EXAMPLES OF TRAUMA AND DISASTER CONFRONT US EVERYDAY

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2 Disclosure Virtually Better, Inc (VBI), part owner managed under Emory University's Conflict of Interest Policy Virtual Iraq created by Dr. Skip Rizzo at USC, not VBI, but VBI is selling virtual reality products

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4 EXAMPLES OF TRAUMA AND DISASTER CONFRONT US EVERYDAY

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7 PSTD: Important Interview Questions Have you ever had any painful or unforgettable experiences where you thought you or someone you loved could be seriously injured or killed? Do you frequently relive the experience? Do you avoid events, places or people associated with the trauma or that remind you of the trauma? Are you easily disturbed by sudden sounds, flashes of light or loud music?

8 Percent PTSD A Prospective Examination of PTSD in Rape Victims Percent of Victims with PTS Assessment Week

9 Severity of PTSD Symptoms Non-PTS PTS Assessment Week Rothbaum BO et al. J Traumatic Stress. 1992;5(3):464; NIMH Grant No. R01MH42178

10 Extinction We view PTSD as a disorder of extinction

11 extinction training = exposure therapy (rodents) (humans)

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14 Exposure Therapy Principles Extinction training based on learning principles reliable findings with animals and phobic disorders exposure to feared stimulus repeatedly and for prolonged period leads to habituation and extinction Therapeutic Exposure

15 Prolonged Imaginal Exposure: Theory Information/Emotional Processing Fear Normal Response to Trauma Fear, Anxiety, Social Conventions Lead to Avoidance Avoidance Reinforced Avoidance Prohibits Emotional Processing Emotional Processing Requires: 1)Activation 2)Corrective information Foa, Hembree & Rothbaum (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences, Therapist Guide. NY. Oxford University Press. Rothbaum, Foa & Hembree (2007). Reclaiming Your Life from a Traumatic Experience: Client Workbook. NY. Oxford University Press.

16 Prolonged Imaginal Exposure: Techniques Imaginal Exposure In Vivo Exposure Includes: Education Breathing Relaxation Processing Virtual Reality Exposure

17 Prolonged Imaginal Exposure Therapy Protocol

18 Prolonged Exposure Therapy (PE) Breathing retraining: 10 minutes in session Education about common reactions to trauma Imaginal exposure (reliving) to the trauma memory In vivo exposure to trauma reminders in between sessions Processing of emotional material 9 12 weekly or twice weekly 90 minute sessions

19 PE Therapy for PTSD (cont d) Imaginal exposure: Patients recount the traumatic memories during sessions and listen to the tape recorded recounting between sessions In vivo exposure: Patients confront safe trauma related situations and objects between sessions, beginning with less fearful situations and moving on to more fearful ones

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22 Conclusions Therapeutic Exposure Long enough for anxiety to decrease To the proper cues To induce changes That generalize: Between session And to other contexts

23 Evidence for Exposure Randomized trials More evidence than any other intervention for PTSD all positive Across Trauma Populations veterans female assault survivors mixed trauma refugees earthquake survivors World Trade Center survivors Cahill, Rothbaum, Resick, & Follette (2008). ISTSS Treatment Guidelines, vol II

24 Eye Movement Desensitization and Reprocessing (EMDR) vs. PE vs. Wait List Control for PTSD Adult Female Rape Victims Barbara O. Rothbaum, PhD, ABPP Millie Astin, PhD Fred Marsteller, PhD

25 Eye Movement Desensitization and Reprocessing (EMDR) Form of exposure + saccadic eye movements Patient focus on disturbing memory finger tracking Positive cognitions

26 Evidence for EMDR: ISTSS Guidelines 7 controlled studies Large effect sizes for EMDR Role of eye movement questioned

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30 1. Medium of Delivery of Exposure

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32 Virtual Reality Interactive computer environment More than simply multimedia Sense of PRESENCE IMMERSIVE

33 Virtual Reality Hardware Head mounted display Position tracker Sensor Hand tracker Computer Monitor Headphones Thunder Chair Microphone

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36 Virtual Reality Exposure Therapy for PTSD Vietnam Veterans Vietnam combat veterans Virtual Huey helicopter Fly over the jungles of Vietnam Walk in clearing near jungle, swamp Imaginal exposure immersed in Vietnam stimuli Rothbaum et al., (2001). Journal of Clinical Psychiatry. NIMH grant No. R21MH55555

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45 2. Enhancing Exposure Therapy with Pharmacological Agents

46 CBT Combined with Medication for PTSD Rothbaum, Cahill, Foa, Davidson, Compton, Connor, Astin, & Hahn (2006). Augmentation of Sertraline with Prolonged Exposure in the Treatment of PTSD. Journal of Traumatic Stress,

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50 The Effects of Prolonged Exposure Therapy and Medication on PTSD Simon, Connor, Lang, Rauch, Krulewicz, LeBeau, Davidson, Stein, Otto, Foa, & Pollack (2008). Paroxetine CR Augmentation for PTSD Refractory to Prolonged Exposure Therapy. Journal of Clinical Psychiatry 69(3),

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54 Choice

55 Preference Between sertraline and PE Study 1: 74 PTSD women: 82 % chose PE Study 2: 31 female assault survivors with PTSD 74% chose PE Both PE and SERT large effect sizes Advantage of PE Women w/ MDD more likely to choose SERT Women with comorbid MDD, larger advantage of PE Feeny et al, Depression & Anxiety, 2009

56 Cost effectiveness of PE vs pharmacotherapy and treatment choice in PTSD: a doubly randomized preference trial N = 200 PTSD Randomized to receive their choice (n = 97) or randomly assigned to treatment (n = 103) Choice arm: PE ( n = 61) or SERT (n = 36) No choice: PE ( n = 48) or SERT (n = 55) Cost in 2012 $ PE was less costly & more QALYs when tx assigned Choice was less costly and more QALYs Conclusions: Choice is cost effective; if choice not possible, PE more cost effective Le, Doctor, Zoellner, Feeny, 2014

57 D Cycloserine Augmentation of Exposure Therapy: Virtual Reality Exposure for Treatment of Fear of Heights A Double Blind, Placebo Controlled Study Rothbaum, Ressler, Davis Emory University Dept of Psychiatry Anderson, Zimand, Tannenbaum, Graap, Hodges Virtually Better, Inc. (2004). Facilitation of Psychotherapy with D Cycloserine, a Putative Cognitive Enhancer. Archives of General Psychiatry, 61,

58 Summary of Extinction Facilitation by D Cycloserine Administration of D Cycloserine (DCS), an NMDA partial agonist, before extinction training produced a dose dependent enhancement of extinction in rodents. DCS enhancement of extinction is cue specific as it did not affect fear potentiated startle in rats simply exposed to the test chamber.

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72 Posttraumatic Stress Disorder (PTSD)

73 Virtual Iraq

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78 DCS enhancement of VRE trial OEF/OIF veterans with PTSD, n=156 5 sessions of Virtual Reality Exposure (VRE) + medication (1 pill 30min before each VRE session) D Cycloserine (50 mg) Placebo Alprazolam (.25 mg) Assessments pre, post, 3, 6, and 12 months Psychophysiology and cortisol reactivity Rothbaum et al., (2014). NIMH grant No. R01MH A2

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88 EXAMPLES OF TREATMENT EFFECTS ON PSYCHOPHYSIOLOGY DURING VR ENVIRONMENT

89 Treatment responder (032): CAPS decreased from 103 (pre treatment) to 68 (post treatment) Decreased skin conductance level, fewer responses, habituation Fewer startle responses of smaller magnitude Decreased RSA

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98 Conclusions VRE > reduced PTSD diagnosis and symptoms Overall, there was no advantage of DCS on PTSD symptoms in primary analyses D cycloserine augmentation treatment in PTSD patients may reduce cortisol and startle reactivity compared to the alprazolam and placebo treatment Increased psychophysiological engagement in VR scenes predicted better outcomes in DCS group Higher cortisol reactivity predicted worse outcomes

99 3. Timing of Exposure Therapy

100 Opportunity Unlike other psychiatric disorders, the precipitant for adult PTSD is a known event, allowing for immediate intervention, presenting the potential to prevent the development of PTSD.

101 Early Interventions

102 Existing evidence suggests 1)the debriefing literature is equivocal at best with some studies indicating it can cause harm; 2)there are no good candidates for immediate intervention;

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104 Early Intervention Conclusions Early interventions may interfere with natural recovery No evidence for which early interventions help Need to have right amount of exposure and arousal for optimum response

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106 Evidence from Davis Lab (animals) Extinction training done very shortly after fear conditioning may prevent consolidation of the original fear memory

107 Effects of Early Psychological Intervention to Prevent PTSD Study Intervention Conditions: Randomly assign 134 ER patients to: 1 Immediate Treatment : 3 total PE sessions: #1 in ED, #2 3 delivered 1 2 wks after ED; or 2 Assessment only (4 and 12 weeks post trauma)

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117 Intensive Outpatient Program (IOP) Post 9/11 veterans and service members No cost to the veteran Two weeks structure Prolonged exposure Potential additional services: Cognitive/neuropsych assessment & treatment Sleep assessment & treatment Skills training in family/relationship management Wellness: yoga, sleep, acupuncture, recreation Career/financial support

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