Interactive Motion-Assisted Exposure Therapy for Veterans with Treatment-Resistant Posttraumatic Stress Disorder: A Randomized Controlled Trial.

BACKGROUND: Veterans with posttraumatic stress disorder (PTSD) tend to benefit less from evidence-based treatments than other PTSD populations. A novel virtual reality and motion-assisted exposure therapy, called 3MDR, provides treatment in an immersive, personalized and activating context. OBJECTIVE: To study the efficacy of 3MDR for veterans with treatment-resistant PTSD. METHOD: In a randomized controlled trial (n = 43) 3MDR was compared to a non-specific treatment component control group. Primary outcome was clinician-rated PTSD symptoms at baseline, after 3MDR, and at the 12-week and 16-week follow-up (primary end point). Intention-to-treat analyses of covariance and mixed models were applied to study differences between groups at the end point and over the course of intervention, controlling for baseline scores. RESULTS: The decrease in PTSD symptom severity from baseline to end point was significantly greater for 3MDR as compared to the control group, with a large effect size (F[1, 37] = 6.43, p = 0.016, d = 0.83). No significant between-group difference was detected in the course of PTSD symptoms during treatment when including all time points. The dropout rate was low (7%), and 45% of the patients in the 3MDR group improved clinically. The number needed to treat was 2.86. CONCLUSIONS: In this trial, 3MDR significantly decreased PTSD symptoms in veterans with, on average, a history of 4 unsuccessful treatments. The low dropout rate may be indicative of high engagement. However, a lack of significant differences on secondary outcomes limits conclusions that can be drawn on its efficacy and underlines the need for larger phase III trials. These data show emerging evidence for 3MDR and its potential to progress PTSD treatment for veterans (Dutch Trial Register Identifier: NL5126).

Perceived treatment processes and effects of interactive motion-assisted exposure therapy for veterans with treatment-resistant posttraumatic stress disorder: a mixed methods study.

Background: A novel intervention, Multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), aims to reduce avoidance and improve engagement for patients with posttraumatic stress disorder (PTSD) who did not sufficiently respond to previous treatments. It has been found to effectively reduce PTSD symptoms for veterans with treatment-resistant PTSD. Symptomatic measures alone might not capture all treatment effects, and addition of qualitative outcomes may provide deeper understanding of treatment processes and treatment-induced changes. Objective: To study the perspectives of veterans with treatment-resistant PTSD on 3MDR treatment processes and effects and explore the relation of their experiences to PTSD symptom improvement. Method: A convergent parallel mixed methods design was applied. For the qualitative part, open-ended question interviews were conducted until data saturation was reached (N = 10). Thematic analysis, rooted in grounded theory, was performed. Quantitative data included pre- to posttreatment responder status based on a structured clinical interview for PTSD. Results: Treatment processes endorsed by the veterans were engaging, regulating distress, feeling supported, facing traumatic memories, allowing emotions, associating, and disengaging from trauma. In terms of effects, veterans reported positive changes following 3MDR, including openness, new learning, self-understanding, closure, and reintegration. High comparability across themes was observed for responders and non-responders, except for the themes closure and reintegration, which were reported more often or more in depth by responders. Conclusions: Veterans indicated 3MDR treatment processes that complied with its aims of breaking through avoidance and increasing engagement, thereby facilitating traumatic memory retrieval and processing. However, this did not necessarily translate into PTSD symptom improvement for all veterans. Walking towards trauma-related pictures was highlighted as unique component of 3MDR and connected to specific treatment processes and effects. Positive changes following 3MDR were experienced outside the domain of PTSD symptom improvement, implicating that 3MDR may beneficially impact veterans beyond symptom changes alone.

Antecedentes: Una nueva intervención, la reconsolidación y desensibilización de la memoria asistida por movimiento multimodular (3MDR), tiene como objetivo reducir la evitación y mejorar la adherencia de los pacientes con trastorno de estrés postraumático (TEPT) que no respondieron lo suficiente a tratamientos anteriores. Se ha descubierto que reduce eficazmente los síntomas de TEPT en los veteranos con TEPT resistente al tratamiento. Las medidas sintomáticas por sí solas pueden no capturar todos los efectos del tratamiento, y la adición de resultados cualitativos puede proporcionar una comprensión más profunda de los procesos de tratamiento y los cambios inducidos por el tratamiento.Objetivo: Estudiar las perspectivas de los veteranos con TEPT resistente al tratamiento sobre los procesos y efectos del tratamiento 3MDR y explorar la relación de sus experiencias con la mejoría de los síntomas de TEPT.Método: Se aplicó un diseño de métodos mixtos paralelos convergentes. Para la parte cualitativa, se realizaron entrevistas con preguntas abiertas hasta que se alcanzó la saturación de datos (N = 10). Se realizó un análisis temático, basado en la Teoría Fundamentada. Los datos cuantitativos incluyeron el estado del participante antes y después del tratamiento basado en una entrevista clínica estructurada para el TEPT.Resultados: Los procesos de tratamiento respaldados por los veteranos fueron los de involucramiento, regular la angustia, sentirse apoyados, enfrentar recuerdos traumáticos, permitir emociones, asociar, y desligarse del trauma. En términos de efectos, los veteranos informaron cambios positivos después de 3MDR, incluida la apertura, nuevo aprendizaje, la autocomprensión, el cierre y la reintegración. Se observó una alta comparabilidad entre los temas de los que respondieron y los que no respondieron, excepto para los temas cierre y reintegración, que fueron informados con más frecuencia o con mayor profundidad por los que respondieron.Conclusiones: Los veteranos indicaron que los procesos de tratamiento 3MDR cumplieron con sus objetivos de romper con la evitación y aumentar la adherencia, facilitando así la recuperación y el procesamiento de la memoria traumática. Sin embargo, esto no se tradujo necesariamente en una mejoría de los síntomas de TEPT para todos los veteranos. Caminar hacia imágenes relacionadas con el trauma se destacó como un componente único de 3MDR y conectado con procesos y efectos de tratamiento específicos. Los cambios positivos después de 3MDR se experimentaron fuera del dominio de la mejora de los síntomas del TEPT, lo que implica que 3MDR puede tener un impacto beneficioso en los veteranos más allá de los cambios en los síntomas por sí solos.

Exposure-related cortisol predicts outcome of psychotherapy in veterans with treatment-resistant posttraumatic stress disorder.

BACKGROUND: Hypothalamic-pituitary-adrenal axis functioning has been related to treatment outcome in posttraumatic stress disorder (PTSD). Previous studies have primarily focused on cortisol levels before and after a course of therapy and findings have not been fully consistent. This study investigated session-related cortisol levels in veterans with treatment-resistant PTSD over the course of a novel motion-assisted virtual reality exposure therapy and aimed to determine whether cortisol levels were related to changes in PTSD symptom severity. METHODS: Veterans (N = 22) received six exposure sessions during which salivary cortisol samples were collected pre-session, post-session and in the late afternoon following sessions. PTSD symptom severity was assessed by structured clinical interviews at pre- and post-treatment. Average cortisol levels were compared between responders and non-responders. Linear regression analyses were conducted with PTSD symptom change as criterion variable, average cortisol levels as predictor, and timing of sampling and baseline PTSD symptoms as covariates. RESULTS: Responders to treatment tended to have higher average cortisol levels at pre-session (p = 0.064) and post-session (p = 0.050) compared to non-responders. Higher average pre-session and post-session cortisol levels predicted greater PTSD symptom improvement (pre: b = -1.83, p = 0.009; post: b = -3.57, p = 0.004). CONCLUSION: This study provides preliminary evidence for session-related cortisol as biomarker of response to exposure-based therapies for PTSD. Higher cortisol levels may have facilitated fear extinction and reconsolidation, and may indicate increased physiological stress activation necessary for appropriate treatment engagement. Further work involving comparable methodology is encouraged to establish session-related cortisol as biomarker and to determine the mechanisms through which it interacts with treatment outcome.

Associations between perceived social support, posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD): implications for treatment.

Background: Perceived social support (PSS) is one of the most important risk factors for the onset and maintenance of posttraumatic stress disorder (PTSD) symptoms, however the relationship between PSS and Complex PTSD (CPTSD) is unknown. The evidence-base for CPTSD treatment is currently lacking, though increasingly important given the recent publication of the ICD-11, which now allows for a formal diagnosis of CPTSD. Objective: This research aims to develop understanding of the relationship between PSS and CPTSD with a view to informing the development of new and existing treatments. Method: A cross-sectional study was undertaken with 246 individuals recruited to the National Centre for Mental Health (NCMH) cohort. Measures of PSS and PTSD/CPTSD were undertaken with this clinical sample and linear and logistic regression were conducted to assess for associations between PSS and the PTSD symptom clusters of DSM-5 and ICD-11, and to explore the predictive utility of any PSS association on the likelihood of a CPTSD presentation. Results: It was found that individuals with a presentation of CPTSD tend to exhibit lower levels of PSS, compared with individuals not presenting with CPTSD, and lower PSS had a statistically significant unique association with the likelihood of presenting with CPTSD. Conclusions: Intervention aiming to improve PSS could be particularly helpful for some individuals with CPTSD, especially those with disturbances in relationships, and there is opportunity to develop skills training within a phase-based approach to treatment that targets factors related to PSS.

Antecedentes: El apoyo social percibido (ASP) es uno de los factores de riesgo más importantes para el inicio y mantención de los síntomas del trastorno de estrés postraumático (TEPT), sin embargo se desconoce la relación entre ASP y TEPT Complejo (TEPTC). Actualmente faltan tratamientos basados en la evidencia para TEPTC, a pesar de la importancia creciente dada la reciente publicación de la CIE-11, que permite el diagnóstico formal de TEPTC.Objetivo: Esta investigación pretende desarrollar una comprensión de la relación entre el ASP y TEPTC con el fin de informar la existencia de tratamientos nuevos y ya existentes.Método: Se realizó un estudio transversal con 246 individuos reclutados de una cohorte del Centro Nacional de Salud Mental (NCMH por sus siglas en inglés. Las medidas de ASP y TEPT/TEPTC fueron realizadas con esta muestra clínica y se condujo una regresión lineal y logística para evaluar la asociación entre ASP y síntomas de TEPT de los grupos del DSM-5 y CIE-11, y explorar la utilidad predictiva de cualquier asociación de ASP en la probabilidad de presentación de un TEPTC.Resultados: Se encontró que individuos con una presentación de TEPTC tendían a mostrar niveles más bajos de ASP, comparados con individuos que no se presentaban con TEPTC, y ASP más bajos tenían una asociación única estadísticamente significativa con la probabilidad de presentarse con TEPTC.Conclusiones: La intervención que pretende mejorar el ASP podría ser particularmente de ayuda para algunos individuos con TEPTC, especialmente aquellos con alteraciones en las relaciones, y existe oportunidad de desarrollar entrenamiento en destrezas con una aproximación basado en fases para tratar aquellos factores claves relacionados con ASP.

An Innovative Framework for Delivering Psychotherapy to Patients With Treatment-Resistant Posttraumatic Stress Disorder: Rationale for Interactive Motion-Assisted Therapy.

Despite an array of evidence-based psychological treatments for patients with a posttraumatic stress disorder (PTSD), a majority of patients do not fully benefit from the potential of these therapies. In veterans with PTSD, up to two-thirds retain their diagnosis after psychotherapy and often their disorder is treatment-resistant, which calls for improvement of therapeutic approaches for this population. One of the factors hypothesized to underlie low response in PTSD treatment is high behavioral and cognitive avoidance to traumatic reminders. In the current paper we explore if a combination of personalized virtual reality, multi-sensory input, and walking during exposure can enhance treatment engagement, overcome avoidance, and thereby optimize treatment effectiveness. Virtual reality holds potential to increase presence and in-session attention and to facilitate memory retrieval. Multi-sensory input such as pictures and music can personalize this experience. Evidence for the positive effect of physical activity on fear extinction and associative thinking, as well as embodied cognition theories, provide a rationale for decreased avoidance by literally approaching cues of the traumatic memories. A dual-attention task further facilitates new learning and reconsolidation. These strategies have been combined in an innovative framework for trauma-focused psychotherapy, named Multi-modular Motion-assisted Memory Desensitization and Reconsolidation (3MDR). In this innovative treatment the therapeutic setting is changed from the face-to-face sedentary position to a side-by-side activating context in which patients walk toward trauma-related images in a virtual environment. The framework of 3MDR has been designed as a boost for patients with treatment-resistant PTSD, which is illustrated by three case examples. The intervention is discussed in context of other advancements in treatment for treatment-resistant PTSD. Novel elements of this approach are activation, personalization and empowerment. While developed for veterans with PTSD who do not optimally respond to standardized treatments, this innovative framework holds potential to also be used for other patient populations and earlier stages of treatment for patients with PTSD.