Barbara O. Rothbaum

Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma

Major depressive disorder is associated with considerable morbidity, disability, and risk for suicide. Treatments for depression most commonly include antidepressants, psychotherapy, or the combination. Little is known about predictors of treatment response for depression. In this study, 681 patients with chronic forms of major depression were treated with an antidepressant (nefazodone), Cognitive Behavioral Analysis System of Psychotherapy (CBASP), or the combination. Overall, the effects of the antidepressant alone and psychotherapy alone were equal and significantly less effective than combination treatment. Among those with a history of early childhood trauma (loss of parents at an early age, physical or sexual abuse, or neglect), psychotherapy alone was superior to antidepressant monotherapy. Moreover, the combination of psychotherapy and pharmacotherapy was only marginally superior to psychotherapy alone among the childhood abuse cohort. Our results suggest that psychotherapy may be an essential element in the treatment of patients with chronic forms of major depression and a history of childhood trauma.

Effects of D-Cycloserine on Extinction: Translation From Preclinical to Clinical Work

Administration of benzodiazepines or serotonin reuptake inhibitors in combination with behavior therapy for the treatment of many anxiety disorders has generally lead to only modest gains. In this article we suggest that pharmacotherapy aimed not at treating the symptoms of anxiety but instead aimed at improving the learning that takes place in exposure therapy might actually improve the effectiveness of exposure therapy. This idea was based on animal work showing that the partial N-methyl-D-aspartate (NMDA) agonist D-cycloserine (DCS) facilitated extinction of fear when given either before or shortly after exposure to fearful cues, reduced return of fear that is normally seen when extinction training is followed by stress, and led to generalized extinction, where DCS given in combination with exposure to one fearful cue led to extinction to another cue previously paired with the same aversive event. These finding suggested that DCS might facilitate exposure-based psychotherapy, which was verified in a small clinical study showing that DCS facilitated exposure therapy for fear of heights in a well-controlled virtual reality environment.

Applying Learning Principles to the Treatment of Post-Trauma Reactions

Abstract: Posttraumatic stress disorder (PTSD) can be characterized as a failure of recovery caused, in part, by a failure of fear extinction after trauma. By studying the process of extinction, we can be informed regarding the etiology and maintenance of PTSD. The normal response to trauma in humans includes a set of predictable reactions including reexperiencing, avoidance, and hyperarousal that typically extinguish in the days and weeks after the trauma. In the majority of people exposed to trauma, these responses extinguish over time. However, in a substantial minority, extinction fails and these persisting responses become the symptoms of PTSD. Therefore, one of our fundamental hypotheses is that PTSD is a disorder caused in part by the failure of extinction of predictable posttraumatic physiological and psychological reactions. The most empirically validated treatments for PTSD involve exposure of the patient to trauma‐related cues in the absence of danger that then lead to the extinction of these reexperiencing, avoidance, and arousal symptoms. There is also mounting evidence that individuals with PTSD are more resistant to extinction. Regarding early interventions with traumatized individuals, there is mounting evidence that some early one‐time interventions actually may impede extinction, whereas interventions delivered in more than one session, at least several weeks after the trauma, to individuals continuing to experience above average reactions, generally are effective in preventing the development of PTSD. Thus, there appears to be an interaction between timing of the intervention, number of intervention sessions, and either arousal level and/or risk status in determining whether the intervention will be helpful, harmful, or neutral.

Virtual Reality Exposure Therapy for PTSD Vietnam Veterans: A Case Study

Virtual reality (VR) integrates real-time computer graphics, body tracking devices, visual displays, and other sensory input devices to immerse a participant in a computer-generated virtual environment that changes in a natural way with head and body motion. VR exposure (VRE) is proposed as an alternative to typical imaginal exposure treatment for Vietnam combat veterans with posttraumatic stress disorder (PTSD). This report presents the results of the first Vietnam combat veteran with PTSD to have been treated with VRE. The patient was exposed to two virtual environments, a virtual Huey helicopter flying over a virtual Vietnam and a clearing surrounded by jungle. The patient experienced a 34% decrease on clinician-rated PTSD and a 45% decrease on self-rated PTSD. Treatment gains were maintained at 6-month follow-up.

Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics

Although many studies report that the therapeutic alliance predicts psychotherapy outcome, few exclude the possibility that this association is accounted for by 3rd variables, such as prior improvement and prognostically relevant patient characteristics. The authors treated 367 chronically depressed patients with the cognitive-behavioral analysis system of psychotherapy (CBASP), alone or with medication. Using mixed effects growth-curve analyses, they found the early alliance significantly predicted subsequent improvement in depressive symptoms after controlling for prior improvement and 8 prognostically relevant patient characteristics. In contrast, neither early level nor change in symptoms predicted the subsequent level or course of the alliance. Patients receiving combination treatment reported stronger alliances with their psychotherapists than patients receiving CBASP alone. However, the impact of the alliance on outcome was similar for both treatment conditions.

Virtual environments for treating the fear of heights

Can virtual environments help elicit fearful feelings so they can be treated? This article shows how therapists and computer experts used them to do just that. We describe a pilot study that used virtual reality graded exposure techniques to treat acrophobia-the fear of heights. We specifically address two issues: the extent to which we were able to make subjects feel that they were actually present in height situations, and the efficacy of the treatment conducted using virtual height situations. >

Virtual reality graded exposure in the treatment of acrophobia : A case report

This is the first case report to test the efficacy of computer-generated virtual reality (VR) for the treatment of acrophobia (fear of heights). The subject was a 19-year-old undergraduate student with a fear of heights, particularly of elevators. Twice weekly, sessions were conducted for 3 weeks, for a total of 5 sessions. Outcome was assessed on measures of anxiety, avoidance, attitude, distress, and included a behavioral avoidance test. VR graded exposure was successful in reducing fears of heights. VR graded exposure is proposed as a new medium for exposure therapy.

Virtual reality exposure therapy in the treatment of fear of flying: a case report

The efficacy of virtual reality (VR) exposure therapy was examined for the fear of flying. Virtual reality exposure involved six sessions of graded exposure to flying in a virtual airplane. The specific contribution of anxiety management techniques (AMT) and the VR exposure was examined in a single case design. The subject was a 42-year-old female with a debilitating fear and avoidance of flying. All self-report measures of the fear and avoidance of flying decreased following AMT and decreased still further following VR exposure. A planned post-treatment flight was completed with anxiety measures indicating comfortable flight. The implications of this new medium for exposure therapy are discussed.

Emerging treatments for PTSD

Recent innovations in posttraumatic stress disorder (PTSD) research have identified new treatments with significant potential, as well as novel enhancements to empirically-validated treatments. This paper reviews emerging psychotherapeutic and pharmacologic interventions for the treatment of PTSD. It examines the evidence for a range of interventions, from social and family-based treatments to technological-based treatments. It describes recent findings regarding novel pharmacologic approaches including propranolol, ketamine, prazosin, and methylenedioxymethamphetamine. Special emphasis is given to the description of virtual reality and D-cycloserine as enhancements to prolonged exposure therapy.

A Randomized, Double-Blind Evaluation of d-Cycloserine or Alprazolam Combined With Virtual Reality Exposure Therapy for Posttraumatic Stress Disorder in Iraq and Afghanistan War Veterans

OBJECTIVE The authors examined the effectiveness of virtual reality exposure augmented with D-cycloserine or alprazolam, compared with placebo, in reducing posttraumatic stress disorder (PTSD) due to military trauma. METHOD After an introductory session, five sessions of virtual reality exposure were augmented with D-cycloserine (50 mg) or alprazolam (0.25 mg) in a double-blind, placebo-controlled randomized clinical trial for 156 Iraq and Afghanistan war veterans with PTSD. RESULTS PTSD symptoms significantly improved from pre- to posttreatment across all conditions and were maintained at 3, 6, and 12 months. There were no overall differences in symptoms between D-cycloserine and placebo at any time. Alprazolam and placebo differed significantly on the Clinician-Administered PTSD Scale score at posttreatment and PTSD diagnosis at 3 months posttreatment; the alprazolam group showed a higher rate of PTSD (82.8%) than the placebo group (47.8%). Between-session extinction learning was a treatment-specific enhancer of outcome for the D-cycloserine group only. At posttreatment, the D-cycloserine group had the lowest cortisol reactivity and smallest startle response during virtual reality scenes. CONCLUSIONS A six-session virtual reality treatment was associated with reduction in PTSD diagnoses and symptoms in Iraq and Afghanistan veterans, although there was no control condition for the virtual reality exposure. There was no advantage of D-cycloserine for PTSD symptoms in primary analyses. In secondary analyses, alprazolam impaired recovery and D-cycloserine enhanced virtual reality outcome in patients who demonstrated within-session learning. D-cycloserine augmentation reduced cortisol and startle reactivity more than did alprazolam or placebo, findings that are consistent with those in the animal literature.