A Randomized, Head-to-Head Study of Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder.

Virtual reality exposure therapy (VRET) is one of the few interventions supported by randomized controlled trials for the treatment of combat-related posttraumatic stress disorder (PTSD) in active duty service members. A comparative effectiveness study was conducted to determine if virtual reality technology itself improved outcomes, or if similar results could be achieved with a control exposure therapy (CET) condition. Service members with combat-related PTSD were randomly selected to receive nine weeks of VRET or CET. Assessors, but not therapists, were blinded. PTSD symptom improvement was assessed one week and 3 months after the conclusion of treatment using the clinician-administered PTSD scale (CAPS). A small crossover component was included. Results demonstrated that PTSD symptoms improved with both treatments, but there were no statistically significant differences between groups. Dropout rates were higher in VRET. Of those who received VRET, 13/42 (31%) showed >30% improvement on the CAPS, versus 16/43 (37%) who received CET. Three months after treatment, >30% improvement was seen in 10/33 (30%) of VRET participants and 12/33 (36%) in CET. Participants who crossed over (n = 11) showed no statistically significant improvements in a second round of treatment, regardless of condition. This study supported the utility of exposure therapy for PTSD, but did not support additional benefit by the inclusion of virtual reality.

Stellate Ganglion Block for the Treatment of Posttraumatic Stress Disorder: A Randomized, Double-Blind, Controlled Trial.

OBJECTIVE: In this study, we aimed to determine if stellate ganglion block (SGB) could reduce symptoms of posttraumatic stress disorder (PTSD) in comparison with sham therapy in military service members. METHODS: In a randomized trial in which both participants and assessors were blind, participants with PTSD received either an SGB or a sham procedure. Posttraumatic stress disorder symptoms were measured using the CAPS (Clinician-Administered PTSD Scale) and self-report measures of PTSD, depression, anxiety, and pain. Subjects underwent assessment before the procedure and at 1 week, 1 month, and 3 months after the procedure. Patients receiving sham injections were allowed to cross over to the treatment group, and participants who maintained criteria for PTSD were allowed to receive a second SGB treatment. RESULTS: Posttraumatic stress disorder, anxiety, and depression scores all showed improvement across time, but there was no statistically or clinically relevant difference in outcomes between the active and control groups. Individuals who crossed over from sham treatment to SGB similarly showed no greater improvement with the SGB treatment. Improvement in CAPS was greater with a second SGB treatment than after the first treatment. CONCLUSIONS: Although previous case series have suggested that SGB offers an effective intervention for PTSD, this study did not demonstrate any appreciable difference between SGB and sham treatment on psychological or pain outcomes. Future studies should examine if differences in treatment methods or patient population could allow individuals with PTSD to benefit from SGB, but current evidence does not support widespread or indiscriminant clinical use of the procedure for PTSD.

Outcomes from eye movement desensitization and reprocessing in active-duty service members with posttraumatic stress disorder.

OBJECTIVE: Eye movement desensitization and reprocessing (EMDR) is one of the therapy interventions recommended by the Veterans Affairs and Department of Defense Clinical Practice Guidelines. However, the literature concerning the effectiveness of this treatment modality in military service members is sparse. This study investigated the efficacy of EMDR in active-duty service members. METHOD: We conducted an effectiveness study with a record review from active-duty military mental health clinics where clinical outcomes had been monitored over a 10-week period using self-report measures of posttraumatic stress and disability. Symptom scores were examined over time in 331 service members who met presumptive criteria for the disorder on the PTSD Checklist-Military Version (PCL-M), who were in psychotherapy, and who received (n = 46) or didn't receive (n = 285) EMDR. RESULTS: Results indicated that patients receiving EMDR had significantly fewer therapy sessions over 10 weeks but had significantly greater gains in their PCL-M scores than did individuals not receiving EMDR. CONCLUSIONS: Randomized, controlled trials are still needed, but these findings provide further support for the use of EMDR in service members with PTSD. (PsycINFO Database Record

Alcohol-Related Consequences Mediating PTSD Symptoms and Mental Health-Related Quality of Life in OEF/OIF Combat Veterans.

Veterans returning from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have been found to be at increased risk for post-traumatic stress disorder (PTSD) and alcohol use disorders, leading to negative mental health-related quality of life (MHRQoL). The current study examined the unique impact of alcohol consumption levels versus alcohol-related consequences on the relationship between PTSD symptoms and MHRQoL in a sample of OEF/OIF combat veterans (N = 205, median age 29, 95% men). Mediation analyses indicated that the effect of PTSD symptoms on MHRQoL was explained only by alcohol-related consequences and not by alcohol consumption. Findings highlight the importance of including alcohol-related consequences in clinical assessment and intervention programs for OEF/OIF veterans. Additionally, this study enhances knowledge regarding the underlying mechanisms of functional impairment related to PTSD and alcohol use disorders.

Importance of Virtual Reality to Virtual Reality Exposure Therapy, Study Design of a Randomized Trial.

Post Traumatic Stress Disorder (PTSD) can be a debilitating problem in service members who have served in Iraq or Afghanistan. Virtual Reality Exposure Therapy (VRET) is one of the few interventions demonstrated in randomized controlled trials to be effective for PTSD in this population. There are theoretical reasons to expect that Virtual Reality (VR) adds to the effectiveness of exposure therapy, but there is also added expense and difficulty in using VR. Described is a trial comparing outcomes from VRET and a control exposure therapy (CET) protocol in service members with PTSD.

Risk of PTSD in service members who were fired upon by the enemy is higher in those who also returned fire.

An unusual characteristic of the recent wars in Iraq and Afghanistan is that, because of attacks by snipers and improvised explosive devices (IED), many U.S. service members may come under attack without having exchanged fire. It was hypothesized that this would be associated with greater severity of post-traumatic stress disorder (PTSD) symptoms. The severity of self-reported symptoms of PTSD and depression were examined among service members who reported being shot at or attacked by an IED, those who had these experiences but who also shot at the enemy, and those who reported neither experience. Results showed that those with neither exposure reported the lowest symptom severity, but, contrary to expectations, service members who had been attacked but not shot at the enemy had less severe symptoms than those who had exchanged fire. This may support findings from earlier generations of veterans that shooting at or killing the enemy may be a particularly traumatic experience.

Impact of childhood maltreatment on physical health-related quality of life in U.S. active duty military personnel and combat veterans.

Previous studies have found an association between childhood maltreatment (CM) and health-related quality of life (HRQoL), and to a lesser extent have considered whether psychiatric symptoms may explain the relationship. This study aimed to further our understanding of the link between CM and HRQoL by testing whether posttraumatic stress disorder (PTSD) or depressive symptoms mediate the relationship between childhood maltreatment and physical HRQoL. Mediation models were examined in a sample of male Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) active duty and combat veterans (n=249). PTSD and depressive symptoms mediated the relationship between CM and overall physical HRQoL, as well as participation in daily activities due to physical health, bodily pain, and social functioning. Mediation of the relationship between childhood maltreatment and physical and social functioning by depression and PTSD symptoms may lend support to neurobiological hypotheses that childhood maltreatment sensitizes the nervous system and after repeated trauma may lead to the development of psychiatric symptoms, which have a major impact on morbidity and mortality.

Apparent comorbidity of bipolar disorder in a population with combat-related post-traumatic stress disorder.

Combat is often associated with the diagnosis of post-traumatic stress disorder. Battle may also lead to other emotional extremes. Sometimes this is enough to meet criteria for a diagnosis of bipolar disorder (BPD), but it is open to debate if this is clinically appropriate. This study examined the rate of BPD, as assessed by structured interview, in combat veterans who clinicians believed met the criteria for post-traumatic stress disorder but not BPD. Structured interviews were conducted with 109 such participants. Close to 81% endorsed a history of a major depressive episode, 34.9% endorsed a history of manic episode, and 27.5% endorsed a history of a hypomanic episode. According to the interviews, 54.1% participants experienced BPD, including 34.9% who experienced BPD type I. Clinicians were aware of these results and observed the individuals for a prolonged period afterward, but the clinical diagnosis did not change to include BPD in any of these individuals. Future research is needed to establish reliable and valid methods to make a diagnosis of BPD in the presence of comorbid conditions and stressors and thus guide clinicians with better treatment options.

Stellate ganglion block improves refractory post-traumatic stress disorder and associated memory dysfunction: a case report and systematic literature review.

The prevalence of post-traumatic stress disorder (PTSD) has reached epidemic proportions among U.S. veterans, many of whom also have concurrent alcohol use disorder. This case report describes improvements in PTSD symptom severity and memory dysfunction in a combat-exposed veteran with persistent PTSD and alcohol use disorder following two treatments of stellate ganglion block (SGB). PTSD severity was measured using the PTSD Checklist, Military Version. Memory function was evaluated using the Rey Auditory Verbal Learning Test. One month after the first SGB, a 43.6% reduction in PTSD severity was observed along with increases in immediate memory (50%), recent memory (28%), and recognition memory (25%). Following a second SGB, PTSD severity decreased by 57.7% and memory function substantially improved, with pronounced changes in immediate memory (50%), recent memory (58%), and recognition memory (36%). One year after SGB treatments, the patient has stopped drinking alcohol, continues to have sustained relief from PTSD, has improved memory function, and has become gainfully employed. Future studies that employ robust epidemiologic methodologies are needed to generate confirmatory evidence that would substantiate SGB's clinical utility as an adjunctive treatment option for PTSD.

Post-traumatic stress disorder symptom severity in service members returning from Iraq and Afghanistan with different types of injuries.

INTRODUCTION: Risk for post-traumatic stress disorder (PTSD) varies in part due to the nature of the traumatic event involved. Both injury and return from combat pose high risk of PTSD symptoms. How different injuries may predispose towards PTSD is less well understood. METHODS: A retrospective record review was conducted from 1402 service members who had returned to Naval Medical Center San Diego from Iraq or Afghanistan and who had completed the PTSD Checklist as part of their post-deployment screening. Rates of PTSD were examined in relation to mechanism of injury. RESULTS: Of those without injury, 8% met Diagnostic and Statistical Manual criteria for PTSD. Thirteen percent of those with a penetrating injury, 29% with blunt trauma, and 33% with combination injuries met criteria for PTSD. PTSD severity scores varied significantly according to type of injury. DISCUSSION: The World War I concept of "shell shock" implied that blast-related injuries were more likely to result in psychological symptoms than were other injuries. These data may support that idea. Circumstance of injury, population differences, and reporting bias could also have influenced the results. CONCLUSION: These results suggest that service members with blunt or combination injuries merit particular attention when screening for PTSD.

Development and testing of virtual reality exposure therapy for post-traumatic stress disorder in active duty service members who served in Iraq and Afghanistan.

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.

Severe mania complicating treatment of narcolepsy with cataplexy.

We report the case of a 22-year-old male who exhibited severe manic behavior shortly after beginning treatment with modafinil and venlafaxine for narcolepsy with cataplexy. The manic episode persisted several weeks after medication cessation and required management with a mood stabilizer. Reinstitution of modafinil and an alternate antidepressant for recurrent sleepiness and cataplexy was well tolerated and very effective. Sleep physicians should be aware that psychostimulants, including modafinil, and antidepressant medications commonly prescribed for treatment of narcolepsy may precipitate mania in patients with underlying bipolar disorder.

A randomized, controlled trial of virtual reality-graded exposure therapy for post-traumatic stress disorder in active duty service members with combat-related post-traumatic stress disorder.

Abstract Virtual reality (VR)-based therapy has emerged as a potentially useful means to treat post-traumatic stress disorder (PTSD), but randomized studies have been lacking for Service Members from Iraq or Afghanistan. This study documents a small, randomized, controlled trial of VR-graded exposure therapy (VR-GET) versus treatment as usual (TAU) for PTSD in Active Duty military personnel with combat-related PTSD. Success was gauged according to whether treatment resulted in a 30 percent or greater improvement in the PTSD symptom severity as assessed by the Clinician Administered PTSD Scale (CAPS) after 10 weeks of treatment. Seven of 10 participants improved by 30 percent or greater while in VR-GET, whereas only 1 of the 9 returning participants in TAU showed similar improvement. This is a clinically and statistically significant result (χ(2) = 6.74, p < 0.01, relative risk 3.2). Participants in VR-GET improved an average of 35 points on the CAPS, whereas those in TAU averaged a 9-point improvement (p < 0.05). The results are limited by small size, lack of blinding, a single therapist, and comparison to a relatively uncontrolled usual care condition, but did show VR-GET to be a safe and effective treatment for combat-related PTSD.

Reality graded exposure therapy with physiological monitoring for the treatment of combat related post traumatic stress disorder: a pilot study.

A high percentage of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans have been diagnosed with Posttraumatic Stress Disorder (PTSD) during and following their respective combat tours. Virtual Reality (VR) treatment has been documented as an exceptional treatment for anxiety disorders and specifically for PTSD. An Office of Naval Research (ONR) funded pilot study, completed by the Virtual Reality Medical Center and Naval Medical Center San Diego (NMCSD), investigated the use of Virtual Reality Graded Exposure Therapy (VR-GET) study with participants who had been diagnosed with PTSD following their combat deployments. A significant reduction in PTSD symptoms severity was noted. Implications for treatment with VR-GET and future research areas of investigation, including the use of VR-GET with smart phones and the internet, are suggested.

Insomnia is the most commonly reported symptom and predicts other symptoms of post-traumatic stress disorder in U.S. service members returning from military deployments.

This study retrospectively reviewed records from current members of the U.S. military who had completed the PTSD Checklist (PCL) at 0 and 3-months after returning from deployments. Insomnia was the most commonly reported symptom of PTSD on the PCL and had the highest average severity scores. At initial screen, 41% of those who had been to Iraq or Afghanistan reported sleep problems. Those who had initially reported any insomnia had significantly higher overall scores for PTSD severity at follow-up than did service members without such a complaint. These results show that insomnia is a particularly frequent, severe, and persistent complaint in service members returning from deployment. Such complaints merit particular attention in relation to the possibility of PTSD.

Exposure therapy with and without virtual reality to treat PTSD while in the combat theater: a parallel case series.

Exposure therapy (ET) has been observed to be an effective modality for the treatment of combat-related posttraumatic stress disorder (PTSD). Recently, efforts have been made to use virtual reality (VR) to enhance outcome with modes of ET. How such therapy applies to service members who are facing the reality of a combat deployment has been unknown. This case series documents the first use of VR-based therapy to the treatment of PTSD in a combat theater. Results of therapy are reported from a mental health clinic in Camp Fallujah, Iraq. Combat PTSD constituted a relatively small percentage of overall mental health patients seen. Those who did present with PTSD were offered VR-based ET or traditional ET. Patients who received either treatment modality showed significant gains, and no service member in treatment had to be medically evacuated because of ongoing PTSD symptoms. This demonstrates that ET, with or without the use of VR, can be an effective means of helping service members with mental health issues while they serve in theater.

Use of a portable biofeedback device to improve insomnia in a combat zone, a case report.

Insomnia is a common problem in situations of stress. Some forms of stress, however, may contraindicate the use of traditional, pharmacological interventions. Working in a combat zone is such a situation. Alternative means of improving sleep are clearly needed for Service Members. We report a case involving a medical provider who was serving in a military, emergency-services facility in Iraq, and who presented with anxiety, depressed mood, and insomnia. Symptoms were sub-threshold for major depressive disorder or acute stress disorder. Mood and anxiety symptoms responded to traditional therapy techniques, but problems with insomnia remained. The patient was given a portable biofeedback device that employs an infrared sensor photoplethysmograph to measure heart rate variability (HRV) from peripheral finger pulse. One week later, sleep was significantly improved. Symptom improvement lasted to at least 6 weeks while in theater. One year later, a check-in with the patient revealed that after returning home, he had been diagnosed with post traumatic stress disorder (PTSD). PTSD symptoms had resolved after 6 months of psychopharmacology and cognitive behavioral therapy. These results indicate that biofeedback may be a useful means of improving sleep in a combat zone, but that such improvements may not necessarily prevent the development of more serious symptoms later. No clear causality can be inferred from a single case, and further study is needed to determine if this finding have wider applicability.

VR PTSD exposure therapy results with active duty OIF/OEF combatants.

Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Reports indicate that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality exposure therapy has been previously used for PTSD with reports of positive outcomes. This paper will present a brief description of the USC/ICT Virtual Iraq/Afghanistan PTSD therapy application and present clinical outcome data from active duty patients treated at the Naval Medical Center-San Diego (NMCSD) as of October 2009. Initial outcomes from the first twenty patients to complete treatment indicate that 16 no longer meet diagnostic criteria for PTSD at post treatment. Research and clinical tests using the Virtual Iraq/Afghanistan software are also currently underway at Weill Cornell Medical College, Emory University, Fort Lewis and WRAMC along with 20 other test sites.

Spousal military deployment as a risk factor for postpartum depression.

OBJECTIVE: To compare the Edinburgh Postnatal Depression Scale (EPDS) results in women whose spouses had deployed during or after pregnancy vs. those whose spouses had not. STUDY DESIGN: A chart review of 6-week postpartum visits of women with active-duty spouses was conducted over 10 months. Associations between military deployments and EPDS score were examined by Student's t test, and rates of positive screens (with a cutoff of 12) between groups were compared by odds ratio (OR). Linear regression was used to calculate predictors of EPDS score. RESULTS: A total of 415 charts were analyzed. The average EPDS score of women whose partner did deploy during the pregnancy was 7.36 compared to 4.81 for those whose partners did not (p < 0.001). The percentage of positive screens for women whose partner deployed during the pregnancy was 25.27% compared with 10.94% for an OR of 2.75 (p < 0.001). Linear regression showed partner's deployment during pregnancy to be an independent predictor of EPDS score (p < 0.005). CONCLUSION: Deployment of a spouse during pregnancy may be a risk factor for depression. Aggressive screening of this at-risk population is recommended.