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Appel G, Han BH, Re'Em Y, Louka C, Sundararajan R, Tom A, An A, Difede J, Avery JD, Zaidi SR. Omission and Commission in Morally Injurious Experiences Among COVID-19 Health Care Professionals. Prim Care Companion CNS Disord 2024; 26:23m03651. [PMID: 38442032 DOI: 10.4088/pcc.23m03651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
Objective: To produce a qualitative description of the impact of moral injury on medical providers during the COVID-19 pandemic. Methods: A convergent mixed-methods study design was used to explore experiences of health care workers during the first 12 months of the COVID-19 pandemic. Participants completed the Moral Injury Symptom Scale-HP (MISS-HP) and a 60-minute interview, in which they described their work experiences from March 2020 through January 2021. The study was conducted between May 2021 and August 2021. Results: Eight physicians and 6 nurses were interviewed. Most participants (71%) worked in the emergency department, while 29% worked in the medical intensive care unit (MICU). MISS-HP scores were 49 on average and ranged from 29 to 73. Among the demographic groups, MICU participants scored the highest (56) and men scored the lowest (40). There were no significant differences in scores between any demographic group. The analysis of interview data showed how omissions and commissions in one's professional duties created internal conflicts, which were inextricably linked to a deeper sense of feelings of guilt and blame around experiences of betraying or being betrayed and an inability to uphold one's moral values. Conclusions: The pandemic upended a previously reliable and imperceptible experience of a background of safety, in which the provision of both material resources and human presence was expected without question. Future directions generated from this study might examine the role of dependency on leadership structures and relationships with self and others that create the conditions for moral injury. Prim Care Companion CNS Disord 2024;26(1):23m03651. Author affiliations are listed at the end of this article.
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Affiliation(s)
- Giselle Appel
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
- Corresponding Author: Giselle Appel, BA, Department of Psychiatry, Weill Cornell Medical College, 525 East 68th St, New York, NY 10065
| | - Bernadine H Han
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | - Yochai Re'Em
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | - Charalambia Louka
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | | | - Abdallah Tom
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | - Anjile An
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - JoAnn Difede
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | - Jonathan D Avery
- Department of Psychiatry, Weill Cornell Medicine, New York, New York
| | - Sara R Zaidi
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York
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2
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Wang CC, Difede J. A Two-Phased Telehealth Model to Treat Post-Traumatic Stress Disorder in a Health Care Worker due to the COVID-19 Pandemic: A Case Report. Telemed J E Health 2024; 30:601-606. [PMID: 37585569 DOI: 10.1089/tmj.2023.0326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
Background: We report a case describing the use of a two-step telehealth intervention to treat symptoms of post-traumatic stress disorder (PTSD) that developed in a frontline health care worker (HCW) during the COVID-19 pandemic. HCWs are at increased risk of adverse psychological outcomes, including PTSD, due to the nature of their work, which has been exacerbated by the global pandemic. Methods: This case represents the first successfully completed participant in a larger ongoing trial to address psychological distress, PTSD, and comorbidities in HCWs consequent to the COVID-19 pandemic. Following a two-step intervention of self-directed narrative writing delivered entirely online followed by prolonged exposure therapy using videoconferencing, the HCW displayed significant improvement in symptoms of PTSD, depression, anxiety, and substance use. Results: The treatment model described here offers preliminary support for a two-step remote delivery approach to meet the need for scalable self-directed distance technology-based mental health interventions for HCWs. This study is registered on clinicaltrials.gov (NCT04626050).
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Affiliation(s)
- Crystal C Wang
- Department of Psychiatry, Weill Cornell Medical College, New York, New York, USA
| | - JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, New York, New York, USA
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3
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Emrich M, McAleavey AA, Peskin M, Walsh JA, Sombrotto LB, Difede J. Bringing mental health to the frontlines: A proactive team-based model for healthcare workers during the COVID-19 pandemic. Gen Hosp Psychiatry 2023; 85:120-125. [PMID: 37864866 DOI: 10.1016/j.genhosppsych.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/18/2023] [Accepted: 09/28/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE A novel team-based service was developed at the beginning of the pandemic in which sixty liaisons were assigned to provide proactive, tailored psychological support for healthcare workers (HCWs) across three of NewYork-Presbyterian's Weill Cornell affiliated hospitals. METHOD The program took the proactive approach of bringing mental health awareness to every department and major division that interfaced with COVID-19 patients. Virtual and in-person team-based "town hall" meetings were offered to provide psychoeducation, facilitate discussion, foster adaptive coping and social cohesion, and identify employees who would benefit from further individualized support. RESULTS The program's success was reflected in the number of town halls (1000+) and attendees (6000+) and in qualitative feedback from departments who requested ongoing services. CONCLUSIONS This article presents the development, implementation, challenges, and opportunities in designing a team-based support model for HCWs. This model may be useful for organizations that seek to develop similar programs.
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Affiliation(s)
- Mariel Emrich
- Weill Cornell Medical College, Psychiatry Department, 525 East 68th Street, Box 200, New York, NY 10065, USA; University of Connecticut, Department of Psychological Sciences, 406 Babbidge Road, Unit 1020, Storrs, CT 06269, USA
| | - Andrew A McAleavey
- Weill Cornell Medical College, Psychiatry Department, 525 East 68th Street, Box 200, New York, NY 10065, USA
| | - Melissa Peskin
- Weill Cornell Medical College, Psychiatry Department, 525 East 68th Street, Box 200, New York, NY 10065, USA
| | - Jennifer A Walsh
- Weill Cornell Medical College, Psychiatry Department, 525 East 68th Street, Box 200, New York, NY 10065, USA
| | - Lisa B Sombrotto
- Weill Cornell Medical College, Psychiatry Department, 525 East 68th Street, Box 200, New York, NY 10065, USA
| | - JoAnn Difede
- Weill Cornell Medical College, Psychiatry Department, 525 East 68th Street, Box 200, New York, NY 10065, USA.
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4
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Difede J, McAleavey AA, Emrich M, Jick A, Ovalles A, Wyka K, Spielman L, Olden M, Peskin M, Becket-Davenport C, Rubenstein A, Brownstein MJ, Damiano E, Itzkowitz D, Lu SF, Needell NJ, Kocsis JH, Gordon-Elliott JS, Simon NG. A proof-of-concept randomized crossover clinical trial of a first-in-class vasopressin 1a receptor antagonist for PTSD: Design, methods, and recruitment. Contemp Clin Trials Commun 2023; 33:101116. [PMID: 37008794 PMCID: PMC10060168 DOI: 10.1016/j.conctc.2023.101116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/19/2023] Open
Abstract
Background Almost eight million Americans suffer from Posttraumatic Stress Disorder (PTSD). Current PTSD drug therapies rely on repurposed antidepressants and anxiolytics, which produce undesirable side effects and have recognized compliance issues. Vasopressin represents a promising and novel target for pharmacological intervention. Logistical issues implementing a clinical trial for a novel PTSD pharmaceutical are relatively uncharted territory as trials concerning a new agent have not been published in the past several decades. All published trials have repurposed FDA-approved psychoactive medications with known risk profiles. Our recruitment challenges are discussed in this context. Methods An 18-week proof-of-concept randomized crossover clinical trial of a first-in-class vasopressin 1a receptor antagonist (SRX246) for PTSD was conducted. All participants received SRX246 for 8 weeks, the placebo for 8 weeks, and the drug vs. placebo arms were compared. Participants were assessed every 2 weeks for PTSD symptoms as well as other medication effects. Results were expected to provide an initial demonstration of safety and tolerability in this clinical population and potentially clinical efficacy in SRX246-treated patients measured by Clinician Administered PTSD Scale (CAPS) score changes, clinical impression, and other indices compared to placebo. The primary hypothesis was that SRX246 would result in a clinically meaningful 10-point reduction in mean CAPS score compared to placebo. Discussion This study is the first to investigate an oral vasopressin 1a receptor antagonist for PTSD. As a wave of PTSD clinical trials with new pharmaceutical compounds are beginning now, lessons learned from our recruitment challenges may be invaluable to these endeavors.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | | | - Mariel Emrich
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Adina Jick
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Annell Ovalles
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katarzyna Wyka
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Lisa Spielman
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Megan Olden
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Melissa Peskin
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | | | - Amy Rubenstein
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | | | - Eve Damiano
- Azevan Pharmaceuticals, Inc. Bethlehem, PA, USA
| | | | - Shi-fang Lu
- Azevan Pharmaceuticals, Inc. Bethlehem, PA, USA
- Department of Biological Sciences, Lehigh University, Bethlehem, PA, USA
| | - Nancy J. Needell
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - James H. Kocsis
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | | | - Neal G. Simon
- Azevan Pharmaceuticals, Inc. Bethlehem, PA, USA
- Department of Biological Sciences, Lehigh University, Bethlehem, PA, USA
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Difede J, Rothbaum BO, Rizzo AA, Wyka K, Spielman L, Reist C, Roy MJ, Jovanovic T, Norrholm SD, Cukor J, Olden M, Glatt CE, Lee FS. Enhancing exposure therapy for posttraumatic stress disorder (PTSD): a randomized clinical trial of virtual reality and imaginal exposure with a cognitive enhancer. Transl Psychiatry 2022; 12:299. [PMID: 35896533 PMCID: PMC9329292 DOI: 10.1038/s41398-022-02066-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/30/2022] [Accepted: 07/07/2022] [Indexed: 11/08/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is a significant public health issue. Yet, there are limited treatment options and no data to suggest which treatment will work for whom. We tested the efficacy of virtual reality exposure (VRE) or prolonged imaginal exposure (PE), augmented with D-cycloserine (DCS) for combat-related PTSD. As an exploratory aim, we examined whether brain-derived neurotrophic factor (BDNF) and fatty acid amide hydrolase (FAAH) moderated treatment response. Military personnel with PTSD (n = 192) were recruited into a multisite double-blind randomized controlled trial to receive nine weeks of VRE or PE, with DCS or placebo. Primary outcome was the improvement in symptom severity. Randomization was stratified by comorbid depression (MDD) and site. Participants in both VRE and PE showed similar meaningful clinical improvement with no difference between the treatment groups. A significant interaction (p = 0.45) suggested VRE was more effective for depressed participants (CAPS difference M = 3.51 [95% CI 1.17-5.86], p = 0.004, ES = 0.14) while PE was more effective for nondepressed participants (M = -8.87 [95% CI -11.33 to -6.40], p < 0.001, ES = -0.44). The main effect of DCS vs. placebo was not significant. Augmentation by MDD interaction (p = 0.073) suggested that depressed participants improved more on placebo (M = -8.43 [95% CI -10.98 to -5.88], p < 0.001, ES = -0.42); DCS and placebo were equally effective for nondepressed participants. There was an apparent moderating effect of BDNF Val66Met polymorphism on DCS augmentation (ES = 0.67). Met66 allele carriers improved more on DCS (ES = -0.25). FAAH 385 A carriers improved more than non-carriers (ES = 0.33), particularly those with MDD (ES = 0.62). This study provides a step toward precision therapeutics for PTSD by demonstrating that comorbid MDD and genetic markers may help guide treatment selection.ClinicalTrials.gov Identifier: NCT01352637.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA.
| | | | - Albert A Rizzo
- University of Southern California Institute for Creative Technologies, Los Angeles, CA, USA
| | - Katarzyna Wyka
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Lisa Spielman
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Reist
- Department of Psychiatry, VA Long Beach Healthcare System, Long Beach, CA, USA
- University of California, Irvine, Irvine, CA, USA
- Science 37, Los Angeles, CA, USA
| | - Michael J Roy
- Department of Medicine and Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, USA
| | - Seth D Norrholm
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, USA
| | - Judith Cukor
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Megan Olden
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Charles E Glatt
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Francis S Lee
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
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6
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Warhit A, Ahern M, Turman ML, Emrich M, Avery J, Raso R, Difede J, Penzner JB. Novel Support Model for the Management of Occupational Stress Among Frontline Healthcare Workers During the COVID-19 Pandemic: a New Training Opportunity. Acad Psychiatry 2021; 45:660-661. [PMID: 33860471 PMCID: PMC8049619 DOI: 10.1007/s40596-021-01456-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/07/2021] [Indexed: 05/15/2023]
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7
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Boydstun CD, Pandita S, Finkelstein-Fox L, Difede J. Harnessing virtual reality for disaster mental health: A systematic review. Translational Issues in Psychological Science 2021. [DOI: 10.1037/tps0000282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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8
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Malta LS, Giosan C, Szkodny LE, Altemus MM, Rizzo AA, Silbersweig DA, Difede J. Predictors of involuntary and voluntary emotional episodic memories of virtual reality scenarios in Veterans with and without PTSD. Memory 2020; 28:724-740. [PMID: 32462992 DOI: 10.1080/09658211.2020.1770289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study investigated predictors of involuntary and voluntary memories of stressful virtual reality scenarios. Thirty-two veterans of the two Persian Gulf Wars completed verbal memory tests and diagnostic assessments. They were randomly assigned to a Recounting (16) or a Suppression (16) condition. After immersion in the VR scenarios, the Recounting group described the scenarios and the Suppression group suppressed thoughts of the scenarios. One week later, participants completed surprise voluntary memory tests and another thought suppression task. The best predictors of voluntary memory were verbal memory ability, dissociation, and to a lesser extent, physiological arousal before and after scenarios. Dissociation and physiological stress responses selectively affected memory for neutral elements. Higher distress during scenarios impaired voluntary memory but increased the frequency of involuntary memories. Physiological stress responses promoted more frequent involuntary memories immediately after the scenarios. More frequent initial involuntary memories, tonic physiological arousal, and stronger emotional responses to dangerous events predicted difficulty inhibiting involuntary memories at follow-up. The effects of thought suppression were transient and weaker than those of other variables. The findings suggest that posttraumatic amnesia and involuntary memories of adverse events are more related to memory ability and emotional and physiological stress responses than to post-exposure suppression.
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Affiliation(s)
- Loretta S Malta
- Weill Medical College of Cornell University, 1300 York Ave, New York, NY 10065
| | - Cezar Giosan
- Weill Medical College of Cornell University, 1300 York Ave, New York, NY 10065.,Department of Psychology, University of Bucharest, Panduri 90, Bucharest, Romania, 032075
| | - Lauren E Szkodny
- Weill Medical College of Cornell University, 1300 York Ave, New York, NY 10065
| | - Margaret M Altemus
- Weill Medical College of Cornell University, 1300 York Ave, New York, NY 10065
| | - Albert A Rizzo
- Weill Medical College of Cornell University, 1300 York Ave, New York, NY 10065.,Institute for Creative Technologies, University of Southern California, 12015 Waterfront Drive, Playa Vista, CA 90094-2536
| | - David A Silbersweig
- Weill Medical College of Cornell University, 1300 York Ave, New York, NY 10065
| | - JoAnn Difede
- Weill Medical College of Cornell University, 1300 York Ave, New York, NY 10065
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9
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Katz AC, Norr AM, Buck B, Fantelli E, Edwards-Stewart A, Koenen-Woods P, Zetocha K, Smolenski DJ, Holloway K, Rothbaum BO, Difede J, Rizzo A, Skopp N, Mishkind M, Gahm G, Reger GM, Andrasik F. Changes in physiological reactivity in response to the trauma memory during prolonged exposure and virtual reality exposure therapy for posttraumatic stress disorder. Psychol Trauma 2020; 12:756-764. [PMID: 32338946 DOI: 10.1037/tra0000567] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A key symptom of posttraumatic stress disorder (PTSD) is hyperreactivity to trauma-relevant stimuli. Though physiological arousal is reliably elevated in PTSD, the question remains whether this arousal responds to treatment. Virtual reality (VR) has been posited to increase emotional engagement during prolonged exposure therapy (PE) for PTSD by augmenting imaginal exposures with trauma-relevant sensory information. However, the comparative effects of VR exposure therapy (VRE) have received limited empirical inquiry. METHOD Ninety active-duty soldiers with combat-related PTSD participating in a randomized-controlled trial to receive PE, VRE, or a waitlist-control (WL) condition had their physiological reactivity, indexed by galvanic skin response (GSR), to their trauma memories assessed at pre-, mid-, and posttreatment. RESULTS Although both VRE and PE conditions showed reduced GSR reactivity to trauma memories from pre- to posttreatment, only the VRE group differed significantly from WL. Across the sample, reductions in GSR were significantly correlated with reductions in self-reported PTSD and anxiety symptoms. CONCLUSIONS This was the first study comparing effects of VRE and PE on psychophysiological variables. Given previous research finding limited differences between VRE and PE in PTSD symptom reduction, these findings lend support to the rationale for including VR in exposure therapy protocols while raising important questions about the potential benefits of VRE. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | - Aaron M Norr
- VA Puget Sound Healthcare System, Seattle Division
| | | | | | | | | | | | | | | | | | | | | | - Nancy Skopp
- National Center for Telehealth and Technology
| | | | | | - Greg M Reger
- VA Puget Sound Healthcare System, Seattle Division
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10
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Rosenfield D, Smits JAJ, Hofmann SG, Mataix-Cols D, de la Cruz LF, Andersson E, Rück C, Monzani B, Pérez-Vigil A, Frumento P, Davis M, de Kleine RA, Difede J, Dunlop BW, Farrell LJ, Geller D, Gerardi M, Guastella AJ, Hendriks GJ, Kushner MG, Lee FS, Lenze EJ, Levinson CA, McConnell H, Plag J, Pollack MH, Ressler KJ, Rodebaugh TL, Rothbaum BO, Storch EA, Ströhle A, Tart CD, Tolin DF, van Minnen A, Waters AM, Weems CF, Wilhelm S, Wyka K, Altemus M, Anderson P, Cukor J, Finck C, Geffken GR, Golfels F, Goodman WK, Gutner CA, Heyman I, Jovanovic T, Lewin AB, McNamara JP, Murphy TK, Norrholm S, Thuras P, Turner C, Otto MW. Changes in Dosing and Dose Timing of D-Cycloserine Explain Its Apparent Declining Efficacy for Augmenting Exposure Therapy for Anxiety-related Disorders: An Individual Participant-data Meta-analysis. J Anxiety Disord 2019; 68:102149. [PMID: 31698111 PMCID: PMC9119697 DOI: 10.1016/j.janxdis.2019.102149] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/19/2019] [Accepted: 09/22/2019] [Indexed: 12/25/2022]
Abstract
The apparent efficacy of d-cycloserine (DCS) for enhancing exposure treatment for anxiety disorders appears to have declined over the past 14 years. We examined whether variations in how DCS has been administered can account for this "declining effect". We also investigated the association between DCS administration characteristics and treatment outcome to find optimal dosing parameters. We conducted a secondary analysis of individual participant data obtained from 1047 participants in 21 studies testing the efficacy of DCS-augmented exposure treatments. Different outcome measures in different studies were harmonized to a 0-100 scale. Intent-to-treat analyses showed that, in participants randomized to DCS augmentation (n = 523), fewer DCS doses, later timing of DCS dose, and lower baseline severity appear to account for this decline effect. More DCS doses were related to better outcomes, but this advantage leveled-off at nine doses. Administering DCS more than 60 minutes before exposures was also related to better outcomes. These predictors were not significant in the placebo arm (n = 521). Results suggested that optimal DCS administration could increase pre-to-follow-up DCS effect size by 50%. In conclusion, the apparent declining effectiveness of DCS over time may be accounted for by how it has been administered. Optimal DCS administration may substantially improve outcomes. Registration: The analysis plan for this manuscript was registered on Open Science Framework (https://osf.io/c39p8/).
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Affiliation(s)
- David Rosenfield
- Department of Psychology, Southern Methodist University, Dallas, USA.
| | - Jasper A J Smits
- Institute for Mental Health Research and Department of Psychology, The University of Texas, Austin, USA
| | - Stefan G Hofmann
- Department of Psychological and Brain Sciences, Boston University, Boston, USA
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Lorena Fernández de la Cruz
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Erik Andersson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Benedetta Monzani
- Department of Psychology, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Ana Pérez-Vigil
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Paolo Frumento
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Michael Davis
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | | | - JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, NY, USA
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | - Lara J Farrell
- School of Applied Psychology, Griffith University, Brisbane, Australia; Menzies Health Institute of Queensland, Brisbane, Australia
| | - Daniel Geller
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA; Harvard Medical School, Boston, USA
| | - Maryrose Gerardi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | - Adam J Guastella
- Brain and Mind Research Institute, Central Clinical School, University of Sydney, Sydney, Australia
| | - Gert-Jan Hendriks
- Behavioral Science Institute, Radboud University Nijmegen, The Netherlands; Overwaal Center of Expertise for Anxiety Disorders OCD and PTSD, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, the Netherlands
| | - Matt G Kushner
- Department of Psychiatry, University of Minnesota-Twin Cities, Minneapolis, USA
| | - Francis S Lee
- Department of Psychiatry, Weill Cornell Medical College, NY, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, USA
| | - Cheri A Levinson
- Department of Psychiatry, Washington University School of Medicine, St Louis, USA
| | - Harry McConnell
- Menzies Health Institute of Queensland, Brisbane, Australia; School of Medicine, Griffith University, Brisbane, Australia
| | - Jens Plag
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, Germany
| | - Mark H Pollack
- Department of Psychiatry, Rush University Medical Center, Chicago, USA
| | - Kerry J Ressler
- Harvard Medical School, Boston, USA; McLean Hospital, Belmont, USA
| | - Thomas L Rodebaugh
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | - Eric A Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, USA
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, Germany
| | | | - David F Tolin
- The Institute of Living, Hartford, USA; Yale University School of Medicine, New Haven, USA
| | - Agnes van Minnen
- Behavioral Science Institute, Radboud University Nijmegen, The Netherlands
| | - Allison M Waters
- School of Applied Psychology, Griffith University, Brisbane, Australia
| | - Carl F Weems
- Department of Human Development and Family Studies, Iowa State University, Ames, USA
| | - Sabine Wilhelm
- Department of Psychiatry, Massachusetts General Hospital, Boston, USA; Harvard Medical School, Boston, USA
| | - Katarzyna Wyka
- Department of Psychiatry, Weill Cornell Medical College, NY, USA; City University of New York Graduate School of Public Health and Health Policy, New York, USA
| | | | - Page Anderson
- Department of Psychology, Georgia State University, Atlanta, USA
| | - Judith Cukor
- Department of Psychiatry, Weill Cornell Medical College, NY, USA
| | - Claudia Finck
- DRK Kliniken Berlin Wiegmann Klinik, Berlin, Germany
| | | | | | | | - Cassidy A Gutner
- Department of Psychiatry, Boston University School of Medicine, Boston, USA
| | - Isobel Heyman
- Great Ormond Street Hospital for Children, London, UK; University College, London, UK
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | - Adam B Lewin
- Department of Pediatrics, University of South Florida, Tampa, USA
| | | | - Tanya K Murphy
- Department of Pediatrics, University of South Florida, Tampa, USA
| | - Seth Norrholm
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, USA
| | - Paul Thuras
- Department of Psychiatry, University of Minnesota-Twin Cities, Minneapolis, USA
| | - Cynthia Turner
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Michael W Otto
- Department of Psychological and Brain Sciences, Boston University, Boston, USA
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11
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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12
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Peskin M, Markowitz JC, Difede J. Interpersonal psychotherapy for posttraumatic stress disorder due to military sexual trauma: A case report. Journal of Psychotherapy Integration 2018. [DOI: 10.1037/int0000112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Norr AM, Smolenski DJ, Katz AC, Rizzo AA, Rothbaum BO, Difede J, Koenen-Woods P, Reger MA, Reger GM. Virtual reality exposure versus prolonged exposure for PTSD: Which treatment for whom? Depress Anxiety 2018; 35:523-529. [PMID: 29734488 DOI: 10.1002/da.22751] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 02/12/2018] [Accepted: 03/08/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The majority of studies comparing active psychological treatments for posttraumatic stress disorder (PTSD) do not find significant differences at posttreatment. This was the case in a recent trial examining prolonged exposure (PE) and virtual reality exposure (VRE) among active-duty soldiers with combat-related PTSD. Matching individual patients to specific treatments provides a potential avenue to improve significantly the public health impact of effective treatments for PTSD. A composite moderator approach was used to identify profiles of patients who would see superior PTSD symptom reduction in VRE or PE to inform future treatment matching. METHODS Active duty U.S. army soldiers (N = 108) were enrolled in a randomized clinical trial comparing VRE and PE in the treatment of PTSD stemming from deployments to Iraq or Afghanistan. Eighteen baseline variables were examined to identify treatment response heterogeneity in two patient groups: those with a superior response to PE and those with a superior response to VRE. The final composite moderator comprised four of 18 baseline variables. RESULTS Results revealed that patients who were predicted to see greater PTSD symptom reduction in VRE were likely to be younger, not taking antidepressant medication, had greater PTSD hyperarousal symptoms, and were more likely to have greater than minimal suicide risk. CONCLUSIONS Results suggest that treatment matching based on patient profiles could meaningfully improve treatment efficacy for combat-related PTSD. Future research can build on these results to improve our understanding of how to improve treatment matching for PTSD.
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Affiliation(s)
- Aaron M Norr
- VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Derek J Smolenski
- Defense Health Agency, Psychological Health Center of Excellence, Tacoma, WA, USA
| | | | - Albert A Rizzo
- Institute for Creative Technologies, University of Southern California, Los Angeles, CA, USA
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | | | - Mark A Reger
- VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Greg M Reger
- VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
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14
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McAleavey AA, Wyka K, Peskin M, Difede J. Physical, functional, and psychosocial recovery from burn injury are related and their relationship changes over time: A Burn Model System study. Burns 2018; 44:793-799. [DOI: 10.1016/j.burns.2017.12.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/12/2017] [Accepted: 12/17/2017] [Indexed: 11/29/2022]
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15
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Hunnicutt-Ferguson K, Wyka KE, Peskin M, Cukor J, Olden M, Difede J. Posttraumatic Stress Disorder, Functional Impairment, and Subjective Distress in World Trade Center Disaster Workers. J Trauma Stress 2018. [PMID: 29539098 DOI: 10.1002/jts.22268] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Posttraumatic stress disorder (PTSD) is associated with functional deficits, poor physical health, and diminished quality of life. Limited research has examined PTSD symptom clusters and their associations with functioning and distress among disaster recovery workers, a population at high risk for PTSD due to potential for repeated trauma. The purpose of this study was to investigate associations between overall PTSD severity, as well as PTSD symptom clusters, and social and occupational functioning and subjective distress in World Trade Center (WTC) disaster workers after the terrorist attacks on September 11, 2001 (9/11). Disaster workers deployed to the site of the attacks completed assessments at three time points over approximately 5 years post-9/11. Our sample consisted of participants who met criteria for PTSD or subthreshold PTSD at baseline (n = 514), 1-year (n = 289), and 2-year follow-up (n = 179). Adjusted linear regression indicated that Clinician Administered PTSD Scale (CAPS)-rated PTSD severity was positively associated with subjective distress, and deficits in social and occupational functioning, over time, CAPS Criterion F items; βs = .20 to .62, ps < .001. The reexperiencing and avoidance/numbing symptom clusters were associated with increased subjective distress, the avoidance/numbing and hyperarousal clusters were associated with deficits in social functioning, and the reexperiencing and hyperarousal clusters were associated with worse occupational functioning. These associations were consistent across the study period. Findings point to the importance of targeting PTSD symptom clusters associated with specific areas of functional impairment, with the goal of improving global outcomes.
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Affiliation(s)
| | - Katarzyna E Wyka
- Department of Psychiatry, Weill Cornell Medicine, New York, New York, USA.,City University of New York Graduate School of Public Health and Health Policy, New York, New York, USA
| | - Melissa Peskin
- Department of Psychiatry, Weill Cornell Medicine, New York, New York, USA
| | - Judith Cukor
- Department of Psychiatry, Weill Cornell Medicine, New York, New York, USA
| | - Megan Olden
- Department of Psychiatry, Weill Cornell Medicine, New York, New York, USA
| | - JoAnn Difede
- Department of Psychiatry, Weill Cornell Medicine, New York, New York, USA
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16
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Mataix-Cols D, Fernández de la Cruz L, Monzani B, Rosenfield D, Andersson E, Pérez-Vigil A, Frumento P, de Kleine RA, Difede J, Dunlop BW, Farrell LJ, Geller D, Gerardi M, Guastella AJ, Hofmann SG, Hendriks GJ, Kushner MG, Lee FS, Lenze EJ, Levinson CA, McConnell H, Otto MW, Plag J, Pollack MH, Ressler KJ, Rodebaugh TL, Rothbaum BO, Scheeringa MS, Siewert-Siegmund A, Smits JAJ, Storch EA, Ströhle A, Tart CD, Tolin DF, van Minnen A, Waters AM, Weems CF, Wilhelm S, Wyka K, Davis M, Rück C, Altemus M, Anderson P, Cukor J, Finck C, Geffken GR, Golfels F, Goodman WK, Gutner C, Heyman I, Jovanovic T, Lewin AB, McNamara JP, Murphy TK, Norrholm S, Thuras P. D-Cycloserine Augmentation of Exposure-Based Cognitive Behavior Therapy for Anxiety, Obsessive-Compulsive, and Posttraumatic Stress Disorders: A Systematic Review and Meta-analysis of Individual Participant Data. JAMA Psychiatry 2017; 74:501-510. [PMID: 28122091 DOI: 10.1001/jamapsychiatry.2016.3955] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Whether and under which conditions D-cycloserine (DCS) augments the effects of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders is unclear. OBJECTIVE To clarify whether DCS is superior to placebo in augmenting the effects of cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders and to evaluate whether antidepressants interact with DCS and the effect of potential moderating variables. DATA SOURCES PubMed, EMBASE, and PsycINFO were searched from inception to February 10, 2016. Reference lists of previous reviews and meta-analyses and reports of randomized clinical trials were also checked. STUDY SELECTION Studies were eligible for inclusion if they were (1) double-blind randomized clinical trials of DCS as an augmentation strategy for exposure-based cognitive behavior therapy and (2) conducted in humans diagnosed as having specific phobia, social anxiety disorder, panic disorder with or without agoraphobia, obsessive-compulsive disorder, or posttraumatic stress disorder. DATA EXTRACTION AND SYNTHESIS Raw data were obtained from the authors and quality controlled. Data were ranked to ensure a consistent metric across studies (score range, 0-100). We used a 3-level multilevel model nesting repeated measures of outcomes within participants, who were nested within studies. RESULTS Individual participant data were obtained for 21 of 22 eligible trials, representing 1047 of 1073 eligible participants. When controlling for antidepressant use, participants receiving DCS showed greater improvement from pretreatment to posttreatment (mean difference, -3.62; 95% CI, -0.81 to -6.43; P = .01; d = -0.25) but not from pretreatment to midtreatment (mean difference, -1.66; 95% CI, -4.92 to 1.60; P = .32; d = -0.14) or from pretreatment to follow-up (mean difference, -2.98, 95% CI, -5.99 to 0.03; P = .05; d = -0.19). Additional analyses showed that participants assigned to DCS were associated with lower symptom severity than those assigned to placebo at posttreatment and at follow-up. Antidepressants did not moderate the effects of DCS. None of the prespecified patient-level or study-level moderators was associated with outcomes. CONCLUSIONS AND RELEVANCE D-cycloserine is associated with a small augmentation effect on exposure-based therapy. This effect is not moderated by the concurrent use of antidepressants. Further research is needed to identify patient and/or therapy characteristics associated with DCS response.
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Affiliation(s)
- David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden2Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Lorena Fernández de la Cruz
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Benedetta Monzani
- Institute of Psychiatry, Psychology, and Neuroscience, Department of Psychology, King's College London, London, United Kingdom
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Dallas, Texas
| | - Erik Andersson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ana Pérez-Vigil
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Paolo Frumento
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Rianne A de Kleine
- Center for Anxiety Disorders Overwaal, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, the Netherlands7Behavioral Science Institute, NijCare, Radboud University Nijmegen, Nijmegen, the Netherlands
| | - JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Boadie W Dunlop
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Lara J Farrell
- School of Applied Psychology, Griffith University, Brisbane, Queensland, Australia11Menzies Health Institute of Queensland, Brisbane, Queensland, Australia
| | - Daniel Geller
- Department of Psychiatry, Massachusetts General Hospital, Boston13Harvard Medical School, Boston, Massachusetts
| | - Maryrose Gerardi
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Adam J Guastella
- Brain and Mind Research Institute, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Stefan G Hofmann
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - Gert-Jan Hendriks
- Center for Anxiety Disorders Overwaal, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, the Netherlands7Behavioral Science Institute, NijCare, Radboud University Nijmegen, Nijmegen, the Netherlands
| | - Matt G Kushner
- Department of Psychiatry, University of Minnesota, Minneapolis
| | - Francis S Lee
- Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
| | | | - Harry McConnell
- Menzies Health Institute of Queensland, Brisbane, Queensland, Australia19School of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Michael W Otto
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - Jens Plag
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Mark H Pollack
- Department of Psychiatry, Rush University Medical Center, Chicago, Illinois
| | - Kerry J Ressler
- Harvard Medical School, Boston, Massachusetts22McLean Hospital, Belmont, Massachusetts
| | - Thomas L Rodebaugh
- Department of Psychological and Brain Sciences, Washington University School of Medicine, St Louis, Missouri
| | - Barbara O Rothbaum
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Michael S Scheeringa
- Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Jasper A J Smits
- Institute for Mental Health Research, Department of Psychology, The University of Texas, Austin
| | - Eric A Storch
- Department of Pediatrics, University of South Florida, Tampa27Rogers Behavioral Health, Tampa, Florida
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Candyce D Tart
- New Mexico Veterans Affairs Health Care System, Albuquerque, New Mexico
| | - David F Tolin
- The Institute of Living, Hartford, Connecticut30Yale University School of Medicine, New Haven, Massachusetts
| | - Agnes van Minnen
- Center for Anxiety Disorders Overwaal, Institution for Integrated Mental Health Care Pro Persona, Nijmegen, the Netherlands7Behavioral Science Institute, NijCare, Radboud University Nijmegen, Nijmegen, the Netherlands
| | - Allison M Waters
- School of Applied Psychology, Griffith University, Brisbane, Queensland, Australia11Menzies Health Institute of Queensland, Brisbane, Queensland, Australia
| | - Carl F Weems
- Department of Human Development and Family Studies, Iowa State University, Ames
| | - Sabine Wilhelm
- Department of Psychiatry, Massachusetts General Hospital, Boston13Harvard Medical School, Boston, Massachusetts
| | - Katarzyna Wyka
- Department of Psychiatry, Weill Cornell Medical College, New York, New York32Cuny School of Public Health, City University of New York Graduate School of Public Health and Health Policy, New York
| | - Michael Davis
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden2Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | | | - Margaret Altemus
- Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Page Anderson
- Department of Psychology, Georgia State University, Atlanta
| | - Judith Cukor
- Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Claudia Finck
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Gary R Geffken
- Department of Psychiatry, University of Florida, Gainesville
| | - Fabian Golfels
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Wayne K Goodman
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cassidy Gutner
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Isobel Heyman
- Great Ormond Street Hospital for Children, University College London, London, United Kingdom
| | - Tanja Jovanovic
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Adam B Lewin
- Department of Pediatrics, University of South Florida, Tampa
| | | | - Tanya K Murphy
- Department of Pediatrics, University of South Florida, Tampa
| | - Seth Norrholm
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Paul Thuras
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
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Jayasinghe N, Finkelstein-Fox L, Sar-Graycar L, Ojie MJ, Bruce ML, Difede J. Systematic Review of the Clinical Application of Exposure Techniques to Community-Dwelling Older Adults with Anxiety. Clin Gerontol 2017; 40:141-158. [PMID: 28452667 PMCID: PMC6072459 DOI: 10.1080/07317115.2017.1291546] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Although exposure techniques are a first-line intervention for anxiety, clear evidence is lacking for their efficacy in treating the prevalent and debilitating condition of late life anxiety. This study sought to review the current literature on use of exposure with community-dwelling older patients. METHODS Searches of electronic databases were conducted to identify articles published through December 7, 2016. Inclusion criteria were: 1) sample age > 55, 2) therapy that included exposure, 3) anxiety as a target of the treatment. Exclusion criteria were: 1) not available in English, 2) no quantitative data, 3) inpatient setting. Methodological data and findings were extracted from the articles chosen for review. RESULTS The 54 eligible articles presented a total of 16 case studies, 9 uncontrolled trials, 24 controlled trials, and 6 secondary studies. A majority of the studies were conducted in the U.S.A with participants who received individual treatment. In vivo and imaginal exposure were the most frequently delivered techniques, and most treatments were multicomponent. Most studies found a reduction in anxiety symptoms. CONCLUSIONS Important research gaps need to be addressed. CLINICAL IMPLICATIONS The surveyed research provides a modest foundation of evidence for mental health practitioners who wish to incorporate exposure into treatment plans.
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Affiliation(s)
| | - Lucy Finkelstein-Fox
- Weill Cornell Medical College, New York, NY, U.S.A
- University of Connecticut, Storrs, CT, U.S.A
| | | | - Mary-Jane Ojie
- Weill Cornell Medical College, New York, NY, U.S.A
- Kennedy Krieger Institute/Johns Hopkins School of Medicine, Baltimore, MD, U.S.A
| | | | - JoAnn Difede
- Weill Cornell Medical College, New York, NY, U.S.A
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Reger GM, Koenen-Woods P, Zetocha K, Smolenski DJ, Holloway KM, Rothbaum BO, Difede J, Rizzo AA, Edwards-Stewart A, Skopp NA, Mishkind M, Reger MA, Gahm GA. Randomized controlled trial of prolonged exposure using imaginal exposure vs. virtual reality exposure in active duty soldiers with deployment-related posttraumatic stress disorder (PTSD). J Consult Clin Psychol 2016; 84:946-959. [PMID: 27606699 DOI: 10.1037/ccp0000134] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Prolonged exposure (PE) is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD) but there is limited research with active-duty military populations. Virtual reality exposure (VRE) has shown promise but randomized trials are needed to evaluate efficacy relative to existing standards of care. This study evaluated the efficacy of VRE and PE for active duty soldiers with PTSD from deployments to Iraq and Afghanistan. METHOD Active-duty soldiers (N = 162) were randomized to 10-sessions of PE, VRE, or a minimal attention waitlist (WL). Blinded assessors evaluated symptoms at baseline, halfway through treatment, at posttreatment, and at 3- and 6-month follow-ups using the Clinician Administered PTSD Scale (CAPS). RESULTS Intent-to-treat analyses found that both PE and VRE resulted in significant reductions in PTSD symptoms relative to those in the WL. The majority of patients demonstrated reliable change in PTSD symptoms. There was no difference between PE and VRE regarding treatment drop out before completing 10 sessions (44 and 41% for VRE and PE, respectively). Contrary to hypotheses, analyses at posttreatment did not show that VRE was superior to PE. Post hoc analyses found that PE resulted in significantly greater symptom reductions than VRE at 3- and 6-month follow-up. Both treatments significantly reduced self-reported stigma. CONCLUSIONS PE is an efficacious treatment for active-duty Army soldiers with PTSD from deployments to Iraq or Afghanistan. Results extend previous evidence supporting the efficacy of PE to active-duty military personnel and raise important questions for future research on VRE. (PsycINFO Database Record
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Affiliation(s)
| | | | | | | | | | | | - JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College
| | - Albert A Rizzo
- Institute for Creative Technologies, University of Southern California
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Rizzo A, Cukor J, Gerardi M, Alley S, Reist C, Roy M, Rothbaum BO, Difede J. Virtual Reality Exposure for PTSD Due to Military Combat and Terrorist Attacks. J Contemp Psychother 2015. [DOI: 10.1007/s10879-015-9306-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jayasinghe N, Sparks MA, Kato K, Wilbur K, Ganz SB, Chiaramonte GR, Stevens BL, Barie PS, Lachs MS, O'Dell M, Evans AT, Bruce ML, Difede J. Exposure-Based CBT for Older Adults After Fall Injury: Description of a Manualized, Time-Limited Intervention for Anxiety. Cogn Behav Pract 2014; 21:432-445. [PMID: 25364226 DOI: 10.1016/j.cbpra.2014.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Fall accidents among older adults can be devastating events that, in addition to their physical consequences, lead to disabling anxiety warranting the attention of mental health practitioners. This article presents "Back on My Feet," an exposure-based cognitive-behavioral therapy (CBT) protocol that is designed for older adults with posttraumatic stress disorder (PTSD), subthreshold PTSD, or fear of falling resulting from a traumatic fall. The protocol can be integrated into care once patients have been discharged from hospital or rehabilitation settings back to the community. Following a brief description of its development, the article presents a detailed account of the protocol, including patient evaluation and the components of the eight home-based sessions. The protocol addresses core symptoms of avoidance, physiological arousal/anxiety, and maladaptive thought patterns. Because older patients face different coping challenges from younger patients (for whom the majority of evidence-based CBT interventions have been developed), the discussion ends with limitations and special considerations for working with older, injured patients. The article offers a blueprint for mental health practitioners to address the needs of patients who may present with fall-related anxiety in primary care and other medical settings. Readers who wish to develop their expertise further can consult the online appendices, which include a clinician manual and patient workbook, as well as guidance on additional resources.
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Abstract
The term translational research is typically used to refer both to "bench to bedside" research, in which preclinical research findings inform the development of novel therapeutics, and to the dissemination of new treatments to the community to encourage the use of the new health practices and treatments. Both definitions are germane to understanding the evidence base for treatment of post-traumatic stress disorder (PTSD) today. This article offers (a) an overview of evidence-based treatments for PTSD, (b) a description of a translational model of PTSD, and (c) a discussion of common barriers to dissemination and implementation of the empirically validated treatments. Recent studies in the field are discussed with a focus on pharmacotherapies, psychotherapies, and combined treatments.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, New York, New York 10065; , ,
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Giosan C, Malta LS, Wyka K, Jayasinghe N, Evans S, Difede J, Avram E. Sleep disturbance, disability, and posttraumatic stress disorder in utility workers. J Clin Psychol 2014; 71:72-84. [PMID: 25099348 DOI: 10.1002/jclp.22116] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The objective of the present study was to examine the associations between sleep disturbance, posttraumatic stress disorder (PTSD), and functional disability in a population exposed to a singular traumatic event. METHOD The participants were a population of 2,453 predominantly male utility workers who were deployed to the World Trade Center site in the aftermath of the 9/11 attack. They underwent psychiatric screenings comprising measures of sleep disturbance, PTSD, and functional disability. RESULTS Analyses indicated that (a) rates of sleep disturbances were significantly higher among participants diagnosed with PTSD than those without, (b) PTSD severity was significantly associated with sleep disturbance, and (c) sleep disturbance moderated the relationship between PTSD and disability. CONCLUSION Sleep disturbance is associated with occupational, social functioning, and PTSD severity, suggesting that ameliorating sleep may lead to increased occupational and social functioning, as well as better treatment responses in PTSD.
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Difede J, Cukor J, Wyka K, Olden M, Hoffman H, Lee FS, Altemus M. D-cycloserine augmentation of exposure therapy for post-traumatic stress disorder: a pilot randomized clinical trial. Neuropsychopharmacology 2014; 39:1052-8. [PMID: 24217129 PMCID: PMC3957110 DOI: 10.1038/npp.2013.317] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 10/15/2013] [Accepted: 11/04/2013] [Indexed: 11/09/2022]
Abstract
Viewing post-traumatic stress disorder (PTSD) as a disorder of emotional learning, this study used a cognitive enhancer synergistically with virtual reality exposure (VRE) therapy for the treatment of PTSD. The main objective was to determine if a novel pharmacotherapy, D-cycloserine (DCS), enhanced the efficacy of the psychotherapy. Pre-clinical studies suggest that when fear extinction occurs during DCS administration, neuroplasticity may be enhanced. VRE therapy is a particularly promising format to test the hypothesis that DCS enhances extinction learning, as sensory fear cues are standardized across patients. In a pilot randomized, double-blind, placebo-controlled trial, 100 mg of DCS or placebo was administered 90 min before each weekly VRE session, to ensure peak plasma concentrations during the sessions in 25 patients with chronic PTSD. The primary outcome measure was the Clinician Administered PTSD Scale (CAPS). Secondary outcome measures included the Beck Depression Inventory-II and the State-Trait Anger Expression Inventory-2. Assessments occurred at pre-treatment, following sessions 3, 6, 10, post-treatment, and at 6 months. The difference in CAPS between the VRE-DCS (n=13) and VRE-placebo (n=12) groups increased over time beginning at 6 weeks, with medium to large between-group effect sizes immediately post-treatment and 6 months later (d=0.68 and d=1.13, respectively). A similar pattern was observed for depression, anger expression, and sleep. PTSD remission rates were significantly greater for the VRE-DCS group (46% vs 8% at post-treatment; 69% vs 17% at 6 months). Patients in the VRE-DCS group showed earlier and greater improvement in PTSD symptoms compared with the VRE-placebo group. These results suggest a promising new treatment for PTSD.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA,NewYork-Presbyterian Hospital, New York, NY, USA,Department of Psychiatry, Weill Cornell Medical College, 525 East 68th Street, Box 200, New York, NY 10065, USA, Tel: +1 212 746 3079, Fax: +1 212 746 0719, E-mail:
| | - Judith Cukor
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA,NewYork-Presbyterian Hospital, New York, NY, USA
| | - Katarzyna Wyka
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Megan Olden
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA,NewYork-Presbyterian Hospital, New York, NY, USA
| | - Hunter Hoffman
- Department of Mechanical Engineering, Human Interface Technology Laboratory, and Human Photonics Laboratory, University of Washington, Seattle, WA, USA
| | - Francis S Lee
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA,NewYork-Presbyterian Hospital, New York, NY, USA
| | - Margaret Altemus
- Department of Psychiatry, Weill Cornell Medical College, New York, NY, USA,NewYork-Presbyterian Hospital, New York, NY, USA
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Rizzo A“S, Buckwalter JG, Forbell E, Reist C, Difede J, Rothbaum BO, Lange B, Koenig S, Talbot T. Virtual Reality Applications to Address the Wounds of War. Psychiatr Ann 2013. [DOI: 10.3928/00485713-20130306-08] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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McLay RN, Graap K, Spira J, Perlman K, Johnston S, Rothbaum BO, Difede J, Deal W, Oliver D, Baird A, Bordnick PS, Spitalnick J, Pyne JM, Rizzo A. Development and testing of virtual reality exposure therapy for post-traumatic stress disorder in active duty service members who served in Iraq and Afghanistan. Mil Med 2012; 177:635-42. [PMID: 22730837 DOI: 10.7205/milmed-d-11-00221] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
This study was an open-label, single-group, treatment-development project aimed at developing and testing a method for applying virtual reality exposure therapy (VRET) to active duty service members diagnosed with combat post-traumatic stress disorder (PTSD). Forty-two service members with PTSD were enrolled, and 20 participants completed treatment. The PTSD Checklist-Military version, Patient Health Questionnaire-9 for depression, and the Beck Anxiety Inventory were used as outcome measures. Of those who completed post-treatment assessment, 75% had experienced at least a 50% reduction in PTSD symptoms and no longer met DSM-IV criteria for PTSD at post treatment. Average PSTD scores decreased by 50.4%, depression scores by 46.6%, and anxiety scores by 36%. Intention-to-treat analyses showed that statistically significant improvements in PTSD, depression, and anxiety occurred over the course of treatment and were maintained at follow up. There were no adverse events associated with VRET treatment. This study provides preliminary support for the use of VRET in combat-related PTSD. Further study will be needed to determine the wider utility of the method and to determine if it offers advantages over other established PTSD treatment modalities.
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Affiliation(s)
- Robert N McLay
- Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA
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Rizzo A, Parsons TD, Lange B, Kenny P, Buckwalter JG, Rothbaum B, Difede J, Frazier J, Newman B, Williams J, Reger G. Virtual Reality Goes to War: A Brief Review of the Future of Military Behavioral Healthcare. J Clin Psychol Med Settings 2011; 18:176-87. [DOI: 10.1007/s10880-011-9247-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Cukor J, Wyka K, Jayasinghe N, Weathers F, Giosan C, Leck P, Roberts J, Spielman L, Crane M, Difede J. Prevalence and predictors of posttraumatic stress symptoms in utility workers deployed to the World Trade Center following the attacks of September 11, 2001. Depress Anxiety 2011; 28:210-7. [PMID: 21394854 DOI: 10.1002/da.20776] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 11/02/2010] [Accepted: 11/06/2010] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Recent attention has begun to be focused on the effects of disaster recovery work on nonrescue workers. The goal of this study was to assess the prevalence and predictors of posttraumatic stress disorder (PTSD) and related symptoms in a population of utility workers deployed to the World Trade Center (WTC) site in the aftermath of 9/11. METHODS Utility workers deployed to the WTC site were screened at their place of employment between 10 and 34 months following the WTC attacks, utilizing both structured interviews and self-report measures. PTSD symptoms were assessed by the CAPS and the PCL; co-morbid disorders were also assessed. 2,960 individuals with complete CAPS and PCL data were included in the analyses. RESULTS Eight percent of participants had symptoms consistent with full PTSD, 9.3% with subthreshold PTSD, 6% with MDD, 3.5% with GAD, and 2.5% with panic disorder. Although risk factors included psychiatric and trauma history, 51% of individuals with probable PTSD had neither; subjective perception of threat to one's life was the best predictor of probable PTSD. Extent of exposure predicted 89% of PTSD cases in those without a psychiatric or trauma history, but only 67% of cases among those with both. CONCLUSIONS Nonrescue workers deployed to a disaster site are at risk for PTSD and depression. Extent of exposure affected the most vulnerable workers differently than the least vulnerable ones. These results suggest that the relationship among predictors of PTSD may be different for different vulnerability groups, and underscore the importance of screening, education, and prevention programs for disaster workers.
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Affiliation(s)
- Judith Cukor
- Department of Psychiatry, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA.
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Reger GM, Holloway KM, Candy C, Rothbaum BO, Difede J, Rizzo AA, Gahm GA. Effectiveness of virtual reality exposure therapy for active duty soldiers in a military mental health clinic. J Trauma Stress 2011; 24:93-6. [PMID: 21294166 DOI: 10.1002/jts.20574] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Exposure therapy is an evidence-based treatment for posttraumatic stress disorder (PTSD), but research evaluating its effectiveness with active duty service members is limited. This report examines the effectiveness of virtual reality exposure therapy (VRE) for active duty soldiers (N = 24) seeking treatment following a deployment to Iraq or Afghanistan. Relative to their pretreatment self-reported symptoms on the PTSD Checklist, Military Version (M = 60.92; SD = 11.03), patients reported a significant reduction at posttreatment (M = 47.08; SD = 12.70; p < .001). Sixty-two percent of patients (n = 15) reported a reliable change of 11 points or more. This study supports the effectiveness of exposure therapy for active duty soldiers and extends previous research on VRE to this population.
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Affiliation(s)
- Greg M Reger
- Madigan Army Medical Center, Building 9933A, National Center for Telehealth and Technology, Fort Lewis, WA 98433, USA.
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Rizzo AA, Lange B, Buckwalter JG, Forbell E, Kim J, Sagae K, Williams J, Rothbaum BO, Difede J, Reger G, Parsons T, Kenny P. An intelligent virtual human system for providing healthcare information and support. Stud Health Technol Inform 2011; 163:503-509. [PMID: 21335847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Over the last 15 years, a virtual revolution has taken place in the use of Virtual Reality simulation technology for clinical purposes. Shifts in the social and scientific landscape have now set the stage for the next major movement in Clinical Virtual Reality with the "birth" of intelligent virtual humans. Seminal research and development has appeared in the creation of highly interactive, artificially intelligent and natural language capable virtual human agents that can engage real human users in a credible fashion. No longer at the level of a prop to add context or minimal faux interaction in a virtual world, virtual humans can be designed to perceive and act in a 3D virtual world, engage in spoken dialogues with real users and can be capable of exhibiting human-like emotional reactions. This paper will present an overview of the SimCoach project that aims to develop virtual human support agents to serve as online guides for promoting access to psychological healthcare information and for assisting military personnel and family members in breaking down barriers to initiating care. The SimCoach experience is being designed to attract and engage military Service Members, Veterans and their significant others who might not otherwise seek help with a live healthcare provider. It is expected that this experience will motivate users to take the first step--to empower themselves to seek advice and information regarding their healthcare and general personal welfare and encourage them to take the next step towards seeking more formal resources if needed.
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Affiliation(s)
- Albert A Rizzo
- University of Southern California, Institute for Creative Technologies, Playa Vista, CA 90064, USA.
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Abstract
Posttraumatic stress disorder (PTSD) is a chronic, debilitating, psychological condition that occurs in a subset of individuals who experience or witness life-threatening traumatic events. PTSD is highly prevalent in those who served in the military. In this paper, we present the underlying theoretical foundations and existing research on virtual reality exposure therapy, a recently emerging treatment for PTSD. Three virtual reality scenarios used to treat PTSD in active duty military and combat veterans and survivors of terrorism are presented: Virtual Vietnam, Virtual Iraq, and Virtual World Trade Center. Preliminary results of ongoing trials are presented.
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Rizzo AS, Difede J, Rothbaum BO, Reger G, Spitalnick J, Cukor J, McLay R. Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD. Ann N Y Acad Sci 2010; 1208:114-25. [PMID: 20955333 DOI: 10.1111/j.1749-6632.2010.05755.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Numerous reports indicate that the growing incidence of posttraumatic stress disorder (PTSD) in returning Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) military personnel is creating a significant health care and economic challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. Virtual reality-delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper will detail the development and early results from use of the Virtual Iraq/Afghanistan exposure therapy system. The system consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern contexts for exposure therapy, including a city and desert road convoy environment. The process for gathering user-centered design feedback from returning OEF/OIF military personnel and from a system deployed in Iraq (as was needed to iteratively evolve the system) will be discussed, along with a brief summary of results from an open clinical trial using Virtual Iraq with 20 treatment completers, which indicated that 16 no longer met PTSD checklist-military criteria for PTSD after treatment.
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Affiliation(s)
- Albert Skip Rizzo
- Institute for Creative Technologies, Department of Psychiatry and School of Gerontology, University of Southern California, Playa Vista, California 90094, USA.
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Abstract
The growing number of soldiers returning home with psychiatric and neurologic disorders, notably posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI), underscores the need for an interdisciplinary framework for understanding the emergent consequences of combat. Among the challenges facing the scientific community is the development of effective treatment strategies for TBI from blast and other injuries, given the confounding effects of comorbid psychological symptoms on accurate diagnoses. At the individual level, emerging technologies-including virtual reality, the use of genetic biomarkers to inform treatment response, and new brain imaging methodology-are playing an important role in the development of differential therapeutics to best address a soldier's particular clinical needs. At the macro level, new approaches toward understanding the political, cultural, and ideological contexts of mass conflict, the decision to join in violence, and ways of preventing genocide are discussed.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry, Weill Cornell Medical College, New York, New York 10065, USA.
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Frielingsdorf H, Bath KG, Soliman F, Difede J, Casey BJ, Lee FS. Variant brain-derived neurotrophic factor Val66Met endophenotypes: implications for posttraumatic stress disorder. Ann N Y Acad Sci 2010; 1208:150-7. [PMID: 20955337 DOI: 10.1111/j.1749-6632.2010.05722.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Recently, a common single nucleotide polymorphism (SNP) has been identified in the gene encoding brain-derived neurotrophic factor (BDNF). The variant BDNF(Met) has been shown to have decreased activity-dependent BDNF secretion from neurons and to lead to impairments in specific forms of learning and altered susceptibility to stress. A mouse model containing BDNF(Met) has also been linked to increased anxiety-like behavior. In a translational study, mice and human carriers of the BDNF(Met) allele were compared in their ability to extinguish a learned fear memory. Both showed slower suppression of the learned fear response. In humans, the neural correlates of this behavior were validated using fMRI. As anxiety and fear extinction lie at the core of symptoms and therapeutic approaches to posttraumatic stress disorder (PTSD), we propose that BDNF genotype and neuroimaging may be useful as biomarkers to provide guidance for more customized therapeutic directions. The aim of this paper is to review the available knowledge on the BDNF Val66Met SNP, with emphasis on anxiety- and fear-related endophenotypes and its potential implications for PTSD.
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Affiliation(s)
- Helena Frielingsdorf
- The Sackler Institute for Developmental Psychobiology, Weill Medical College of Cornell University, New York, New York 10065, USA.
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Abstract
This paper provides a current review of existing evidence-based treatments for posttraumatic stress disorder (PTSD), with a description of psychopharmacologic options, prolonged exposure therapy, cognitive processing therapy, and eye movement desensitization and reprocessing, especially as they pertain to military populations. It further offers a brief summary of promising treatments with a developing evidence base, encompassing both psychotherapy and pharmacotherapy. Finally, challenges to the treatment of PTSD are summarized and future directions suggested.
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Affiliation(s)
- Judith Cukor
- Department of Psychiatry, Weill Cornell Medical College of Cornell University, New York, New York 10065, USA.
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Olden M, Cukor J, Rizzo AS, Rothbaum B, Difede J. House calls revisited: leveraging technology to overcome obstacles to veteran psychiatric care and improve treatment outcomes. Ann N Y Acad Sci 2010; 1208:133-41. [PMID: 20955335 PMCID: PMC4018828 DOI: 10.1111/j.1749-6632.2010.05756.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Despite an increasing number of military service members in need of mental health treatment following deployment to Iraq and Afghanistan, numerous psychological and practical barriers limit access to care. Perceived stigma about admitting psychological difficulties as well as frequent long distances to treatment facilities reduce many veterans' willingness and ability to receive care. Telemedicine and virtual human technologies offer a unique potential to expand services to those in greatest need. Telemedicine-based treatment has been used to address multiple psychiatric disorders, including posttraumatic stress disorder, depression, and substance use, as well as to provide suicide risk assessment and intervention. Clinician education and training has also been enhanced and expanded through the use of distance technologies, with trainees practicing clinical skills with virtual patients and supervisors connecting with clinicians via videoconferencing. The use of these innovative and creative vehicles offers a significant and as yet unfulfilled promise to expand delivery of high-quality psychological therapies, regardless of clinician and patient location.
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Affiliation(s)
- Megan Olden
- Department of Psychiatry, Weill Cornell Medical College of Cornell University, New York, New York 10065, USA.
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Cukor J, Spitalnick J, Difede J, Rizzo A, Rothbaum BO. Emerging treatments for PTSD. Clin Psychol Rev 2009; 29:715-26. [DOI: 10.1016/j.cpr.2009.09.001] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Revised: 09/01/2009] [Accepted: 09/02/2009] [Indexed: 11/16/2022]
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Evans S, Patt I, Giosan C, Spielman L, Difede J. Disability and posttraumatic stress disorder in disaster relief workers responding to september 11, 2001 World Trade Center Disaster. J Clin Psychol 2009; 65:684-94. [DOI: 10.1002/jclp.20575] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Giosan C, Malta L, Jayasinghe N, Spielman L, Difede J. Relationships between memory inconsistency for traumatic events following 9/11 and PTSD in disaster restoration workers. J Anxiety Disord 2009; 23:557-61. [PMID: 19117719 DOI: 10.1016/j.janxdis.2008.11.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 10/20/2008] [Accepted: 11/08/2008] [Indexed: 10/21/2022]
Abstract
The present study examined the relationships between memories for a single incident traumatic event - the 9/11 attack on the World Trade Center (WTC)--and posttraumatic stress disorder (PTSD). 2641 disaster restoration workers deployed at the WTC site in the aftermath of the attack were evaluated longitudinally, one year apart, for PTSD, using clinical interviews. Their recollection of the traumatic events was also assessed at these times. The results showed that recall of traumatic events amplified over time and that increased endorsement of traumas at Time 2 was associated with more severe PTSD symptoms. It was also shown that, of all the exposure variables targeted, memory of the perception of life threat and of seeing human remains were differentially associated with PTSD symptoms. Implications of the results are also discussed.
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Affiliation(s)
- Cezar Giosan
- Department of Psychiatry, Weill Medical College of Cornell University, New York, USA.
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Malta LS, Wyka KE, Giosan C, Jayasinghe N, Difede J. Numbing symptoms as predictors of unremitting posttraumatic stress disorder. J Anxiety Disord 2009; 23:223-9. [PMID: 18755571 DOI: 10.1016/j.janxdis.2008.07.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Revised: 07/09/2008] [Accepted: 07/11/2008] [Indexed: 11/25/2022]
Abstract
This prospective longitudinal study examined the ability of re-experiencing, avoidance, numbing, and hyperarousal symptoms to predict persistence of posttraumatic stress disorder (PTSD) in disaster workers followed for 2 years. Cluster analyses suggested that overall severity was the best predictor of PTSD at follow up, but for groups with PTSD of moderate severity, numbing symptoms were also associated with PTSD at the 2-year follow up. Regression analyses with all four symptom groups as independent variables found that only numbing and re-experiencing symptoms predicted PTSD at the 1 year follow up, and only numbing symptoms predicted PTSD at the 2-year follow up. Findings suggest that numbing symptom severity could be used as a risk index of very chronic PTSD, especially when the overall PTSD severity falls in the moderate range.
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Affiliation(s)
- Loretta S Malta
- Weill Medical College of Cornell Department of Psychiatry, New York, NY 10065, United States.
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Yeh SC, Newman B, Liewer M, Pair J, Treskunov A, Reger G, Rothbaum B, Difede J, Spitalnick J, McLay R, Parsons T, Rizzo A. A Virtual Iraq System for the Treatment of Combat-Related Posttraumatic Stress Disorder. ACTA ACUST UNITED AC 2009. [DOI: 10.1109/vr.2009.4811017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Difede J, Cukor J, Jayasinghe N, Patt I, Jedel S, Spielman L, Giosan C, Hoffman HG. Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. J Clin Psychiatry 2007; 68:1639-47. [PMID: 18052556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
OBJECTIVE This preliminary study endeavored to evaluate the use of virtual reality (VR) enhanced exposure therapy for the treatment of posttraumatic stress disorder (PTSD) consequent to the World Trade Center attacks of September 11, 2001. METHOD Participants were assigned to a VR treatment (N = 13) or a waitlist control (N = 8) group and were mostly middle-aged, male disaster workers. All participants were diagnosed with PTSD according to DSM-IV-TR criteria using the Clinician-Administered PTSD Scale (CAPS). The study was conducted between February 2002 and August 2005 in offices located in outpatient buildings of a hospital campus. RESULTS Analysis of variance showed a significant interaction of time by group (p < .01) on CAPS scores, with a between-groups posttreatment effect size of 1.54. The VR group showed a significant decline in CAPS scores compared with the waitlist group (p < .01). CONCLUSIONS Our preliminary data suggest that VR is an effective treatment tool for enhancing exposure therapy for both civilians and disaster workers with PTSD and may be especially useful for those patients who cannot engage in imaginal exposure therapy.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry, Weill Medical College of Cornell University, New York, NY 10021, USA.
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Palmieri PA, Weathers FW, Difede J, King DW. Confirmatory factor analysis of the PTSD Checklist and the Clinician-Administered PTSD Scale in disaster workers exposed to the World Trade Center Ground Zero. Journal of Abnormal Psychology 2007; 116:329-41. [PMID: 17516765 DOI: 10.1037/0021-843x.116.2.329] [Citation(s) in RCA: 192] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although posttraumatic stress disorder (PTSD) factor analytic research has yielded little support for the DSM-IV 3-factor model of reexperiencing, avoidance, and hyperarousal symptoms, no clear consensus regarding alternative models has emerged. One possible explanation is differential instrumentation across studies. In the present study, the authors used confirmatory factor analysis to compare a self-report measure, the PTSD Checklist (PCL), and a structured clinical interview, the Clinician-Administered PTSD Scale (CAPS), in 2,960 utility workers exposed to the World Trade Center Ground Zero site. Although two 4-factor models fit adequately for each measure, the latent structure of the PCL was slightly better represented by correlated reexperiencing, avoidance, dysphoria, and hyperarousal factors, whereas that of the CAPS was slightly better represented by correlated reexperiencing, avoidance, emotional numbing, and hyperarousal factors. After accounting for method variance, the model specifying dysphoria as a distinct factor achieved slightly better fit. Patterns of correlations with external variables provided additional support for the dysphoria model. Implications regarding the underlying structure of PTSD are discussed.
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Affiliation(s)
- Patrick A Palmieri
- Center for the Treatment and Study of Traumatic Stress and Department of Psychiatry, St. Thomas Hospital, Summa Health System, Akron, OH 44310, USA.
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Evans S, Giosan C, Patt I, Spielman L, Difede J. Anger and its association to distress and social/occupational functioning in symptomatic disaster relief workers responding to the September 11, 2001, World Trade Center disaster. J Trauma Stress 2006; 19:147-52. [PMID: 16568457 DOI: 10.1002/jts.20107] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Empirical evidence suggests that anger plays a significant role in posttraumatic stress disorder (PTSD) and may impede recovery from traumatic events. The purpose of this study was to assess the role of anger and its relationship to distress and social/occupational functioning in disaster relief workers (DRWs) who had PTSD symptoms who were deployed to the World Trade Center after September 11, 2001. Six hundred twenty-six utility workers (96% male) completed measures of anger, distress, PTSD severity, and social/occupational functioning. Results indicated that anger was significantly higher in DRWs who had PTSD symptoms than in those who did not, and statistically significant associations were found among anger, distress, PTSD severity, and social/occupational functioning in workers who had PTSD symptoms. Careful assessment of anger in DRWs exposed to traumatic events is warranted as well as longitudinal studies to further understand the relationship between anger and PTSD.
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Affiliation(s)
- Susan Evans
- Department of Psychiatry, Weill Medical College of Cornell University, 525 East 68th Street, Box 147, New York, NY 10021, USA.
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Leck P, Difede J, Patt I, Giosan C, Szkodny L. Incidence of male childhood sexual abuse and psychological sequelae in disaster workers exposed to a terrorist attack. Int J Emerg Ment Health 2006; 8:267-74. [PMID: 17131772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This study documents the prevalence of male childhood sexual abuse (CSA) and psychological sequelae in a sample of disaster workers deployed to the World Trade Center (WTC) site following the September 11, 2001 terrorist attack. There are limited data on male CSA and its psychological impact, especially on a large non-treatment seeking sample. As part of a mandatory medical screening program, workers were assessed with well-validated and widely used clinician interview and self-report measures following their involvement in the restoration of services to Ground Zero and surrounding areas of lower Manhattan. Frequency of CSA measured by the Traumatic Events Interview (TEI) was 4.3% (n = 92). Clinician interview and self-report data were analyzed using t-tests, revealing statistically significant relationships (but not clinically meaningful scores) between CSA and scores on the CAPS, PCL, BDI, STAXI, and SDS. Further analyses revealed that individuals endorsing CSA were three-times more likely to score high (vs. low) on the BDI and CAPS. Since disaster workers traditionally summon images of strength and mastery, professionals may overlook CSA and symptoms of depression and PTSD in this population.
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Affiliation(s)
- Pam Leck
- Department of Psychiatry, Weill Medical College, Cornell University, New York, NY, USA.
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Jayasinghe N, Spielman L, Cancellare D, Difede J, Klausner EJ, Giosan C. Predictors of treatment utilization in world trade center attack disaster workers: role of race/ethnicity and symptom severity. Int J Emerg Ment Health 2005; 7:91-9. [PMID: 16107041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
This study examined treatment utilization in disaster workers deployed to the World Trade Center (WTC) during or after the terrorist attacks of September 11, 2001. Among 174 workers who accepted psychotherapy referrals following psychiatric screening for WTC-related symptoms, 74 (42.5%) attended at least one session, while 100 (57.5%) chose not to attend at all. The study assessed whether treatment utilization was associated with sociodemographic background, trauma history, psychiatric history, WTC attack exposure, diagnoses, or symptom severity. Analyses indicated that, of study variables, race/ethnicity and clinician-rated Post Traumatic Stress Disorder (PTSD) symptom severity distinguished workers who utilized treatment from those who did not. Implications for outreach and referral are discussed.
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Affiliation(s)
- Nimali Jayasinghe
- Department of Psychiatry Weill Medical College Cornell University NewYork, NY, USA.
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Abstract
Attribution of responsibility for a traumatic event has been related to subsequent adjustment. Self-blame has been associated with better adjustment in some cases and worse in others, whereas other-blame has consistently been associated with poorer outcomes. This study assessed the relationship between attribution of responsibility and acute stress disorder (ASD) in burn victims. Hospitalized burn patients (N = 124) underwent psychological assessment within 2 weeks of their burn injury. Participants were categorized as reporting self-blame (N = 49), other-blame (N = 36), both (N = 10), or neither (N = 29). Twenty-three percent of those with other-blame were diagnosed with ASD, compared with 0% of those with self-blame. Self-blame and other-blame also were related to ASD in logistic regression analyses controlling for demographic and medical variables. With both types of blame in the same model, self-blame was significantly associated with lower rates of ASD, whereas other-blame was related to higher rates, but this did not reach significance. When analyzed in separate models, both of these relationships attained statistical significance. These findings have implications for identifying and treating people at risk for posttraumatic stress disorder after exposure to trauma.
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Affiliation(s)
- Jennifer F Lambert
- Department of Psychology, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
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Abstract
Done properly by experienced therapists, re-exposure to memories of traumatic events via imaginal exposure therapy can lead to a reduction of Post-traumatic Stress Disorder (PTSD) symptoms. Exposure helps the patient process and habituate to memories and strong emotions associated with the traumatic event: memories and emotions they have been carefully avoiding. But many patients are unwilling or unable to self-generate and re-experience painful emotional images. The present case study describes the treatment of a survivor of the World Trade Center (WTC) attack of 9-11-01 who had developed acute PTSD. After she failed to improve with traditional imaginal exposure therapy, we sought to increase emotional engagement and treatment success using virtual reality (VR) exposure therapy. Over the course of six 1-h VR exposure therapy sessions, we gradually and systematically exposed the PTSD patient to virtual planes flying over the World Trade Center, jets crashing into the World Trade Center with animated explosions and sound effects, virtual people jumping to their deaths from the burning buildings, towers collapsing, and dust clouds. VR graded exposure therapy was successful for reducing acute PTSD symptoms. Depression and PTSD symptoms as measured by the Beck Depression Inventory and the Clinician Administered PTSD Scale indicated a large (83%) reduction in depression, and large (90%) reduction in PTSD symptoms after completing VR exposure therapy. Although case reports are scientifically inconclusive by nature, these strong preliminary results suggest that VR exposure therapy is a promising new medium for treating acute PTSD. This study may be examined in more detail at www.vrpain.com.
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Affiliation(s)
- JoAnn Difede
- Weill Medical College of Cornell University, New York, New York, USA.
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Abstract
OBJECTIVES The principal goals of this study were to determine whether ASD predicted chronic PTSD and whether dissociation is more characteristic of the acute-trauma period than PTSD symptoms. METHODS Eighty-three hospitalized adult burn patients were assessed with structured interviews and self-report measures within 2 weeks of injury and again at least 6 months postburn. RESULTS Nineteen percent had ASD. Dissociative symptoms were not more common or more severe than PTSD symptoms. Thirty-six percent had chronic PTSD. While ASD predicted chronic PTSD, meeting the symptom criteria for PTSD within 2 weeks postburn also predicted chronic PTSD. CONCLUSIONS Our data support the inclusion of an ASD diagnosis in the DSM, which would allow the diagnosis of symptoms in the first month posttrauma as a psychiatric disorder but questions whether dissociation is more characteristic of the acute trauma period than the PTSD symptom clusters.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry and William Randolph Hearst Burn Center, The New York Presbyterian Hospital, New York, NY 10021, USA.
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Affiliation(s)
- JoAnn Difede
- Department of Psychiatry, Weill Medical College of Cornell University, New York, New York 10021, USA.
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Abstract
This study investigated the association of trauma symptoms and hypnotizability in 43 hospitalized survivors of burn injury. Three to 17 days after the injury, participants rated the frequency of intrusive and avoidance symptoms and were interviewed with the posttraumatic stress disorder module of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-III-R. The Hypnotic Induction Profile was also administered at the postburn, hospital stage of recovery. Results indicated that when participants were divided into low, mid-range, and high hypnotizability categories, high hypnotizability was associated with more intrusive, avoidance, and arousal symptoms. Although causal relations cannot be assessed in this cross-sectional study, these results suggest that, as compared to the low and mid-range categories, high hypnotizables may experience a greater frequency of trauma symptoms after burn injury.
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Affiliation(s)
- Katherine N DuHamel
- Ruttenberg Cancer Center, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
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