asking about their perspectives on the utility of virtually attending IVEs with patients while simultaneously having access to real-time subjective and physiological data (i.e., heart rate, galvanic skin conductance) to guide exposure exercises and assure optimal stimulus engagement. RESULTS Findings showed clinicians to have a favorable view of applying technology devices and systems to enhance IVEs of PE therapy. Most clinicians (93.8%) believed that real-time monitoring of IVEs-particularly monitoring patients' subjective distress and completion of and duration of time in the IVE-would be useful and significantly enhance PE therapy. CONCLUSION The positive perceptions toward integrating technology into IVEs in this study have important implications for the development and implementation of technology-enhanced PE therapy. A mobile technology system that incorporates real-time indicators of engagement (i.e., both subjective and physiological) during IVEs and allows clinicians to review recordings of, or virtually accompany, patients during IVEs has the potential to innovate and transform PE and other exposure-based treatments. Clinicians also believed that technology-enhanced IVEs may help reduce early termination from PE.
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Affiliation(s)
- Delisa G. Brown
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Amber M. Jarnecke
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Tanya C. Saraiya
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Elizabeth Santa-Ana
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Ralph H. Johnson VA Medical Center, Charleston, SC
| | - Ron Acierno
- Ralph H. Johnson VA Medical Center, Charleston, SC
- Louis A. Faillace Department of Psychiatry, University of Texas Health Science Center at Houston, Houston, TX
| | | | - Robert Adams
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Zeriscope, Inc., Charleston, SC
| | | | - Sudie E. Back
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
- Ralph H. Johnson VA Medical Center, Charleston, SC
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Lewis MW, Webb CA, Kuhn M, Akman E, Jobson SA, Rosso IM. Predicting Fear Extinction in Posttraumatic Stress Disorder. Brain Sci 2023; 13:1131. [PMID: 37626488 PMCID: PMC10452660 DOI: 10.3390/brainsci13081131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
Fear extinction is the basis of exposure therapies for posttraumatic stress disorder (PTSD), but half of patients do not improve. Predicting fear extinction in individuals with PTSD may inform personalized exposure therapy development. The participants were 125 trauma-exposed adults (96 female) with a range of PTSD symptoms. Electromyography, electrocardiogram, and skin conductance were recorded at baseline, during dark-enhanced startle, and during fear conditioning and extinction. Using a cross-validated, hold-out sample prediction approach, three penalized regressions and conventional ordinary least squares were trained to predict fear-potentiated startle during extinction using 50 predictor variables (5 clinical, 24 self-reported, and 21 physiological). The predictors, selected by penalized regression algorithms, were included in multivariable regression analyses, while univariate regressions assessed individual predictors. All the penalized regressions outperformed OLS in prediction accuracy and generalizability, as indexed by the lower mean squared error in the training and holdout subsamples. During early extinction, the consistent predictors across all the modeling approaches included dark-enhanced startle, the depersonalization and derealization subscale of the dissociative experiences scale, and the PTSD hyperarousal symptom score. These findings offer novel insights into the modeling approaches and patient characteristics that may reliably predict fear extinction in PTSD. Penalized regression shows promise for identifying symptom-related variables to enhance the predictive modeling accuracy in clinical research.
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Affiliation(s)
- Michael W. Lewis
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, MA 02478, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - Christian A. Webb
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, MA 02478, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - Manuel Kuhn
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, MA 02478, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
| | - Eylül Akman
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, MA 02478, USA
| | - Sydney A. Jobson
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, MA 02478, USA
| | - Isabelle M. Rosso
- Center for Depression, Anxiety, and Stress Research, McLean Hospital, Belmont, MA 02478, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA
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Hawajri O, Lindberg J, Suominen S. Virtual Reality Exposure Therapy as a Treatment Method Against Anxiety Disorders and Depression-A Structured Literature Review. Issues Ment Health Nurs 2023; 44:245-269. [PMID: 37075308 DOI: 10.1080/01612840.2023.2190051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Mental illness is a growing global health problem affecting individuals and society. In Sweden, the number of people suffering from mental health illnesses, such as anxiety and depression, is increasing and is expected to be one of the largest public health challenges in 2030. As mental illness increases, the area also needs effective forms of treatment. This study aims to investigate if Virtual Reality Exposure Therapy (VRET) works as a treatment method for adults suffering from anxiety disorders and depression. A structured literature review based on 24 articles found in the databases PubMed, MEDLINE, CINAHL and PsycInfo. Two reviewers independently reviewed and collectively extracted data from the included articles. The articles have been analyzed by using thematic analysis. The results suggest that Virtual reality exposure therapy can work as an effective treatment method for adults with anxiety disorders. It also indicates that VRET may act as a health-promoting intervention to reduce anxiety disorders, phobias, and depression symptoms. Virtual reality exposure therapy can be an effective treatment method and health-promoting effort against anxiety disorders in adults. An essential factor for the patients who accept VRET as a treatment is the initial information therapists give.
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Affiliation(s)
- Omar Hawajri
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
| | | | - Sakari Suominen
- School of Health Sciences, University of Skövde, Skövde, Sweden
- Department of Public Health, University of Turku, Turku, Finland
- Turku University Hospital, Turku, Finland
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Bryant RA. Is Fear Extinction Impairment Central to Psychopathology? Curr Top Behav Neurosci 2023; 64:195-212. [PMID: 37668874 DOI: 10.1007/7854_2023_439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
As discussed in this chapter, there have been enormous advances in our understanding of how anxiety disorders develop, are maintained, and can be treated. Many of these advances have been the result of translational studies using fear conditioning and extinction models. Despite these successes, we recognize, as a field, that there are important limitations in the extent to which extinction can explain how anxiety disorders and behaviors remit. Clinically speaking, the outstanding challenge for treatment of anxiety disorders is to improve the current suboptimal success rates. Over the past 30 years, we have not improved our treatment success rates despite employing many pharmacological and pharmacological strategies. While extinction and related fear circuitry mechanisms most certainly appear to play a role in treatment of anxiety disorders, they are also apparently insufficient to fully accommodate the varied responses individuals exhibit with this treatment approach. Increasingly diverse and innovative approaches are needed that accommodate the multitude of change mechanisms involved in treating anxiety. However, this is not to suggest ignoring the key role that extinction and memory updating processes play in overcoming anxiety.
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Affiliation(s)
- Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia.
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Wiebe A, Kannen K, Selaskowski B, Mehren A, Thöne AK, Pramme L, Blumenthal N, Li M, Asché L, Jonas S, Bey K, Schulze M, Steffens M, Pensel MC, Guth M, Rohlfsen F, Ekhlas M, Lügering H, Fileccia H, Pakos J, Lux S, Philipsen A, Braun N. Virtual reality in the diagnostic and therapy for mental disorders: A systematic review. Clin Psychol Rev 2022; 98:102213. [PMID: 36356351 DOI: 10.1016/j.cpr.2022.102213] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 08/21/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders. OBJECTIVE To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders. DATA SOURCE Systematic literature searches via PubMed (last literature update: 9th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders. ELIGIBILITY CRITERIA To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology. STUDY EVALUATION For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria. RESULTS Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder. CONCLUSION While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application. REVIEW REGISTRATION PROSPERO register CRD42020188436. FUNDING The review was funded by budgets from the University of Bonn. No third party funding was involved.
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Affiliation(s)
- Annika Wiebe
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Kyra Kannen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Benjamin Selaskowski
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Aylin Mehren
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Ann-Kathrin Thöne
- School of Child and Adolescent Cognitive Behavior Therapy (AKiP), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa Pramme
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Nike Blumenthal
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mengtong Li
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Laura Asché
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Stephan Jonas
- Institute for Digital Medicine, University Hospital Bonn, Bonn, Germany
| | - Katharina Bey
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Marcel Schulze
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Maria Steffens
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Max Christian Pensel
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Matthias Guth
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Felicia Rohlfsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Mogda Ekhlas
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Lügering
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Helena Fileccia
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Julian Pakos
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Silke Lux
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Alexandra Philipsen
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany
| | - Niclas Braun
- Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany.
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Biological markers in clinical psychological research - A systematic framework applied to HPA axis regulation in PTSD. COMPREHENSIVE PSYCHONEUROENDOCRINOLOGY 2022; 11:100148. [PMID: 35967927 PMCID: PMC9363642 DOI: 10.1016/j.cpnec.2022.100148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 05/17/2022] [Accepted: 06/07/2022] [Indexed: 11/21/2022] Open
Abstract
Biological markers, particularly endocrine measurements, are increasingly being integrated into clinical psychological research. We introduce a systematic framework that classifies different functions of such biomarkers. The framework distinguishes between diagnostic biomarkers which add a biological perspective to conventional clinical assessments, prognostic biomarkers that inform about an individual’s risk to develop or maintain a mental health disorder, and intervention-related biomarkers. Regarding interventions, including prevention and treatment, it further distinguishes between prescriptive biomarkers which predict an individual’s response to an intervention, outcome biomarkers which evaluate intervention-related changes on a biological level and indicators of change mechanisms. We demonstrate how to apply the framework by exemplarily classifying and describing previously published systematic reviews and primary empirical studies on endogenous, peripheral cortisol concentrations as a biomarker for posttraumatic stress disorder (PTSD). The evidence on cortisol’s diagnostic and prognostic value is heterogeneous and still sparse regarding parameters based on multiple cortisol measurements, such as the cortisol awakening response. With regard to interventions, most research focused on trauma-focused psychotherapy and cortisol reactivity to trauma reminders. This field of research appears to be growing and very promising due to its potential to optimize PTSD-related interventions. The proposed framework can help in gaining a systematic overview of existing research. It can assist in structuring, comparing, summarizing and evaluating empirical studies, and in identifying research gaps. Iagnostic biomarkers can inform about biological alterations in mental disorders. Prognostic biomarkers can help to predict the development of a mental disorder. Biomarkers can indicate the outcome, differential effects, or mechanisms of change of clinical psychological interventions.
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Enhancing Prolonged Exposure therapy for PTSD using physiological biomarker-driven technology. Contemp Clin Trials Commun 2022; 28:100940. [PMID: 35664505 PMCID: PMC9160482 DOI: 10.1016/j.conctc.2022.100940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 11/20/2022] Open
Abstract
Prolonged Exposure (PE) therapy is one of the most efficacious, evidence-based treatments for posttraumatic stress disorder (PTSD). A key component of PE involves in vivo exposures (IVEs) during which patients approach situations or activities in "real life" that are safe but avoided because they elicit a fear response. Despite their critical role in treatment, little research has focused on IVEs. This gap in knowledge is primarily due to the fact that IVEs are typically conducted by patients in between therapy sessions, leaving clinicians reliant upon patient self-report. This approach has numerous shortcomings, which the current study addresses by leveraging technology to develop an innovative device that allows for physiological, biomarker-driven, therapist-guided IVEs. The new system enables clinicians to virtually accompany patients during IVEs and provides real-time physiological (heart rate, skin conductance) and self-report (subjective units of distress) data that clinicians can use to modify the exposure and optimize therapeutic value. This Small Business Innovation Research (SBIR) Phase I project aims to: (1) integrate physiological sensors and live audio/visual streaming into a system for clinicians to guide patients during IVEs; (2) determine feasibility and acceptability of the system; and (3) conduct a pilot randomized clinical trial among veterans with PTSD (N = 40) to evaluate the preliminary efficacy of the system in reducing PTSD symptoms during PE. This paper describes the rationale, design, and methodology of the Phase I project. The findings from this study have the potential to innovate clinical practice, advance the science of exposure therapy, and improve clinical outcomes.
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Key Words
- CAPS-5, Clinician-Administered PTSD Scale for DSM-5
- DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
- FDA, U.S. Food and Drug Administration
- IRB, Institutional Review Board
- MINI, Mini International Neuropsychiatric Interview
- MUSC, Medical University of South Carolina
- Military
- PCL-5, PTSD Checklist for DSM-5
- PTSD
- PTSD, posttraumatic stress disorder
- Physiology
- Posttraumatic stress disorder
- RCT, randomized controlled trial
- Technology
- U.S., United States
- VA, U.S. Department of Veterans Affairs
- Veterans
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Tao K, Huang Y, Shen Y, Sun L. Automated Stress Recognition Using Supervised Learning Classifiers by Interactive Virtual Reality Scenes. IEEE Trans Neural Syst Rehabil Eng 2022; 30:2060-2066. [PMID: 35857724 DOI: 10.1109/tnsre.2022.3192571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Virtual reality (VR) technology offers a great opportunity to explore stress disorder therapies. We created a VR stress training system, which incorporates three highly interactive stressful scenes to elicit stress, and demonstrate the concurrent variations between physiological data (heart rate, electrodermal activity and eye-blink rate) and self-reported stress ratings through a self-designed customized perceived stress questionnaire (SSAI) and wearable devices. Several supervised learning models were rigorously applied to automate stress recognition. Our findings include the evaluations of the VR system by computing Cronbach's alpha ( α = 0.72 ) and Kaiser-Meyer-Olkin (KMO) coefficient ( η = 0.78 ) through a retrospective survey, which were subsequently confirmed as reliable on four aspects (sense of presence, sense of space, sense of immersion and sense of reality) via factor analysis. Additionally, we demonstrate the effectiveness of physiology-based stress level classification (no stress, low stress and high stress) and continuous SSAI score prediction, with accuracy reaching 0.742 by bagging ensemble learning model and goodness-of-fit reaching 0.44 via multivariate stepwise regression. This study provides detailed insight regarding the effect of objective physiological measures on the validation of subjective self-ratings under a novel complex VR stress training system, which stimulates the further investigations of stress disorder recognition and treatment.
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Maples-Keller J, Watkins LE, Nylocks KM, Yasinski C, Coghlan C, Black K, Jovanovic T, Rauch SA, Rothbaum BO, Norrholm SD. Acquisition, extinction, and return of fear in veterans in intensive outpatient prolonged exposure therapy: A fear-potentiated startle study. Behav Res Ther 2022; 154:104124. [PMID: 35642990 DOI: 10.1016/j.brat.2022.104124] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 04/27/2022] [Accepted: 05/13/2022] [Indexed: 11/02/2022]
Abstract
Prolonged exposure (PE) therapy is a first-line treatment for posttraumatic stress disorder (PTSD) and involves repeated presentation of trauma-related cues without aversive outcomes. A primary learning mechanism of PE is fear extinction (new learning that a dangerous cue is now safe) and its retention (maintaining this new learning over time). Extant research suggests extinction is impaired in PTSD patients. In this study, we employed an established fear-potentiated startle-based paradigm to examine fear acquisition, extinction learning and retention before and after completion of intensive outpatient treatment. First, PTSD patients undergoing PE (n = 55) were compared to trauma-exposed patients without PTSD (n = 57). We identified excessive fear in PTSD patients during acquisition and extinction before treatment compared to non-PTSD patients. At post-treatment, we examined the return of fear after extinction in PTSD patients showing high or low treatment response to PE (≥50% change in PTSD symptom severity vs. < 50%). High PE responders maintained fear extinction learning whereas low PE responders showed significant return of fear at post-treatment. These results replicate and extend previous findings of impaired extinction in PTSD and provide support for the proposed theoretical link between fear extinction and PE response.
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13
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Maples-Keller JL, Norrholm SD, Burton M, Reiff C, Coghlan C, Jovanovic T, Yasinski C, Jarboe K, Rakofsky J, Rauch S, Dunlop BW, Rothbaum BO. A randomized controlled trial of 3,4-methylenedioxymethamphetamine (MDMA) and fear extinction retention in healthy adults. J Psychopharmacol 2022; 36:368-377. [PMID: 35166140 DOI: 10.1177/02698811211069124] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Fear conditioning and extinction are well-characterized cross-species models of fear-related posttraumatic stress disorder (PTSD) symptoms, and recent animal data suggest that 3,4-methylenedioxymethamphetamine (MDMA) enhances fear extinction retention. AIMS This study investigated the effect of MDMA on fear learning, extinction training, and retention in healthy humans. METHODS The study involved a randomized placebo-controlled, two-group, parallel design trial in a sample of healthy adults, age 21-55 recruited from a major metropolitan area. The experimental paradigm included a fear acquisition session followed by an extinction training session 24 hours later, and 2 hours after study drug administration. Fear extinction retention was measured 48 hours after extinction training. Participants (N = 34; 70.6% male and 29.4% female) were randomly assigned in 1:1 ratio to 100 mg MDMA or placebo. All randomized participants completed the trial and were included in primary analyses. Safety was monitored via adverse events and vital signs. MDMA was well-tolerated with no serious adverse events. RESULTS Results indicated a significant main effect of session between extinction training and retention with no significant group differences. Significantly more participants in the MDMA group retained extinction learning compared to the placebo group (χ2 = 7.29, p = 0.007). CONCLUSION Although we did not observe the hypothesized facilitation of extinction retention, the findings from this initial human trial provide compelling rationale to continue to explore the potential for MDMA to impact extinction retention.Clinical Trials Registry Name and Identifier: Evaluation of MDMA on Startle Response (NCT0318176) https://clinicaltrials.gov/ct2/show/NCT03181763?term = MDMA&draw = 2&rank = 9.
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Affiliation(s)
- Jessica L Maples-Keller
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Seth D Norrholm
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mark Burton
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Collin Reiff
- Department of Psychiatry, New York University, New York, NY, USA
| | - Callan Coghlan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Carly Yasinski
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Kathleen Jarboe
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey Rakofsky
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Sheila Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.,Atlanta VA Healthcare System
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
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14
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Faw MH, Buley T, Malinin LH. Being There: Exploring Virtual Symphonic Experience as a Salutogenic Design Intervention for Older Adults. Front Psychol 2021; 12:541656. [PMID: 34925115 PMCID: PMC8674500 DOI: 10.3389/fpsyg.2021.541656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 11/12/2021] [Indexed: 11/13/2022] Open
Abstract
This co-design study examined salutogenic potential of mobile virtual reality (VR) experiences as an alternative to participation in a community-based symphonic engagement program (B Sharp), previously found to benefit people with dementia (PWD) and their informal caregivers. Six focus groups were conducted with sixteen adults aged 76–90; three participants had dementia, and two were informal spousal caregivers. No participants had prior VR experience. The study assessed the feasibility of replicating the community-based-arts program in VR, with the goal of enhancing its salutogenic qualities (e.g., positive distraction, engagement, and social connection). Video-recordings of participants while using a mobile head-mounted display (HMD) were analyzed using qualitative thematic analysis to compare perceptions of different virtual experiences, including replication or enhancement of B Sharp and a campus tour. Findings suggest participants had positive perceptions of enhanced VR experiences with no adverse effects, although PWD were less enthusiastic and HMD usability was complicated by eyewear use and comfort with technology. Participants reacted most favorably to the enhanced symphonic experience, where they were “virtually” onstage during the performance, suggesting unique experiences beyond what is possible in the real world have the greatest potential for deep immersion for older adults. Results suggest VR has strong potential to replicate and enhance salutogenic qualities of community-based programming by enabling greater access to experiences for older adults and by increasing enjoyment and engagement through experiences not otherwise feasible. Furthermore, this study illuminates advantages of a user-centered, co-design approach when developing VR experiences with community partners and older adults.
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Affiliation(s)
- Meara H Faw
- Department of Communication Studies, Colorado State University, Fort Collins, CO, United States
| | - Taylor Buley
- Department of Communication Studies, Colorado State University, Fort Collins, CO, United States
| | - Laura Healey Malinin
- Department of Design and Merchandising, College of Health and Human Sciences, Colorado State University, Fort Collins, CO, United States
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15
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Ney LJ, Crombie KM, Mayo LM, Felmingham KL, Bowser T, Matthews A. Translation of animal endocannabinoid models of PTSD mechanisms to humans: Where to next? Neurosci Biobehav Rev 2021; 132:76-91. [PMID: 34838529 DOI: 10.1016/j.neubiorev.2021.11.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 12/11/2022]
Abstract
The endocannabinoid system is known to be involved in mechanisms relevant to PTSD aetiology and maintenance, though this understanding is mostly based on animal models of the disorder. Here we review how human paradigms can successfully translate animal findings to human subjects, with the view that substantially increased insight into the effect of endocannabinoid signalling on stress responding, emotional and intrusive memories, and fear extinction can be gained using modern paradigms and methods for assessing the state of the endocannabinoid system in PTSD.
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Affiliation(s)
- Luke J Ney
- School of Psychological Sciences, University of Tasmania, Australia; School of Psychology and Counselling, Queensland University of Technology, Australia.
| | - Kevin M Crombie
- Department of Psychiatry and Behavioral Sciences, University of Texas at Austin, United States
| | - Leah M Mayo
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Science, Linköping University, Sweden
| | - Kim L Felmingham
- Department of Psychological Sciences, University of Melbourne, Australia
| | | | - Allison Matthews
- School of Psychological Sciences, University of Tasmania, Australia
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16
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Vergallito A, Gallucci A, Pisoni A, Punzi M, Caselli G, Ruggiero GM, Sassaroli S, Romero Lauro LJ. Effectiveness of noninvasive brain stimulation in the treatment of anxiety disorders: a meta-analysis of sham or behaviour-controlled studies. J Psychiatry Neurosci 2021; 46:E592-E614. [PMID: 34753789 PMCID: PMC8580831 DOI: 10.1503/jpn.210050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/23/2021] [Accepted: 07/02/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The possibility of using noninvasive brain stimulation to treat mental disorders has received considerable attention recently. Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are considered to be effective treatments for depressive symptoms. However, no treatment recommendation is currently available for anxiety disorders, suggesting that evidence is still limited. We conducted a systematic review of the literature and a quantitative analysis of the effectiveness of rTMS and tDCS in the treatment of anxiety disorders. METHODS Following PRISMA guidelines, we screened 3 electronic databases up to the end of February 2020 for English-language, peer-reviewed articles that included the following: a clinical sample of patients with an anxiety disorder, the use of a noninvasive brain stimulation technique, the inclusion of a control condition, and pre/post scores on a validated questionnaire that measured symptoms of anxiety. RESULTS Eleven papers met the inclusion criteria, comprising 154 participants assigned to a stimulation condition and 164 to a sham or control group. We calculated Hedge's g for scores on disorder-specific and general anxiety questionnaires before and after treatment to determine effect size, and we conducted 2 independent random-effects meta-analyses. Considering the well-known comorbidity between anxiety and depression, we ran a third meta-analysis analyzing outcomes for depression scores. Results showed a significant effect of noninvasive brain stimulation in reducing scores on disorder-specific and general anxiety questionnaires, as well as depressive symptoms, in the real stimulation compared to the control condition. LIMITATIONS Few studies met the inclusion criteria; more evidence is needed to strengthen conclusions about the effectiveness of noninvasive brain stimulation in the treatment of anxiety disorders. CONCLUSION Our findings showed that noninvasive brain stimulation reduced anxiety and depression scores compared to control conditions, suggesting that it can alleviate clinical symptoms in patients with anxiety disorders.
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Affiliation(s)
| | | | - Alberto Pisoni
- From the Department of Psychology, University of Milano Bicocca, Milan, Italy (Vergallito, Pisoni, Punzi, Romero Lauro); the Neuromi, Milan, Italy (Vergallito, Gallucci, Pisoni, Romero Lauro); the Department of Neuroscience, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy (Gallucci); the Studi Cognitivi, Milan, Italy (Caselli, Ruggiero, Sassaroli); and the Faculty of Psychology, Sigmund Freud University, Milan, Italy (Caseli, Ruggiero, Sassaroli)
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17
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Psychobiological Treatment Response to a Two-Week Posttraumatic Stress Disorder and Mild Traumatic Brain Injury Integrated Treatment Program: A Case Report. COGNITIVE AND BEHAVIORAL PRACTICE 2021. [DOI: 10.1016/j.cbpra.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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18
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Gramlich MA, Smolenski DJ, Norr AM, Rothbaum BO, Rizzo AA, Andrasik F, Fantelli E, Reger GM. Psychophysiology during exposure to trauma memories: Comparative effects of virtual reality and imaginal exposure for posttraumatic stress disorder. Depress Anxiety 2021; 38:626-638. [PMID: 33666322 DOI: 10.1002/da.23141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/29/2020] [Accepted: 02/12/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND This investigation involved an in-depth examination of psychophysiological responses during exposure to the trauma memory across 10 sessions among active duty soldiers with combat-related posttraumatic stress disorder (PTSD) treated by Prolonged Exposure (PE) or Virtual Reality Exposure (VRE). We compared psychophysiological changes, session-by-session, between VRE and traditional imaginal exposure. METHODS Heart rate (HR), galvanic skin response (GSR), and peripheral skin temperature were collected every 5 min during exposure sessions with 61 combat veterans of Iraq/Afghanistan and compared to the PTSD Checklist (PCL-C) and Clinician-Administered PTSD Scale (CAPS) outcomes using multilevel modeling. RESULTS Over the course of treatment, participants in the PE group had higher HR arousal compared to participants in the VRE group. With reference to GSR, in earlier sessions, participants demonstrated a within-session increase, whereas, in later sessions, participants showed a within-session habituation response. A significant interaction was found for GSR and treatment assignment for within-session change, within-person effect, predicting CAPS (d = 0.70) and PCL-C (d = 0.66) outcomes. CONCLUSION Overall, these findings suggest that exposure to traumatic memories activates arousal across sessions, with GSR being most associated with reductions in PTSD symptoms for participants in the PE group.
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Affiliation(s)
| | - Derek J Smolenski
- Psychological Health Center of Excellence, Defense Health Agency, Joint Base Lewis-McChord, Washington, USA
| | - Aaron M Norr
- VISN 20 Northwest Network Mental Illness Research, Education and Clinical Center (MIRECC), Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Barbara O Rothbaum
- Department of Psychiatry, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Albert A Rizzo
- Institute for Creative Technologies, University of Southern California, Los Angeles, California, USA
| | - Frank Andrasik
- Department of Psychology, University of Memphis, Memphis, Tennessee, USA
| | | | - Greg M Reger
- VA Puget Sound Health Care System, Tacoma, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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19
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Ressler KJ. Translating Across Circuits and Genetics Toward Progress in Fear- and Anxiety-Related Disorders. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:247-255. [PMID: 34690590 PMCID: PMC8475910 DOI: 10.1176/appi.focus.19205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 06/13/2023]
Abstract
(Reprinted with permission from Am J Psychiatry 2020; 177:214-222).
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20
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Reist C, Jovanovic T, Kantarovich D, Weingast L, Hollifield M, Novin M, Khalaghizadeh S, Jafari B, George R, Riser M, Woodford J, Norrholm SD. An analysis of fear inhibition and fear extinction in a sample of veterans with obstructive sleep apnea (OSA): Implications for co-morbidity with post-traumatic stress disorder (PTSD). Behav Brain Res 2021; 404:113172. [PMID: 33577879 DOI: 10.1016/j.bbr.2021.113172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 01/13/2021] [Accepted: 02/04/2021] [Indexed: 01/05/2023]
Abstract
Obstructive sleep apnea (OSA) is a respiratory condition characterized by interrupted sleep due to repeated, temporary collapse of the soft tissue of the upper airway that can lead to a cascade of physiological and psychological adverse health outcomes. The most common therapeutic interventions for OSA patients include the application of continuous positive airway pressure (CPAP) which acts to keep the airway open and, as such, provides less interrupted and more restorative sleep. Improved sleep has been linked to more efficacious treatments for psychiatric conditions most notably those that include cognitive-behavioral elements, new learning, and memory consolidation. In the current study, we investigated the acquisition, inhibition, and extinction of conditioned fear in OSA patients, before and after CPAP therapy, using an established fear-potentiated startle paradigm. Patients with OSA displayed an intact ability to acquire, inhibit, and extinguish fear prior to CPAP treatment and this ability was significantly enhanced following CPAP usage. In addition, those patients with more severe OSA, as measured by apnea-hypopnea index (AHI), were more likely to show improved fear inhibition and extinction. Lastly, we observed impairments in discrimination between reinforced and nonreinforced conditioned stimuli, in the inhibition of fear, and in fear extinction in a subset of patients with OSA and co-morbid posttraumatic stress disorder (PTSD). These data suggest that evolving treatment algorithms for PTSD should address disrupted sleep problems prior to initiation of inhibition/extinction-based exposure therapies.
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Affiliation(s)
- Christopher Reist
- Research Service, Long Beach VA Healthcare System, 5901 East 7(th) Street, Long Beach, CA, 90822, United States; Science 37, 12121 Bluff Creek Drive, Los Angeles, CA, 90094, United States
| | - Tanja Jovanovic
- Neuroscience Center for Anxiety, Stress, and Trauma (NeuroCAST), Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 3901 Chrysler Service Drive, Detroit, MI, 48201, United States
| | - Diana Kantarovich
- Chicago Medical School, Rosalind Franklin University, 3333 Green Bay Road, North Chicago, IL, 60064, United States
| | - Leah Weingast
- Teachers College, Columbia University, 525 West 120(th) Street, New York, NY, 10027, United States
| | - Michael Hollifield
- Research Service, Long Beach VA Healthcare System, 5901 East 7(th) Street, Long Beach, CA, 90822, United States
| | - Mahmood Novin
- Research Service, Long Beach VA Healthcare System, 5901 East 7(th) Street, Long Beach, CA, 90822, United States
| | - Sakineh Khalaghizadeh
- Research Service, Long Beach VA Healthcare System, 5901 East 7(th) Street, Long Beach, CA, 90822, United States
| | - Behrouz Jafari
- Research Service, Long Beach VA Healthcare System, 5901 East 7(th) Street, Long Beach, CA, 90822, United States
| | - Renie George
- Neuroscience Center for Anxiety, Stress, and Trauma (NeuroCAST), Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 3901 Chrysler Service Drive, Detroit, MI, 48201, United States
| | - Manessa Riser
- Neuroscience Center for Anxiety, Stress, and Trauma (NeuroCAST), Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 3901 Chrysler Service Drive, Detroit, MI, 48201, United States
| | - Jessica Woodford
- Neuroscience Center for Anxiety, Stress, and Trauma (NeuroCAST), Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 3901 Chrysler Service Drive, Detroit, MI, 48201, United States
| | - Seth D Norrholm
- Neuroscience Center for Anxiety, Stress, and Trauma (NeuroCAST), Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, 3901 Chrysler Service Drive, Detroit, MI, 48201, United States.
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21
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Stuke H, Schoofs N, Johanssen H, Bermpohl F, Ülsmann D, Schulte-Herbrüggen O, Priebe K. Predicting outcome of daycare cognitive behavioural therapy in a naturalistic sample of patients with PTSD: a machine learning approach. Eur J Psychotraumatol 2021; 12:1958471. [PMID: 34589175 PMCID: PMC8475102 DOI: 10.1080/20008198.2021.1958471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Identifying predictors for treatment outcome in patients with posttraumatic stress disorder (PTSD) is important in order to provide an effective treatment, but robust and replicated treatment outcome predictors are not available up to now. OBJECTIVES We investigated predictors of treatment outcome in a naturalistic sample of patients with PTSD admitted to an 8-week daycare cognitive behavioural therapy programme following a wide range of traumatic events. METHOD We used machine learning (linear and non-linear regressors and cross-validation) to predict outcome at discharge for 116 patients and sustained treatment effects 6 months after discharge for 52 patients who had a follow-up assessment. Predictions were based on a wide selection of demographic and clinical assessments including age, gender, comorbid psychiatric disorders, trauma history, posttraumatic symptoms, posttraumatic cognitions, depressive symptoms, general psychopathology and psychosocial functioning. RESULTS We found that demographic and clinical variables significantly, but only modestly predicted PTSD treatment outcome at discharge (r = 0.21, p = .021 for the best model) and follow-up (r = 0.31, p = .026). Among the included variables, more severe posttraumatic cognitions were negatively associated with treatment outcome. Early response in PTSD symptomatology (percentage change of symptom scores after 4 weeks of treatment) allowed more accurate predictions of outcome at discharge (r = 0.56, p < .001) and follow-up (r = 0.43, p = .001). CONCLUSION Our results underscore the importance of early treatment response for short- and long-term treatment success. Nevertheless, it remains an unresolved challenge to identify variables that can robustly predict outcome before the initiation of treatment.
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Affiliation(s)
- Heiner Stuke
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nikola Schoofs
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Helen Johanssen
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Bermpohl
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dominik Ülsmann
- Friedrich Von Bodelschwingh-Clinic for Psychiatry, Psychotherapy and Psychosomatics, Berlin, Germany
| | - Olaf Schulte-Herbrüggen
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Friedrich Von Bodelschwingh-Clinic for Psychiatry, Psychotherapy and Psychosomatics, Berlin, Germany
| | - Kathlen Priebe
- Department of Psychiatry and Psychotherapy, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Rauch SAM, Sripada R, Burton M, Michopoulos V, Kerley K, Marx CE, Kilts JD, Naylor JC, Rothbaum BO, McLean CP, Smith A, Norrholm SD, Jovanovic T, Liberzon I, Williamson DE, Yarvis CJS, Dondanville KA, Young-McCaughan S, Keane TM, Peterson AL. Neuroendocrine biomarkers of prolonged exposure treatment response in military-related PTSD. Psychoneuroendocrinology 2020; 119:104749. [PMID: 32554173 DOI: 10.1016/j.psyneuen.2020.104749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/16/2020] [Accepted: 05/29/2020] [Indexed: 11/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with dysregulation of the neuroendocrine system, including cortisol, allopregnanolone, and pregnanolone. Preliminary evidence from animal models suggests that baseline levels of these biomarkers may predict response to PTSD treatment. We report the change in biomarkers over the course of PTSD treatment. Biomarkers were sampled from individuals participating in (1) a randomized controlled trial comparing a web-version of Prolonged Exposure (Web-PE) therapy to in-person Present-Centered Therapy (PCT) and (2) from individuals participating in a nonrandomized effectiveness study testing PE delivered in-person as part of an intensive outpatient PTSD program. We found that higher cortisol reactivity during script-driven imagery was associated with higher baseline PTSD severity and that baseline allopregnanolone, pregnanolone, and cortisol reactivity were associated with PTSD treatment responder status over the course of intensive outpatient treatment. These findings demonstrate that peripherally assessed biomarkers are associated with PTSD severity and likelihood of successful treatment outcome of PE delivered daily over two weeks. These assessments could be used to determine which patients are likely to respond to treatment and which patients require augmentation to increase the likelihood of optimal response to PTSD treatment.
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Affiliation(s)
- Sheila A M Rauch
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033, USA; Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Rebecca Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA; University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA.
| | - Mark Burton
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Vasiliki Michopoulos
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Kimberly Kerley
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Christine E Marx
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 40 Duke Medicine Circle, Durham, NC, 27710, USA; Durham Veterans Administration Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Durham, NC, 27705, USA.
| | - Jason D Kilts
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 40 Duke Medicine Circle, Durham, NC, 27710, USA; Durham Veterans Administration Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Durham, NC, 27705, USA.
| | - Jennifer C Naylor
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 40 Duke Medicine Circle, Durham, NC, 27710, USA; Durham Veterans Administration Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Durham, NC, 27705, USA.
| | - Barbara O Rothbaum
- Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, 12 Executive Park, 3rd Floor, Atlanta, GA, 30029, USA.
| | - Carmen P McLean
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA, 94025, USA; Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 291 Campus Dr., Stanford, CA, 94305, USA.
| | - Alicia Smith
- Emory University School of Medicine, Department of Obstetrics and Gynecology, 101 Woodruff Circle NE, Ste 4217, Atlanta, 30322, USA.
| | - Seth D Norrholm
- Atlanta VA Medical Center, 1670 Clairmont Road, Decatur, GA, 30033, USA; Wayne State University, 3901 Chrysler Dr, Detroit, MI, 48201, USA.
| | - Tanja Jovanovic
- Wayne State University, 3901 Chrysler Dr, Detroit, MI, 48201, USA.
| | - Israel Liberzon
- Texas A&M University, 8447 Riverside Parkway, Bryan, TX, 77808-3260, USA.
| | - Douglas E Williamson
- Duke University School of Medicine, Department of Psychiatry and Behavioral Sciences, 40 Duke Medicine Circle, Durham, NC, 27710, USA; Durham Veterans Administration Medical Center and VA Mid-Atlantic MIRECC, 508 Fulton Street, Durham, NC, 27705, USA.
| | - Col Jeffrey S Yarvis
- Carl R. Darnall Army Medical Center, Department of Behavioral Health, 36065 Santa Fe Ave., Fort Hood, TX, 76544, USA.
| | - Katherine A Dondanville
- University of Texas Health Science Center at San Antonio, Department of Psychiatry and Behavioral Sciences, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA.
| | - Stacey Young-McCaughan
- University of Texas Health Science Center at San Antonio, Department of Psychiatry and Behavioral Sciences, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA.
| | - Terence M Keane
- VA Boston Healthcare System, National Center for PTSD (116B-2), 150 South Huntington Avenue, Boston, MA, 02130, USA; Boston University School of Medicine, Department of Psychiatry, 720 Harrison Avenue, Room 906, Boston, MA, 02118, USA.
| | - Alan L Peterson
- University of Texas Health Science Center at San Antonio, Department of Psychiatry and Behavioral Sciences, 7703 Floyd Curl Dr., San Antonio, TX, 78229, USA; South Texas Veterans Health Care System, Research and Development Service, 7400 Merton Minter, San Antonio, TX, 78229, USA; University of Texas at San Antonio, Department of Psychology, One UTSA Circle, San Antonio, TX, 78249, USA.
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Rauch SAM, King A, Kim HM, Powell C, Rajaram N, Venners M, Simon NM, Hamner M, Liberzon I. Cortisol awakening response in PTSD treatment: Predictor or mechanism of change. Psychoneuroendocrinology 2020; 118:104714. [PMID: 32446108 PMCID: PMC7984524 DOI: 10.1016/j.psyneuen.2020.104714] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022]
Abstract
PTSD is associated with abnormalities in hypothalamic-pituitary-adrenal (HPA) axis activity. This includes enhanced HPA axis negative feedback, attenuated cortisol awakening response, and attenuated cortisol response to personal trauma script. Whether HPA axis function predicts treatment response or treatment related symptom reduction in PTSD remains unclear. In addition, the relative effects of different treatment modalities (i.e., medication and psychotherapy) on HPA axis is unclear. To address this gap in knowledge, the PROGrESS study examined cortisol awakening response across treatment in Veterans with chronic PTSD randomized to receive Prolonged Exposure + Placebo (PE + PLB), Sertraline + PE (SERT + PE) or Sertraline + Enhanced Medication Management (SERT + EMM). Salivary cortisol awakening response (CAR) was assessed at baseline, mid-treatment (week 6 and 12), post-treatment (week 24) and follow-up (week 36 and 52). Among males at baseline, combat veterans with PTSD showed lower CAR Area Under the Curve Increase (AUCi; M = 3.15, SD = 9.57) than Combat controls (M = 7.63, SD = 9.07; p = .02), demonstrating combat veterans with PTSD have a less responsive system than combat controls. Higher PTSD severity was also related to lower CAR AUCi (r = -0.52, p = .03). When controlling for PTSD severity, higher baseline CAR AUCi was related to attenuated reduction in PTSD and lower likelihood of high treatment response over treatment (z = -2.06, p = .04).
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Affiliation(s)
- Sheila A M Rauch
- Atlanta VA Healthcare System, 1670 Clairmont Road, Decatur, GA, 30033, Georgia; Emory University School of Medicine, 12 Executive Park, 3rdFloor, Atlanta, GA, 30029, Georgia.
| | - Anthony King
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, United States; University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109, United States
| | - H Myra Kim
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109, United States
| | - Corey Powell
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, 3550 Rackham, 950 E. Washington Street, Ann Arbor, MI, 48109, United States
| | - Nirmala Rajaram
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, United States
| | - Margaret Venners
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, United States; National Center for PTSD, Dissemination and Training Division, 795 Willow Road, Menlo Park, CA 94025, United States
| | - Naomi M Simon
- New York University Medical School, Department of Psychiatry, One Park Avenue 8thFloor, New York, NY 10016, United States; Massachusetts General Hospital, Department of Psychiatry, One Bowdoin Square, 6th Floor, Boston, MA 02114, United States
| | - Mark Hamner
- Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC, 29401, United States; Medical University of South Carolina, Department of Psychiatry, 67 President Street, Charleston, SC 29425, United States
| | - Israel Liberzon
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, United States; University of Michigan, Department of Psychiatry, 4250 Plymouth Road, Ann Arbor, MI, 48109, United States; Texas A&M Health Science Center, Department of Psychiatry and Behavioral Science, United States
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Flanagan JC, Mitchell JM, Baker NL, Woolley J, Wangelin B, Back SE, McQuaid JR, Neylan TC, Wolfe WR, Brady KT. Enhancing prolonged exposure therapy for PTSD among veterans with oxytocin: Design of a multisite randomized controlled trial. Contemp Clin Trials 2020; 95:106074. [PMID: 32561468 DOI: 10.1016/j.cct.2020.106074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/06/2020] [Accepted: 06/12/2020] [Indexed: 12/17/2022]
Abstract
Posttraumatic stress disorder (PTSD) is the most highly prevalent mental health disorder among U.S. military Veterans. Prolonged Exposure (PE) therapy is one of the most widely used evidence-based treatments for PTSD, but there is substantial room for improvement in outcomes and retention rates. Accumulating data suggest that oxytocin offers a promising pharmacological approach towards achieving this goal. Therefore, the primary objective of this two-site Phase II study is to examine the ability of oxytocin (vs. placebo) administration combined with PE therapy to (1) reduce PTSD symptom severity, (2) accelerate the rate of PTSD symptom improvement, and (3) improve PE adherence and retention rates. To accomplish these objectives, we will employ a randomized, double-blind, placebo-controlled trial and use standardized, repeated dependent measures of change at five time points (baseline, mid-treatment, end of treatment, and 3 and 6 month follow-up). Intranasal oxytocin (40 IU) will be administered directly prior to each PE therapy session. Findings from this study will provide critical new information regarding the efficacy of oxytocin to augment psychosocial treatment for PTSD, as well as information regarding the physiological mechanisms underlying PTSD and positive treatment response. ClinicalTrials.gov Identifier: NCT04228289.
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Affiliation(s)
- Julianne C Flanagan
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - Jennifer M Mitchell
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA; Department of Neurology, University of California San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
| | - Nathaniel L Baker
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Joshua Woolley
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
| | - Bethany Wangelin
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - Sudie E Back
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
| | - John R McQuaid
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
| | - Thomas C Neylan
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA; Department of Neurology, University of California San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
| | - William R Wolfe
- Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA.
| | - Kathleen T Brady
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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Roque A, Craske MG, Treanor M, Rosenfield D, Ritz T, Meuret AE. Stress-induced cortisol reactivity as a predictor of success in treatment for affective dimensions. Psychoneuroendocrinology 2020; 116:104646. [PMID: 32200225 PMCID: PMC8978549 DOI: 10.1016/j.psyneuen.2020.104646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/31/2020] [Accepted: 03/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Response rates to first-line treatments for depression and anxiety remain unsatisfactory. Identification of predictors or moderators that can optimize treatment matching is of scientific and clinical interest. This study examined the role of prolonged laboratory-induced stress cortisol reactivity as a predictor of outcome for a treatment of affective dimensions (TAD). Patients received 15-sessions of a treatment targeting reductions in negative affect or increases in positive affect (Craske et al., 2019). A second aim was to examine whether treatment type would moderate the association between cortisol reactivity and treatment outcome. METHODS Thirty-five participants underwent a 36-minute intermittent stress induction task composed of a mental arithmetic task and a fear-potentiated startle task one week before treatment initiation. Cortisol was collected at five-time points with reactivity being quantified as peak during the task minus basal level of cortisol the evening before the assessment. Using multilevel modeling, we examined the associations between cortisol reactivity and slopes of symptom improvement. RESULTS Cortisol reactivity was related to treatment outcome, with average and higher levels of stress-induced cortisol response predicting greater decreases in symptoms throughout treatment and 6-month follow-up. Treatment condition differences (moderation) were not observed in the effect of cortisol reactivity on symptoms. CONCLUSION Our findings demonstrate the impact of greater cortisol stress reactivity on treatment outcome. Future studies should investigate how to enhance this therapeutic benefit through capitalizing on endogenous diurnal fluctuations or exogenous cortisol manipulation.
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Affiliation(s)
- Andres Roque
- Department of Psychology, Southern Methodist University
| | | | - Michael Treanor
- Department of Psychology, University of California Los Angeles
| | | | - Thomas Ritz
- Department of Psychology, Southern Methodist University
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Seligowski AV, Harnett NG, Merker JB, Ressler KJ. Nervous and Endocrine System Dysfunction in Posttraumatic Stress Disorder: An Overview and Consideration of Sex as a Biological Variable. BIOLOGICAL PSYCHIATRY. COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2020; 5:381-391. [PMID: 32033924 PMCID: PMC7150641 DOI: 10.1016/j.bpsc.2019.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/06/2019] [Indexed: 12/12/2022]
Abstract
Decades of research into the biological mechanisms of posttraumatic stress disorder (PTSD) suggests that chronic activation of the stress response leads to long-lasting changes in the structure and function of the nervous and endocrine systems. While the prevalence of PTSD is twice as high in females as males, little is known about how sex differences in neuroendocrine systems may contribute to PTSD. In response to the paucity of research on sex-related mechanisms, the National Institutes of Health created a policy that asks researchers to consider sex as a biological variable. This review provides an overview of the current understanding of nervous and endocrine dysfunction in PTSD (e.g., neural circuitry, autonomic arousal, hormonal response), highlighting areas where the influence of sex has been characterized and where further research is needed. We also provide recommendations for using the sex-as-a-biological-variable policy to address specific gaps in PTSD neuroscience research.
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Affiliation(s)
- Antonia V Seligowski
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Division of Depression and Anxiety, McLean Hospital, Belmont, Massachusetts.
| | - Nathaniel G Harnett
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Division of Depression and Anxiety, McLean Hospital, Belmont, Massachusetts
| | - Julia B Merker
- Division of Depression and Anxiety, McLean Hospital, Belmont, Massachusetts
| | - Kerry J Ressler
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts; Division of Depression and Anxiety, McLean Hospital, Belmont, Massachusetts
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27
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Liu R, Xu M, Zhang Y, Peli E, Hwang AD. A Pilot Study on EEG-Based Evaluation of Visually Induced Motion Sickness. J Imaging Sci Technol 2020; 64:205011-2050110. [PMID: 33907364 PMCID: PMC8075303 DOI: 10.2352/j.imagingsci.technol.2020.64.2.020501] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The most prominent problem in virtual reality (VR) technology is that users may experience motion sickness-like symptoms when they immerse into a VR environment. These symptoms are recognized as visually induced motion sickness (VIMS) or virtual reality motion sickness (VRMS). The objectives of this study were to investigate the association between the electroencephalogram (EEG) and subjectively rated VIMS level (VIMSL) and find the EEG markers for VIMS evaluation. In this study, a VR-based vehicle-driving simulator (VDS) was used to induce VIMS symptoms, and a wearable EEG device with four electrodes, the Muse, was used to collect EEG data of subjects. Our results suggest that individual tolerance, susceptibility, and recoverability to VIMS varied largely among subjects; the following markers were shown to be significantly different from no-VIMS and VIMS states (P < 0.05): (1) Means of gravity frequency (GF) for theta@FP1, alpha@TP9, alpha@FP2, alpha@TP10, and beta@FP1; (2) Standard deviation of GF for alpha@TP9, alpha@FP1, alpha@FP2, alpha@TP10, and alpha@(FP2-FP1); (3) Standard deviation of power spectral entropy (PSE) for FP1; (4) Means of Kolmogorov complexity (KC) for TP9, FP1, and FP2. These results also demonstrate that it is feasible to perform VIMS evaluation using an EEG device with a small number of electrodes.
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Affiliation(s)
- Ran Liu
- College of Computer Science, Chongqing University, Chongqing, China
- Schepens Eye Research Institute, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- School of microelectronics and communication engineering, Chongqing University, Chongqing, China
| | - Miao Xu
- College of Information Science and Engineering, Shanxi Agricultural University, Taigu County, Jinzhong City, Shanxi Province, China
| | - Yanzhen Zhang
- School of microelectronics and communication engineering, Chongqing University, Chongqing, China
| | - Eli Peli
- Schepens Eye Research Institute, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Alex D Hwang
- Schepens Eye Research Institute, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Abstract
Anxiety and fear-related disorders are common and disabling, and they significantly increase risk for suicide and other causes of morbidity and mortality. However, there is tremendous potential for translational neuroscience to advance our understanding of these disorders, leading to novel and powerful interventions and even to preventing their initial development. This overview examines the general circuits and processes thought to underlie fear and anxiety, along with the promise of translational research. It then examines some of the data-driven "next-generation" approaches that are needed for discovery and understanding but that do not always fit neatly into established models. From one perspective, these disorders offer among the most tractable problems in psychiatry, with a great deal of accumulated understanding, across species, of neurocircuit, behavioral, and, increasingly, genetic mechanisms, of how dysregulation of fear and threat processes contributes to anxiety-related disorders. One example is the progressively sophisticated understanding of how extinction underlies the exposure therapy component of cognitive-behavioral therapy approaches, which are ubiquitously used across anxiety and fear-related disorders. However, it is also critical to examine gaps in our understanding between reasonably well-replicated examples of successful translation, areas of significant deficits in knowledge, and the role of large-scale data-driven approaches in future progress and discovery. Although a tremendous amount of progress is still needed, translational approaches to understanding, treating, and even preventing anxiety and fear-related disorders offer great opportunities for successfully bridging neuroscience discovery to clinical practice.
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29
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Mozgai S, Hartholt A, Rizzo A“S. Systematic Representative Design and Clinical Virtual Reality. PSYCHOLOGICAL INQUIRY 2020. [DOI: 10.1080/1047840x.2019.1693873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Sharon Mozgai
- University of Southern California Institute for Creative Technologies, Los Angeles, California
| | - Arno Hartholt
- University of Southern California Institute for Creative Technologies, Los Angeles, California
| | - Albert “Skip” Rizzo
- University of Southern California Institute for Creative Technologies, Los Angeles, California
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30
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Fernández-Álvarez J, Di Lernia D, Riva G. Virtual Reality for Anxiety Disorders: Rethinking a Field in Expansion. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1191:389-414. [PMID: 32002939 DOI: 10.1007/978-981-32-9705-0_21] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The principal aim to this chapter is to present the latest ideas in virtual reality (VR), some of which have already been applied to the field of anxiety disorders, and others are still pending to be materialized. More than 20 years ago, VR emerged as an exposure tool in order to provide patients and therapists with more appealing ways of delivering a technique that was undoubtedly effective but also rejected and thus underused. Throughout these years, many improvements were achieved. The first section of the chapter describes those improvements, both considering the research progresses and the applications in the real world. In a second part, our main interest is to expand the discussion of the new applications of VR beyond its already known role as an exposure tool. In particular, VR is enabling the materialization of numerous ideas that were previously confined to a merely philosophical discussion in the field of cognitive sciences. That is, VR has the enormous potential of providing feasible ways to explore nonclassical ways of cognition, such as embodied and situated information processing. Despite the fact that many of these developments are not fully developed, and not specifically designed for anxiety disorders, we want to introduce these new ideas in a context in which VR is experiencing an enormous transformation.
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Affiliation(s)
| | | | - Giuseppe Riva
- Universita Cattolica del Sacro Cuore, Milan, Italy. .,ATN-P Lab, Istituto Auxologico Italiano, Milan, Italy.
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Difede J, Rothbaum BO, Rizzo AA, Wyka K, Spielman L, Jovanovic T, Reist C, Roy MJ, Norrholm SD, Glatt C, Lee F. Enhanced exposure therapy for combat-related Posttraumatic Stress Disorder (PTSD): Study protocol for a randomized controlled trial. Contemp Clin Trials 2019; 87:105857. [PMID: 31669451 DOI: 10.1016/j.cct.2019.105857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/25/2019] [Accepted: 10/02/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND PTSD, which has been identified in up to 23% of post-9-11 veterans, often results in a chronic, pernicious course. Thus, effective treatments are imperative. The Institute of Medicine (IOM) concluded that the only intervention for PTSD with sufficient evidence to conclude efficacy is exposure therapy. This Phase III trial compares the efficacy of exposure therapy for combat-related PTSD delivered in two different formats- via virtual reality exposure therapy (VRE) or prolonged exposure therapy (PE)- combined with D-Cycloserine (DCS), a cognitive enhancer shown to facilitate the extinction of fear. METHODS/DESIGN Military personnel of any duty status and civilians deployed to Iraq and Afghanistan were eligible. Participants were randomly assigned to 9 sessions of exposure therapy (VRE or PE) and medication (50 mg DCS or placebo). Participants were treated at three geographically diverse sites. Participants were re-assessed at 3-months post-treatment. The co-primary hypotheses are that (1) DCS will augment response to exposure therapy (both VRE and PE) on PTSD symptoms; (2) VRE will be associated with greater improvement than PE. Genetic and psychophysiological markers will be evaluated as potential moderators and mediators of treatment outcomes as well as secondary outcomes. DISCUSSION This study is the first to compare the relative efficacy of DCS-augmented VRE versus PE on PTSD symptoms. The design has several advantages: participants received an active, effective treatment and predictors of response to treatment included genetic and psychobiological measures. The results may directly influence the future delivery of services, and contribute to the development of a standardized treatment protocol. TRIAL REGISTRATION NCT01352637.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, 525 East 68(th) Street, New York, NY 10065, United States.
| | - Barbara O Rothbaum
- Emory University School of Medicine, 12 Executive Pard Drive, Atlanta, GA 30329, United States
| | - Albert A Rizzo
- University of Southern California Institute for Creative Technologies, 12015 East Waterfront Drive, Los Angeles, CA 90094, United States
| | - Katarzyna Wyka
- Department of Psychiatry, Weill Cornell Medical College, 525 East 68(th) Street, New York, NY 10065, United States
| | - Lisa Spielman
- Department of Psychiatry, Weill Cornell Medical College, 525 East 68(th) Street, New York, NY 10065, United States
| | - Tanja Jovanovic
- Emory University School of Medicine, 12 Executive Pard Drive, Atlanta, GA 30329, United States
| | - Christopher Reist
- Department of Research, Long Beach VA Medical Center, 5901 East 7(th) Street, Long Beach, CA 90822, United States
| | - Michael J Roy
- Department of Medicine and Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Seth D Norrholm
- Emory University School of Medicine, 12 Executive Pard Drive, Atlanta, GA 30329, United States
| | - Charles Glatt
- Department of Psychiatry, Weill Cornell Medical College, 525 East 68(th) Street, New York, NY 10065, United States
| | - Francis Lee
- Department of Psychiatry, Weill Cornell Medical College, 525 East 68(th) Street, New York, NY 10065, United States
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Maples-Keller JL, Rauch SAM, Jovanovic T, Yasinski CW, Goodnight JM, Sherrill A, Black K, Michopoulos V, Dunlop BW, Rothbaum BO, Norrholm SD. Changes in trauma-potentiated startle, skin conductance, and heart rate within prolonged exposure therapy for PTSD in high and low treatment responders. J Anxiety Disord 2019; 68:102147. [PMID: 31669786 DOI: 10.1016/j.janxdis.2019.102147] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 09/09/2019] [Accepted: 09/18/2019] [Indexed: 01/29/2023]
Abstract
While exposure-based psychotherapy is recommended as a first-line treatment for posttraumatic stress disorder (PTSD) given strong evidence for its effectiveness, some patients fail to receive full benefit. Psychophysiological data may be important complementary indices for investigating variability in treatment response and changes over the course of treatment. The focus of the present investigation was to examine change in psychophysiological indices pre- to post-treatment and to investigate if changes differed for high versus low PTSD treatment responders. Participants included veterans with primary PTSD diagnoses who received a two-week intensive prolonged exposure (PE) treatment. Psychophysiological assessment included trauma-potentiated startle, heart rate, and skin conductance recordings during presentation of three standard virtual reality (VR)-based, trauma-relevant scenes presented through a head mounted display. Results indicate that 48.6% were classified as high treatment responders (≥50% reduction in PCL-5 from baseline). Trauma-potentiated startle was observed in all patients at pre-treatment, F = 13.58, p < .001, in that startle magnitude was increased during VR stimuli relative to baseline regardless of responder status. However, in high treatment responders, there was an interaction of VR with time, F = 14.10, p = .001; VR scenes did not potentiate startle post-treatment. Specifically, high treatment responders were less reactive to trauma stimuli following PE treatment. There was no effect of time in the low responder group. Heart rate reactivity data revealed a significant main effect of treatment, F = 45.7, p = .035, but no significant interaction with responder status. Skin conductance reactivity did not significantly change from pre to post-treatment. These results suggest that trauma-potentiated startle may represent an objective marker of fear- and anxiety-related symptom reduction that is sensitive to both traditional outpatient as well as intensive treatment approaches.
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Post-traumatic stress and alcohol use disorders: recent advances and future directions in cue reactivity. Curr Opin Psychol 2019; 30:109-116. [DOI: 10.1016/j.copsyc.2019.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 01/26/2023]
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Tuerk PW, Schaeffer CM, McGuire JF, Adams Larsen M, Capobianco N, Piacentini J. Adapting Evidence-Based Treatments for Digital Technologies: a Critical Review of Functions, Tools, and the Use of Branded Solutions. Curr Psychiatry Rep 2019; 21:106. [PMID: 31584124 DOI: 10.1007/s11920-019-1092-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW We provide a critical review of digital technologies in evidence-based treatments (EBTs) for mental health with a focus on the functions technologies are intended to serve. The review highlights issues related to clarity of purpose, usability, and assumptions related to EBT technology integration, branding, and packaging. RECENT FINDINGS Developers continue to use technology in creative ways, often combining multiple functions to convey existing EBTs or to create new technology-enabled EBTs. Developers have a strong preference for creating and investigating whole-source, branded solutions related to specific EBTs, in comparison to developing or investigating technology tools related to specific components of behavior change, or developing specific clinical protocols that can be delivered via existing technologies. Default assumptions that new applications are required for each individual EBT, that EBTs are best served by the use of only one technology solution rather than multiple tools, and that an EBT-specific technology product should include or convey all portions of an EBT slow scientific progress and increase risk of usability issues that negatively impact uptake. We contend that a purposeful, functions-based approach should guide the selection, development, and application of technology in support of EBT delivery.
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Affiliation(s)
- Peter W Tuerk
- Sheila C. Johnson Center for Clinical Services, University of Virginia, Charlottesville, VA, USA.
- Department of Human Services, University of Virginia, 417 Emmet St. South, Charlottesville, VA, 22904, USA.
| | - Cindy M Schaeffer
- Division of Child and Adolescent Psychiatry, University of Maryland-Baltimore, Baltimore, MD, USA
| | - Joseph F McGuire
- Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
| | | | - Nicole Capobianco
- Department of Human Services, University of Virginia, Charlottesville, VA, USA
| | - John Piacentini
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
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35
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Anxiety Level Recognition for Virtual Reality Therapy System Using Physiological Signals. ELECTRONICS 2019. [DOI: 10.3390/electronics8091039] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Virtual reality exposure therapy (VRET) can have a significant impact towards assessing and potentially treating various anxiety disorders. One of the main strengths of VRET systems is that they provide an opportunity for a psychologist to interact with virtual 3D environments and change therapy scenarios according to the individual patient’s needs. However, to do this efficiently the patient’s anxiety level should be tracked throughout the VRET session. Therefore, in order to fully use all advantages provided by the VRET system, a mental stress detection system is needed. The patient’s physiological signals can be collected with wearable biofeedback sensors. Signals like blood volume pressure (BVP), galvanic skin response (GSR), and skin temperature can be processed and used to train the anxiety level classification models. In this paper, we combine VRET with mental stress detection and highlight potential uses of this kind of VRET system. We discuss and present a framework for anxiety level recognition, which is a part of our developed cloud-based VRET system. Physiological signals of 30 participants were collected during VRET-based public speaking anxiety treatment sessions. The acquired data were used to train a four-level anxiety recognition model (where each level of ‘low’, ‘mild’, ‘moderate’, and ‘high’ refer to the levels of anxiety rather than to separate classes of the anxiety disorder). We achieved an 80.1% cross-subject accuracy (using leave-one-subject-out cross-validation) and 86.3% accuracy (using 10 × 10 fold cross-validation) with the signal fusion-based support vector machine (SVM) classifier.
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López CM, Lancaster CL, Wilkerson A, Gros DF, Ruggiero KJ, Acierno R. Residual Insomnia and Nightmares Postintervention Symptom Reduction Among Veterans Receiving Treatment for Comorbid PTSD and Depressive Symptoms. Behav Ther 2019; 50:910-923. [PMID: 31422847 DOI: 10.1016/j.beth.2019.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 01/30/2023]
Abstract
While evidence-based interventions can help the substantial number of veterans diagnosed with comorbid PTSD and depression, an emerging literature has identified sleep disturbances as predictors of treatment nonresponse. More specifically, predicting effects of residual insomnia and nightmares on postintervention PTSD and depressive symptoms among veterans with comorbid PTSD and depression has remained unclear. The present study used data from a clinical trial of Behavioral Activation and Therapeutic Exposure (BA-TE), a combined approach to address comorbid PTSD and depression, administered to veterans (N = 232) to evaluate whether residual insomnia and nightmare symptoms remained after treatment completion and, if so, whether these residual insomnia and nightmare symptoms were associated with higher levels of comorbid PTSD and depression at the end of treatment. Participants (ages 21 to 77 years old; 47.0% Black; 61.6% married) completed demographic questions, symptom assessments, and engagement-related surveys. Hierarchical multiple linear regression models demonstrated that residual insomnia was a significant predictor of PTSD and depression symptom reduction above and beyond the influence of demographic and engagement factors (e.g., therapy satisfaction). Consistent with previous research, greater residual insomnia symptoms were predictive of smaller treatment gains. Findings illustrate the potential significance of insomnia during the course of transdiagnostic treatment (e.g., PTSD and depression), leading to several important clinical assessment and treatment implications.
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Affiliation(s)
| | - Cynthia L Lancaster
- Ralph H. Johnson Veterans Affairs Medical Center; Medical University of South Carolina
| | | | - Daniel F Gros
- Ralph H. Johnson Veterans Affairs Medical Center; Medical University of South Carolina
| | | | - Ron Acierno
- College of Nursing, Medical University of South Carolina; Ralph H. Johnson Veterans Affairs Medical Center
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37
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Kim YJ, van Rooij SJ, Ely TD, Fani N, Ressler KJ, Jovanovic T, Stevens JS. Association between posttraumatic stress disorder severity and amygdala habituation to fearful stimuli. Depress Anxiety 2019; 36:647-658. [PMID: 31260599 PMCID: PMC6943827 DOI: 10.1002/da.22928] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 05/01/2019] [Accepted: 05/11/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Amygdala hyperreactivity to threat has been proposed to be a causal contributor to posttraumatic stress disorder (PTSD). However, emerging literature in healthy samples shows higher test-retest reliability for amygdala habituation (the change over time in response to repeated stimuli) than for its reactivity to threat. Amygdala habituation has received relatively little attention in relationship to PTSD, despite the key role of this region in the etiology of the disorder. Thus, we investigated habituation to repeated fearful face stimuli and PTSD, in a large sample of trauma exposed African American women. METHODS African American women (N = 100) were recruited from a nonprofit hospital serving a largely low-income population with a high risk of trauma exposure. Participants underwent functional magnetic resonance imaging, passively viewing fearful and neutral face stimuli, and reported their history of trauma exposure and current PTSD symptoms. We examined associations between PTSD symptom severity and amygdala reactivity (fearful > neutral) and habituation (early > late) to fearful faces. Secondary analyses tested whether amygdala habituation to fearful faces mediated the association between childhood trauma and PTSD. RESULTS PTSD symptom severity and PTSD status (based on self-report measure) were both positively associated with amygdala habituation to repeated fearful face stimuli. Whole-brain analysis showed that this association extended to the bilateral hippocampus and left fusiform gyrus. The association held when controlling for trauma history and depressive symptoms. Amygdala habituation to fearful faces partially mediated the association between childhood trauma severity and PTSD symptom severity. CONCLUSION Individuals with greater PTSD symptom severity showed greater amygdala habituation to social threat cues (fearful faces), and greater habituation may partly explain the association between childhood trauma exposure and current PTSD symptoms. Further examination of the dynamics of the amygdala response to threat cues may lead to new insights in the understanding and treatment of stress-related disorders.
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Affiliation(s)
- Ye Ji Kim
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Sanne J.H. van Rooij
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Timothy D. Ely
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Negar Fani
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Kerry J. Ressler
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts,Division of Depression & Anxiety Disorders, McLean Hospital, Belmont, Massachusetts
| | - Tanja Jovanovic
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Jennifer S. Stevens
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
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38
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Glenn DE, Risbrough VB, Simmons AN, Acheson DT, Stout DM. The Future of Contextual Fear Learning for PTSD Research: A Methodological Review of Neuroimaging Studies. Curr Top Behav Neurosci 2019; 38:207-228. [PMID: 29063483 DOI: 10.1007/7854_2017_30] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
There has been a great deal of recent interest in human models of contextual fear learning, particularly due to the use of such paradigms for investigating neural mechanisms related to the etiology of posttraumatic stress disorder. However, the construct of "context" in fear conditioning research is broad, and the operational definitions and methods used to investigate contextual fear learning in humans are wide ranging and lack specificity, making it difficult to interpret findings about neural activity. Here we will review neuroimaging studies of contextual fear acquisition in humans. We will discuss the methodology associated with four broad categories of how contextual fear learning is manipulated in imaging studies (colored backgrounds, static picture backgrounds, virtual reality, and configural stimuli) and highlight findings for the primary neural circuitry involved in each paradigm. Additionally, we will offer methodological recommendations for human studies of contextual fear acquisition, including using stimuli that distinguish configural learning from discrete cue associations and clarifying how context is experimentally operationalized.
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Affiliation(s)
- Daniel E Glenn
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, La Jolla, CA, 92093, USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr. MC0804, La Jolla, San Diego, CA, 92093, USA
| | - Victoria B Risbrough
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, La Jolla, CA, 92093, USA.
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr. MC0804, La Jolla, San Diego, CA, 92093, USA.
| | - Alan N Simmons
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, La Jolla, CA, 92093, USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr. MC0804, La Jolla, San Diego, CA, 92093, USA
| | - Dean T Acheson
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, La Jolla, CA, 92093, USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr. MC0804, La Jolla, San Diego, CA, 92093, USA
| | - Daniel M Stout
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, La Jolla, CA, 92093, USA
- Department of Psychiatry, University of California San Diego, 9500 Gilman Dr. MC0804, La Jolla, San Diego, CA, 92093, USA
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Abstract
The processing and regulation of fear is one of the key components of posttraumatic stress disorder (PTSD). Fear can involve both acute and potential threats that can manifest in different behaviors and result from activity within different neural nodes and networks. Fear circuits have been studied extensively in animal models for several decades and in human neuroimaging research for almost 20 years. Therefore, the centrality of fear processing to PTSD lends the disorder to be more tractable to investigation at the level of brain and behavior, and provides several observable phenotypes that can be linked to PTSD symptoms. Moreover, psychophysiological metrics of fear conditioning offer tools that can be used to shift diagnostic paradigms in psychiatry toward neurobiology-consistent with a Research Domain Criteria approach to PTSD. In general, mammalian fear processing can be divided into fear learning (or acquisition), during which an association develops between previously neutral stimuli and aversive outcomes, and fear extinction, in which the latter associations are suppressed by a new form of learning. This review describes translational research in both fear acquisition and extinction, along with their relevance to PTSD and PTSD treatment, focusing specifically on the empirical value and potential clinical utility of psychophysiological methods.
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40
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Koek RJ, Luong TN. Theranostic pharmacology in PTSD: Neurobiology and timing. Prog Neuropsychopharmacol Biol Psychiatry 2019; 90:245-263. [PMID: 30529001 DOI: 10.1016/j.pnpbp.2018.12.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/17/2018] [Accepted: 12/05/2018] [Indexed: 02/06/2023]
Abstract
Recent reviews and treatment guidelines regard trauma-focused cognitive-behavior therapies as the treatments of choice for chronic post-traumatic stress disorder (PTSD). However, many patients do not engage in this treatment when it is available, drop out before completion, or do not respond. Medications remain widely used, alone and in conjunction with psychotherapy, although the limitations of traditional monoamine-based pharmacotherapy are increasingly recognized. This article will review recent developments in psychopharmacology for PTSD, with a focus on current clinical data that apply putative neurobiologic mechanisms to medication use-i.e., a theranostic approach. A theranostic approach however, also requires consideration of timing, pre, peri or post trauma in conjunction with underlying dynamic processes affecting synaptic plasticity, the HPA axis, hippocampal activation, PFC-amygdala circuitry and fear memory.
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Affiliation(s)
- Ralph J Koek
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Sepulveda Ambulatory Care Center, VA Greater Los Angeles Healthcare System, North Hills, CA, USA.
| | - Tinh N Luong
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Olive View Medical Center, Sylmar, CA, USA
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Jovanovic T, Duncan EJ, Kaye J, Garza K, Norrholm SD, Inslicht SS, Neylan TC, Mathew SJ, Iosifescu D, Rothbaum BO, Mayberg HS, Dunlop BW. Psychophysiological treatment outcomes: Corticotropin-releasing factor type 1 receptor antagonist increases inhibition of fear-potentiated startle in PTSD patients. Psychophysiology 2019; 57:e13356. [PMID: 30807663 DOI: 10.1111/psyp.13356] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 01/21/2019] [Accepted: 02/05/2019] [Indexed: 12/24/2022]
Abstract
After exposure to a traumatic event, a subset of people develop post-traumatic stress disorder (PTSD). One of the key deficits in PTSD is regulation of fear, and impaired inhibition of fear-potentiated startle (FPS) has been identified as a potential physiological biomarker specific to PTSD. As part of a larger clinical trial, this study investigated the effects of a CRF receptor 1 antagonist, GSK561679, on inhibition of fear-potentiated startle during a conditional discrimination fear-conditioning paradigm, termed AX+/BX-. Prior research using this paradigm has demonstrated deficits in inhibition of conditioned fear in several PTSD populations. The randomized, double-blind, placebo-controlled clinical trial compared fear inhibition between female PTSD participants taking 350 mg/day GSK561679 (n = 47 pre- and 29 post-treatment) and patients taking a placebo pill (n = 52 pre- and 30 post-treatment) daily for 6 weeks. There was no significant difference between the two groups in their acquisition of fear or discrimination between threat and safety cues, and no pre-post-treatment effect on these measures. However, there was a significant effect of treatment on inhibition of FPS during the AB trials in the AX+/BX- transfer test (p < 0.05). While all PTSD participants showed typical impairments in fear inhibition prior to treatment, GSK561679 enhanced fear inhibition post-treatment, independent of clinical effects. The current study suggests that CRF receptor 1 antagonism may have specific effects within neural circuitry mediating fear inhibition responses, but not overall symptom presentation, in PTSD.
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Affiliation(s)
- Tanja Jovanovic
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Erica J Duncan
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Joanna Kaye
- Department of Psychology, Drexel University, Philadelphia, Pennsylvania
| | - Kristie Garza
- Neuroscience Program, Graduate Division of Biological and Biomedical Sciences, Emory University, Atlanta, Georgia
| | - Seth D Norrholm
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Sabra S Inslicht
- Department of Psychiatry, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Thomas C Neylan
- Department of Psychiatry, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Sanjay J Mathew
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine and Michael E. Debakey Veterans Affairs Medical Center, Houston, Texas
| | - Dan Iosifescu
- Department of Psychiatry, NYU Langone School of Medicine, New York, New York
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Helen S Mayberg
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia.,Icahn School of Medicine at Mount Sinai, New York, New York
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
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Abstract
In this review, the effects of stress on alcohol drinking are discussed. The interactions between biological stress systems and alcohol drinking are examined, with a focus on the hypothalamic pituitary adrenal axis, corticotropin releasing factor, dynorphin, neuropeptide Y, and norepinephrine systems. Findings from animal models suggest that these biological stress systems may be useful targets for medications development for alcohol use disorder and co-occurring stress-related disorders in humans.
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Affiliation(s)
- Marcus M Weera
- Marcus M. Weera, Ph.D., is a postdoctoral fellow in the Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana. Nicholas W. Gilpin, Ph.D., is a professor in the Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Nicholas W Gilpin
- Marcus M. Weera, Ph.D., is a postdoctoral fellow in the Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana. Nicholas W. Gilpin, Ph.D., is a professor in the Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
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43
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You can do that?!: Feasibility of virtual reality exposure therapy in the treatment of PTSD due to military sexual trauma. J Anxiety Disord 2019; 61:55-63. [PMID: 30005843 DOI: 10.1016/j.janxdis.2018.06.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 03/30/2018] [Accepted: 06/14/2018] [Indexed: 01/23/2023]
Abstract
This initial feasibility study examined the use of virtual reality exposure therapy (VRE) in the treatment of MST-related PTSD, with newly developed content tailored to MST. Participants included 15 veterans (26% male) with MST-related PTSD. Assessment of PTSD, depression, and psychophysiological indicators of distress occurred at pre-treatment, post-treatment, and 3-month follow-up. Treatment included 6-12 VRE sessions. There were significant reductions in pre- to post-treatment PTSD (CAPS severity: t(10) = 3.69, p = .004; PCL-5: t(10) = 3.79, p = .004) and depressive symptoms, (PHQ-9: t(8) = 2.83, p = .022), which were maintained at follow-up. There also was a significant pre- to post-treatment reduction in heart rate response to a trauma cue. Cohen's d effect sizes were large (CAPS: d = 1.11; PCL-5: d = 1.14, PHQ-9: d = .94), and the percentage of participants meeting PTSD criteria continued to decline from post-treatment (53%) to follow-up (33%). Findings indicate VRE can be safely delivered and is a promising treatment for MST-related PTSD.
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44
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Park MJ, Kim DJ, Lee U, Na EJ, Jeon HJ. A Literature Overview of Virtual Reality (VR) in Treatment of Psychiatric Disorders: Recent Advances and Limitations. Front Psychiatry 2019; 10:505. [PMID: 31379623 PMCID: PMC6659125 DOI: 10.3389/fpsyt.2019.00505] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/27/2019] [Indexed: 11/13/2022] Open
Abstract
In this paper, we conduct a literature survey on various virtual reality (VR) treatments in psychiatry. We collected 36 studies that used VR to provide clinical trials or therapies for patients with psychiatric disorders. In order to gain a better understanding of the management of pain and stress, we first investigate VR applications for patients to alleviate pain and stress during immersive activities in a virtual environment. VR exposure therapies are particularly effective for anxiety, provoking realistic reactions to feared stimuli. On top of that, exposure therapies with simulated images are beneficial for patients with psychiatric disorders such as phobia and posttraumatic stress disorder (PTSD). Moreover, VR environments have shown the possibility of changing depression, cognition, even social functions. We review empirical evidence from VR-based treatments on psychiatric illnesses such as dementia, mild cognitive impairment (MCI), schizophrenia and autism. Through cognitive training and social skill training, rehabilitation through VR therapies helps patients to improve their quality of life. Recent advances in VR technology also demonstrate potential abilities to address cognitive and functional impairments in dementia. In terms of the different types of VR systems, we discuss the feasibility of the technology within different stages of dementia as well as the methodological limitations. Although there is room for improvement, its widespread adoption in psychiatry is yet to occur due to technical drawbacks such as motion sickness and dry eyes, as well as user issues such as preoccupation and addiction. However, it is worth mentioning that VR systems relatively easily deliver virtual environments with well-controlled sensory stimuli. In the future, VR systems may become an innovative clinical tool for patients with specific psychiatric symptoms.
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Affiliation(s)
- Mi Jin Park
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dong Jun Kim
- Department of Health Sciences & Technology, Department of Medical Device Management & Research, and Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
| | - Unjoo Lee
- Department of Electronic Engineering, Hallym University, Kangwon, South Korea
| | - Eun Jin Na
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hong Jin Jeon
- Department of Psychiatry, Depression Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Health Sciences & Technology, Department of Medical Device Management & Research, and Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, South Korea
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45
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Flanagan JC, Sippel LM, Santa Maria MMM, Hartwell KJ, Brady KT, Joseph JE. Impact of Oxytocin on the neural correlates of fearful face processing in PTSD related to childhood Trauma. Eur J Psychotraumatol 2019; 10:1606626. [PMID: 31105906 PMCID: PMC6508045 DOI: 10.1080/20008198.2019.1606626] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 01/04/2023] Open
Abstract
Background: Posttraumatic stress disorder (PTSD) related to exposure to abuse and neglect during childhood is associated with particularly severe and persistent deleterious outcomes. Amygdala hyperreactivity has been observed in childhood trauma survivors and implicated in symptoms of PTSD. Objective: The neuropeptide oxytocin holds promise as a potential treatment for PTSD due to its ability to attenuate amygdala response to threat cues. However, the effect of oxytocin on amygdala reactivity in individuals with childhood trauma-related PTSD has not been investigated. Method: We employed a double-blind, randomized, placebo-controlled crossover design to examine the effects of intranasal oxytocin (24 IU) versus placebo on amygdala reactivity to fearful faces among childhood-trauma exposed individuals with PTSD (n = 17) and without PTSD (control group; n = 16). Results: Region-of-interest based amygdala fMRI signal magnitude did not differ by group, drug, or group x drug interaction. Self-report of childhood trauma exposure severity was negatively associated with the oxytocin-related change in left amygdala response in the PTSD group, but not in the control group. Supplementary and exploratory whole-brain analyses conducted separately in each group revealed that left amygdala reactivity to fearful faces was absent on placebo but increased on oxytocin in the control group. The PTSD group showed right amygdala activation to fearful faces in both the oxytocin and placebo conditions, but the left amygdala response observed in the placebo condition was diminished on oxytocin. Conclusions: Findings extend the literature pertaining to the potential for oxytocin to attenuate neural correlates of PTSD to a childhood trauma-related PTSD sample.
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Affiliation(s)
- Julianne C Flanagan
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Lauren M Sippel
- National Center for PTSD, White River Junction, VT, USA.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Megan M Moran Santa Maria
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Karen J Hartwell
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.,Ralph H. Johnson VAMC, Charleston, SC, USA
| | - Kathleen T Brady
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA.,Ralph H. Johnson VAMC, Charleston, SC, USA
| | - Jane E Joseph
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, USA
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46
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Vujanovic AA, Wardle MC, Bakhshaie J, Smith LJ, Green CE, Lane SD, Schmitz JM. Distress tolerance: Associations with trauma and substance cue reactivity in low-income, inner-city adults with substance use disorders and posttraumatic stress. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2018; 32:264-276. [PMID: 29771557 DOI: 10.1037/adb0000362] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cue reactivity has great potential to advance our understanding of posttraumatic stress disorder (PTSD), substance use disorder (SUD), and PTSD/SUD comorbidity. The present investigation examined distress tolerance (DT) with regard to trauma and substance cue reactivity. Participants included 58 low-income, inner-city adults (49.1% women; Mage = 45.73, SD = 10.00) with substance dependence and at least 4 symptoms of PTSD. A script-driven cue reactivity paradigm was utilized. Four DT measures were administered, including the Distress Tolerance Scale (DTS), Mirror-Tracing Persistence Task (MTPT), Breath-Holding Task (BH), and Paced Auditory Serial Addition Task (PASAT). Lower DT, as indexed by MTPT duration, was significantly predictive of greater levels of self-reported substance cravings/urges in response to trauma cues, above and beyond covariates. Lower DTS scores predicted lower levels of self-reported control/safety ratings in response to substance cues. None of the DT indices was significantly predictive of heart rate variability. Clinical and research implications are discussed. (PsycINFO Database Record
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Affiliation(s)
| | - Margaret C Wardle
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston
| | | | - Lia J Smith
- Department of Psychology, University of Houston
| | - Charles E Green
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston
| | - Scott D Lane
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston
| | - Joy M Schmitz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston
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47
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Psychotherapeutic treatment and HPA axis regulation in posttraumatic stress disorder: A systematic review and meta-analysis. Psychoneuroendocrinology 2018; 98:186-201. [PMID: 30193225 DOI: 10.1016/j.psyneuen.2018.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/29/2018] [Accepted: 08/01/2018] [Indexed: 12/20/2022]
Abstract
Posttraumatic stress disorder (PTSD) has been associated with dysregulation of the hypothalamic-pituitary- adrenal (HPA) axis. Research over the past years has investigated potential changes of these alterations in the context of psychotherapy. Yet, no systematic review has been conducted. To summarize the current state of research on psychotherapy and HPA hormones, namely cortisol, dehydroepiandrosterone and its sulfate form (DHEA(S)), we searched for studies investigating predictions or changes in hormones over treatment course within the databases PubMed, Scopus, Medline, PsychINFO, Pilots/ProQuest, and Web of Science, and in the grey literature up to May 2018. Controlled and uncontrolled trials investigating adult samples with a clinical status of PTSD were eligible for inclusion. Twelve studies (428 participants) were included. Study quality was overall sufficient. Hormone assessment designs differed considerably. Treatment efficacy on PTSD symptom reduction was mostly high, but predictions of pre-treatment hormone concentrations on treatment efficacy were largely non-significant. Changes from pre- to post-test in basal cortisol (g = -0.07, 95% CI = -0.36; 0.21) and in the cortisol awakening response (g = -0.07, 95% CI = -0.48; 0.35) were also non-significant. Future studies require comparable designs and need to be sufficiently powered to be able to detect potential associations with HPA regulation.
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48
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Modulation of the endocannabinoid system by sex hormones: Implications for posttraumatic stress disorder. Neurosci Biobehav Rev 2018; 94:302-320. [DOI: 10.1016/j.neubiorev.2018.07.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/10/2018] [Accepted: 07/10/2018] [Indexed: 12/11/2022]
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49
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Pan X, Wang Z, Wu X, Wen SW, Liu A. Salivary cortisol in post-traumatic stress disorder: a systematic review and meta-analysis. BMC Psychiatry 2018; 18:324. [PMID: 30290789 PMCID: PMC6173866 DOI: 10.1186/s12888-018-1910-9] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 09/25/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Studies investigating salivary cortisol level as susceptibility marker for post-traumatic stress disorder (PTSD) produced inconsistent results. The aim of this study was to compare salivary cortisol concentration levels in PTSD patients with those in controls by synthesizing published data. METHODS We did a systematic review, meta-analysis and meta-regression of studies comparing concentrations of salivary cortisol between patients with PTSD and controls. The electronic databases of PubMed, Embase, Web of Science and Psyc-ARTICLES were searched for relevant articles. A random-effects model with restricted maximum-likelihood estimator is used to synthesize the effect size (assessed by standardized mean difference). RESULTS A total of 784 articles were identified of which 22 were included in the final analysis. A trend of lower salivary cortisol levels was found in PTSD patients when compared with the controls (SMD = - 0.28, 95% CI-0.53;-0.04, p = 0.022). Subgroup analysis showed that the salivary cortisol levels were lower in patients with PTSD than in controls in studies conducted after 2007 or in studies using saliva samples collected in the morning. CONCLUSIONS The evidence from this meta-analysis supports that salivary samples collected in the morning consistently showed a lower salivary cortisol level in patients with PTSD than in controls, although whether salivary cortisol could be used as a diagnostic tool requires further research.
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Affiliation(s)
- Xiongfeng Pan
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Zhipeng Wang
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Xiaoli Wu
- 0000 0001 0379 7164grid.216417.7Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Shi Wu Wen
- 0000 0001 2182 2255grid.28046.38Department of Obstetrics and Gynaecology, University of Ottawa, Ottawa, ON Canada ,0000 0000 9606 5108grid.412687.eOttawa Hospital Research Institute, Ottawa, ON Canada
| | - Aizhong Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China.
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In session extinction and outcome in Virtual Reality Exposure Therapy for PTSD. Behav Res Ther 2018; 109:1-9. [PMID: 30059794 DOI: 10.1016/j.brat.2018.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/15/2018] [Accepted: 07/13/2018] [Indexed: 02/04/2023]
Abstract
Recent research emphasizes emotional engagement and between-session extinction, but no longer within-session extinction, as the primary mechanisms underlying exposure therapy for the treatment of PTSD. No previous studies have examined change in subjective units of distress (SUDS) in virtual reality exposure (VRE) for PTSD despite its potential facilitation of engagement (see McLay et al., 2012; Reger & Gahm, 2008). Using in session data from Rothbaum et al. (2014) we examined patterns of within- and between-session SUDS change in veterans receiving VRE for PTSD augmented by d-cycloserine, alprazolam, or placebo. The number of treatment sessions significantly predicted SUDS rating (t = -7.74, p < 0.001). Time in session continued to serve as a significant predictor of SUDS (t = 13.44, p < 0.001). Specifically, engagement increased within session and then reduction (extinction/habituation) was apparent across sessions. Treatment group was a predictor of SUDS rating within treatment sessions (t = 2.26, p < 0.05) but not across sessions, such that participants receiving medication experienced greater increases in SUDS within-session than those receiving placebo. Responder status was a predictor of SUDS reduction across treatment sessions (t = -4.43, p < 0.001) but did not produce an overall or within-session effect on SUDS. Thus, medications impact within-session SUDS changes but do not impact between-session reductions in SUDS- the change most consistently and closely related to magnitude of therapeutic change and responder status.
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