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Emerging treatments for ptsd
CPR-01005; No of Pages 12 Clinical Psychology Review xxx (2009) xxx–xxx Contents lists available at Clinical Psychology Review Emerging treatments for PTSD Judith Cukor Josh Spitalnick JoAnn Difede , Albert Rizzo Barbara O. Rothbaum a Weill Cornell Medical College, 525 East 68th Street, Box 200, New York, NY 10065, USAb Virtually Better, Inc., 2440 Lawrenceville Hwy, Suite 200, Decatur, GA 30033, USAc University of Southern California Institute for Creative Technologies, 13274 Fiji Way, Marina del Rey, CA. 90292, USAd Emory University School of Medicine, 1256 Briarcliff Road, Atlanta, GA 30306, USA Available online xxxx Recent innovations in posttraumatic stress disorder (PTSD) research have identiﬁed new treatments withsigniﬁcant 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 Posttraumatic stress disorder 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 Emerging treatments virtual reality and D-cycloserine as enhancements to prolonged exposure therapy.
2009 Elsevier Ltd. All rights reserved.
Acceptance and Commitment Therapy (ACT) . . . . . . . . . . . . . . . . . . . .
Virtual reality: an emerging alternative treatment for PTSD . . . . . . . . . . . . . . . . .
Rationale for Virtual Reality Exposure therapy (VRE) . . . . . . . . . . . . . . . . . .
☆ Disclosure: Dr. Spitalnick is employed by Virtually Better, Inc. which is developing products related to the research described in this article. However, Virtually Better did not create the Virtual Iraq described in this chapter.
⁎ Corresponding author. Tel.: +1 212 746 4492; fax: +1 212 821 0994.
E-mail addresses: (J. Cukor), (J. Spitalnick), (J. Difede), (A. Rizzo), (B.O. Rothbaum).
0272-7358/$ – see front matter 2009 Elsevier Ltd. All rights reserved.
doi: Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx Application of VR to treat anxiety disorders . . . . . . . . . . . . . . . . . . . . .
Application of VR for PTSD among OIF/OEF soldiers . . . . . . . . . . . . . . . . . . .
Virtual Reality Graded Exposure Therapy (VRGET). . . . . . . . . . . . . . . . . . .
Methylenedioxymethamphetamine (MDMA; Ecstasy) . . . . . . . . . . . . . . . . . . . .
special emphasis given to virtual reality (VR) exposure therapy andD-cycloserine as enhancements to traditional treatments as there is While the diagnostic category of PTSD has existed only since much excitement surrounding these approaches.
1980 when it was ﬁrst included in the DSM III, hundreds of clinicaltrials have sought to identify methods of ameliorating its distressingsymptoms. These methods have ranged from pharmacological 2. Psychological interventions approaches which directly treat PTSD and related symptoms tocognitive-behavioral treatments (CBT) that are based on principles 2.1. Social and family based treatments of conditioning and learning. For example, exposure therapy, a CBTapproach, is currently considered the ﬁrst-line treatment for PTSD 2.1.1. Couple and family therapy given its well-documented clinical efﬁcacy ( PTSD has been associated with marital and relationship difﬁculty, ). A recent Institute of aggression toward partners and children, sexual dysfunction and Medicine (IOM) report concluded that exposure therapy is the only emotional distancing ), with more treatment with sufﬁcient empirical evidence to recommend it than 75% of married or partnered Operation Iraqi Freedom/Operation The efﬁcacy of CBT trauma-focused treatments including Enduring Freedom (OIF/OEF) Veterans reporting problems with prolonged exposure (cognitive processing therapy family relationships Numerous (CPT) and eye movement desensitization and couple and family treatment strategies have been developed but few reprocessing (EMDR) have received support, have been studied. describes the two approaches to while evidence for pharmacologic therapies remains inconclusive family treatment. The ﬁrst focuses on the disruptions to the family (although two medications have received an FDA indi- system caused by the trauma and PTSD symptoms. Treatment targets cation for PTSD.
reparations of the family dynamic and decrease of stress to the Despite the abundance of evidence pointing to the efﬁcacy of system, borrowing largely from couples and family treatments, and exposure therapy, PTSD remains a difﬁcult disorder to treat and marginalizes treatment of the PTSD itself. The second focuses on the identifying alternative treatment options is imperative. This is individual's PTSD and garners the support of the partner and/or family particularly true for Veterans and active duty personnel, given the in helping the individual to recover.
likely return home of several hundred-thousand active duty soldiers Couples based treatments include Critical Action Theory for over the course of the next 3 years combined with the probable need combat-related PTSD ), emotional- for re-deployment of U.S. soldiers to additional combat zones such as ly-focused therapy (and others (However, no studies have Although there have been signiﬁcant advances in the treatment of evaluated the efﬁcacy of these techniques. PTSD, treatment failures persist. A meta-analysis of 26 studies with 44 propose the application of Integrative Behav- treatment conditions reported that overall, 56% of those enrolled in ioral Couple Therapy to the Veteran population, though no data treatment and 67% of those who completed treatment no longer met supports its use as yet. The theoretical background highlights the role criteria for PTSD after treatment and 44% of enrollees and 54% of of experiential avoidance that causes the individual to distance him/ completers had clinically meaningful improvement by standards herself from his/her interpersonal relationships and prevents the deﬁned by the authors ( individual from approaching future opportunities to face discomfort, While these rates are impressive for short-term treatment of thereby hindering recovery.
an often chronic disorder, the high rate of treatment failures calls In one of the more promising treatments with data on its efﬁcacy, for the innovation and dissemination of alternative or augmented described Cognitive Behavioral Conjoint Therapy for PTSD, designed for couples where one or both partners have PTSD. The 15 This article will review emerging psychotherapeutic and pharma- session protocol treats the couple as a unit using three stages: 1) cologic treatments for PTSD. While the term "emerging treatments" Psychoeducation and safety building, 2) Confronting avoidance, enhanc- has no uniform deﬁnition in the literature, we use it to refer to ing relationship satisfaction and improving communication, and 3) Cog- interventions with some theoretical basis that have garnered the nitive interventions addressing relationship problems and symptoms of beginnings of scientiﬁc and popular support. By deﬁnition, this PTSD, focusing on maladaptive thoughts around the trauma. Only one excludes interventions that have a strong scientiﬁc foundation or to preliminary uncontrolled study has been completed ( which signiﬁcant study has been dedicated such as prolonged with 7 married male Vietnam Veterans and exposure therapy (PE), CPT and EMDR which will not be addressed their spouses. Signiﬁcant improvement in PTSD scores by clinician rating here. Our synthesis of the literature is presented below, with a and spouse rating were noted, though not by Veteran rating. Wives also description followed by a brief analysis of each treatment and with reported marginally greater relationship satisfaction, while Veterans Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx reported improvements in depression and anxiety. A current NIMH These mixed preliminary ﬁndings highlight the need for further funded grant is now devoted to the reﬁnement and testing of this research, including whether an emphasis on the social aspects of PTSD can effectively address PTSD symptoms such as reexperiencing and studied the application of family systems hyperarousal or whether interpersonal treatments are best used to therapy (FST) in 26 Operation Desert Storm Veterans who had been augment traditional PTSD treatment.
deployed to the European theater and requested family systemstreatment as compared to a quasi-control group of 13 Veterans and 2.2. Behavioral treatments their spouses who did not request treatment and 62 other Veteransfrom the same unit who were assessed 15–18 months after demo- 2.2.1. Behavioral activation bilization (posttest only group). The authors describe the treatment Behavioral activation (BA) entails a structured approach to increas- as focusing on the systemic effect of the stressors in one to ﬁve ing client engagement in activities, including identifying and scheduling sessions lasting 90–120 min over a 2–8 week period. Goal setting and events for homework. The technique may be especially relevant for psychoeducation were followed by cognitive restructuring around" individuals with PTSD where symptoms of avoidance and social iso- extreme beliefs" and strengthening feelings of trust, self-efﬁcacy and lation are prominent.
safety. Structural systems interventions focused on restoring family A case study of a police ofﬁcer with a history of multiple trauma roles, strategic prescriptions enhanced family members' sense of including military service treated with 11 sessions focusing on BA control, and dysfunctional marital or parental patterns were reported that the patient no longer met criteria for either PTSD or identiﬁed and reworked. Finally, the Veteran was given the ability MDD following treatment. However, only signiﬁcant reductions in the to share narratives of their most disturbing military experiences.
avoidance subscale emerged. ).
Results indicated improvements in symptoms of anxiety and A pilot study provided 11 Veterans with 16 sessions of BA utilized depression, as well as family systemic adjustment. The quasi-control to identify avoided situations, plan goals, and practice activities.
group reported smaller improvement in psychiatric symptoms, and Therapists also worked with patients to identify triggers of anxiety deterioration in family adjustment which may support the use of FST and behavioral and emotional responses to it ).
as a treatment. However, generalization from this study is poor due Between sessions, patients approached their avoided activities, to signiﬁcant variability in treatment time, design, and delivery, and although not those that were trauma speciﬁc. Of the 9 completers, the lack of randomization for group assignment.
CAPS scores showed a signiﬁcant decrease pre- to post-treatment, but Thus data on couples and family treatment is scarce, however the four of the ﬁve patients who showed a reliable change still met theoretical basis for its use in the treatment of PTSD is strong. The diagnosis of PTSD after treatment. There were no signiﬁcant changes application to a military population is compelling: Returning Service on mean depression scores.
Members often report feeling like they don't belong or that they are A small randomized trial ( misunderstood. Engaging the partner and the family is a natural area ) of 8 participants with traumatic injury compared 4 to intervene. It can increase feelings of acceptance and belongingness, individuals receiving 4–6 sessions of BA to a TAU (treatment as usual) help family members to understand the Veteran's experience and group 1 month after the traumatic injury occurred. Signiﬁcant PTSD illustrate to the Veteran that they have the support of their loved ones.
changes were noted in the BA group, but depression scores increased The family relationship can serve as a support or obstacle in recovery in half of the sample and decreased in the other half, which certainly from combat-related distress, underscoring the importance of the needs clariﬁcation. Success in this small randomized trial may be family relationship as a target for intervention ().
attributable to the nature of a traumatically injured population inwhich concerns about physical limitations may increase behavioralavoidance and a treatment involving routine discussion with doctors 2.1.2. Interpersonal psychotherapy regarding activity scheduling in light of the individual's changed The symptoms of PTSD are often accompanied by a disruption of functioning can be especially signiﬁcant.
social relationships from intimate familial connections to broader social These initial results do not seem to imply that the use of BA alone is and occupational networks. Interpersonal therapy focuses on social sufﬁcient to address the entire PTSD symptom picture. At present, BA functioning which is theorized to consequently lead to improvements is best treated as a component of other treatment approaches rather in all symptoms.
than stand alone treatment for PTSD.
A pilot study of 14 subjects with chronic PTSD from diverse precipitating interpersonal traumas foundthat a 14 week, individual interpersonal treatment was successful in 2.2.2. Trauma Management Therapy improving social relationships and in reducing symptoms of PTSD. The Trauma Management Therapy (TMT) was developed by treatment focused on trust and interpersonal difﬁculties arising after ) to address negative the trauma and resulted in 69% of subjects showing a reduction of 50% symptoms including social withdrawal, numbing, expression of in their CAPS scores and 12 of the 14 subjects no longer meeting anger, and interpersonal difﬁculties. The original protocol entailed criteria for PTSD after treatment.
29 sessions over the course of 17 weeks. Psychoeducation and Preliminary results of group applications of interpersonal therapy exposure were implemented in individual sessions. After the have been mixed. An 8 week interpersonal therapy group with 13 completion of exposure, programmed practice, entailing controlling subjects with mixed adulthood precipitating traumas (including one's own exposure at home was implemented, and a social and motor vehicle accidents, interpersonal violence and combat expo- emotional rehabilitation (SER) phase began. SER was conducted in sure) found interpersonal therapy to be effective in improving social small groups of 2–5 individuals and included social skills training and functioning, symptoms of depression and general well-being, but only emphasized how to establish and maintain friendships. It included moderately effective in addressing symptoms of PTSD anger management and taught how to communicate to non-Veterans Another study of interper- about military-speciﬁc issues. Results were very promising for the 11 sonal treatment in a group format randomly assigned 48 women with completers (of 15) with signiﬁcant improvement on anxiety, ﬂash- PTSD resulting from an interpersonal trauma to the treatment or backs, nightmares, sleep difﬁculty, heart rate reactivity and overall waitlist control. Results showed that the treatment was signiﬁcantly social functioning.
more effective in treating symptoms of PTSD and depression as Initial results on TMT are promising, though length of treatment compared to the waitlist group ).
may be prohibitive in some contexts.
Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx 2.2.3. Interoceptive exposure 2.3. Imagery-based treatments Interoceptive exposure, typically used in the treatment of panic disorder, entails inducing harmless physiological sensations that are 2.3.1. Imagery Rescripting often associated with arousal, for example, provoking shortness of Imagery Rescripting (IR) was introduced by breath through purposeful hyperventilation. The application to PTSD as an enhancement to prolonged exposure for is a logical one, as the habituation to these physiological sensations chronic sexual abuse survivors. It is conceptually based on an and tolerance to distress may be helpful in addressing symptoms of expanded information processing model with a key goal of therapy anxiety, emotional and physical distress and hyperarousal.
to facilitate cognitive change in the meaning of the events and the A pilot study of 7 patients with diverse traumas incorporated pathogenic schemas associated with it. The treatment is based on the interoceptive exposure ). Treatment consisted theory that imagery has a more powerful impact on positive emotion of 12 weekly 90-minute sessions, including 4 sessions of interocep- than verbal processing, and therefore cognitive behavioral techniques tive exposure, 4 of imaginal exposure and 4 of in vivo exposure.
used to promote positive change should also employ imagery Results at a post-treatment assessment showed improvements in (). The patient ﬁrst engages in an PTSD symptomatology as well as anxiety sensitivity, posttraumatic imaginal exposure which is immediately followed by a rescripting.
cognitions, anxiety and depression in 5 of 7 patients. These gains During rescripting the patient is encouraged to imagine the trauma were generally maintained at 1-month follow-up. At 3-month follow- experience while developing mastery imagery by imagining them- up, 4 patients no longer met criteria for PTSD but 2 showed symptom selves as an adult entering the room during the trauma and rescuing and protecting the vulnerable child. This phase lasts 4 sessions, with The limited data on this technique leaves many questions unan- audiotapes of the entire exposure and rescripting for homework. For swered. This small study failed to show whether there is an additive sessions 5 through 8, the imagery exercise begins with checking in effect to including this technique above the success of traditional with the child and focuses on the modiﬁcation of pathogenic schemas.
A randomized trial (assigned participants from an outpatient clinic with a variety of traumas toimaginal exposure with imagery rescripting (IE + IR) or imaginal 2.2.4. Mindfulness exposure alone (IE). These patients were compared to a natural Depersonalization is a state deﬁned as a mechanical existence in waitlist group necessitated when demand exceeded capacity of the which feelings are numbed and presence is surreal. This condition is clinic. Both treatment groups were treated with 10 sessions; 9 diametrically opposed to the state of mindfulness in which one is in sessions contained imaginal exposure with or without rescripting; in touch with the present moment with a full and vivid awareness of vivo exposure was not utilized. No differences in post-treatment PTSD sensations and being. An assessment of 239 adults with trauma improvement were noted between the 2 treatment arms with history without PTSD found that the Accepting without Judgment treatment response at 63% for the IE group and 62% for the IE + IR subscale of the Kentucky Inventory of Mindfulness Skills was sig- group, but both groups fared better than those in the waitlist.
niﬁcantly correlated with symptoms of PTSD, and the Acting with Signiﬁcantly greater anger control and reduction in guilt scores was Awareness subscale was related to trauma-related reexperiencing reported in the IE + IR group with signiﬁcantly fewer dropouts as compared to the IE group. No clinician administered measures were is logical, therefore to consider the use of mindfulness to enhance traditional treatments for trauma-related symptoms. The use of In another study (), mindfulness has been incorporated into protocols for the treatment 23 individuals injured in industrial accidents who still had PTSD following treatment with PE were treated with IR. PE was stopped ) but studies have yet to evaluate its independent when SUDS scores showed no habituation over time, though there is no information regarding how many sessions that averaged or whatcriteria were used to inform this decision. IR was then implemented, 2.2.5. Yoga and acupuncture with each session containing imaginal exposure, mastery/adaptive Scarce data supports the efﬁcacy of yoga and acupuncture for PTSD, imagery, and then post-imagery reprocessing. Following IR, signiﬁ- but studies are beginning to evaluate their use in this population. Unpub- cant improvements were noted in symptoms of PTSD, depression, and lished data on the efﬁcacy of yoga programs found some beneﬁt for yoga anxiety, although, again no clinician administered PTSD measures in improving depression in a PTSD Veteran population, and an added were utilized.
beneﬁt for some intrusive and hyperarousal symptoms with the addi- In sum, these studies indicate there may be utility in IR treatment tion of breathing techniques Positive results for PTSD. Large-scale RCTs utilizing independent assessment compar- in the treatment of depression with yoga breathing show decreased ing IE to IE + IR are needed indicate whether IR enhances imaginal levels of cortisol following treatment ( exposure with improved treatment of negative symptoms and ) and point to the need for further exploration emotions such as guilt and anger. Proponents of IR claim it is more of the effects of yoga and breathing techniques especially for the palatable than PE and point to the lower dropout rates in their study.
hyperarousal symptoms of PTSD.
They indicate that mastery and positive feelings elicited by the One pilot study shows potentially promising results for the use of rescripted imagery is encouraging. However, these conclusions are acupuncture in the treatment of PTSD premature and further research regarding engagement in the ) in which 73 patients were randomly techniques is necessary.
assigned to an acupuncture, group CBT, or waitlist condition. Theacupuncture condition consisted of 2 one-hour sessions per week.
2.3.2. Imagery Rehearsal Therapy Signiﬁcant improvements were noted in the acupuncture group on Imagery Rehearsal Therapy (IRT) was created by PTSD, depression, anxiety and global impairment comparable to the to treat nightmares presenting in the aftermath of a trauma.
group CBT condition and signiﬁcantly different from the waitlist IRT is delivered in a group format and has been administered in 1, 3 control group immediately following treatment and at a 3 month and 6 sessions that frame nightmares as trauma induced, habit- follow-up. Notably, group CBT is not yet a proven therapy for PTSD, sustaining behaviors that may be controlled by the individual.
and further research is necessary to evaluate the utility of this Instruction in pleasant imagery is presented, and strategies for coping with unpleasant imagery are taught. In the next stage of treatment, Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx participants write down their nightmare and any changes to it they offered for the applicability of this treatment to a PTSD population, choose and then imagine the changed experience for 10–15 min, including teaching the patient techniques to manage the strong present it to the group, and rehearse the new dream daily.
emotions elicited by trauma-focused methods and the focus on One RCT conducted with survivors of sexual assault with PTSD emotion regulation with techniques to manage overwhelming (N = 168) found that IRT showed moderate to large effect sizes emotion may make exposure treatment more palatable to hesitant compared to a wait-list control in nightmare improvement. PTSD symptoms signiﬁcantly decreased in 65% of the treated sample, as describe the use of these compared to symptom exacerbation or no change in 69% of controls.
techniques in their "STAIR" program (skills training in affective and Changes were maintained at 3 and 6 month post-treatment assess- interpersonal regulation) in a population of patients with a history of CSA. Treatment consisted of two phases. Phase 1 consisted of A study of crime victims with PTSD (N = 62; 8 sessions focusing on psychoeducation, skills acquisition, applica- tion/practice and homework. Phase 2 entailed imaginal exposure, similarly positive results which were maintained at 12 month follow- cognitive restructuring, a focus on coping with emotions post- up. A study of adolescent girls with PTSD and a history of sexual abuse exposure and emotion regulation. Comparisons with a group in a residential facility found that IRT improved frequency of receiving 12 weekly phone contacts lasting 15 min each found greater nightmares, but did not affect overall sleep quality or PTSD symptoms improvements in the STAIR group on affect regulation, interpersonal compared to waitlist control ( problems and symptoms of PTSD following treatment and at 3 and ). A study of "Sleep Dynamic Therapy", a more 9 month follow-ups. similarly devoted comprehensive sleep treatment incorporating IRT, signiﬁcantly 9 sessions to phase 1 treatment entailing psychoeducation about improved sleep and PTSD symptoms in an uncontrolled study of 69 interpersonal victimization and affect regulation and breathing natural disaster victims ( exercises. Phase 2 consisted of 9 sessions of structured writing Applications to military populations have been mixed. A promising about life experiences including traumatic victimization. Results uncontrolled study of 12 male combat Veterans ( showed signiﬁcant improvement in PTSD symptomatology, mood found positive results on outcome symptoms and interpersonal problems compared to a control group.
measures of nightmares, PTSD, depression and anxiety post-treat- The design of these studies makes it impossible to draw any ment and at 12 month follow-up. A study of 15 male Veterans with conclusions regarding the effectiveness of DBT. As exposure techni- PTSD and trauma-related nightmares ( ques were utilized, treatment efﬁcacy cannot be attributed to the ) attending 6 sessions of IRT did not enhanced protocols. Research must focus on what patient qualities ﬁnd signiﬁcant gains post-treatment on any outcome measure.
suggest use of DBT, when it is most helpful to implement, and which However, at 3 months post-treatment, signiﬁcant improvements skills in particular are useful.
were noted on trauma-related nightmare frequency and PTSDsymptoms. None of these participants had been treated with PE or 2.4.2. Acceptance and Commitment Therapy (ACT) CPT and the authors posit that this treatment may not be ideal for Advocates for the use of ACT for the treatment of PTSD Veteran populations or for individuals who are naïve about and conceptualize the disorder as a result of ineffectual control of hesitant toward trauma-focused therapy.
unwanted thoughts, feelings and memories related to the trauma.
IRT has received support as an effective treatment for nightmares, ACT is utilized to reduce experiential avoidance but conclusions regarding improvements of other PTSD symptoms ) and help assimilate the experiences of the trauma memory into require more caution. Further study of effectiveness in military a valued life (However, no empirical research populations is especially warranted in light of the mixed but has evaluated the use of ACT in the treatment of PTSD.
promising results among Veterans. A comparison of establishedtreatments for PTSD with IRT could further elucidate the contribution 2.5. "Power" therapies of this technique.
2.5.1. Thought Field Therapy 2.4. Therapies focusing on distress tolerance Thought Field Therapy (TFT), introduced by is based on the foundation that control of all emotions and physiological activity is accessible in an individual through the energy Dialectical Behavior Therapy (DBT) is a cognitive-behavioral points of acupuncture. TFT evokes changes in these mechanisms by treatment developed by for individuals diagnosed activating meridian treatment points, in a process whereby clients with borderline personality disorder (BPD). At the core of the imagine an anxiety-provoking situation, rate their distress and then treatment is an emphasis on emotion dysregulation. It also focuses tap on meridian points with their ﬁngertips. No controlled studies on striking a balance between acceptance and change, with the use of have been published. Claims of success lack a scientiﬁc basis and rely validation as a principal technique in addressing this dialectic. DBT is on numerous "testimonials" for evidence. In sum, there is no con- often comprised of a combination of individual psychotherapy vincing evidence for the theory or efﬁcacy of TFT.
sessions and weekly skills building groups utilizing techniques suchas mindfulness, emotion regulation, distress tolerance, and interper- 2.5.2. Trauma Incident Reduction sonal effectiveness to address emotion regulation.
Trauma Incident Reduction or TIR was introduced by The application of DBT to individuals with PTSD has been proposed . The client is instructed to imagine the traumatic event without in two manners. The ﬁrst entails the use of DBT for individuals with verbalizing it, followed by a verbal account. The process of TIR greatly BPD with signiﬁcant trauma histories and PTSD who have completed approximates the work done in imaginal exposure, however, the Stage 1 treatment targeting severe behavior dyscontrol but continue authors assert that it is unique in its emphasis on client insight in the to experience emotion dysregulation. In Stage II DBT, individuals resolution process which distinguishes it from a conditioning model.
begin exposure to their trauma experience. No data has been Only one controlled trial has been reported comparing TIR to a accumulated studying this application waitlist control in female inpatients with trauma history The second application of DBT entails the use of DBT techniques to but participants did not have to have PTSD or any prepare the patient prior to or concurrently with a traditional diagnosis for inclusion. Positive effects were noted after only one exposure protocol ). Several reasons are session, though it lasted 3–4 h long, compared to a waitlist control.
Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx Other data consists only of uncontrolled case studies or case series research should focus on the effectiveness of techniques delivered online and address questions such as whether more severe popula- It is unlikely that the reported success in the trial of TIR is due to tions can be included in this type of treatment and issues related to anything unique in the treatment above and beyond the contribution ethical and legal considerations of exposure to the trauma.
Videoconferencing involves the use of a camera to remotely project the image and sound of the individual onto a computer screen 2.5.3. Visio Kinesthetic Disassociation so the therapist and patient can interact by seeing and hearing each Visio Kinesthetic Disassociation, or VK/DD other in real time through a live connection. This has the beneﬁts of uses "directed meta-self-visualiza- addressing stigma and accessibility and allows therapists to monitor tion" to have clients dissociate and see themselves from the outside as non-verbal behavior. A study of 32 individuals receiving CBT therapy they watch themselves in a traumatic scene. This dissociation helps to in-person and 16 receiving treatment via videoconferencing found alter parts of the memory in order to correct negative emotions. Only that after 16–25 weeks, signiﬁcant improvement on PTSD symptom- one small baseline study has been atology was noted in both treatment groups conducted with 5 patients, using 2 sessions of relaxation therapy Importantly, no differences in effect followed by 2 session of VK/DD. Following this intervention, 3 of the were noted between groups, providing preliminary support for the patients showed signiﬁcant reduction in frequency of intrusive use of videoconferencing in the treatment of PTSD.
imagery, 1 patient showed partial improvement and 1 showed noimprovement. There exists only one other case series 2.6.2. Virtual reality: an emerging alternative treatment for PTSD ). The contribution of VK/DD to the PTSD treatment lit- Special emphasis is given here to the description of virtual reality, erature is unclear.
as there is a substantive effort to implement its practice to treat U.S.
military personnel deployed to Operation Iraqi Freedom/Operation 2.6. Technological-based treatments Enduring Freedom (OIF/OEF).
2.6.1. Internet and computer based treatments 2.6.3. Rationale for Virtual Reality Exposure therapy (VRE) Internet based treatments have been proposed as a delivery- Virtual reality (VR) integrates real time computer graphics and method for the treatment of anxiety disorders , especially PTSD that visual displays that allow users to feel a sense of immersion in the may address some logistical impediments including geographic and virtual environments. VR offers a promising technological adjunct to ﬁscal constraints. Speciﬁcally, it may offer treatment to those in traditional imaginal exposure treatment of PTSD. Imaginal exposure remote areas who are limited in access to specialized healthcare by requires patients to repeatedly narrate their trauma experiences with geography. It may also be appealing to individuals who are concerned their eyes closed to facilitate engagement of their imaginative with the stigma of mental health treatment and offer a viable alter- capacities. However, the avoidance inherent in PTSD may render native to individuals whose anxiety disorder precludes the travel or engagement in imaginal exposure impossible for some patients.
social interaction necessary in traditional treatments. A recent meta- Moreover, most people with PTSD never seek treatment ( analysis of Internet and computer-based treatments (ICT) of anxiety Some who do seek treatment are hesitant to engage in disorders (found that among 4 waitlist con- narrating the trauma repeatedly, and still others who express a trolled studies of PTSD, there was an overall moderate, signiﬁcant willingness to undertake the exposure exercise are unable to engage weighted mean effect size of .75 across outcome measures. The their emotions or senses, retelling a ﬂat emotionless tale that reﬂects authors conclude that although there is preliminary support for the their numbness and avoidance. These obstacles to engagement may use of ICT for PTSD, there is limited data to substantiate its use at this lead to treatment failures, as theory suggests that emotional engage- ment and fear activation plays an essential role in exposure therapy.
assessed an 8 week cognitive propose that fear relevant information behavioral Internet-delivered program "DE-STRESS" in a military associated with the patient's memory for the traumatic event (i.e., population. Participants were randomly assigned to the DE-STRESS the fear structure) must be accessed and activated through emotional group (N = 24) or an Internet-based supportive counseling (N = 21).
engagement in order for a reduction in fear to occur. Repeated DE-STRESS entailed therapist-guided exploration of self-monitoring engagement with the fear structure in a safe therapeutic environment triggers, developing a hierarchy of trauma triggers, stress manage- leads to a decrease in anxiety, through the processes of habituation ment, in vivo exposure, trauma writing sessions and relapse and extinction, thereby allowing for the incorporation of new prevention. They had a dropout rate of 30% across treatment groups information. Furthermore, research has established that poorer which is comparable to other studies of PTSD, with no differences emotional engagement in treatment predicts poorer treatment between groups. The treatment group had signiﬁcantly greater decreases in symptoms of PTSD, depression and anxiety 6 months VR theory proposes that these obstacles may be addressed by directly delivering multiple sensory cues that may evoke the trauma Another model, interapy memory. Patient's imaginative capacities are augmented with visual, is a cognitive behavioral auditory, olfactory, and even haptic computer-generated simulation approach utilizing exposure and cognitive restructuring techniques.
experiences, increasing the patient's "sense of presence" in the virtual The treatment is conducted twice weekly for 5 weeks during which environment. VR exposure may also attenuate dropouts associated time the participant has 10 writing sessions lasting 45 min in which with avoidance by offering a graded and systematic approach to the they describe their trauma in detail, work on cognitive reappraisal, avoided stimuli that can be carefully monitored and tailored to the and work on perspective of the effect of the trauma on their lives. To individual patient's needs ( date, the largest assessment of Interapy was conducted in a community sample with 69 individuals in the treatment group and32 waitlist controls Participants in the treatment 2.6.4. Application of VR to treat anxiety disorders group improved signiﬁcantly more than those in the waitlist control, The application of VR to treat psychiatric disorders began in the with large effect sizes for PTSD symptoms and general psychopathol- 1990s with an emphasis on anxiety disorders, though VR has been ogy. Notably, many of the traumas endorsed in this population may used to treat diverse disorders, including addictions, autism-spectrum not meet criterion A for PTSD (i.e. losing a loved one, divorce). Future disorders, as well as motor and cognitive assessment and Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx both psychophysiological activity and PTSD symptoms, although criteria was still met for severe PTSD. Finally, describe a virtual bus environment that simulates a terrorist attack to studies for anxiety disorders found that VRE represents an effective treat survivors of terrorist bus bombings in Israel.
treatment modality for various anxiety disorders, including fear ofﬂying, social phobia, and speciﬁc phobias, with effect sizes ranging 2.6.5. Application of VR for PTSD among OIF/OEF soldiers from .92 to 1.79, and with an average overall effect size across studies The need to develop alternative treatments, especially ones that may appeal to the younger population of returning OIF/OEF military is were the ﬁrst to validate the efﬁcacy of underscored by the ﬁndings of They report that VRE with a psychiatric population (fear of heights) and found that VRE among Iraq/Afghanistan War Veterans who endorsed symptoms was effective in signiﬁcantly reducing fear of and improving attitudes indicative of a disorder, only 23 to 40% sought mental health services, toward heights, in contrast to a control group that reported no such especially citing concerns about stigmatization. VR may represent a changes. Since then, multiple case studies and open clinical trials have palatable variation on the traditional approaches to treatment, could successfully applied VR to treat phobias.
be promoted in a way that reduces the typical stigma associated with The ﬁrst VR application for PTSD, known as Virtual Vietnam, was seeking mental health treatment, and, given its emphasis on developed by researchers at Emory University and Georgia Institute of technology, could be couched as a "high-tech" tool that helps soldiers Technology in 1997 to treat PTSD in Vietnam Veterans. In a case study, with "post-combat reintegration training," especially given that the the ﬁrst Vietnam Veteran to be treated was a 50-year-old Caucasian current generation of active duty personnel have grown up with male still experiencing PTSD 20 years following the Vietnam War. The gaming technology (The Ofﬁce of Naval Research results of this trial found that he experienced improvement on all commissioned two open trials designed to evaluate the efﬁcacy of measures of PTSD as well as maintenance of these gains 6 months VR in treating PTSD in OIF/OEF active duty soldiers.
later (Following this case study, an openclinical trial of 16 male Vietnam Veterans with PTSD, consisting of an 2.6.6. Virtual Iraq average of 13 VRE sessions, also found signiﬁcant reductions in PTSD Virtual Iraq consists of two primary virtual scenarios, a Middle and related symptoms ( Eastern city and a Humvee scenario that allows the user to drive down ). At 6 month follow up, a reduction in PTSD symptoms was a desert road. Two additional environments (i.e., a USA and an found, including statistically signiﬁcant reduction from baseline in Afghanistan-speciﬁc environment) have recently been added.
symptoms associated with speciﬁc reported trauma experiences on The ﬂexibility of the Virtual Iraq system enables the therapist to the primary outcome measure, the Clinician Administered PTSD Scale manipulate the environments in multiple ways in real time, including (CAPS). Eight of 8 participants at the 6-month follow-up reported the establishment of ambient settings (e.g., time of day, weather reductions in PTSD symptoms, ranging from 15% to 67%. conditions, background noise, night vision options), and the intro- reported several key ﬁndings about the utility of VRE.
duction or removal of animated vehicles, pedestrians (civilian and Out of the 16 participants treated with VRE: 1) no person decompen- military), and helicopters/jets taking off, ﬂying overhead, or landing. It sated as a result of the study, and 2) no participant was hospitalized also provides options for the delivery of a variety of combat relevant during the study for complications related to VRE.
elements, such as improvised explosive devices (IEDs), rocket- In 2002, published a case study propelled grenades (RPGs), car bombs, and insurgent attacks, all of applying VRE to treat PTSD consequent to the World Trade Center which can be actuated via mouse-clicks on a clinician control panel.
attacks of September 11, 2001. The virtual environment stimuli The city scene allows the user to walk around an 18-square-block included actual 9/11 audio recordings made by national news Middle Eastern city, with either a gamepad controller, or with a networks, planes ﬂying into the two towers, explosions and falling "thumbmouse" mounted on a realistically weighted replica of a M4 debris as seen from the WTC, as well as human avatars falling from the riﬂe. The city includes a variety of scenes such as a marketplace, burning WTC towers. The ﬁrst case report applied VRE over six one- warehouses, a security checkpoint, mosques, empty streets, apart- hour sessions, with reductions in depression symptoms, as measured ments, old buildings, and dirt lots with piled garbage. The function- by the Beck Depression Inventory, and reductions in PTSD symptoms, ality of this environment allows for the patient to both enter buildings as measured by the CAPS, by 83% and 90%, respectively. This case and climb stairs to get to rooftops, with various audio-visual events underscores some of the possible added value of VR, given that the such as explosions, helicopters ﬂying, gunﬁre, and people walking.
individual previously failed to improve with traditional exposure The Humvee scenario incorporates an expansive sand dune or therapy. In a follow up clinical trial, participants representing a range mountain backdrop interspersed with palm trees and other vegeta- of those with direct exposure to the attacks including ﬁreﬁghters, tion, intact and broken down structures, bridges, battle wreckage, a disaster rescue and recovery workers, and civilians, were assigned checkpoint, debris and virtual human ﬁgures who create ambushes at either to VRE (n = 13) or a waitlist (WL) control group (n = 8) various points, all controlled by the therapist. Patients can be In contrast to the WL group who did not evidence any positioned as the driver, passenger, or in the turret, alone, or with a reduction in PTSD symptoms, the group receiving VRE demonstrated a team inside the Humvee, as well as with or without a convoy of other signiﬁcant decrease in CAPS scores both relative to pre-treatment and Humvees. A standard gamepad controller is used to drive the vehicle, to the WL group with a between-groups post treatment effect size of and features vibrotactile sensations that the user can feel when 1.54 which were maintained at six-month follow-up. Interestingly, explosions occur.
ﬁve of the participants in the VRE were nonresponders to prior In both environments, the visual stimuli presented via the head imaginal exposure.
mounted display (HMD) can be supplemented by directional 3D Researchers worldwide are actively evaluating virtual environ- audio, vibrotactile, and olfactory stimuli. Customized, coordinated ments to treat PTSD. ) vibratory sensations (e.g., explosions, vehicle engine rumble) are utilized driving scenarios to treat PTSD resulting from motor vehicle provided by inexpensive audio-tactile sound transducers placed in a accidents (MVAs). An uncontrolled trial of six subjects found that 10 low-cost ﬂoor platform beneath the patient. Olfactory cues are also sessions of VRE was successful in treating symptoms of PTSD, with possible via a USB-enabled device that uses up to 8 scent cartridges, a patients reporting high levels of presence and satisfaction with series of fans, and a small air compressor to deliver scents (e.g., treatment. presented a case study of an MVA burning rubber, cordite, garbage, diesel fuel, Middle Eastern spices, survivor treated with VRE for 4 sessions, with resulting reductions in gunpowder) to participants with the click of a mouse. The therapist Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx controls each stimulus via mouse interaction with a control panel on a populations. Challenges to the utility of virtual reality include the computer screen while in full audio contact with the patient. This expense of the systems and the need to create new environments for enables a clinician to match or supplement the patient's spoken each traumatic event. Yet with the progression of the ﬁeld, these trauma narrative within the VR simulation and allows for a challenges are becoming easier to address. Price of equipment in the customized approach that is individually tailored to the patient's past ten years has decreased dramatically and further deﬂation is experience and treatment progress.
anticipated. Current environments are often developed with key In initial VRE clinical trials using the Virtual Iraq, the standard elements that can be used as a framework in the creation of other treatment protocol consisted of one to two weekly, 90–120 minute settings addressing other different types of traumas, and one ﬂexible sessions, over 5 to 10 weeks. The VRE exposure exercises followed the environment such as that of Virtual Iraq can incorporate the trauma of principles of graded behavioral exposure and the pace was individ- thousands who were exposed to events in similar contexts.
ualized and patient-driven. Assessment data was obtained at baseline Nevertheless these challenges are notable, and the key question and prior to sessions 3,5,7,9, and 10, as well as at one week and three remains whether VRET offers efﬁcacy beyond the rates of treatments utilizing prolonged exposure.
Results from a case study from Emory University reported a 56% reduction in CAPS scores following VRE for an active duty OIF soldier 3. Pharmacologic treatments (). In another casestudy, six sessions of VRE were effective in reducing PTSD and Though recent guidelines suggest that psychotherapy should be psychological distress in an active duty army soldier ( initiated as a ﬁrst-line treatment for PTSD before pharmacological An open clinical trial using VRE for PTSD with active duty personnel yielded promising results with 20 study participants medications are often necessary to palliate symptoms, and the pursuit completing treatment at two sites, Naval Medical Center San Diego of more effective medication is essential to developing a range of and Camp Pendleton effective treatment options. The most commonly used medications . For this sample, (19 male, 1 female, mean have been antidepressants, and speciﬁcally SSRIs age = 28.1) scores on the PCL-M scores decreased from a mean of 54.5 to a mean of 35.6. Correcting for the PCL-M no-symptom baseline a Cochrane systematic review that pharmacologic intervention can be of 17 indicated a 50% decrease in symptoms and 16 of the 20 effective, especially with the use of SSRIs. However, the difference completers no longer met DSM criteria for PTSD at posttreatment.
between medication and placebo in short-term intervention was 5.76 Scores on measures of anxiety also signiﬁcantly decreased by 33% and points on the CAPS and the NICE guideline (2005) reported that with depression scores signiﬁcantly decreased by nearly 50%. The average few exceptions, the overall effect size in medication trials did not number of sessions for this sample was just under 11. Notably, two of exceed the criterion of 0.5 required to be clinically effective. The the successful treatment completers had documented mild and Cochrane review (2006) reported that war Veterans were more moderate traumatic brain injuries, which suggests that this form of resistant to medication than other groups, though more research is exposure can be useful for this population. Currently, Virtual Iraq is required to ascertain the precise nature of this relationship.
being implemented clinically and in clinical research trials byapplying VRE to treat PTSD among Veteran and active duty OIF/OEF 3.1. D-cycloserine Service Members at numerous army medical centers, universities,over 15 Veterans Administration Hospital sites, and 8 U.S. Air Force Among pharmacologic innovations, arguably the most signiﬁcant bases around the country.
in its potential is D-cycloserine (DCS; trade name Seromycin), whichis being used in conjunction with prolonged exposure treatment. DCS 2.6.7. Virtual Reality Graded Exposure Therapy (VRGET) is a broad-spectrum antibiotic that has been used in clinical trials over A second open trial is underway assessing the effects of Virtual the last decade as a cognitive enhancer. It is a partial agonist at the N- Reality Graded Exposure Therapy (VRGET) among OIF/OEF active- methyl-D-aspartate (NMDA) receptor, which is known to play an duty personnel. VRGET applies graded exposure while presenting VR- essential role in learning and memory. Both fear learning and based visual and auditory stimuli (e.g., combat scenarios and sounds, extinction are blocked by antagonists at the glutamatergic NMDA other common household sounds, people talking). A case study receptor, and DCS has been shown to facilitate extinction learning in described the treatment of a 32 year-old male, Second Class Petty animal models of conditioned fear and in some human trials of other Ofﬁcer and Corpsman VRGET consisted of 10 90- types of learning minute weekly sessions, including presentation of meditation and attentional refocusing and applying these skills while relating a narrative of the trauma. The authors reported that on the PCL-M, the In the ﬁrst clinical study of DCS (a double- level of "intrusive PTSD symptoms" suggested the presence of clinical blinded randomized controlled clinical trial was conducted with 27 PTSD at both the pre- and mid-treatment assessments, while PCL-M patients with acrophobia. Patients were assigned to receive either DCS scores were lower at the post-treatment assessment. However, there or placebo prior to 2 sessions (a suboptimal dose) of VR exposure is not sufﬁcient information provided to characterize whether these therapy. At assessments 1–2 weeks and 3 months following the changes were signiﬁcant. The authors comment that they decided to exposure, patients in the DCS group reported signiﬁcantly less anxiety continue VRGET with this individual for an additional 10 sessions for a and had lower skin conductance ﬂuctuations in the virtual environ- total of 20 sessions.
ment compared to those in the placebo group. In addition, at 3 months This was followed by a case series of six active-duty corpsmen with post-treatment, those with DCS reported greater real-life exposure to a mean pre-treatment PCL-M score of 47.3 ().
heights and had greater impressions of self-improvement relative to Following the treatment of VRGET combined with meditation and those in the placebo group.
attentional refocus, "partial remission" was reported in four of the six Positive results were reported from a double-blind randomized subjects, though statistical information was not provided. Clinical controlled trial of DCS conducted with 27 individuals with social trials are necessary to determine the value of VRGET, as these case phobia in a 5-session treatment (). Patients who studies offer limited information from which to draw conclusions.
took DCS prior to the 4 sessions of exposure to social situations The use of virtual reality seems especially promising as an showed signiﬁcantly greater reductions in general social anxiety emerging treatment for PTSD with special relevance to military symptoms, both immediately post-treatment and at a one-month Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx follow-up, compared to individuals in the placebo condition. Similarly received ketamine during their hospitalization to 28 who did not, positive results were found in a randomized controlled trial of 56 although amount of time between injury and PTSD assessment is participants with social anxiety Those who unclear. Contrary to expectation, those who received ketamine had received 50 mg of DCS prior to treatment showed signiﬁcantly greater signiﬁcantly lower rates of PTSD than those who did not (26.9% vs.
improvement on symptom severity, dysfunctional cognitions, and 46.4%, respectively), despite more severe burns, greater burn size, life-impairment as compared to a placebo group.
longer stay in the intensive care unit and more surgeries. Ketamine Several studies are currently evaluating the use of DCS to enhance acts as an antagonist at the NMDA receptor which may cause a imaginal exposure or VR enhanced exposure for the treatment of disruption of the memory process, either of the hospital experience or PTSD. The mechanism by which DCS operates can be conceptualized the traumatic experience itself. The authors warn, however, that these using the same principles as those used for other anxiety disorders.
results must be interpreted with caution since the negative correla- The repeated exposure to the traumatic memory utilized for PTSD tion between PTSD and ketamine, while present, was weak (ROC treatment facilitates extinction of feared emotional responses to the curve = 0.569). Furthermore, patients were not randomized in this memory. Facilitation of this fear extinction by an agonist at the NMDA retrospective review, and it is unknown what factors inﬂuenced receptor may enhance or accelerate treatment effects of exposure for whether the patient received ketamine. Thus, further research must explore the nature of this relationship and rule out the possibility of In sum, research indicates that DCS may facilitate extinction of other factors driving this correlation between ketamine and lower fear, lead to generalized extinction and reduce post-treatment relapse rates of PTSD.
after another event This seems apromising medication with low dosage and frequency of intake which may enhance efﬁciency of treatment. However, data has not yetemerged in PTSD populations and there is a clear need for further Increased central nervous system adrenergic activity, resulting in study of DCS.
greater release of norepinephrine and increased sensitivity tonorepinephrine at receptor sites, has been implicated in PTSD Increased activity occurs especially at nightand has been associated with poor sleep and nightmares. Prazosin, an Propranolol is a non-selective beta-adrenergic blocker used in the alpha-1 adrenergic receptor blocker, is primarily prescribed as an treatment of hypertension. Prolonged adrenergic activation in the anti-hypertensive and for the treatment of benign prostatic hyper- immediate aftermath of a trauma has been linked to increased risk for plasia ). Its role in inhibiting adrenergic activity suggests PTSD (possibly through increased fear conditioning it may be a useful tool in targeting these PTSD symptoms.
). posit that this is a consequence Case studies, retrospective chart reviews, and open label trials of a release of an excessive amount of epinephrine during the trauma, have all reported the effectiveness of Prazosin for the treatment of and that the administration of propranolol soon after a trauma could nightmares An initial randomized cause the blockage of the receptors and consequently prevent the crossover trial ) assigned 10 Vietnam Veterans development of PTSD. Preliminary research on the use of propranolol with PTSD for more than 25 years to a prazosin or placebo group. Each as a preventative measure against PTSD supports this theory ( group received treatment for 9 weeks, then after a 2-week medica- tion-free period were given the other treatment. CAPS scores and These principles were recently applied to a treatment model in a number of distressing nightmares at 20 weeks signiﬁcantly differed randomized controlled study of 19 patients with chronic PTSD between prazosin and placebo groups (p < .001). A larger randomized Individuals with PTSD wrote a script of their controlled trial randomly assigned 40 Veterans trauma experience and then received propranolol or a placebo. One with nightmares and sleep difﬁculty to receive Prazosin or placebo week later psychophysiologic reactivity was measured while partici- prior to bedtime. Medication dosage began at 1 mg but was increased pants listened to a recording of a script of their trauma experience.
over the course of treatment if symptoms were not responding, with a Individuals who received propranolol at the initial session had maximum dose of 15. Four Mean dosage of prazosin was 13 mg signiﬁcantly lower levels of reactivity compared to the placebo (SD = 3). After 8 weeks, signiﬁcant differences emerged between group, perhaps due to drug inhibition of memory consolidation.
groups on number of distressing nightmares, and sleep quality.
Notably, PTSD symptoms were not included as an outcome measure in Individuals in the prazosin group reported a mean 50% decrease in this study. The applications of these ﬁndings to PTSD treatment nightmares as compared to a 15% decrease for the placebo group cannot be determined until further studies have been performed.
(p = .02). A recent study of 22 Veterans with PTSD found prazosin waseffective not only in treating nightmares but also non-nightmare distressed awakenings ).
Ketamine is a nonbarbituate anesthetic administered intravenous- This evidence suggest that prazosin may be a promising adjunctive ly especially to burn patients in some military hospitals. Ketamine is medication to target speciﬁc sleep-related disturbances in PTSD associated with dissociation and psychosis, leading to the concern patients, but RCTs must be conducted to answer questions regarding that it will yield greater rates of PTSD. One retrospective study of 50 best dosage, effectiveness for women and non-military populations victims of moderate accidental trauma compared those who received and actual clinical signiﬁcance. Trials are ongoing in civilian ketamine (n = 13) to those who received opioids (n = 24) or non- opioid analgesics (n = 13) in their initial emergency treatment).
3.5. Methylenedioxymethamphetamine (MDMA; Ecstasy) Assessments occurred within three days of admission and foundincreased symptoms of acute stress disorder (including symptoms of The clinical use of MDMA to enhance psychotherapy was dissociation, reexperiencing, avoidance and hyperarousal) in the documented as early as 1978, though its prohibition as an illegal ketamine group relative to the other two groups.
substance in the mid 1980s precluded early clinical research to explore its efﬁcacy (). More than a decade later, the Food different results in a retrospective chart review of 147 injured OIF/OEF and Drug Administration approved the clinical trial of MDMA for patients at one military medical center, comparing 119 patients who enhancing psychotherapy for chronic PTSD ). Though Please cite this article as: Cukor, J., et al., Emerging treatments for PTSD, Clinical Psychology Review (2009), doi: J. Cukor et al. / Clinical Psychology Review xxx (2009) xxx–xxx conclusive results have yet to be published, a recent review by area is likely to yield important treatment advances and should be a outlines the theory behind the use of MDMA. The ﬁrst of three models that he cites for the use of MDMA assisted-therapy proposes Therapies aimed at augmenting exposure therapy by increasing that during the session, negative material related to fearful memories distress tolerance and compliance or targeting negative symptoms (i.e., a trauma) may emerge and can then be processed with a and sleep difﬁculties are signiﬁcant in their attempts to address therapist without intensely negative emotions. The second model "treatment failures." Behavioral treatments such as behavioral focuses on the positive moods induced by MDMA that lead to the activation and mindfulness may be effective to enhance protocols therapeutic goals of feelings of wholeness and integration. The ﬁnal with proven techniques shown to ameliorate some but not all PTSD model emphasizes the improved trust and emotional alliance that is symptoms, but not as a stand-alone treatment for PTSD. Trauma formed between the patient and the therapist as a result of the management therapy shows promise for the treatment of negative MDMA, which may be a key ingredient in the success of treatment.
symptoms of PTSD in conjunction with exposure therapy. Imagery- Parrott described the beneﬁcial effects of MDMA as reported in the based treatments show potential; IRT is effective in the treatment of existing literature as including recognition of positive aspects of self nightmares in PTSD but has questionable effect for other symptoms. IR and others; positive moods, cognitions and beliefs; the emergence of emerges as an effective treatment for PTSD, though no data exists to past negative events and the decrease in negative feelings associated compare its efﬁcacy to that of imaginal exposure. No conclusions can with it; and the strengthening of the therapeutic alliance. However, he be drawn about treatment aiming to affect emotion around exposure, also cautions that reported negative effects must be further explored.
as use of ACT in PTSD populations has not yet been documented, and These include negative mood states and psychobiological reactivity DBT shows promise in women with a history of childhood abuse, but that have been reportedly associated with MDMA, negative emotions generalizeability is unclear. "Power" therapies lack any evidence to and psychobiological distress that have been noted in the aftermath, back their lofty claims of success.
and the question of the use of CNS stimulants in a vulnerable psy- Caution should be taken before employing any emerging therapies chiatric population which may potentially lead to a worsening of outside of research protocols developed to test their efﬁcacy. In symptoms. Thus, there is a signiﬁcant need for further research community care and private practice, empirically-validated treat- regarding both the positive and negative effects of MDMA before it ments recommended by the PTSD Expert Consensus Guidelines may be considered for clinical use.
should be used as ﬁrst-line treatments with emerging therapiesutilized as alternatives only when the ﬁrst line treatment is notsuccessful or requires augmentation. Randomized controlled trials are necessary to further evaluate the contribution of these alternative andaugmented treatments, but the future clearly holds exciting possibil- The recent proliferation in treatments for PTSD suggests that ities for the treatment of PTSD.
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Coalition for Safe Community Needle Disposal Removing Home Generated Sharps from October 2009 Purpose of Presentation Understand the current and future sharps disposal problem in the U.S. Recognize that removing needles from the household trash is a shared responsibility among al stakeholders