Relationship between change in in-vivo exposure distress and PTSD symptoms during exposure therapy for active duty soldiers

Virtual Reality and Stress Management: A Systematic Review

Amidst the growing prevalence of chronic stress and its potential negative impacts on mental health, this review explores the use of virtual reality (VR) as a stress management solution, aiming to assess its viability and effectiveness in this context. A comprehensive search was conducted on MEDLINE, PsycINFO, and Embase from inception until February 2024. Eligible studies were primary research papers that focused on the use of VR as an intervention to mitigate psychological stress and/or distress. We included studies where the assessment of stress levels primarily relied on self-report measures. A total of 50 studies involving 2885 participants were included in our systematic review. VR-based interventions varied across studies, implementing tools such as cognitive behavioural therapy, exposure therapy, mindfulness and relaxation, repetition tasks, and psychoeducation. The reviewed studies yielded mixed results; however, a strong indication was present in highlighting the promising potential of VR-based interventions. Many studies observed a decrease in psychiatric symptoms in participants and reported increased quality of life. Various studies also found VR to be a valuable tool in promoting stress reduction and relaxation. VR was proven useful in exposing participants to stressors in a safe, controlled way. These potential benefits appear to come with no risk of harm to the participants. Although the findings are heterogenous, there is sufficient evidence supporting the use of VR for stress management across a range of contexts and populations. Overall, VR appears to be a generally low-risk, feasible intervention for those struggling with stress.

Therapeutic interventions impact brain function and promote post-traumatic growth in adults living with post-traumatic stress disorder: A systematic review and meta-analysis of functional magnetic resonance imaging studies

Introduction

The present systematic review and meta-analysis explores the impacts of cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and prolonged exposure (PE) therapy on neural activity underlying the phenomenon of post-traumatic growth for adult trauma survivors.

Methods

We utilized the following databases to conduct our systematic search: Boston College Libraries, PubMed, MEDLINE, and PsycINFO. Our initial search yielded 834 studies for initial screening. We implemented seven eligibility criteria to vet articles for full-text review. Twenty-nine studies remained for full-text review after our systematic review process was completed. Studies were subjected to several levels of analysis. First, pre-and post- test post-traumatic growth inventory (PTGI) scores were collected from all studies and analyzed through a forest plot using Hedges' g. Next, Montreal Neurological Institute (MNI) coordinates and t-scores were collected and analyzed using an Activation Likelihood Estimation (ALE) to measure brain function. T-scores and Hedges' g values were then analyzed using Pearson correlations to determine if there were any relationships between brain function and post-traumatic growth for each modality. Lastly, all studies were subjected to a bubble plot and Egger's test to assess risk of publication bias across the review sample.

Results

Forest plot results indicated that all three interventions had a robust effect on PTGI scores. ALE meta-analysis results indicated that EMDR exhibited the largest effect on brain function, with the R thalamus (t = 4.23, p < 0.001) showing robust activation, followed closely by the R precuneus (t = 4.19, p < 0.001). Pearson correlation results showed that EMDR demonstrated the strongest correlation between increased brain function and PTGI scores (r = 0.910, p < 0.001). Qualitative review of the bubble plot indicated no obvious traces of publication bias, which was corroborated by the results of the Egger's test (p = 0.127).

Discussion

Our systematic review and meta-analysis showed that CPT, EMDR, and PE each exhibited a robust effect on PTG impacts across the course of treatment. However, when looking closer at comparative analyses of neural activity (ALE) and PTGI scores (Pearson correlation), EMDR exhibited a more robust effect on PTG impacts and brain function than CPT and PE.

Use of Virtual Reality Techniques to Rehabilitate Military Veterans with Post-Traumatic Stress Disorder (Review)

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder developing after a traumatic event like participation in combat activities. Objective diagnosis of combat PTSD and effective rehabilitation of war veterans is a current multifaceted problem with particularly high social costs. This review aims to evaluate the potential of virtual reality technique used as exposure therapy tool (VRET) to rehabilitate combat veterans and service members with PTSD. The review was written following the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The final analysis includes 75 articles published in 2017-2022. VRET therapeutic effect mechanisms were examined along with protocols and scenarios of VRET combined with other interventions influencing PTSD treatment like pharmacotherapy, motion-assisted multi-modular memory desensitization and reconsolidation (3MDR), transcranial magnetic stimulation. The necessity is substantiated of psychophysiological measurements for objectification of PTSD clinical criteria and its dynamics during treatment. It was shown that inclusion of VRET to the package of PTSD rehabilitation interventions positively affects the results due to the enhanced effect of presence and greater experience personalization. Thus, VRET may be an effective, controlled, and cost-effective alternative for PTSD treatment in combatants, including those not responding to conventional therapy.

Temporal Relationship Between Change in Subjective Distress and PTSD Symptom Decrease During Prolonged Exposure Therapy for Posttraumatic Stress Disorder

There is growing evidence that change in distress is an indicator of change during Prolonged Exposure (PE) for posttraumatic stress disorder (PTSD). However, temporal sequencing studies investigating whether change in distress precedes PTSD symptom decline are lacking. These studies are essential since the timeline between indicators of change and treatment outcome is a key assumption for mediation. The aim of the present study was to assess the temporal relationship between within- and between-session change in subjective distress and PTSD symptom decrease. We analyzed session data from 86 patients with PTSD. Data were analyzed using dynamic panel models. We distinguished temporal effects (within-persons) from averaged effects (between-persons). Results regarding the temporal effect showed that within-session change in subjective distress preceded PTSD symptom improvement while the reversed effect was absent. Averaged within-session change in subjective distress was also related to PTSD symptom improvement. Results regarding the temporal effect of between-session change in subjective distress showed that it did not precede PTSD symptom improvement. Averaged between-session change in subjective distress was related to PTSD symptom improvement. This study provides evidence for within- but not between-session change in subjective distress as indicator of change during PE. We also found that the way of modeling potential indicators of change affects results and implications. We recommend future studies to analyze mediators during treatment using temporal rather than averaged effects.

A Decade in Review: A Systematic Review of Virtual Reality Interventions for Emotional Disorders

Research is increasingly demonstrating the therapeutic benefits of virtual reality interventions for various mental health conditions, though these rarely translate from research to application in clinical settings. This systematic review aims to examine the efficacy of current virtual reality interventions for emotional disorders, with a focus on clinical and technological features that influence translation of treatments from research to clinical practice. A comprehensive systematic literature search was conducted following PRISMA guidelines, for studies including the application of a virtual reality intervention to a clinical population of adults with an emotional disorder. Thirty-seven eligible studies were identified, appraised, and assessed for bias. Treatment effects were typically large across studies, with virtual reality being considered an efficacious treatment modality for various anxiety disorders and post-traumatic stress disorder. Virtual reality interventions were typically used for delivering exposure in cognitive behavioural therapy approaches. Considerable variability was seen in cost, technological specifications, degree of therapist involvement, delivery format, dosage, duration, and frequency of treatment. Suboptimal methodological rigour was identified in some studies. Remote use of virtual reality was rare, despite increasing options for in home use. Virtual reality interventions have the potential to overcome barriers to care and better meet the needs of consumers. Future research should examine the efficacy of virtual reality for treatment of depressive disorders and obsesive compulsive disorder. Improved methodological reporting and development of transdiagnostic and remotely delivered virtual reality interventions, will likely increase the translation of this treatment modality.

Determining the median effective dose of prolonged exposure therapy for veterans with posttraumatic stress disorder

Prolonged exposure therapy (PE) is an effective treatment for posttraumatic stress disorder (PTSD). Identifying metrics of treatment response can guide treatment delivery. The median effective dose represents the number of sessions at which there is a 50% probability of clinically meaningful improvement (i.e., 10-point reduction in PTSD checklist). The goal of the current study was to investigate the median effective dose of PE. We identified a cohort of Iraq and Afghanistan war veterans who received psychotherapy for PTSD in the Veterans Health Administration between 2001 and 2017. From this cohort, 10,234 veterans who received PE (as identified using natural language processing) and had ≥2 PTSD symptom measures were included in analyses. To determine how the number of PE sessions and covariates affected clinically meaningful improvement, we utilized a Cox proportional hazards regression, followed by Kaplan-Meier curves to determine the median effective dose. The median effective dose of PE was four sessions. Although some covariates were found to be statistically significant predictors of clinically meaningful improvement (e.g., age, gender, PTSD medications, and depressive disorder comorbidity), these effects were small. Clinicians and patients should consider evaluating treatment response after four sessions to determine preliminary effectiveness of PE.