Background: As Posttraumatic stress disorder (PTSD) in adolescents significantly impacts their well-being, effective treatment is of great importance. Little is known, however, about the novel,... Show moreBackground: As Posttraumatic stress disorder (PTSD) in adolescents significantly impacts their well-being, effective treatment is of great importance. Little is known, however, about the novel, multi-modal virtual reality supported, exposure-based psychotherapeutic interventions such as 3MDR in this population.Objective: To describe the 3MDR treatment of an adolescent with PTSD who did not respond to previous exposure-based PTSD interventions.Method: A 14-year-old girl diagnosed with PTSD received six sessions of 3MDR embedded in family therapy.Result: The patient tolerated the 3MDR intervention very well. Personalized music and self-selected pictures appeared to be a good fit, contributing to enhanced engagement in and adherence to the therapy. She no longer met criteria for PTSD post-intervention, and at 18 months follow-up.Conclusion: This case report suggests that 3MDR has potential as a trauma treatment for adolescents with treatment-resistant PTSD. Show less
Does, F.H.S. van der; Nagamine, M.; Wee, N.J.A. van der; Chiba, T.; Edo, N.; Kitano, M.; ... ; Giltay, E.J. 2023
Background: After the Great East Japan Earthquake [GEJE], approximately 70,000 Japan Ground Self Defense Force [JGSDF] personnel were deployed, risking Post-Traumatic Stress Disorder [PTSD]. The... Show moreBackground: After the Great East Japan Earthquake [GEJE], approximately 70,000 Japan Ground Self Defense Force [JGSDF] personnel were deployed, risking Post-Traumatic Stress Disorder [PTSD]. The network approach to psychopathology suggests that symptoms may cause and exacerbate each other, resulting in the emergence and maintenance of disorders, including PTSD. It is therefore important to further explore the temporal interplay between symptoms. Most studies assessing the factor structure of the Impact of Event Scale-Revised [IES-R] have used cross-sectional designs. In this study, the structure of the IES-R was re-evaluated while incorporating the temporal interplay between symptoms.Methods: Using Dynamic Time Warping [DTW] the distances between PTSD symptoms on the IES-R were modelled in 1120 JGSDF personnel. Highly correlated symptoms were clustered at the group level using Distatis three-way principal component analyses of the distance matrices. The resulting clusters were compared to the original three subscales of the IES-R using a Confirmatory Factor Analysis (CFA).Results: The DTW analysis yielded four symptom clusters: Intrusion (five items), Hyperarousal (six items), Avoidance (six items), and Dissociation (five items). CFA yielded better fit estimates for this four-factor solution (RMSEA = 0.084, CFI = 0.918, TLI = 0.906), compared to the original three subscales of the IES-R (RMSEA = 0.103, CFI = 0.873, TLI = 0.858).Conclusions: DTW offers a new method of modelling the temporal relationships between symptoms. It yielded four IES-R symptom clusters, which may facilitate understanding of PTSD as a complex dynamic system. Show less
Gerrmann, J.; Boeschoten, M.; Nijdam, M.J.; Aa, N. van der; Eidhof, M.B.; Hoeboer, C.M.; ... ; June ter Heide, F.J. 2023
While spouses of military veterans have not been directly exposed to threats during deployment, they often experience a substantial post-deployment-related health burden while living with and... Show moreWhile spouses of military veterans have not been directly exposed to threats during deployment, they often experience a substantial post-deployment-related health burden while living with and caring for a partner with deployment-related mental health issues. Drawing from in-depth interviews, this study examined how female spouses of military veterans deal with the psychosocial effects of deployment. We show how these women cope. They keep their family lives going by maintaining hope for the future. We argue that hope is a dynamic practice between reality and possibility, and different forms of hope co-exist. These range from temporary formulations of present-centered hope, and permanent hopes directed towards the future. We illustrate how spouses challenge discourses around curative futures and adjust their hopes to maintain a more satisfactory everyday life and a positive horizon towards the future. Show less
Post-traumatic stress disorder (PTSD) is a prevalent psychiatric condition that significantly impacts daily functioning in patients but lacks adequate treatment options. 3,4... Show morePost-traumatic stress disorder (PTSD) is a prevalent psychiatric condition that significantly impacts daily functioning in patients but lacks adequate treatment options. 3,4-methylenedioxymethamphetamine (MDMA) as an adjunct to psychotherapy for the treatment of PTSD has been studied increasingly for the last two decades and has shown promising results through quantitative data. However, few qualitative studies have been conducted to investigate patients’ experiences who participate in these trials. This study intends to complement and clarify the quantitative findings resulting from a Phase-II clinical trial for assessing the safety and efficacy of MDMA-assisted psychotherapy for PTSD by using a qualitative approach based on available material of 4 recorded and transcripted integrative sessions per participant. An Interpretative Phenomenological Analysis (IPA) was conducted for 7 participants who met criteria for severe PTSD to develop a deeper understanding of the treatment and its efficacy. Analysis results provided real-life statements from participants that reflect perceived mechanisms of change and showed to what extent their proposed working mechanisms integrate into daily life. Show less
BackgroundKetamine and its enantiomers are widely researched and increasingly used to treat mental disorders, especially treatment-resistant depression. The phenomenology of ketamine-induced... Show moreBackgroundKetamine and its enantiomers are widely researched and increasingly used to treat mental disorders, especially treatment-resistant depression. The phenomenology of ketamine-induced experiences and their relation to its psychotherapeutic potential have not yet been systematically investigated.AimsTo describe the phenomenology of patient experiences during oral esketamine treatment for treatment-resistant depression (TRD) and to explore the potential therapeutic relevance of these experiences.MethodsIn-depth interviews were conducted with 17 patients after a 6-week, twice-weekly ‘off label’ generic oral esketamine (0.5–3.0mg/kg) treatment program. Interviews explored participants’ perspectives, expectations, and experiences with oral esketamine treatment. Audio interviews were transcribed and analyzed using an Interpretative Phenomenological Analysis (IPA) framework.ResultsThe effects of ketamine were highly variable, and psychological distress was common in most patients. Key themes included (a) perceptual effects (auditory, visual, proprioceptive), (b) detachment (from body, self, emotions, and the world), (c) stillness and openness, (d) mystical-type effects (transcendence, relativeness, spirituality), and (e) fear and anxiety. Key themes related to post-session reports included (a) feeling hungover and fatigued, and (b) lifting the blanket: neutralizing mood effects.ConclusionPatients reported several esketamine effects with psychotherapeutic potential, such as increased openness, detachment, an interruption of negativity, and mystical-type experiences. These experiences deserve to be explored further to enhance treatment outcomes in patients with TRD. Given the frequency and severity of the perceived distress, we identify a need for additional support in all stages of esketamine treatment. Show less
Jones, C.; Smith-MacDonald, L.; Veelen, N. van; VanderLaan, A.; Kaneva, Z.; Dunleavy, R.S.; ... ; Bremault-Phillips, S. 2022
Background As provisions of mental healthcare services to military and veteran populations increases the risk to service providers developing secondary traumatic stress (STS), efforts are needed to... Show moreBackground As provisions of mental healthcare services to military and veteran populations increases the risk to service providers developing secondary traumatic stress (STS), efforts are needed to examine the impact of delivering novel interventions which may include 3MDR. As a virtual-reality supported intervention, 3MDR exposes the patient, therapist and operator to graphic and sensory stimuli (i.e. narratives, imagery, smells, and music) in the course of the intervention. 3MDR is actively being researched at multiple sites internationally within military and veteran populations. It is, therefore, crucial to ensure the safety and wellbeing of 3MDR therapists and operators who are exposed to potentially distressing sensory stimuli. Objective The purpose of this study is to qualitatively examine the impact and experiences of STS amongst therapists and operators in delivering 3MDR. For this study, impact will be defined as therapists or operators experiencing perceived STS as a result of delivering 3MDR. Methods This exploratory qualitative study recruited 3MDR therapists and operators (N = 18) from Canada, the Netherlands, the United Kingdom, and the United States who had previously delivered 3MDR therapy. Telephone or video-conferencing interviews were used to gather data that was subsequently transcribed and thematically analyzed. Results Four themes emerged among the therapists (n = 13) and operators (n = 5): (1) personal cost and benefits of 3MDR, (2) professional paradox of a 3MDR therapist, (3) perceived effect of 3MDR on patients, and (4) recommendations for future 3MDR use. Conclusions STS was not noted to be a significant challenge for 3MDR therapists and operators. Future research may investigate optimal means of providing training and ongoing support for 3MDR therapists and operators. Show less
Smart wearables are increasingly used to help people deal with stress. Still, a less explored area of research in this field concerns the partnerships that smart wearables can take on when engaging... Show moreSmart wearables are increasingly used to help people deal with stress. Still, a less explored area of research in this field concerns the partnerships that smart wearables can take on when engaging people in stress-coping activities. To facilitate further understanding of the human-wearable partnerships, we designed Grippy, a smart wearable system composed of a physical glove and a smartphone application to help the wearer actively explore and cope with stress in daily situations. We introduced Grippy, as a speculative probe, to six participants (four master students and two university employees) who wore it for five successive days. Participants were interviewed about their use experience of Grippy during and after these five days. Qualitative data collected from the interviews was interpreted regarding how Grippy could fit into people’s stress-coping activities across different daily contexts and what kinds of partnerships with the smart wearable were perceived by the participants. In addition, we reflect on the design issues that led to the mismatch between our design intentions and people’s actual use experiences. We discuss how these results have deepened our understanding of human-wearable partnerships in the context of stress management and the usability issues that might hinder the expression and acceptance of smart wearables designed as partners. We end the discussion by reflecting on the implications of smart wearables as partners in mental healthcare. Show less
Background: Ketamine and its enantiomer esketamine represent promising new treatments for treatment-resistant depression (TRD). Esketamine induces acute, transient psychoactive effects. How... Show moreBackground: Ketamine and its enantiomer esketamine represent promising new treatments for treatment-resistant depression (TRD). Esketamine induces acute, transient psychoactive effects. How patients perceive esketamine treatment, and which conditions facilitate optimal outcomes, remains poorly understood. Understanding patient perspectives on these phenomena is important to identify unmet needs, which can be used to improve (es)ketamine treatments. Aims: To explore the perspectives of TRD patients participating in "off label" oral esketamine treatment. Materials and methods: In-depth interviews were conducted with 17 patients (11 women) after a six-week, twice-weekly esketamine treatment program, and subsequently after six months of at-home use. Interviews explored participants' perspectives, expectations, and experiences with esketamine treatment. Audio interviews were transcribed verbatim and analysed following an Interpretative Phenomenological Analysis (IPA) framework. Results: Key themes included overwhelming experiences; inadequate preparation; letting go of control; mood states influencing session experiences; presence and emotional support, and supportive settings. Patients' attempts to let go and give into vs. attempts to maintain control over occasionally overwhelming experiences was a central theme. Multiple factors influenced patients' ability to give into the experience and appeared to impact their mood and anxiety about future sessions, including level of preparation and education, physical and emotional support, and setting during the session. Conclusion: Better preparation beforehand, an optimized treatment setting, and emotional and psychological support during (es)ketamine sessions can help patients to "let go" and may lead to better quality of care and outcomes. Recommendations to improve quality of patient care in (es)ketamine treatment are provided, including suggestions for the training of nurses and other support staff. Show less
Objectives: Several medical and psychiatric disorders have stage-based treatment decision-making methods. However, international treatment guidelines for posttraumatic stress disorder (PTSD) fail... Show moreObjectives: Several medical and psychiatric disorders have stage-based treatment decision-making methods. However, international treatment guidelines for posttraumatic stress disorder (PTSD) fail to give specific treatment recommendations based on chronicity or stage of the disorder. There is convincing evidence of a finite range of PTSD symptom trajectories, implying that different phenotypes of the disorder can be distinguished, which are highly relevant for a staging typology of PTSD. Methods: State-of-the-art review building on prior work on staging models in other disorders as a mapping tool to identify and synthesize toward PTSD. Results: We propose a four-stage model of PTSD ranging from stage 0: trauma-exposed asymptomatic but at risk to stage 4: severe unremitting illness of increasing chronicity. We favor a symptom description in various chronological characteristics based on neurobiological markers, information processing systems, stress reactivity, and consciousness dimensions. We also advocate for a separate phenomenology of treatment resistance since this can yield treatment recommendations. Conclusion: A staging perspective in the field of PTSD is highly needed. This can facilitate the selection of interventions that are proportionate to patients' current needs and risk of illness progression and can also contribute to an efficient framework to organize biomarker data and guide service delivery. Therefore, we propose that a neurobiologically driven trajectory-based typology of PTSD can help deduct several treatment recommendations leading to a more personalized and refined grid to strategize, plan and evaluate treatment interventions. Show less
Background and Purpose: PTSD and mTBI are persistent and frequently comorbid after combat, yet current therapies often achieve only modest impact. A novel exposure-based “walk and talk” cognitive... Show moreBackground and Purpose: PTSD and mTBI are persistent and frequently comorbid after combat, yet current therapies often achieve only modest impact. A novel exposure-based “walk and talk” cognitive therapy, Motion-Assisted, Multi-Modal Memory Desensitization and Reconsolidation (3MDR), featuring participant-selected music and pictures and an eye movement (EM) task in an immersive virtual environment, has shown efficacy in treatment-resistant male veterans, but has not been studied in women or after TBI. The EM task is adapted from eye movement desensitization and reprocessing (EMDR) therapy, but dismantling studies of EMDR have questioned EM benefit. This pilot study assesses 3MDR in male and female veterans with comorbid PTSD and mTBI, and the impact of EM on response. We hypothesized that 3MDR would prove efficacious, both with (EM+) and without EM (EM-).Design: Participants with probable PTSD (PCL-5 ≥ 34) and mTBI were randomized to EM + or EM-across 10 sessions. Participants provided songs and pictures that they rated on impactfulness. While walking in the 3MDR virtual environment, participants started with a song to bring them back to the time of their trauma, and then traversed two hallways, actively walking toward emotionally evocative pictures that they then discussed with their therapist. Key words or feelings they expressed were superimposed over the picture, then read aloud, whereupon EM + participants recited numbers flashing on a ball crisscrossing the picture. These procedures were repeated for multiple pictures per session. A song to return the participant to present day closed each session. Change in PCL-5 score from pre-to post-intervention was the primary outcome, with additional measures at 3 and 6 months.Results: Sixteen (80%) of 20 participants completed the intervention (8 EM+, 8 EM-); 9 (6 EM+, 3 EM-) had resolution of PTSD diagnosis and two improved significantly without resolution. Average PCL-5 score declined from 52.0 (95% confidence intervals: 46.3, 57.7) at baseline to 33.6 (24.3, 42.9) post-intervention (p < 0.01). The EM + group achieved statistically significant improvement (p = 0.01) while the EM-did not (p = 0.10).Conclusion: For veterans with PTSD and comorbid mTBI, 3MDR is effective, and the EM component may add value. Confirmation with larger studies is important. Show less
Measuring physiological parameters of stress in horses during groundwork, for example when involved in equine-assisted interventions, is important to gain insight into the stress levels of the... Show moreMeasuring physiological parameters of stress in horses during groundwork, for example when involved in equine-assisted interventions, is important to gain insight into the stress levels of the horses. Heart rate and heart rate variability can be used as physiological indicators of stress in horses. Heart rate monitors could be easily incorporated into practice, as they are not expensive and easy to use. However, it is questionable whether heart rate monitors present accurate heart rate variability results in exercising horses, similar to electrocardiograms. The aim of this study was to determine the accuracy of heart rate monitors for the assessment of heart rate variability in horses during groundwork exercise. Simultaneous telemetric electrocardiograms (Televet) and heart rate monitor (Polar H10 transmitter and M430 receiver, Hylofit electrodes) recordings were performed on 28 horses (15 mares and 13 geldings). Results indicate that the heart rate monitor accurately determined heart rate and time-domain heart rate variability parameters when compared to electrocardiograms during both baseline and groundwork conditions. As expected, heart rate significantly increased and the heart rate variability significantly decreased during groundwork compared to baseline conditions. This indicates that the heart rate monitor can be used to accurately determine heart rate variability during groundwork. Show less
Bremault-Phillips, S.; Bright, K.S.; Phillips, A.; Vermetten, E. 2022
Introduction: Small-scale clinical studies with psychedelic drugs have shown promising results for the treatment of several mental disorders. Before psychedelics become registered medicines, it is... Show moreIntroduction: Small-scale clinical studies with psychedelic drugs have shown promising results for the treatment of several mental disorders. Before psychedelics become registered medicines, it is important to know the full range of adverse events (AEs) for making balanced treatment decisions. Objective: To systematically review the presence of AEs during and after administration of serotonergic psychedelics and 3,4-methyenedioxymethamphetamine (MDMA) in clinical studies. Methods: We systematically searched PubMed, PsycINFO, Embase, and ClinicalTrials.gov for clinical trials with psychedelics since 2000 describing the results of quantitative and qualitative studies. Results: We included 44 articles (34 quantitative + 10 qualitative), describing treatments with MDMA and serotonergic psychedelics (psilocybin, lysergic acid diethylamide, and ayahuasca) in 598 unique patients. In many studies, AEs were not systematically assessed. Despite this limitation, treatments seemed to be overall well tolerated. Nausea, headaches, and anxiety were commonly reported acute AEs across diagnoses and compounds. Late AEs included headaches (psilocybin, MDMA), fatigue, low mood, and anxiety (MDMA). One serious AE occurred during MDMA administration (increase in premature ventricular contractions requiring brief hospitalization); no other AEs required medical intervention. Qualitative studies suggested that psychologically challenging experiences may also be therapeutically beneficial. Except for ayahuasca, a large proportion of patients had prior experience with psychedelic drugs before entering studies. Conclusions: AEs are poorly defined in the context of psychedelic treatments and are probably underreported in the literature due to study design (lack of systematic assessment of AEs) and sample selection. Acute challenging experiences may be therapeutically meaningful, but a better understanding of AEs in the context of psychedelic treatments requires systematic and detailed reporting. Show less
Flameling, J.; Does, F. van der; Veelen, N. van; Vermetten, E. 2022
BackgroundInsights into the neurobiological basis of resilience can have important implications for the prevention and treatment of stress-related disorders, especially in populations that are... Show moreBackgroundInsights into the neurobiological basis of resilience can have important implications for the prevention and treatment of stress-related disorders, especially in populations that are subjected to high-stress environments. Evaluating large-scale resting-state networks (RSNs) can provide information regarding resilient specific brain function which may be useful in understanding resilience. This study aimed to explore functional connectivity patterns specific for (high) resilience in Dutch policemen after exposure to multiple work-related traumatic events. We investigated resting-state functional connectivity (RSFC) of the salience network (SN), limbic network, and the default-mode network (DMN). MethodsResting-state functional MRI scans were obtained from trauma-exposed executive personnel of the Dutch police force and non-trauma-exposed recruits from the police academy. Participants were divided into three groups: a resilient group (n = 31; trauma exposure; no psychopathology), a vulnerable group (n = 32; trauma exposure, psychopathology), and a control group (n = 19; no trauma exposure, no psychopathology). RSFC of the three networks of interest was compared between these groups, using an independent component analysis and a dual regression approach. ResultsWe found decreased resilience-specific positive RSFC of the salience network with several prefrontal regions. The DMN and limbic network RFSC did not show resilience-specific patterns. ConclusionThis study shows a differential RSFC specific for resilient police officers. This differential RSFC may be related to a greater capacity for internal-focused thought and interoceptive awareness, allowing more effective higher-order responses to stress in highly resilient individuals. Show less
Objective Military members and veterans are at elevated risk of treatment-resistant posttraumatic stress disorder (TR-PTSD) due to higher rates of exposure to potentially traumatic events during... Show moreObjective Military members and veterans are at elevated risk of treatment-resistant posttraumatic stress disorder (TR-PTSD) due to higher rates of exposure to potentially traumatic events during the course of duty. Knowledge of TR-PTSD is limited, and specific protocols or evidence-based TR-PTSD therapies are lacking. Multimodal motion-assisted memory desensitization and reconsolidation (3MDR) therapy is an emerging intervention for combat-related TR-PTSD. The purpose of this study was to preliminarily assess the effectiveness of 3MDR in addressing TR-PTSD in Canadian military members and veterans. Methods This study is a longitudinal mixed-methods clinical trial. English-speaking military members and veterans aged 18-60 with TR-PTSD were recruited to participate. The intervention consisted of six sessions of 3MDR therapy. Quantitative data were collected pretreatment, posttreatment, and longitudinally at 1, 3, and 6 months after completion of 3MDR. Results Results from the first 11 participants to complete the 3MDR protocol exhibited statistically significant improvement (surviving multiple comparison correction) in clinically administered and self-reported scores for PTSD (CAPS-5 and PCL-5), moral injury (MISS-M-SF), depression (PHQ-9), anxiety (GAD-7), emotional regulation (DERS-18), and resilience (CD-RS-25). Conclusion The preliminary and exploratory results from this clinical trial support the growing body of literature illustrating 3MDR as an effective treatment for military-related TR-PTSD. These results are notable given participants' previous lack of success with frontline psychotherapeutic and pharmacological interventions. Given that there are currently very limited treatment options for TR-PTSD, 3MDR could prove to be a valuable treatment option for military members and veterans with TR-PTSD. Show less
Service members and veterans can be exposed to potentially traumatic and morally injurious experiences (PMIEs) including participating in, witnessing, or failing to prevent an act(s) that... Show moreService members and veterans can be exposed to potentially traumatic and morally injurious experiences (PMIEs) including participating in, witnessing, or failing to prevent an act(s) that transgresses their core beliefs. Violation of one's deeply held morals and values can be profoundly distressing and shatter one's sense of self at the deepest level. Relationships with self, others, the world, and for some, the Sacred, can also be fractured. Post-Traumatic Stress Disorder (PTSD) and/or Moral Injury (MI) can result. Left unresolved, MI can leave individuals struggling with guilt, shame, cognitive dissonance, and negative self-attributions. A holistic approach that addresses the psychological and spiritual harm associated with MI is warranted. We wonder if forgiveness can help individuals struggling with MI to address the harm caused by actions or inactions, release negative emotions, and mend relationships. Commonly used by Spiritual/Religious (S/R) Leaders, forgiveness practices are increasingly being explored by Mental Health Professionals as a complement to evidence-based treatment approaches. This article provides case examples that illustrate the use of forgiveness practices that promote recovery and identifies programs used in clinical practice that incorporate forgiveness. Research is yet needed to better understand the importance of forgiveness in the treatment and healing of PTSD and/or MI. This requires an interdisciplinary discourse between Mental Health Professionals and S/R Leaders working in the field of MI. Such engagement and integrated use of forgiveness practices may yield improved outcomes not only for service members and veterans, but for all those struggling as a result of PTSD and/or MI. Show less
