Development and validation of a brief screener for posttraumatic stress disorder risk in emergency medical settings

OBJECTIVE

Predicting risk of posttraumatic stress disorder (PTSD) in the acute care setting is challenging given the pace and acute care demands in the emergency department (ED) and the infeasibility of using time-consuming assessments. Currently, no accurate brief screening for long-term PTSD risk is routinely used in the ED. One instrument widely used in the ED is the 27-item Immediate Stress Reaction Checklist (ISRC). The aim of this study was to develop a short screener using a machine learning approach and to investigate whether accurate PTSD prediction in the ED can be achieved with substantially fewer items than the IRSC.

METHOD

This prospective longitudinal cohort study examined the development and validation of a brief screening instrument in two independent samples, a model development sample (N = 253) and an external validation sample (N = 93). We used a feature selection algorithm to identify a minimal subset of features of the ISRC and tested this subset in a predictive model to investigate if we can accurately predict long-term PTSD outcomes.

RESULTS

We were able to identify a reduced subset of 5 highly predictive features of the ISRC in the model development sample (AUC = 0.80), and we were able to validate those findings in the external validation sample (AUC = 0.84) to discriminate non-remitting vs. resilient trajectories.

CONCLUSION

This study developed and validated a brief 5-item screener in the ED setting, which may help to improve the diagnostic process of PTSD in the acute care setting and help ED clinicians plan follow-up care when patients are still in contact with the healthcare system. This could reduce the burden on patients and decrease the risk of chronic PTSD.

A virtual environment for the treatment of chronic combat-related post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is one of the most disabling psychopathological conditions affecting the veteran population. An estimated 830,000 U.S. veterans currently have symptoms of chronic combat-related PTSD. No therapeutic approach has proven to be consistently effective in the management of combat-related PTSD. Behavior therapies with an exposure element have proven more effective than most other types of treatment, but a significant number of patients do not seem to benefit from them, possibly because of difficulties imagining, visualizing, or describing their traumatic experiences. In this article, we describe Virtual Vietnam, a set of two virtual environments we have developed for the treatment of combat-related PTSD, and its use as one component of a comprehensive treatment program.

Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder

BACKGROUND

Virtual reality (VR) integrates real-time computer graphics, body-tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment that changes in a natural way with head and body motion. VR exposure (VRE) is proposed as an alternative to typical imaginal exposure treatment for Vietnam combat veterans with posttraumatic stress disorder (PTSD).

METHOD

This report presents the results of an open clinical trial using VRE to treat Vietnam combat veterans who have DSM-IV PTSD. In 8 to 16 sessions, 10 male patients were exposed to 2 virtual environments: a virtual Huey helicopter flying over a virtual Vietnam and a clearing surrounded by jungle.

RESULTS

Clinician-rated PTSD symptoms as measured by the Clinician Administered PTSD Scale, the primary outcome measure, at 6-month follow-up indicated an overall statistically significant reduction from baseline (p = .0021) in symptoms associated with specific reported traumatic experiences. All 8 participants interviewed at the 6-month follow-up reported reductions in PTSD symptoms ranging from 15% to 67%. Significant decreases were seen in all 3 symptom clusters (p < .02). Patient self-reported intrusion symptoms as measured by the Impact of Event Scale were significantly lower (p < .05) at 3 months than at baseline but not at 6 months, although there was a clear trend toward fewer intrusive thoughts and somewhat less avoidance.

CONCLUSION

Virtual reality exposure therapy holds promise for treating PTSD in Vietnam veterans.

Dreams and exposure therapy in PTSD

Exposure therapy is a well-established treatment for PTSD that requires the patient to focus on and describe the details of a traumatic experience. Nightmares that refer to or replicate traumatic experiences are prominent and distressing symptoms of PTSD and appear to exacerbate the disorder. With this apparent paradox in mind, exposure therapy and the literature on sleep and PTSD are reviewed in the context of the relationship between therapeutic exposure and exposure to trauma-related stimuli that occurs in dreams. It is concluded that nightmares that replay the trauma and disrupt sleep do not meet requirements for therapeutic exposure, whereas other dreaming may aid in the recovery from trauma.

Virtual reality: using the virtual world to improve quality of life in the real world

Mental health professionals are increasingly integrating advances in technology to improve the health of those in their care (American Psychological Association, 2000). The authors describe the immersive properties of virtual reality and its importance for clinical purposes and then review the literature describing current clinical applications of virtual reality (VR) and research documenting its efficacy. Virtual reality has been used in the treatment of specific phobias, posttraumatic stress disorder, eating disorders, and pain management.

Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is a common illness associated with significant disability. Few large, placebo-controlled trials have been reported.

METHODS

Outpatients with a DSM-III-R diagnosis of moderate-to-severe PTSD were randomized to 12 weeks of double-blind treatment with either sertraline (N = 100) in flexible daily doses in the range of 50 to 200 mg or placebo (N = 108). Primary outcome measures consisted of the Clinician-Administered PTSD Scale (CAPS-2) total severity score, the patient-rated Impact of Event Scale (IES), and the Clinical Global Impression-Severity (CGI-S) and -Improvement (CGI-I) ratings.

RESULTS

Mixed-effects analyses found significantly steeper improvement slopes for sertraline compared with placebo on the CAPS-2 (t = 2.96, P =.003), the IES (t = 2.26, P =.02), the CGI-I score (t = 3.62, P<.001), and the CGI-S score (t = 4.40, P<.001). An intent-to-treat end-point analysis found a 60% responder rate for sertraline and a 38% responder rate for placebo (chi(2)(1) = 8.48, P =.004). Sertraline treatment was well tolerated, with a 9% discontinuation rate because of adverse events, compared with 5% for placebo. Adverse events that were significantly more common in subjects given sertraline compared with placebo consisted of insomnia (35% vs 22%), diarrhea (28% vs 11%), nausea (23% vs 11%), fatigue (13% vs 5%), and decreased appetite (12% vs 1%).

CONCLUSION

The results of the current study suggest that sertraline is a safe, well-tolerated, and significantly effective treatment for PTSD.

Posttraumatic stress disorder in rape victims: autonomic habituation to auditory stimuli

Impaired capacity for physiological habituation may contribute to the persistence of PTSD. Habituation of autonomic responses to auditory tones was examined in 43 women in three groups: 14 adult female rape survivors with chronic PTSD, 11 without PTSD, and a comparison group of 18 who had not been raped. There were no significant differences among the groups in baseline cardiac or electrodermal activity. The PTSD group showed significantly slower electrodermal habituation, as measured by trials to extinction and percentage of nonhabituators, than did the comparison groups. The present study found slower habituation of electrodermal responses for PTSD rape victims to neutral stimuli than for non-PTSD victims and nonvictims.

A controlled study of virtual reality exposure therapy for the fear of flying

Fear of flying (FOF) affects an estimated 10-25% of the population. Patients with FOF (N = 49) were randomly assigned to virtual reality exposure (VRE) therapy, standard exposure (SE) therapy, or a wait-list (WL) control. Treatment consisted of 8 sessions over 6 weeks, with 4 sessions of anxiety management training followed by either exposure to a virtual airplane (VRE) or exposure to an actual airplane at the airport (SE). A posttreatment flight on a commercial airline measured participants' willingness to fly and anxiety during flight immediately after treatment. The results indicated that VRE and SE were both superior to WL, with no differences between VRE and SE. The gains observed in treatment were maintained at a 6-month follow up. By 6 months posttreatment, 93% of VRE participants and 93% of SE participants had flown. VRE therapy and SE therapy for treatment of FOF were unequivocally supported in this controlled study.

A controlled study of virtual reality exposure therapy for the fear of flying

Fear of flying (FOF) affects an estimated 10-25% of the population. Patients with FOF (N = 49) were randomly assigned to virtual reality exposure (VRE) therapy, standard exposure (SE) therapy, or a wait-list (WL) control. Treatment consisted of 8 sessions over 6 weeks, with 4 sessions of anxiety management training followed by either exposure to a virtual airplane (VRE) or exposure to an actual airplane at the airport (SE). A posttreatment flight on a commercial airline measured participants' willingness to fly and anxiety during flight immediately after treatment. The results indicated that VRE and SE were both superior to WL, with no differences between VRE and SE. The gains observed in treatment were maintained at a 6-month follow up. By 6 months posttreatment, 93% of VRE participants and 93% of SE participants had flown. VRE therapy and SE therapy for treatment of FOF were unequivocally supported in this controlled study.

Integration of pharmacotherapy and psychotherapy for bipolar disorder

There is no question that pharmacotherapy is the treatment of choice for bipolar disorder. However. an integration of psychotherapeutic techniques with pharmacotherapy has been recommended by the American Psychiatric Association practice guideline for the treatment of bipolar disorder. Psychotherapy aims to address risk factors and associated features that are difficult to address with pharmacotherapy alone. The most common psychotherapeutic approaches added to pharmacotherapy for bipolar disorder include psychoeducation, individual cognitive-behavioral therapy, marital and family interventions, individual interpersonal therapy, and adjunctive therapies such as those for substance use. Each of these approaches is described in detail, and research regarding their efficacy is presented.

A placebo-controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania

BACKGROUND

The major treatments reported to be effective in the treatment of trichotillomania are cognitive-behavioral therapy (CBT) with habit reversal and serotonin-norepinephrine reuptake inhibitors such as clomipramine. However, the 2 treatments have not been previously compared with each other. This study examines the efficacy of CBT and clomipramine compared with placebo in the treatment of trichotillomania.

METHOD

Twenty-three patients with trichotillomania as determined by the Structured Clinical Interview for DSM-III-R entered and 16 completed a 9-week, placebo-controlled, randomized, parallel-treatment study of CBT and clomipramine. Efficacy was evaluated by the Trichotillomania Severity Scale, the Trichotillomania Impairment Scale, and the Clinical Global Impressions-Improvement scale, which were conducted by an independent assessor blinded to the treatment condition.

RESULTS

CBT had a dramatic effect in reducing symptoms of trichotillomania and was significantly more effective than clomipramine (p = .016) or placebo (p = .026). Clomipramine resulted in symptom reduction greater than that with placebo, but the difference fell short of statistical significance. Placebo response was minimal.

CONCLUSION

Clinicians should be aware of the potential treatments available for trichotillomania. A larger and more definitive study comparing CBT and a serotonin-norepinephrine reuptake inhibitor is indicated.

The use of virtual reality exposure in the treatment of anxiety disorders

One possible alternative to standard in vivo exposure may be virtual reality exposure. Virtual reality integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment. Virtual reality exposure (VRE) is potentially an efficient and cost-effective treatment of anxiety disorders. VRE therapy has been successful in reducing the fear of heights in the first known controlled study of virtual reality in the treatment of a psychological disorder. Outcome was assessed on measures of anxiety, avoidance, attitudes, and distress. Significant group differences were found on all measures such that the VRE group was significantly improved at posttreatment but the control group was unchanged. The efficacy of virtual reality exposure therapy was also supported for the fear of flying in a case study. The potential for virtual reality exposure treatment for these and other disorders is explored.

Virtual reality exposure therapy for PTSD Vietnam Veterans: a case study

Virtual reality (VR) integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment that changes in a natural way with head and body motion. VR exposure (VRE) is proposed as an alternative to typical imaginal exposure treatment for Vietnam combat veterans with posttraumatic stress disorder (PTSD). This report presents the results of the first Vietnam combat veteran with PTSD to have been treated with VRE. The patient was exposed to two virtual environments, a virtual Huey helicopter flying over a virtual Vietnam and a clearing surrounded by jungle. The patient experienced a 34% decrease on clinician-rated PTSD and a 45% decrease on self-rated PTSD. Treatment gains were maintained at 6-month follow-up.

A controlled trial of venlafaxine in trichotillomania: interim phase I results

This article reports the preliminary findings of a two-phase trial examining the efficacy of venlafaxine in trichotillomania. Phase 1 is a 12-week, open-label, prospective trial of venlafaxine in trichotillomania. Venlafaxine was effective in significantly reducing the symptoms of trichotillomania; 8 of 12 patients were considered responders. The implications of the efficacy of venlafaxine in trichotillomania are discussed, including its important advantages over other available antidepressant and anxiolytic medications.

A controlled study of eye movement desensitization and reprocessing in the treatment of posttraumatic stress disordered sexual assault victims

Eye movement desensitization and reprocessing (EMDR) is a new method developed to treat posttraumatic stress disorder (PTSD). This study evaluated the efficacy of EMDR compared to a no-treatment wait-list control in the treatment of PTSD in adult female sexual assault victims. Twenty-one subjects were entered, and 18 completed. Treatment was delivered in four weekly individual sessions. Assessments were conducted pre- and posttreatment and 3 months following treatment termination by an independent assessor kept blind to treatment condition. Measures included standard clinician- and self-administered PTSD and related psychopathology scales. Results indicated that subjects treated with EMDR improved significantly more on PTSD and depression from pre- to posttreatment than control subjects, leading to the conclusion that EMDR was effective in alleviating PTSD in this study.

Virtual reality exposure therapy

It has been proposed that virtual reality (VR) exposure may be an alternative to standard in vivo exposure. Virtual reality integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment. Virtual reality exposure is potentially an efficient and cost-effective treatment of anxiety disorders. VR exposure therapy reduced the fear of heights in the first controlled study of virtual reality in treatment of a psychiatric disorder. A case study supported the efficacy of VR exposure therapy for the fear of flying. The potential for virtual reality exposure treatment for these and other disorders is explored, and therapeutic issues surrounding the delivery of VR exposure are discussed.

Sertraline in the treatment of rape victims with posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a significant problem following rape, yet reports on the efficacy of pharmacological agents in this population are lacking. The results of an open 12-week clinical trial utilizing sertraline (mean dose 105 mg) in the treatment of adult female rape victims with chronic PTSD are presented. The five completers were, on average, 41.6 years old and 15.6 years postassault. Sertraline reduced PTSD and related symptoms in these rape victims. The mean Clinician Administered PTSD Scale (CAPS) scores decreased by 53%, with four out of five participants responding positively to treatment. These preliminary results support the need for systematic assessment of sertraline in this population.

Virtual reality exposure therapy in the treatment of fear of flying: a case report

The efficacy of virtual reality (VR) exposure therapy was examined for the fear of flying. Virtual reality exposure involved six sessions of graded exposure to flying in a virtual airplane. The specific contribution of anxiety management techniques (AMT) and the VR exposure was examined in a single case design. The subject was a 42-year-old female with a debilitating fear and avoidance of flying. All self-report measures of the fear and avoidance of flying decreased following AMT and decreased still further following VR exposure. A planned post-treatment flight was completed with anxiety measures indicating comfortable flight. The implications of this new medium for exposure therapy are discussed.

Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia

OBJECTIVE

The authors' goal was to examine the efficacy of computer-generated (virtual reality) graded exposure in the treatment of acrophobia (fear of heights).

METHOD

Twenty college students with acrophobia were randomly assigned to virtual reality graded exposure treatment (N = 12) or to a waiting-list comparison group (N = 8). Seventeen students completed the study. Sessions were conducted individually over 8 weeks. Outcome was assessed by using measures of anxiety, avoidance, attitudes, and distress associated with exposure to heights before and after treatment.

RESULTS

Significant differences between the students who completed the virtual reality treatment (N = 10) and those on the waiting list (N = 7) were found on all measures. The treatment group was significantly improved after 8 weeks, but the comparison group was unchanged.

CONCLUSIONS

The authors conclude that treatment with virtual reality graded exposure was successful in reducing fear of heights.

The assessment of trichotillomania

Trichotillomania is a disorder characterized by hair-pulling and resulting hair loss. Hair is usually pulled from the scalp, eyelashes, eyebrows, beard, and pubic area. Sufferers often resort to wearing wigs or elaborate hair styles and make-up to camouflage bald patches. It occurs more frequently in women and is associated with considerable distress. The two treatments of choice currently are pharmacotherapy and cognitive-behavioral therapy. The choice of assessment procedures includes self-monitoring, saving hairs, interview, observational rating, digital photograph and computer scoring, significant others' report, and standardized measures. Goals of assessment in trichotillomania and advantages and disadvantages of assessment procedures are discussed. The Trichotillomania Diagnostic Interview is presented as a standardized diagnostic interview.

Uncontrollability and unpredictability in post-traumatic stress disorder: an animal model

The disturbances observed in animals subjected to unpredictable and uncontrollable aversive events resemble post-traumatic stress disorder (PTSD) symptoms and thus may constitute an animal model of this disorder. It is argued that the similarity between animals' symptoms and those of trauma victims may reflect common etiological factors. Relevant experiments in which animals exhibit generalized fear and arousal, discrete fear of a conditioned stimulus (CS), analgesia, and avoidance are reviewed with the view that these manifestations may be analogous to the PTSD symptom clusters of persistent arousal, reexperiencing, numbing, and avoidance, respectively. Finally, animal paradigms are suggested to test the validity of the model and specific hypotheses are derived from the animal literature regarding trauma variables that are predictive of particular PTSD symptom clusters.

Treatment of posttraumatic stress disorder in rape victims: a comparison between cognitive-behavioral procedures and counseling

Rape victims with posttraumatic stress disorder (PTSD; N = 45) were randomly assigned to one of four conditions: stress inoculation training (SIT), prolonged exposure (PE), supportive counseling (SC), or wait-list control (WL). Treatments consisted of nine biweekly 90-min individual sessions conducted by a female therapist. Measures of PTSD symptoms, rape-related distress, general anxiety, and depression were administered at pretreatment, posttreatment, and follow-up (M = 3.5 months posttreatment). All conditions produced improvement on all measures immediately post-treatment and at follow-up. However, SIT produced significantly more improvement on PTSD symptoms than did SC and WL immediately following treatment. At follow-up, PE produced superior outcome on PTSD symptoms. The implications of these findings and direction for treatment and future research are discussed.

Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling

Rape victims with posttraumatic stress disorder (PTSD; N = 45) were randomly assigned to one of four conditions: stress inoculation training (SIT), prolonged exposure (PE), supportive counseling (SC), or wait-list control (WL). Treatments consisted of nine biweekly 90-min individual sessions conducted by a female therapist. Measures of PTSD symptoms, rape-related distress, general anxiety, and depression were administered at pretreatment, posttreatment, and follow-up (M = 3.5 months posttreatment). All conditions produced improvement on all measures immediately post-treatment and at follow-up. However, SIT produced significantly more improvement on PTSD symptoms than did SC and WL immediately following treatment. At follow-up, PE produced superior outcome on PTSD symptoms. The implications of these findings and direction for treatment and future research are discussed.

Religious influence on menstrual attitudes and symptoms

Menstrual attitudes and symptoms of 18 Orthodox Jewish Mikvah attenders, 23 Orthodox Jewish Mikvah non-attenders, 35 Protestant women, and 45 Catholic women were compared. When age, education, number of pregnancies, and religiosity were controlled, Mikvah non-attenders and Protestants most strongly endorsed a view of menstruation as a bothersome event. No significant differences were found, however, in expected or retrospectively reported menstrual symptoms. Correlational analyses indicated that attitudes, expectancies, and symptoms were significantly correlated only for the Catholic women. Differences between groups in religiosity and socialization were found. The Jewish women endorsed doctrines such as "menstruation makes women unclean" more than Catholic or Protestant women. Results support the hypothesized differential religious training regarding menstruation, but only offer weak support for the effects of this training on menstrual attitudes, expectancies, and symptoms.