Virtual Reality Graded Exposure Therapy (VRGET) for PTSD and Phobias

Virtual Reality Graded Exposure Therapy (VRGET)–What it is and how it works

VRGET is a technology-based exposure therapy with important implications for the management of post-traumatic stress disorder (PTSD) as well as severe phobias that are difficult to treat using conventional psychological therapies and medications. VRGET combines advanced computer graphics, three-dimensional visual displays, and body-tracking technologies to create realistic virtual environments with the goal of simulating feared situations or objects. Virtual environments have been designed to provide visual, auditory, tactile, vibratory, vestibular, and olfactory stimuli to patients in highly controlled settings. During a virtual exposure session, the therapist closely tracks the patient’s state of arousal by monitoring physiological indicators of stress, including heart rate and respirations. Many individuals are readty to take the next step and engage in real life (i.e., in vivo) exposure to the feared object or situation after they have been desensitized to a virtual environment.

VRGET is more effective than conventional exposure therapy

VRGET is more effective than conventional imaginal exposure therapy and has comparable efficacy to in vivo exposure therapy for the treatment of specific phobias, agoraphobia, panic disorder, and PTSD. Like in vivo and imaginal exposure therapy, VRGET desensitizes the patient to a situation or object that would normally cause anxiety or panic. In a randomized controlled trial, VRGET and conventional cognitive behavioral therapy (CBT) were equally effective treatments of panic disorder with agoraphobia, and patients who underwent VRGET required 33 percent fewer sessions to achieve similar results. Studies also confirm that VRGET is an effective treatment of fear of flying, fear of heights, fear of small animals, fear of driving, and other phobias. VRGET is as effective as and more cost-effective than conventional exposure therapy for fear of flying because patient and therapist avoid the cost and inconvenience of airplanes. A virtual environment simulating the devastation of the September 11, 2001, attacks on the World Trade Towers has been successfully used to treat individuals diagnosed with severe PTSD following the attacks.

VRGET reduced PTSD symptoms in combatants who do not respond to conventional exposure therapy

Findings of a study on combined multisensory exposure and VRGET reported significant reductions in severity of PTSD symptoms in active duty combatants who had failed to respond to other forms of exposure therapy. Several subjects reported significant improvement following only five VRGET sessions; however, there was considerable variability in the number of VRGET sessions needed to reduce symptom severity to the same level.

VRGET is being used to screen individuals at high risk of developing PTSD

Research studies are being aimed at developing virtual reality tools for assessing and preventing combat-related PTSD. STRIVE (Stress resilience in virtual environments) is a highly integrative “stress resilience training” program aimed at enhancing emotional coping strategies prior to active deployment. STRIVE employs an immersive VR environment to simulate combat situations that includes a “virtual mentor” who guides the combatant through a virtual experience while coaching him or her in relaxation and emotion self-regulation skills. The intensity of the virtual stimulus used is determined by the individual’s habituation based on HRV and other measures of autonomic arousal. Physiological biomarkers of stress response are measured before and after VRGET sessions. The STRIVE system permits users to be immersed in stressful combat scenarios and interact with virtual characters for training in a variety of coping strategies that may enhance resilience in the face of extreme stress. The STRIVE protocol may provide a useful tool for predicting the risk of developing PTSD or other psychiatric disorders in new recruits prior to actual combat exposure. Recruits who display high resilience and thus presumably at relatively lower risk of developing PTSD might be more suitable for direct combat roles while individuals who display low resilience might preferentially be assigned to noncombat roles.

Future innovations will integrate VRGET with biofeedback and broadband internet connections permitting in-home therapy

Future integrative approaches to phobias, panic attacks, and other severe anxiety disorders will combine VRGET with biofeedback in outpatient settings or in the patient’s home via broadband Internet connections, with CBT, relaxation, mind–body practices, and appropriate medications. Combining VR environments with real-time feedback based on neurophysiological responses to stress may permit each unique patient to optimize the level and type of VR exposure to enhance resiliency training and speed the rate of recovery from PTSD. Human–computer interface (HCI) systems based on CBT and biofeedback are being developed for resilience training in individuals at risk of developing PTSD following exposure to trauma. Larger studies on patient populations diagnosed with PTSD using headmounted displays and other technologies that create more immersive virtual environments are needed to determine whether combining VRET and EEG biofeedback is practical in clinical settings and yields superior outcomes compared to either approach alone.

Few safety problems

Infrequent cases of disorientation, nausea, dizziness, headache, and blurred vision have been reported following VRGET. Intense sensory stimulation during VRGET can trigger migraine headaches, seizures, or gait abnormalities in individuals who have these disorders. Patients with schizophrenia should not use VRGET because immersion in a virtual environment can exacerbate delusions.

To learn more about VRGET and other non-pharmacologic treatments of PTSD check out my e-book “Post-traumatic stress disorder: the integrative solution.”

Posted in Post-Traumatic Stress Disorder | Tagged , , , , , , , | Leave a comment

Regular exposure to high-density negative ions for seasonal affective disorder (SAD)

Regular exposure to high density negative ions may be as effective as bright light therapy for seasonal depressed mood

I recently posted a blog on the health benefits of light. In addition to bright full-spectrum light and (to a lesser extent) dim blue or red light, emerging evidence suggests that regular daily exposure to high-density negative ions may be an effective treatment of seasonal depressed mood and may have comparable efficacy to bright light exposure for this condition.

Twenty-five depressed patients with seasonal depressed mood were randomized to high-density negative ions (2.7 × 106 ions/cm3) versus low-density negative ions (1 × 104 ions/ cm3) using in-home ion generators 30 minutes daily for 3 weeks. Fifty-eight percent of patients exposed to high-density negative ions experienced significant improvements in mood on standardized rating scales, compared to 15 percent of patients exposed to low-density negative ions. In a 2-week randomized-controlled trial (158 subjects), patients with seasonal depressed mood were randomly assigned to bright light exposure (10,000 lux) versus high-density or low-density negative ions. Patients exposed to high-density negative ions or bright light experienced significant and equivalent improvements in mood. In another controlled trial (128 subjects), bright light exposure, a pleasing auditory stimulus, and high-density negative ions resulted in equivalent and rapid improvements in mood and alertness in mildly depressed and non-depressed adults.

No adverse effects

Adverse effects have not been reported with regular daily exposure to negative ions following the approaches used in published studies.

Integrative mental health care

To learn more about non-pharmacologic therapies of depressed mood and other mental health problems read my e-books on integrative mental health care.

Posted in Depression | Tagged , , , , , , | Leave a comment

Urgent Need for Transforming Mental Health Care

Existing models of care and conventional therapies are limited

Existing models of care and available conventional treatment approaches fail to adequately address the global crisis of mental health care. Mental illness accounts for about one-third of the world’s disability caused by all adult health problems, resulting in enormous personal suffering and socioeconomic costs. Severe mental health problems including major depressive disorder, bipolar disorder, schizophrenia, and substance use disorders affect all age groups and occur in all countries, including the US, Canada, the European Union countries, and other developed and developing countries. Mental illness is the pandemic of the 21st century and will be the next major global health challenge. There is a large and growing gap between mental health care needs of the population and available resources.

Weak evidence and safety problems affect many psychotropic medications

Many individuals diagnosed with bipolar disorder, major depressive disorder, and schizophrenia depend on medications to function and be productive members of society. However, after decades of research and billions of dollars of industry funding, the evidence supporting pharmacologic treatments of major depressive disorder, bipolar disorder, and other psychiatric disorders is not compelling. Many commonly prescribed psychotropic medications including antidepressants and antipsychotics are associated with serious adverse effects, including weight gain, increased risk of diabetes and heart disease, neurologic disorders, and sudden cardiac death. Metabolic syndrome associated with weight gain and increased risk of diabetes and coronary artery disease is a well-documented adverse effect of antipsychotics and other psychotropic agents. Poor treatment outcomes owing to limited efficacy of antidepressants, mood stabilizers, antipsychotics, and other psychotropic medications result in long-term impaired functioning, work absenteeism, and losses in productivity.

CAM therapies can help improve outcomes

In the context of the limitations of available conventional biomedical treatments, accumulating research findings are providing evidence for both safety and efficacy of select complementary and alternative (CAM) treatments of depressed mood, anxiety, and other mental health problems, including select pharmaceutical-grade natural products, lifestyle modifications (Lifestyle Medicine), mind-body approaches, and nonallopathic whole-system approaches such as traditional Chinese medicine and Ayurveda. Examples of natural supplements being investigated as nonpharmacologic therapies include S-adenosyl methionine for depressed mood; the adjunctive use of nutraceuticals (ie, botanicals and other natural product supplements) as stand-alone therapies or in combination with psychotropics such as omega-3 fatty acids, folic acid (especially its active form l-methyl-folinic acid), 5-hydroxytryptophan, and n-acetyl cysteine for mood disorders; a standardized extract of the herbal kava; and the amino acid l-theanine.

To read more click here.

Posted in General | Tagged , , , , | Leave a comment

Increasing Use of Alternative Therapies for Mental Health

Persons diagnosed with a major psychiatric disorder are significantly more likely to use CAM treatments than the general population, and the majority of people who use CAM to self-treat a mental health problem take prescription medications concurrently. Almost one-half of persons diagnosed with major depressive disorder or panic disorder use at least one CAM treatment, compared to less than one-third of the general adult population. Roughly two-thirds of severely depressed or anxious persons who use CAM therapies consult with a mental health professional and 90 percent of the time this is a psychiatrist. The majority of persons who use CAM therapies for a mental health problem do not disclose this to their mental health care provider. This trend is alarming in view of potentially serious safety problems that can result when combining certain herbals or other natural products with pharmaceuticals. More than one-half of persons who self-treat severe depression or anxiety using CAM while concurrently taking a pharmaceutical believe that CAM treatments and conventional medications are equally efficacious.

Posted in Uncategorized | Tagged , , , , , | Leave a comment

Steady Growth in Use of Complementary and Alternative Medicine

In the North America, Europe, and other industrialized world regions, an increasing percentage of the population is using complementary, alternative, and integrative approaches to treat or selftreat medical and mental health problems. A large patient survey (N = 7,503) found that females, college graduates, and persons who believed that they received poor health care were more likely to use CAM, and only one-half of individuals who used CAM notified their health care providers. The majority of CAM users are well educated, committed to personal growth, satisfied with the conventional care provided by their physician or other health care provider, and use both prescription medications and CAM approaches for the same problem. An increasing number of medical schools, nursing schools, and psychology graduate programs offer courses on CAM. Symposia on CAM modalities are included in the annual meetings of the American Medical Association (AMA), the American Psychiatric Association (APA), and other professional medical associations. Approximately half of US physicians—and the majority of European physicians—believe that acupuncture, chiropractic, and homeopathy are valid therapeutic modalities and refer patients to practitioners of these therapies. Increasing numbers of primary care physicians are becoming certified to practice massage, acupuncture, herbal medicine, homeopathy, and other nonallopathic modalities.

Posted in Foundations of Integrative Mental Healthcare | Tagged , , , , | Leave a comment

Limitations of conventional approaches used to evaluate depressed mood

Approaches used in biomedical psychiatry to evaluate depressed mood provide ambiguous information about possible underlying biological or other causes. Conventionally trained psychiatrists rely on structured interviews to obtain salient information about medical, psychiatric, family and social history that may be related to a patient’s complaint of depressed mood. The Mini-mental state exam, Beck Depression Inventory, and Hamilton Depression Inventory are structured interview tools commonly used to assess the relative severity of symptoms as well as social and psychodynamic factors associated with depressed mood. In addition to the clinical interview, laboratory screening studies are sometimes used to assess possible endocrinological, infectious, or metabolic causes of depressed mood. Bioassays that identify underlying medical causes of depressed mood include thyroid studies (FT4 and TSH), fasting blood glucose, liver enzymes, complete blood count (CBC), serum iron levels, serum electrolytes, BUN, and urinary creatinine. When an underlying medical problem, substance abuse or medication side effects contribute to mood changes, these problems are treated directly. When depressed mood does not resolve after a suspected medical cause has been treated, assessment continues until underlying psychological or medical causes are adequately addressed.

Conventional biomedical psychiatric assessment is limited by flawed standardized symptom rating instruments and poorly defined criteria for “response,” “remission,” and “recovery” when describing treatment outcomes in depression. For example a meta-analysis of 70 studies on the Hamilton depression scale suggests that this standardized instrument is conceptually flawed and does not reliably measure treatment outcomes. The response rates of most patients to conventional antidepressants are not well defined because most studies do not quantify treatment outcomes using formal criteria. Furthermore, relatively few psychiatrists are aware of, or regularly employ stringent research criteria to assess clinical outcomes when treating depressed patients.

Posted in Depression | Tagged , , , , , | Leave a comment

Depression causes an enormous economic and social burden

Depression is one of the most serious and costly health problems facing the world today. Because of the high incidence of suicide and other medical or mental illness in depressed individuals, depression is regarded as the leading cause of death and disability from adolescence through middle age. Approximately 15% of adults will experience severe depressed mood during their lifetimes and approximately 15% of these will eventually commit suicide. Available conventional treatment approaches do not adequately address depressed mood. In the medical community and the public at large there is growing debate over the efficacy and safety of antidepressants. It has been argued that many antidepressants are probably no more effective than placebo. This becomes even more concerning when high placebo response rates of most large controlled studies on antidepressants are taken into account.

In the context of widely shared concerns over the effectiveness and safety of prescription antidepressants research evidence is accumulating for many complementary and alternative treatments of depressed mood. To learn about safe and effective CAM treatments of depressed mood read “Depressed Mood: The Integrative Mental Health Solution,” by James Lake M.D.

Posted in Depression | Tagged , , , , , , , | Leave a comment

Complementary and alternative treatments of bipolar disorder

A large percentage of individuals diagnosed with bipolar disorder use complementary and alternative approaches together with prescription medications however there is little evidence for the safety and efficacy of many CAM therapies. The most appropriate and effective treatment approach should be determined by the type and severity of symptoms—including depressed mood, mania or states involving ‘mixed’ depression and mania, psychotic symptoms, insomnia and agitation—the presence of other medical or psychiatric disorders, response to previous mainstream and CAM treatments, patient preferences and constraints on cost and availability of different treatments.

When prominent symptoms of anxiety, psychosis or agitation are present, effective integrative strategies should prioritize the treatment of those symptoms. For example, reasonable integrative approaches when managing an acutely manic patient who is agitated and extremely anxious include an initial loading dose of valproic acid or another conventional mood stabilizer, high potency benzodiazepines, an antipsychotic that is sedating at bedtime—preferably a newer second generation antipsychotic—and possibly also amino acids known to have calming or sedating effects, such as L-tryptophan, 5-HTP or L-theanine. In general, CAM therapies have limited effectiveness against the hypomanic or manic phase of bipolar disorder however select CAM therapies are beneficial for the depressive phase of the disorder, either alone or when used in combination with antidepressant medications.

To read more about safe and effective uses of natural supplements and other complementary and alternative treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake M.D.

Posted in Bipolar Disorder | Tagged , , , , , | Leave a comment

Limitations of conventional medications used to treat bipolar disorder

Different medications are used to treat bipolar disorder including mood stabilizers (e.g. lithium carbonate and valproate), antidepressants, antipsychotics and sedative-hypnotics. Mood stabilizers do what the name implies, that is they keep the mood from going up and down between episodes of depressed mood and mania. Antidepressants are often used to treat the depressed phase of bipolar disorder though they also risk causing or ‘inducing’ mania. Antipsychotics are used to treat symptoms of agitation and psychosis which occur frequently in acute mania. Sedative-hypnotics such as lorazepam are used to treat insomnia and agitation.
Antipsychotics, specifically newer second generation antipsychotics (also called ‘atypical antipsychotics’) are currently regarded as the treatments of first choice for bipolar mania with or without psychosis. The therapeutic benefits of antipsychotics and other medications used to treat bipolar disorder are limited by frequent and potentially serious adverse effects. Earlier so-called ‘first generation’ antipsychotics were associated with frequent neurologic adverse effects (e.g. akathisia) in contrast to the newer second generation antipsychotics which cause weight gain and metabolic adverse effects but less often cause neurologic side effects.

After decades of research there is still no consensus on which particular medication should be tried first. Efforts to identify the most effective medication treatments have been hampered by problems in recent systematic reviews of studies on medications used to treat bipolar disorder including, for example, the use of non-representative patient samples, short trial duration, and experimental design flaws that make it difficult to generalize findings between studies.

Determining which medication may be most efficacious for bipolar mania is not at a simple or straight forward process because of large variations in response and tolerance in individuals with the same symptoms treated with the same medication. Diverse genetic and neurobiological causes of bipolar disorder mean that treatment with the same medication results in a wide range of responses and differences in adverse effects. For example the average weight gain seen in individuals taking second generation antipsychotics (the so-called ‘atypical agents’) is a few kilograms however metabolic differences between individuals can increase that amount 10 to 20 fold. A recent systematic review and meta-analysis of drug trials in acute mania included 68 studies on all drug classes and over 16,000 patients. All drugs were found to be moderately superior to placebo and antipsychotics were found to be more effective than other mood stabilizers in general.

In the context of the limitations of available pharmacologic treatments emerging research findings support the use of select natural products in the treatment of bipolar disorder. To read more about safe and effective uses of natural supplements and other complementary and alternative treatments of bipolar disorder read “Bipolar Disorder: The Integrative Mental Health Solution,” by James Lake M.D.

Posted in Bipolar Disorder | Tagged , , , , , , , | Leave a comment

Poor sleep habits increase the risk of relapse in persons with bipolar disorder

Abnormal sleep is known to increase the risk of developing cardiovascular disease. Sleeping too little or too long, as well as chronic insomnia significantly increase the risk of illness and death related to cardiovascular disease. This is probably related to the fact that chronically disturbed sleep increases the risk of obesity, hypertension, and diabetes, known risk factors for cardiovascular disease. Irregular sleep patterns and insomnia increase relapse risk and predict poor response in individuals diagnosed with bipolar disorder.

Posted in Bipolar Disorder | Tagged , , , , | Leave a comment