EMDR v. other psychological therapies for PTSD: a systematic review and individual participant data meta-analysis.

BACKGROUND: This systematic review and individual participant data meta-analysis (IPDMA) examined the overall effectiveness of eye movement desensitization and reprocessing (EMDR) in reducing posttraumatic stress disorder (PTSD) symptoms, achieving response and remission, and reducing treatment dropout among adults with PTSD compared to other psychological treatments. Additionally, we examined available participant-level moderators of the efficacy of EMDR. METHODS: This study included randomized controlled trials. Eligible studies were identified by a systematic search in PubMed, Embase, PsyclNFO, PTSDpubs, and CENTRAL. The target population was adults with above-threshold baseline PTSD symptoms. Trials were eligible if at least 70% of study participants had been diagnosed with PTSD using a structured clinical interview. Primary outcomes included PTSD symptom severity, treatment response, and PTSD remission. Treatment dropout was a secondary outcome. The systematic search retrieved 15 eligible randomized controlled trials (RCTs); 8 of these 15 were able to be included in this IPDMA (346 patients). Comparator treatments included relaxation therapy, emotional freedom technique, trauma-focused cognitive behavioral psychotherapies, and REM-desensitization. RESULTS: One-stage IPDMA found no significant difference between EMDR and other psychological treatments in reducing PTSD symptom severity (ß = -0.24), achieving response (ß = 0.86), attaining remission (ß = 1.05), or reducing treatment dropout rates (ß = -0.25). Moderator analyses found unemployed participants receiving EMDR had higher PTSD symptom severity at the post-test, and males were more likely to drop out of EMDR treatment than females. CONCLUSION: The current study found no significant difference between EMDR and other psychological treatments. We found some indication of the moderating effects of gender and employment status.

Toward staging differentiation for posttraumatic stress disorder treatment.

OBJECTIVES: Several medical and psychiatric disorders have stage-based treatment decision-making methods. However, international treatment guidelines for posttraumatic stress disorder (PTSD) fail to give specific treatment recommendations based on chronicity or stage of the disorder. There is convincing evidence of a finite range of PTSD symptom trajectories, implying that different phenotypes of the disorder can be distinguished, which are highly relevant for a staging typology of PTSD. METHODS: State-of-the-art review building on prior work on staging models in other disorders as a mapping tool to identify and synthesize toward PTSD. RESULTS: We propose a four-stage model of PTSD ranging from stage 0: trauma-exposed asymptomatic but at risk to stage 4: severe unremitting illness of increasing chronicity. We favor a symptom description in various chronological characteristics based on neurobiological markers, information processing systems, stress reactivity, and consciousness dimensions. We also advocate for a separate phenomenology of treatment resistance since this can yield treatment recommendations. CONCLUSION: A staging perspective in the field of PTSD is highly needed. This can facilitate the selection of interventions that are proportionate to patients' current needs and risk of illness progression and can also contribute to an efficient framework to organize biomarker data and guide service delivery. Therefore, we propose that a neurobiologically driven trajectory-based typology of PTSD can help deduct several treatment recommendations leading to a more personalized and refined grid to strategize, plan and evaluate treatment interventions.

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).

Predictors of Outcome and Residual Symptoms Following Trauma-Focused Psychotherapy in Police Officers With Posttraumatic Stress Disorder.

Police officers exposed to potentially traumatic events (PTE) are at a heightened risk of developing posttraumatic stress disorder (PTSD). Little is known about trauma-focused psychotherapy outcomes in the police. In this naturalistic study, we evaluated whether PTE exposure and baseline clinical characteristics predicted PTSD symptom reduction during treatment and residual PTSD symptoms posttreatment. In consecutive referrals to a specialized mental health service for police officers (N = 665), PTSD was measured pre- and posttreatment using structured clinical interviews. Treatment consisted of brief eclectic psychotherapy for PTSD. We grouped PTE as follows: injury/maltreatment, loss (colleague or private), other job-related, other private traumatic events. Data were analyzed multivariably using structural equation modeling and logistic regression. Treatment effect size was large, d = 3.6, 95% CI [3.4, 3.8]. Police officers who reported more injury/maltreatment or private traumatic had more baseline PTSD symptoms as well as larger symptom reduction during treatment; police officers who reported more losses of loved ones showed smaller PTSD symptom reduction. Concentration problems persisted in 17.7% of police officers posttreatment, and these were predicted by baseline PTSD symptoms and loss of loved ones. Proportions of variance explained by the multivariable models ranged from 0.08 to 0.14. Our findings increase insight into the type of PTE and clinical characteristics of police officers with PTSD who benefit most from trauma-focused treatment. Because loss of loved ones can be presumed to have a profound impact on social and interpersonal functioning, a more specific treatment focus on grief processes may further enhance efficacy.

Neurocognitive functioning over the course of trauma-focused psychotherapy for PTSD: Changes in verbal memory and executive functioning.

OBJECTIVES: Individuals with post-traumatic stress disorder (PTSD) have neurocognitive deficits in verbal memory and executive functioning. In this study, we examined whether memory and executive functioning changed over the course of treatment and which clinical variables were associated with change. DESIGN: Neuropsychological assessments were administered at baseline and endpoint of a randomized controlled trial as secondary outcome. METHODS: Trauma survivors (n = 88) diagnosed with PTSD received trauma-focused psychotherapy within a 17-week randomized controlled trial. Neuropsychological tests were the California Verbal Learning Test, Rivermead Behavioural Memory Test, Stroop Color Word Test, and Trail Making Test. RESULTS: Significant, small- to medium-sized improvements in verbal memory, information processing speed, and executive functioning were found after trauma-focused psychotherapy (Cohen's d 0.16-0.68). Greater PTSD symptom decrease was significantly related to better post-treatment neurocognitive performance (all p < .005). Patients with comorbid depression improved more than patients with PTSD alone on interference tasks (p < .01). No differences emerged between treatment conditions and between patients on serotonergic antidepressants and those who were not. CONCLUSIONS: This study suggests that neurocognitive deficits in PTSD can improve over the course of trauma-focused psychotherapy and are therefore at least partly reversible. Improvements over treatment are in line with previous neuropsychological and neuroimaging studies and effect sizes exceed those of practice effects. Future research should determine whether these changes translate into improved functioning in the daily lives of the patients. PRACTITIONER POINTS: Patients with PTSD have difficulties performing verbal memory tasks (e.g., remembering a grocery list, recall of a story) and executive functioning tasks (e.g., shifting attention between two tasks, ignoring irrelevant information to complete a task). Verbal memory, information processing speed, and executive functioning significantly improved in patients with post-traumatic stress disorder over the course of trauma-focused psychotherapy. Improvements were equal in size for two different trauma-focused psychotherapies (Eye movement desensitization and reprocessing therapy and brief eclectic psychotherapy for PTSD). Medium-sized effects were found for recall of a story, whereas effects in other aspects of verbal memory, information processing speed, and executive functioning were small-sized. No causal attributions can be made because we could not include a control group without treatment for ethical reasons. Findings may be more reflective of patients who completed treatment than patients who prematurely dropped out as completers were overrepresented in our sample.

Treatment of Posttraumatic Stress Disorder: A State-of-the-art Review.

This narrative state-of-the-art review paper describes the progress in the understanding and treatment of Posttraumatic Stress Disorder (PTSD). Over the last four decades, the scientific landscape has matured, with many interdisciplinary contributions to understanding its diagnosis, etiology, and epidemiology. Advances in genetics, neurobiology, stress pathophysiology, and brain imaging have made it apparent that chronic PTSD is a systemic disorder with high allostatic load. The current state of PTSD treatment includes a wide variety of pharmacological and psychotherapeutic approaches, of which many are evidence-based. However, the myriad challenges inherent in the disorder, such as individual and systemic barriers to good treatment outcome, comorbidity, emotional dysregulation, suicidality, dissociation, substance use, and trauma-related guilt and shame, often render treatment response suboptimal. These challenges are discussed as drivers for emerging novel treatment approaches, including early interventions in the Golden Hours, pharmacological and psychotherapeutic interventions, medication augmentation interventions, the use of psychedelics, as well as interventions targeting the brain and nervous system. All of this aims to improve symptom relief and clinical outcomes. Finally, a phase orientation to treatment is recognized as a tool to strategize treatment of the disorder, and position interventions in step with the progression of the pathophysiology. Revisions to guidelines and systems of care will be needed to incorporate innovative treatments as evidence emerges and they become mainstream. This generation is well-positioned to address the devastating and often chronic disabling impact of traumatic stress events through holistic, cutting-edge clinical efforts and interdisciplinary research.

Hotspots in trauma memories and their relationship to successful trauma-focused psychotherapy: a pilot study.

Imaginal exposure is an essential element of trauma-focused psychotherapies for posttraumatic stress disorder (PTSD). Exposure should in particular focus on the "hotspots," the parts of trauma memories that cause high levels of emotional distress which are often reexperienced. Our aim was to investigate whether differences in the focus on hotspots differentiate between successful and unsuccessful trauma-focused psychotherapies. As part of a randomized trial, 45 PTSD patients completed brief eclectic psychotherapy for PTSD. We retrospectively assessed audio recordings of therapy sessions of 20 patients. Frequency of hotspots and the associated emotions, cognitions, and characteristics were compared for the most successful (n = 10) versus the least successful (n = 10) treatments. The mean number of unique hotspots per patient was 3.20, and this number did not differ between successful and unsuccessful treatments. In successful treatments, however, hotspots were more frequently addressed (r = .48), and they were accompanied by more characteristics of hotspots (r = .39), such as an audible change in affect, indicating medium- to large-sized effects. Repeatedly focusing on hotspots and looking for associated characteristics of hotspots may help clinicians to enhance the efficacy of imaginal exposure for patients who would otherwise show insufficient response to treatment.

3MDR treatment in an adolescent with PTSD: a case report.

Background: As Posttraumatic stress disorder (PTSD) in adolescents significantly impacts their well-being, effective treatment is of great importance. Little is known, however, about the novel, multi-modal virtual reality supported, exposure-based psychotherapeutic interventions such as 3MDR in this population.Objective: To describe the 3MDR treatment of an adolescent with PTSD who did not respond to previous exposure-based PTSD interventions.Method: A 14-year-old girl diagnosed with PTSD received six sessions of 3MDR embedded in family therapy.Result: The patient tolerated the 3MDR intervention very well. Personalized music and self-selected pictures appeared to be a good fit, contributing to enhanced engagement in and adherence to the therapy. She no longer met criteria for PTSD post-intervention, and at 18 months follow-up.Conclusion: This case report suggests that 3MDR has potential as a trauma treatment for adolescents with treatment-resistant PTSD.

Trauma-focused therapy for youngsters is often complicated, with a high percentage of dropouts.Elements of 3MDR such as walking, self-selected pictures, and personalized music are a good fit, contributing to enhanced engagement in and adherence to 3MDR therapy.3MDR has potential as a trauma treatment for adolescents with treatment-resistant PTSD.

Treatment response and treatment response predictors of a multidisciplinary day clinic for police officers with PTSD.

OBJECTIVE: Police officers typically face multiple potentially traumatic events and consequently have a higher conditional probability of developing PTSD. Although most police officers with PTSD benefit from first-line treatment, it is unknown whether recommended intensification of treatment for low responders is effective and which factors contribute to response. This study aimed to examine the treatment response of a day clinic for police officers with PTSD and identify predictors of treatment response. METHOD: Between 2009 and 2019, routine outcome monitoring measurements consisting of PTSD symptom severity and general psychological distress were administered at two timepoints among 102 patients undergoing a day clinic treatment consisting of trauma-focused therapy, sociotherapy, and psychomotor therapy. Hierarchical regression was used to assess whether change in PTSD symptom severity was associated with baseline PTSD and depression severity, gender, age, and eligibility for a recognition procedure. RESULTS: Significant improvements in PTSD symptom severity were found over the course of the treatment (d = .59), with 47% of patients showing statistically reliable improvement in their symptoms. The only significant predictor of treatment response was eligibility for a recognition procedure, with the total model explaining approximately 10% of the variation in treatment response. CONCLUSIONS: Intensifying treatment for police officers with PTSD who do not respond to previous trauma-focused treatment appears beneficial for a substantial number of patients. However, eligibility for a recognition procedure may negatively impact treatment response. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychometric evaluation of the Dutch International Trauma Questionnaire for the 11th revision of the International Classification of Diseases posttraumatic stress disorder and complex posttraumatic stress disorder.

BACKGROUND: The International Trauma Questionnaire (ITQ) is a recent self-report measure to assess the severity and probable posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as defined by the 11th revision of the International Classification of Diseases. Few studies have examined the psychometric properties of full and short ITQ versions in depth. Therefore, we aimed to evaluate the psychometric properties of the Dutch-translated 28-item ITQ and the 12-item version. METHOD: Data were used from existing clinical studies and routine clinical assessments for the 28-item (n = 956) and 12-item (N = 4,944) ITQ versions in trauma-exposed treatment-seeking individuals in the Netherlands. Internal consistency and factor validity were assessed, and rates of probable PTSD and CPTSD were estimated. In addition, convergent and discriminant validity were examined by correlations with similar and dissimilar measures. RESULTS: Both versions of the ITQ showed good internal consistency and convergent validity. Confirmatory factor analysis showed that both a first-order correlated six-factor model and a two-factor second-order model were a good representation of the latent structure for the ITQ-12. The ITQ-12 resulted in higher CPTSD rates compared to the ITQ-28 (47% vs. 36.3%), while a similar number of patients met the criteria for either PTSD or CPTSD (70.6% vs. 76.4%). CONCLUSION: Internal consistency and convergent validity for the ITQ-12 and ITQ-28 were supported. The factorial validity was good for the ITQ-12 and acceptable for the ITQ-28. The discrepancy in CPTSD rates between the ITQ-12 and ITQ-28 calls for further testing of scoring methods against diagnostic clinical interviews for CPTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Brief eclectic psychotherapy v. eye movement desensitisation and reprocessing therapy for post-traumatic stress disorder: randomised controlled trial.

BACKGROUND: Trauma-focused cognitive-behavioural therapy (CBT) and eye movement desensitisation and reprocessing therapy (EMDR) are efficacious treatments for post-traumatic stress disorder (PTSD), but few studies have directly compared them using well-powered designs and few have investigated response patterns. AIMS: To compare the efficacy and response pattern of a trauma-focused CBT modality, brief eclectic psychotherapy for PTSD, with EMDR (trial registration: ISRCTN64872147). METHOD: Out-patients with PTSD were randomly assigned to brief eclectic psychotherapy (n = 70) or EMDR (n = 70) and assessed at all sessions on self-reported PTSD (Impact of Event Scale - Revised). Other outcomes were clinician-rated PTSD, anxiety and depression. RESULTS: Both treatments were equally effective in reducing PTSD symptom severity, but the response pattern indicated that EMDR led to a significantly sharper decline in PTSD symptoms than brief eclectic psychotherapy, with similar drop-out rates (EMDR: n = 20 (29%), brief eclectic psychotherapy: n = 25 (36%)). Other outcome measures confirmed this pattern of results. CONCLUSIONS: Although both treatments are effective, EMDR results in a faster recovery compared with the more gradual improvement with brief eclectic psychotherapy.

Sleep spindle dynamics suggest over-consolidation in post-traumatic stress disorder.

Devastating and persisting traumatic memories are a central symptom of post-traumatic stress disorder (PTSD). Sleep problems are highly co-occurrent with PTSD and intertwined with its etiology. Notably, sleep hosts memory consolidation processes, supported by sleep spindles (11-16 Hz). Here we assess the hypothesis that intrusive memory symptoms in PTSD may arise from excessive memory consolidation, reflected in exaggerated spindling. We use a newly developed spindle detection method, entailing minimal assumptions regarding spindle phenotype, to assess spindle activity in PTSD patients and traumatized controls. Our results show increased spindle activity in PTSD, which positively correlates with daytime intrusive memory symptoms. Together, these findings provide a putative mechanism through which the profound sleep disturbance in PTSD may contribute to memory problems. Due to its uniform and unbiased approach, the new, minimal assumption spindle analysis seems a promising tool to detect aberrant spindling in psychiatric disorders.

The Redesign and Validation of Multimodal Motion-Assisted Memory Desensitization and Reconsolidation Hardware and Software: Mixed Methods, Modified Delphi-Based Validation Study.

BACKGROUND: In recent years, the delivery of evidence-based therapies targeting posttraumatic stress disorder (PTSD) has been the focus of the Departments of Defense in countries such as Canada, the Netherlands, and the United States. More than 66% of military members continue to experience symptoms of PTSD that significantly impact their daily functioning and quality of life after completing evidence-based treatments. Innovative, engaging, and effective treatments for PTSD are needed. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) is an exposure-based, virtual reality-supported therapy used to treat military members and veterans with treatment-resistant PTSD. Given the demonstrated efficacy of 3MDR in recently published randomized control trials, there is both an interest in and a need to adapt the intervention to other populations affected by trauma and to improve accessibility to the treatment. OBJECTIVE: We aimed to further innovate, develop, and validate new and existing hardware and software components of 3MDR to enhance its mobility, accessibility, feasibility, and applicability to other populations affected by trauma, including public safety personnel (PSP), via international collaboration. METHODS: This study used a modified Delphi expert consultation method and mixed methods quasi-experimental validation with the purpose of software validation among PSP (first responders, health care providers) participants (N=35). A team of international experts from the Netherlands, the United States, and Canada met on the web on a weekly basis since September 2020 to discuss the adoption of 3MDR in real-world contexts, hardware and software development, and software validation. The evolution of 3MDR hardware and software was undertaken followed by a mixed methods software validation study with triangulation of results to inform the further development of 3MDR. RESULTS: This study resulted in the identification, description, and evolution of hardware and software components and the development of new 3MDR software. Within the software validation, PSP participants widely acknowledged that the newly developed 3MDR software would be applicable and feasible for PSP affected by trauma within their professions. The key themes that emerged from the thematic analysis among the PSP included the desire for occupationally tailored environments, individually tailored immersion, and the applicability of 3MDR beyond military populations. CONCLUSIONS: Within the modified Delphi consultation and software validation study, support for 3MDR as an intervention was communicated. PSP participants perceived that 3MDR was relevant for populations affected by trauma beyond military members and veterans. The resulting hardware and software evolution addressed the recommendations and themes that arose from PSP participants. 3MDR is a novel, structured, exposure-based, virtual reality-supported therapy that is currently used to treat military members and veterans with PTSD. Going forward, it is necessary to innovate and adapt 3MDR, as well as other trauma interventions, to increase effectiveness, accessibility, cost-effectiveness, and efficacy among other populations affected by trauma.

Wellbeing and clinical videoconferencing satisfaction among patients in psychotrauma treatment during the coronavirus pandemic: cross-sectional study.

Background: The coronavirus pandemic appears to put psychiatric patients with pre-existing symptomatology at risk of symptom increase, but evidence is scarce. While the pandemic and stringent governmental measures have accelerated the use of clinical videoconferencing (VCT), patient satisfaction with VCT is unclear. Objective: Aim of the study was to assess the wellbeing of patients in psychotrauma treatment during the coronavirus pandemic and to evaluate their use of and satisfaction with VCT. Method: This study used data from a routine outcome monitoring assessment completed by patients in treatment at a specialized psychotrauma institute and administered before the easing of governmental measures in June 2020. Wellbeing (Brief Symptom Inventory, Cantril Ladder, perceived stress level, and symptom change), VCT use and VCT satisfaction, and their association with demographic variables (gender, age, education level, and refugee status) were analysed. Results: Of the 318 respondents (response rate 64.5%), 139 (43.7%) reported a symptom increase, which was associated with a higher coronavirus-related stress level and general psychopathology as well as lower life satisfaction. There were significant effects of age and education level on wellbeing. VCT was reported to have been used by 228 (71.7%) patients. VCT satisfaction ratings were higher among women and those with lower levels of stress (r = -.20, p < .01) and general psychopathology (r = .21, p < .01). No difference in treatment satisfaction was found between patients who used VCT versus those who did not (mean difference = -.09 95% CI: -.79 to .62, p = .81). Conclusions: The coronavirus pandemic has aggravated mental health complaints according to a substantial percentage of patients in psychotrauma treatment. Although VCT was found to be acceptable, face-to-face treatment may remain necessary for specific target groups with limited access to VCT (such as refugees) and patients with high levels of general psychopathology.

Antecedentes: La pandemia por el coronavirus parece incrementar el riesgo de un aumento de síntomas a los pacientes psiquiátricos con sintomatología preexistente, pero la evidencia es escasa. Si bien la pandemia y las estrictas medidas gubernamentales han acelerado el uso de la videoconferencia clínica (VCT, por sus siglas en inglés), la satisfacción del paciente con la VCT no está clara.Objetivo: El objetivo del estudio fue el de evaluar el bienestar de los pacientes en tratamiento por psicotrauma durante la pandemia por el coronavirus; además, evaluar su uso y su satisfacción con la VCT.Método: Este estudio empleó los datos de las evaluaciones rutinarias de control clínico de un instituto especializado en psicotraumatología completadas por pacientes y realizadas antes de la flexibilización de las medidas gubernamentales en Junio del 2020. Se analizaron el bienestar (Inventario Breve de Síntomas, Escalera de Cantril, nivel de estrés percibido y cambio de síntomas), el uso de la VCT, la satisfacción con la VCT y su asociación con variables demográficas (género, edad, nivel educacional y condición de refugiado).Resultados: De los 318 encuestados (tasa de respuesta del 64,5%), 139 (43,7%) reportaron un aumento de síntomas, lo cual se asoció con niveles de estrés asociado al coronavirus más altos y con psicopatología general, así como con una menor satisfacción con la vida. Hubo efectos significativos entre la edad y el nivel educativo sobre el bienestar. 228 (71,7%) pacientes reportaron haber usado la VCT. Los índices de satisfacción con la VCT fueron más altos entre las mujeres y entre aquellos con menores niveles de estrés (r = −.20, p < .01) y de psicopatología general (r = .21, p < .01). No se encontraron diferencias entre la satisfacción con el tratamiento en pacientes que usaron la VCT en comparación con aquellos que no lo usaron (diferencia media = −.09 IC del 95%: −.79 a .62, p = .81).Conclusiones: La pandemia por el coronavirus ha agravado las quejas de salud mental en un porcentaje importante de pacientes en tratamiento por psicotrauma. A pesar que se halló que la VCT era aceptable, el tratamiento presencial puede seguir siendo necesario para grupos específicos con acceso limitado a la VCT (como los refugiados) y para los pacientes con altos niveles de psicopatología general.

Dutch politicians' coping with terrorist threat.

The psychosocial effects of terrorist threat and close protection have never been studied systematically in political leaders. We conducted a study among 12 Dutch politicians and their partners who were living under terrorist threat and close protection in the aftermath of two political murders. Interviews revealed that their coping with the situation varied and consisted of emotion-focused, defensive, palliative and instrumental coping strategies. Symptoms of post-traumatic stress disorder occurred in some individuals, and tendencies to express milder or stronger opinions on sensitive issues were reported. Psychosocial knowledge can be useful in helping to cope with the situation in the best possible way.

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.

Recognizing hotspots in Brief Eclectic Psychotherapy for PTSD by text and audio mining.

Background: Identifying and addressing hotspots is a key element of imaginal exposure in Brief Eclectic Psychotherapy for PTSD (BEPP). Research shows that treatment effectiveness is associated with focusing on these hotspots and that hotspot frequency and characteristics may serve as indicators for treatment success. Objective: This study aims to develop a model to automatically recognize hotspots based on text and speech features, which might be an efficient way to track patient progress and predict treatment efficacy. Method: A multimodal supervised classification model was developed based on analog tape recordings and transcripts of imaginal exposure sessions of 10 successful and 10 non-successful treatment completers. Data mining and machine learning techniques were used to extract and select text (e.g. words and word combinations) and speech (e.g. speech rate, pauses between words) features that distinguish between 'hotspot' (N = 37) and 'non-hotspot' (N = 45) phases during exposure sessions. Results: The developed model resulted in a high training performance (mean F 1-score of 0.76) but a low testing performance (mean F 1-score = 0.52). This shows that the selected text and speech features could clearly distinguish between hotspots and non-hotspots in the current data set, but will probably not recognize hotspots from new input data very well. Conclusions: In order to improve the recognition of new hotspots, the described methodology should be applied to a larger, higher quality (digitally recorded) data set. As such this study should be seen mainly as a proof of concept, demonstrating the possible application and contribution of automatic text and audio analysis to therapy process research in PTSD and mental health research in general.

Antecedentes:La identificación y el abordaje de los puntos críticos (hotspots en inglés) es un elemento clave para exposición imaginaria en la Psicoterapia Ecléctica Breve para TEPT (BEPP por sus siglas en inglés). La investigación muestra que la efectividad del tratamiento se asocia con la focalización en estos puntos críticosy que la frecuencia y características de los puntos críticos podría servir de indicador para el éxito terapéutico.Objetivo: Este estudio tiene como objetivo desarrollar un modelo para reconocer automáticamente los puntos críticos basados en características de texto y discurso, lo que podría ser una forma eficiente de seguir los progresos del paciente y predecir la eficacia del tratamiento.Metodo: Se desarrolló un modelo de clasificación supervisada multimodal basado en grabaciones y transcripciones de cintas analógicas de sesiones de exposición imaginaria de diez de tratamiento exitosos y diez no exitosos. Se usaron técnicas de minería de datos y técnicas de aprendizaje automático para extraer y seleccionar las características de texto (ej., palabras y combinaciones de palabras) y discurso (ej., velocidad del discurso, pausas entre las palabras) que distinguen entre las fases de 'puntos críticos' (N= 37) y ' puntos no críticos' (N= 45) durante las sesiones de exposición.Resultados: El modelo desarrollado resultó en un alto rendimiento de entrenamiento (puntaje F1 promedio de 0.76) pero un bajo rendimiento de prueba (puntaje F1 promedio = 0.52). Esto muestra que las características de los textos y discursos seleccionados podrían distinguir claramente entre puntos críticos y puntos no críticos en el conjunto de datos actual, pero probablemente no reconocerá muy bien los puntos críticos de nuevos datos de entrada.Conclusiones: Para mejorar el reconocimiento de nuevos puntos críticos, la metodología descrita debería ser aplicada a un conjunto de datos más grande y de mejor alta calidad (grabado digital). Como tal, este estudio debe verse principalmente como una prueba de concepto, demostrando la posible aplicación y contribución del análisis automático de texto y audio para la investigación del proceso terapéutico en TEPT e investigación en salud mental en general.

Moving forward in treatment of posttraumatic stress disorder: innovations to exposure-based therapy.

The field of treatment of posttraumatic stress disorder (PTSD) has been a pacesetter for the changing face of psychotherapy, as is illustrated in the introduction of Virtual Reality Exposure Therapy. This paper outlines a novel approach that builds on a cognitive-motor interaction in a virtual interactive environment. It is based on the theory of memory reconsolidation and the embodiment of cognition. The framework we envision allows the patient to 'step into the past' by using forward motion as an essential ingredient to augment the impact of exposure to traumatic events. The behavioural response of approaching that is the exact opposite from the avoidance usually applied by patients and the enhancement of divergent thinking are the most prominent hypothesized mechanisms of action. This can contribute to strengthening of personal efficacy and self-reflection that is generated by high emotional engagement, as well as a sense of accomplishment and enhanced recovery as illustrated by a clinical case example. We argue that innovations with personalized virtual reality and motion need to be further investigated and implemented in current therapy settings.

El campo del tratamiento del trastorno por estrés postraumático (TEPT) ha sido de los más avanzados en cuanto a los cambios que han tenido lugar en la psicoterapia, como la introducción de la Terapia de Exposición con Realidad Virtual. Este documento describe un enfoque novedoso que se basa en una interacción cognitivo-motora en un entorno virtual interactivo. Se basa en la teoría de la reconsolidación de la memoria y la materialización de la cognición. El marco de trabajo que visualizamos le permite al paciente literalmente entrar en el pasado usando el movimiento hacia adelante como un ingrediente esencial para aumentar el impacto de la exposición a eventos traumáticos. La respuesta conductual de aproximación que es exactamente lo opuesto a la evitación que generalmente aplican los pacientes y la mejora del pensamiento divergente son los mecanismos de acción hipotéticos más prominentes. Esto puede contribuir al fortalecimiento de la eficacia personal y la autorreflexión que se genera por una alta implicación emocional, así como una sensación de logro y una recuperación mejorada como muestra un ejemplo de caso clínico. Argumentamos que las innovaciones con VR y movimiento personalizados deben investigarse más a fondo y aplicarse en los entornos terapéuticos actuales.

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.