Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear

BACKGROUND: Traditional pharmacological approaches to treating psychiatric disorders focus on correcting presumed biochemical abnormalities. However, some disorders, particularly the anxiety-related disorders exemplified by specific phobia, have an emotional learning component to them that can be facilitated with psychotherapy. OBJECTIVE: To determine whether D-cycloserine (DCS), a partial agonist at the N-methyl-d-aspartate receptor that has previously been shown to improve extinction of fear in rodents, will also improve extinction of fear in human phobic patients undergoing behavioral exposure therapy. DESIGN: Randomized, double-blind, placebo-controlled trial examining DCS vs placebo treatment in combination with a precisely controlled exposure paradigm. SETTING: Participants were recruited from the general community to a research clinic. PARTICIPANTS: Twenty-eight subjects with acrophobia diagnosed by the Structured Clinical Interview for DSM-IV were enrolled. INTERVENTIONS: After we obtained pretreatment measures of fear, subjects were treated with 2 sessions of behavioral exposure therapy using virtual reality exposure to heights within a virtual glass elevator. Single doses of placebo or DCS were taken prior to each of the 2 sessions of virtual reality exposure therapy. Subjects, therapists, and assessors were blind to the treatment condition. Subjects returned at 1 week and 3 months posttreatment for measures to determine the presence and severity of acrophobia symptoms. MAIN OUTCOME MEASURES: Included were measures of acrophobia within the virtual environment, measures of acrophobia in the real world, and general measures of overall improvement. An objective measure of fear, electrodermal skin fluctuation, was also included during the virtual exposure to heights. Symptoms were assessed by self-report and by independent assessors at approximately 1 week and 3 months posttreatment. RESULTS: Exposure therapy combined with DCS resulted in significantly larger reductions of acrophobia symptoms on all main outcome measures. Subjects receiving DCS had significantly more improvement compared with subjects receiving placebo within the virtual environment (1 week after treatment, P相似文献   

Reproductive and sexual health benefits in private health insurance plans in Washington State

CONTEXT: Although unintended pregnancy and sexually transmitted diseases (STDs) are considerable problems in the United States, private health insurance plans are inconsistent in their coverage of reproductive and sexual health services needed to address these problems. METHODS: A survey administered to a market-representative sample of 12 health insurance carriers in Washington State assessed benefit coverage for gynecologic services, maternity services, contraceptive services, pregnancy termination, infertility services, reproductive cancer screening, STD services, HIV and AIDS services, and sterilization, as well as for the existence of confidentiality policies. "Core" services in each category were defined based on U.S. Preventive Services Task Force and other recommendations. RESULTS: Of the 91 top-selling plans on which data were collected, 8% were indemnity plans, 14% were point-of-service plans, 21% were preferred-provider organization plans and 57% were health maintenance organization (HMO)-type products; they had a combined enrollment of 1.4 million individuals. Coverage of core services varied widely by type of plan. While a high proportion of plans covered core gynecologic, maternity, reproductive cancer screening, STD and HIV and AIDS services, nearly half of plans did not cover any kind of contraceptive method. Approximately 13% of female enrollees did not have core coverage for gyneco!ogic services, 19% for matemity services, 75% for contraception, 37% for sterilization and 53% for pregnancy termination; 98% of women and men were not covered for infertility treatment. Most carriers did not have specific policies for maintaining privacy of sensitive health information. Overall, benefit coverage was lower for indemnity, preferred-provider organization and HMO plans in Washington State than has previously been seen nationally. CONCLUSIONS: A sizable proportion of women and men in Washington State who rely on private-sector health insurance lack comprehensive coverage for key reproductive and sexual health services.     

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

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

Internet use among patients with psychosomatic disorders: what are the health-related demands and needs?

While Internet-based health-related offers for various disorders are increasing, little is known about the way patients with psychosomatic disorders use the Internet. We conducted a questionnaire survey in outpatient clinics at two university hospitals' Departments of Psychosomatic Medicine. Seventy-four percent of N = 274 patients had Internet home access and 60 percent of those patients reported health-related Internet use. Patients expressed the wish for more professional, evidence-based online information and expert-guided treatment. The survey results support the Internet's high potential in future treatment strategies for patients with psychosomatic disorders.     

A preliminary report on the use of virtual reality technology to elicit craving and cue reactivity in cocaine dependent individuals

In the present feasibility study, we developed a 3-dimensional virtual "crack" cocaine environment and evaluated the environment's ability to elicit subjective craving and cue reactivity (i.e., subjective emotional responding, heart rate and skin conductance) in 11 crack cocaine dependent individuals. Each of the seven 3-D crack cocaine scenes in the cocaine environment depicted actors engaging in a range of using-related behaviors (i.e., smoking crack) whereas the neutral environment contained scenes depicted 3-D aquariums with active aquatic life (baseline measures were obtained following immersion in the neutral environment). Results indicated that craving was significantly elevated during the cocaine-related scenes as compared to baseline. Craving varied by scene content, with scenes depicting active cocaine use eliciting the highest levels of craving. Heart rate was significantly higher in four of the scenes with drug use content and positive affect (i.e., happiness) ratings were significantly lower during cocaine scenes as compared to baseline. Overall, the results suggest that a standardized and stimulus rich virtual reality environment effectively elicits craving and physiologic reactivity. Such technology has potential utility in the development and refinement of exposure-based behavioral and pharmacological interventions for substance use disorders.     

The needs of carers: a comparison between eating disorders and schizophrenia

Objective

This pilot study compares the level of distress and the need for support between carers of patients with anorexia (AN) and bulimia nervosa (BN) and carers of patients with schizophrenia.

Methods

Thirty-two carers of patients suffering from AN and BN and 30 carers of patients with schizophrenia filled out the general health questionnaire (GHQ-12) and the burden inventory (BI). In addition, they were interviewed with a semi-structured research interview, the carers’ needs assessment (CNA), to assess relevant problem areas as well as the need for helpful interventions. Patients with an eating disorder were interviewed with the eating disorder examination (EDE) and patients with schizophrenia with the positive and negative syndrome scale (PANSS) to assess the severity of the disorder.

Results

The mean duration of illness was 5.3 years in the patients with eating disorders and 7.3 years in the patients with schizophrenia. Most of the carers were mothers or partners. In the CNA we found high numbers of problems as well as high numbers of unmet needs for interventions. The most frequently mentioned problem areas in all groups of carers were “disappointment caused by the chronic course of the illness, concerns about the patient’s future” and “problems in communication with the patient”. The most frequently reported need for support in all groups was “counseling and support by a professional”. Carers of patients with BN reported a significantly lower number of problems and of needs for interventions compared to the carers of patients with AN and schizophrenia. Also in the BI and the GHQ-12 we found significantly lower total scores in carers of patients with BN. Carers of patients with AN and schizophrenia did not differ significantly in any of the assessments. The severity or duration of illness of the patients did not correlate with the carers’ burden or needs.

Conclusions

Carers of patients with an eating disorder and carers of patients with schizophrenia are burdened with similar problems and have high levels of unmet needs which are usually not addressed in clinical practice. Carers of anorectic patients have higher levels of difficulties in various areas compared to carers of bulimic patients and did not differ from carers of patients with schizophrenia.