An Innovative Framework for Delivering Psychotherapy to Patients With Treatment-Resistant Posttraumatic Stress Disorder: Rationale for Interactive Motion-Assisted Therapy

Abstract

Despite an array of evidence-based psychological treatments for patients with a posttraumatic stress disorder (PTSD), a majority of patients do not fully benefit from the potential of these therapies. In veterans with PTSD, up to two-thirds retain their diagnosis after psychotherapy and often their disorder is treatment-resistant, which calls for improvement of therapeutic approaches for this population. One of the factors hypothesized to underlie low response in PTSD treatment is high behavioral and cognitive avoidance to traumatic reminders. In the current paper we explore if a combination of personalized virtual reality, multi-sensory input, and walking during exposure can enhance treatment engagement, overcome avoidance, and thereby optimize treatment effectiveness. Virtual reality holds potential to increase presence and in-session attention and to facilitate memory retrieval. Multi-sensory input such as pictures and music can personalize this experience. Evidence for the positive effect of physical activity on fear extinction and associative thinking, as well as embodied cognition theories, provide a rationale for decreased avoidance by literally approaching cues of the traumatic memories. A dual-attention task further facilitates new learning and reconsolidation. These strategies have been combined in an innovative framework for trauma-focused psychotherapy, named Multi-modular Motion-assisted Memory Desensitization and Reconsolidation (3MDR). In this innovative treatment the therapeutic setting is changed from the face-to-face sedentary position to a side-by-side activating context in which patients walk toward trauma-related images in a virtual environment. The framework of 3MDR has been designed as a boost for patients with treatment-resistant PTSD, which is illustrated by three case examples. The intervention is discussed in context of other advancements in treatment for treatment-resistant PTSD. Novel elements of this approach are activation, personalization and empowerment. While developed for veterans with PTSD who do not optimally respond to standardized treatments, this innovative framework holds potential to also be used for other patient populations and earlier stages of treatment for patients with PTSD.

Interactive Motion-Assisted Exposure Therapy for Veterans with Treatment-Resistant Posttraumatic Stress Disorder: A Randomized Controlled Trial

“…A novel intervention, multi-modular motion-assisted memory desensitization and reconsolidation (3MDR), was developed to improve outcomes for veterans who did not sufficiently benefit from evidence-based treatments [18]. It combines known therapeutic techniques of virtual reality and eye movement desensitization and reprocessing therapy (EMDR) in a novel context in which patients walk on a treadmill while interacting with personal trauma-related images and music.…”

“…Based on these findings, we expected that a combination of virtual reality, walking, trauma-related images and music with exposure could result in lower avoidance and more optimal memory retrieval during treatment. Adequate engagement and memory retrieval would in turn lead to processing and reconsolidating the memory, aided by a dual-attention task similar to the one used in EMDR [18,28]. In a first proof of concept veterans with treatment-resistant PTSD (TR-PTSD) positively evaluated the acceptability of 3MDR [29].…”

“…In a first proof of concept veterans with treatment-resistant PTSD (TR-PTSD) positively evaluated the acceptability of 3MDR [29]. Preliminary findings suggested that 3MDR could lead to clinically meaningful changes, which for some patients were not experienced until 4-6 weeks after the intervention [18,29,30].…”

“…The current study aimed to test the efficacy of 3MDR for veterans with TR-PTSD in a randomized controlled trial (RCT) comparing 3MDR to a non-specific treatment component control group (NTCC), consisting of treatment without trauma-focused elements. Based on the literature reviewed above, we expected the combined arsenal of therapeutic techniques in 3MDR to improve treatment outcomes for veterans who did not respond to prior current evidence-based treatment, and we expected that this effect would occur a few weeks after the 3MDR intervention and increase over time [18,30]. Therefore, our primary hypothesis was that 3MDR would significantly decrease PTSD symptoms at the end point, 16 weeks after start of treatment, as compared to the control intervention.…”

“…In addition, we explored the course of symptoms during treatment at 6, 12 and 16 weeks after start of treatment. Based on preliminary findings, we expected to find significant differences in slopes between the groups in favor of 3MDR [18,29].…”