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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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Walshe D, Lewis E, O'Sullivan K, Kim SI. Virtually Driving: Are the Driving Environments "Real Enough" for Exposure Therapy with Accident Victims? An Explorative Study. ACTA ACUST UNITED AC 2005; 8:532-7. [PMID: 16332164 DOI: 10.1089/cpb.2005.8.532] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
There is a small but growing body of research supporting the effectiveness of computer-generated environments in exposure therapy for driving phobia. However, research also suggests that difficulties can readily arise whereby patients do not immerse in simulated driving scenes. The simulated driving environments are not "real enough" to undertake exposure therapy. This sets a limitation to the use of virtual reality (VR) exposure therapy as a treatment modality for driving phobia. The aim of this study was to investigate if a clinically acceptable immersion/presence rate of >80% could be achieved for driving phobia subjects in computer generated environments by modifying external factors in the driving environment. Eleven patients referred from the Accident and Emergency Department of a general hospital or from their General Practitioner following a motor vehicle accident, who met DSM-IV criteria for Specific Phobia-driving were exposed to a computer-generated driving environment using computer driving games (London Racer/Midtown Madness). In an attempt to make the driving environments "real enough," external factors were modified by (a) projection of images onto a large screen, (b) viewing the scene through a windscreen, (c) using car seats for both driver and passenger, and (d) increasing vibration sense through use of more powerful subwoofers. Patients undertook a trial session involving driving through computer environments with graded risk of an accident. "Immersion/presence" was operationally defined as a subjective rating by the subject that the environment "feels real," together with an increase in subjective units of distress (SUD) ratings of >3 and/or an increase of heart rate of >15 beats per minute (BPM). Ten of 11 (91%) of the driving phobic subjects met the criteria for immersion/presence in the driving environment enabling progression to VR exposure therapy. These provisional findings suggest that the paradigm adopted in this study might be an effective and relatively inexpensive means of developing driving environments "real enough," to make VR exposure therapy a viable treatment modality for driving phobia following a motor vehicle accident (MVA).
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Affiliation(s)
- David Walshe
- Department of Psychiatry, University College Cork, St. Stephen's Hospital, Cork, Ireland.
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