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Background: Intensive outpatient programs (IOPs) for trauma-focused therapy, such as prolonged exposure (PE), have the potential to deliver highly effective treatment, quickly and with minimal dropout. Identifying factors that predict maintenance of gains after treatment can help triage individuals who may need additional services., Methods: Growth mixture modeling (GMM) was used to identify classes of posttraumatic stress disorder (PTSD) and depression symptom trajectories across the year following a 2-week IOP, delivering daily PE for PTSD for post-9/11 Veterans. Predictors of trajectories were examined., Results: Three classes of trajectories best-fit the data for PTSD and depression symptoms. Two classes made up the majority of the sample (85%) and both maintained significantly reduced PTSD symptoms across the year following therapy. For a minority of the sample (14.6%), PTSD symptoms rebounded after treatment. These individuals were highly likely to be categorized in the persistent depression class., Conclusions: IOP-delivered PE is effective, and gains are largely maintained. The minority of patients who do not maintain their gains as robustly are likely to report persistent depressive symptoms in treatment and higher PTSD symptoms on a self-report measure., (© 2022 Wiley Periodicals LLC.)

Background: This investigation involved an in-depth examination of psychophysiological responses during exposure to the trauma memory across 10 sessions among active duty soldiers with combat-related posttraumatic stress disorder (PTSD) treated by Prolonged Exposure (PE) or Virtual Reality Exposure (VRE). We compared psychophysiological changes, session-by-session, between VRE and traditional imaginal exposure., Methods: Heart rate (HR), galvanic skin response (GSR), and peripheral skin temperature were collected every 5 min during exposure sessions with 61 combat veterans of Iraq/Afghanistan and compared to the PTSD Checklist (PCL-C) and Clinician-Administered PTSD Scale (CAPS) outcomes using multilevel modeling., Results: Over the course of treatment, participants in the PE group had higher HR arousal compared to participants in the VRE group. With reference to GSR, in earlier sessions, participants demonstrated a within-session increase, whereas, in later sessions, participants showed a within-session habituation response. A significant interaction was found for GSR and treatment assignment for within-session change, within-person effect, predicting CAPS (d = 0.70) and PCL-C (d = 0.66) outcomes., Conclusion: Overall, these findings suggest that exposure to traumatic memories activates arousal across sessions, with GSR being most associated with reductions in PTSD symptoms for participants in the PE group., (© 2021 Wiley Periodicals LLC. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Background: Anhedonic symptoms of posttraumatic stress disorder (PTSD) reflect deficits in reward processing that have significant functional consequences. Although recent evidence suggests that disrupted integrity of fronto-limbic circuitry is related to PTSD development, including anhedonic PTSD symptoms (posttrauma anhedonia [PTA]), little is known about potential structural biomarkers of long-term PTA as well as structural changes in fronto-limbic pathways associated with recovery from PTA over time., Methods: We investigated associations between white matter microstructure, gray matter volume, and PTA in 75 recently traumatized individuals, with a subset of participants (n = 35) completing follow-up assessment 12 months after trauma exposure. Deterministic tractography and voxel-based morphometry were used to assess changes in white and gray matter structure associated with changes in PTA., Results: Reduced fractional anisotropy (FA) of the uncinate fasciculus at around the time of trauma predicted greater PTA at 12-months posttrauma. Further, increased FA of the fornix over time was associated with lower PTA between 1 and 12-months posttrauma. Increased gray matter volume of the ventromedial prefrontal cortex and precuneus over time was also associated with reduced PTA., Conclusions: The microstructure of the uncinate fasciculus, an amygdala-prefrontal white matter connection, may represent a biomarker of vulnerability for later PTA. Conversely, development and recovery from PTA appear to be facilitated by white and gray matter structural changes in a major hippocampal pathway, the fornix. The present findings shed new light on neuroanatomical substrates of recovery from PTA and characterize white matter biomarkers of risk for posttraumatic dysfunction., (© 2020 Wiley Periodicals LLC.)

Background: Many reports have documented the relationship between previous traumatic experiences, including childhood trauma, and the development of later life psychopathology, including posttraumatic stress disorder (PTSD). Identification of individuals at greatest risk for the development of PTSD could lead to preventative interventions. The present study examined the developmental course of PTSD after trauma exposure, using histories of previous traumatic experiences and the severity of the reaction to the trauma as predictors., Methods: Participants (N = 713) were recruited from Emergency Departments in Miami and Atlanta immediately following a traumatic experience. Histories of previous traumatic experiences and the immediate reaction to the new trauma were examined at baseline. Follow-up assessments of PTSD severity were conducted at 1, 3, and 6 months., Results: Histories of child abuse and pre-existing trauma symptoms predicted the immediate response to stress (R 2  = .21, p < .001) and the initial trauma reaction (p < .005).) A mixed-model repeated-measures analysis of variance found that immediate stress response and a history of prior trauma (p < .001) significantly predicted the course of PTSD symptoms. Area under the curve (AUC) analyses suggested that the presence of PTSD at each successive assessment was predicted most substantially by the severity of PTSD at the immediately prior follow-up assessment (AUC > 0.86)., Conclusions: The current findings suggest that previous traumatic experiences lead to a greater immediate reaction to trauma and combine to predict the development of PTSD, the maintenance of which is not moderated by these earlier experiences. The identification of people likely to develop PTSD may be aided by the assessment of prior experiences and immediate reactions., (© 2020 Wiley Periodicals LLC.)

Background: Posttraumatic stress disorder (PTSD) is linked to a specific event, providing the opportunity to intervene in the immediate aftermath of trauma to prevent the development of this disorder. A previous trial demonstrated that trauma survivors who received three sessions of modified prolonged exposure therapy demonstrated decreased PTSD and depression prospectively compared to assessment only. The present study investigated the optimal dosing of this early intervention to test one versus three sessions of exposure therapy in the immediate aftermath of trauma., Methods: Participants (n = 95) recruited from a Level 1 Trauma Center were randomly assigned in a 1.5:1.5:1 ratio in a parallel-group design to the three conditions: one-session exposure therapy, three-session exposure therapy, and assessment only. Follow-up assessments were conducted by study assessors blind to study condition., Results: Mixed-effects model results found no significant differences in PTSD or depression symptoms between the control condition and those who received one or three exposure therapy sessions across 1-12-month follow-up assessment. Results indicate that the intervention did not interfere with natural recovery. Receiver operating characteristic curve analyses on the screening measure used for study inclusion (Predicting PTSD Questionnaire; PPQ) in the larger sample from which the treatment sample was drawn (n = 481) found that the PPQ was a poor predictor of likely PTSD at all follow-up time points (Area under the curve's = 0.55-0.62)., Conclusions: This likely impacted study results as many participants demonstrated natural recovery. Recommendations for future early intervention research are reviewed, including strategies to identify more accurately those at risk for PTSD and oversampling more severe trauma types., (© 2020 Wiley Periodicals, Inc.)

Background: The majority of studies comparing active psychological treatments for posttraumatic stress disorder (PTSD) do not find significant differences at posttreatment. This was the case in a recent trial examining prolonged exposure (PE) and virtual reality exposure (VRE) among active-duty soldiers with combat-related PTSD. Matching individual patients to specific treatments provides a potential avenue to improve significantly the public health impact of effective treatments for PTSD. A composite moderator approach was used to identify profiles of patients who would see superior PTSD symptom reduction in VRE or PE to inform future treatment matching., Methods: Active duty U.S. army soldiers (N = 108) were enrolled in a randomized clinical trial comparing VRE and PE in the treatment of PTSD stemming from deployments to Iraq or Afghanistan. Eighteen baseline variables were examined to identify treatment response heterogeneity in two patient groups: those with a superior response to PE and those with a superior response to VRE. The final composite moderator comprised four of 18 baseline variables., Results: Results revealed that patients who were predicted to see greater PTSD symptom reduction in VRE were likely to be younger, not taking antidepressant medication, had greater PTSD hyperarousal symptoms, and were more likely to have greater than minimal suicide risk., Conclusions: Results suggest that treatment matching based on patient profiles could meaningfully improve treatment efficacy for combat-related PTSD. Future research can build on these results to improve our understanding of how to improve treatment matching for PTSD., (© 2018 Wiley Periodicals, Inc.)

Background: When a memory is recalled, it may again exist in a labile state and stored information becomes amenable to change, a psychobiological process known as reconsolidation. Exposure therapy for anxiety disorders involves accessing a fear memory and modifying it with less fearful information. A preclinical study reported that providing a reminder of a fear memory 10 min prior to extinction training in humans decreased fear up to 1 year later (Schiller et al., 2010)., Methods: For this pilot clinical study, we used virtual reality exposure therapy (VRE) for fear of flying (FoF) to determine if using a cue to reactivate the memory of the feared stimulus 10 min prior to exposure sessions leads to fewer anxiety-related behaviors and a more durable response compared to a neutral cue. FoF participants (N = 89) received four sessions of anxiety management training followed by four sessions of VRE. Participants were randomly assigned to receive an FoF cue (reactivation group) or a neutral cue (control group) prior to the VRE sessions. Heart rate (HR) and skin conductance levels (SCLs) were collected during posttreatment and 3-month follow-up assessments as objective markers of fear responding., Results: Treatment was effective and all clinical measures improved equally between groups at posttreatment with maintained gains through follow-ups. Significant differences were identified with regard to HR and SCL indices., Conclusions: These results suggest that memory reactivation prior to exposure therapy did not have an impact on clinical measures but may enhance the effect of exposure therapy at the physiological level., (© 2017 Wiley Periodicals, Inc.)

Background: Increased psychophysiological reactivity is a hallmark intermediate phenotype of posttraumatic stress disorder (PTSD). Individuals with PTSD exhibit greater skin conductance (SC) responses to trauma scripts than trauma survivors without PTSD. However, trauma scripts require time for development and cannot be easily used in a single visit. Thus, there is a need for a low-cost, easy-to-use, SC recording protocol for PTSD assessment., Methods: Using a mobile device (eSense) connected to a portable tablet computer, we assessed SC reactivity to a standard trauma interview (STI) in 63 participants recruited from Grady Memorial Hospital in Atlanta, GA, approximately 1 year after trauma exposure. SC response (SCR) was calculated by subtracting the SC level (SCL) at the end of the baseline recording from the maximum SCL during the STI., Results: SCL was significantly higher during the STI compared to baseline (P < .001), and individuals with PTSD showed significantly greater SCR than individuals without PTSD (P = .006). Logistic regression using SCR with PTSD diagnosis as the outcome showed an odds ratio of 1.76 (95% CI: 1.11-2.78). Lastly, higher SCR during the STI was also significantly associated with PTSD symptom total score controlling for demographics and trauma severity (b = 0.42, P = .001)., Conclusions: The current study demonstrated feasibility of the use of a mobile device for assessing psychophysiological reactivity in those with PTSD. The use of this low-cost, easy-to-use mobile device to collect objective physiological data in concert with a STI can be easily disseminated in clinical and research settings., (© 2017 Wiley Periodicals, Inc.)

According to current treatment guidelines for Complex PTSD (cPTSD), psychotherapy for adults with cPTSD should start with a "stabilization phase." This phase, focusing on teaching self-regulation strategies, was designed to ensure that an individual would be better able to tolerate trauma-focused treatment. The purpose of this paper is to critically evaluate the research underlying these treatment guidelines for cPTSD, and to specifically address the question as to whether a phase-based approach is needed. As reviewed in this paper, the research supporting the need for phase-based treatment for individuals with cPTSD is methodologically limited. Further, there is no rigorous research to support the views that: (1) a phase-based approach is necessary for positive treatment outcomes for adults with cPTSD, (2) front-line trauma-focused treatments have unacceptable risks or that adults with cPTSD do not respond to them, and (3) adults with cPTSD profit significantly more from trauma-focused treatments when preceded by a stabilization phase. The current treatment guidelines for cPTSD may therefore be too conservative, risking that patients are denied or delayed in receiving conventional evidence-based treatments from which they might profit., (© 2016 Wiley Periodicals, Inc.)

Background: Outcome expectancy, or the degree to which a client believes that therapy will result in improvement, is related to improved treatment outcomes for multiple disorders. There is a paucity of research investigating this relation in regards to posttraumatic stress disorder (PTSD). Additionally, the bulk of the research on outcome expectancy and treatment outcomes has relied mostly on self-report outcome measures., Methods: The relation between outcome expectancy on self-report measures, clinician-rated measures, and two biological indices (fear-potentiated startle and cortisol reactivity) of PTSD symptoms was explored. The sample included combat veterans (N = 116) treated with virtual reality exposure therapy for PTSD., Results: Results supported a negative association between outcome expectancy and both self-report and clinician-rated symptoms at the conclusion of treatment, but outcome expectancy was related to the magnitude of change during treatment for self-report measures only. Outcome expectancy was unrelated to biological measures of treatment response., Conclusions: These findings suggest that outcome expectancy may be related to patient and clinician perceptions of outcomes, but not biological indices of outcome for PTSD., (© 2015 Wiley Periodicals, Inc.)

Background: Understanding cognitive and biological mechanisms of PTSD treatment can help refine treatments and increase rates of response., Methods: Thirty-six veterans with PTSD were randomly assigned to receive Prolonged exposure therapy (PE) or Present-Centered therapy (PCT). We examined symptoms, trauma-related cognitions, and two indices of HPA axis function (cortisol awakening response and cortisol response to a script-driven imagery task)., Results: Thirty veterans started treatment and 26 completed. PE resulted in significantly more symptom reduction than PCT (P = .008). High treatment responders collapsed across treatments showed nominally higher cortisol levels measured at pretreatment 30 min after trauma script exposure compared to low responders (P = .08). At midtreatment, high treatment responders showed higher cortisol levels throughout the imagery task (Ps = .03-.04). There were no differences between high and low treatment responders at posttreatment. Thoughts of incompetence (F (1.6, 35.8) = 16.8, P = .000) and a dangerous world (F (1.3, 29.9) = 8.2, P = .004) significantly improved over time in high treatment responders but showed no change in low responders. Script-associated cortisol response prior to treatment and reductions in thoughts of incompetence accounted for 83% of the variance in reductions in PTSD severity with PE., Conclusions: Both increased cortisol response to personal trauma script prior to PTSD therapy and reductions in cognitive symptoms of PTSD were significantly and uniquely related to reductions in the core symptoms of PTSD in PE. However, contrary to our hypotheses, cortisol measures were not related to cognitive changes., (© 2014 Wiley Periodicals, Inc.)

Background: Prolonged Exposure (PE) therapy is an efficacious treatment for PTSD; despite this, many clinicians do not utilize it due to concerns it could cause patient decompensation., Method: Data were pooled from four published well-controlled studies of female assault survivors with chronic PTSD (n = 361) who were randomly assigned to PE, waitlist (WL), or another psychotherapy, including cognitive processing therapy (CPT), Eye Movement and Desensitization Reprocessing (EMDR), or the combination of PE plus stress inoculation training (SIT) or PE plus cognitive restructuring. PTSD and depression severity scores were converted to categorical outcomes to evaluate the proportion of participants who showed reliable symptom change (both reliable worsening and reliable improvement)., Results: The majority of participants completing one of the active treatments showed reliable improvement on both PTSD and depression compared to WL. Among treatment participants in general, as well as those who received PE, reliable PTSD worsening was nonexistent and the rate of reliable worsening of depression was low. There were no differences on any outcome measures among treatments. By comparison, participants in WL had higher rates of reliable symptom worsening for both PTSD and depression. Potential alternative explanations were also evaluated., Conclusions: PE and a number of other empirically supported therapies are efficacious and safe treatments for PTSD, reducing the frequency of which symptom worsening occurs in the absence of treatment., (© 2013 Wiley Periodicals, Inc.)

The high prevalence of trauma exposure and subsequent negative consequences for both survivors and society as a whole emphasize the need for secondary prevention of posttraumatic stress disorder. However, clinicians and relief workers remain limited in their ability to intervene effectively in the aftermath of trauma and alleviate traumatic stress reactions that can lead to chronic PTSD. The scientific literature on early intervention for PTSD is reviewed, including early studies on psychological debriefing, pharmacological, and psychosocial interventions aimed at preventing chronic PTSD. Studies on fear extinction and memory consolidation are discussed in relation to PTSD prevention and the potential importance of immediate versus delayed intervention approaches and genetic predictors are briefly reviewed. Preliminary results from a modified prolonged exposure intervention applied within hours of trauma exposure in an emergency room setting are discussed, along with considerations related to intervention reach and overall population impact. Suggestions for future research are included. Prevention of PTSD, although currently not yet a reality, remains an exciting and hopeful possibility with current research approaches translating work from the laboratory to the clinic., (© 2012 Wiley Periodicals, Inc.)

Background: Findings regarding the relationship between patient treatment preference and treatment outcome are mixed. This is a secondary data analysis investigating the relationship between treatment preference, and symptom outcome and attrition in a large two-phase depression treatment trial., Methods: Patients met DSM-IV criteria for chronic forms of depression. Phase I was a 12-week, nonrandomized, open-label trial in which all participants (n = 785) received antidepressant medication(s) (ADM). Phase I nonremitters were randomized to Phase II, in which they received 12 weeks of either cognitive-behavioral system of psychotherapy (CBASP) + ADM (n = 193), brief supportive psychotherapy (BSP) + ADM (n = 187), or ADM only (n = 93). Participants indicated their treatment preference (medication only, combined treatment or no preference) at study entry. Symptoms were measured at 2-week intervals with the 24-item Hamilton Rating Scale for Depression (HAM-D)., Results: A large majority of patients reported a preference for combined treatment. Patients who preferred medication only were more likely to endorse a chemical imbalance explanation for depression, whereas those desiring combined treatment were more likely to attribute their depression to stressful experiences. In Phase I, patients who expressed no treatment preference showed greater rates of HAM-D symptom reduction than those with any preference, and patients with a preference for medication showed higher attrition than those preferring combined treatment. In Phase II, baseline treatment preference was not associated with symptom reduction or attrition., Conclusions: Treatment preferences may moderate treatment response and attrition in unexpected ways. Research identifying factors associated with differing preferences may enable improved treatment retention and response., (© 2012 Wiley Periodicals, Inc.)

Background: Brief cognitive-behavioral therapy for panic disorder has the potential to lower health care costs and enhance dissemination of evidence-based interventions to clinical practice. This manuscript evaluates the utility of brief cognitive-behavioral therapy for panic disorder., Methods: A narrative review of studies examining the efficacy of cognitive-behavioral brief treatment of panic disorder, with a specific focus on an ultra-brief, 5-session, intervention developed by our group., Results: Brief cognitive-behavioral therapy for panic disorder is associated with clinically meaningful symptom improvement reflecting large effect sizes, comparable to those observed for standard protocols., Conclusions: Growing evidence encourages the further evaluation and application brief cognitive-behavioral therapy for panic disorder. Controlled trials of cognitive-behavioral therapy have established the dramatic benefit that can be offered by brief treatment (often 12-15 sessions) approaches for Axis I disorders. Yet, as the field advances and core mechanisms of change are identified, there is the potential for offering efficacy in even briefer treatment protocols. In this manuscript, we describe the elements and initial efficacy estimates, based on published studies, for an ultra-brief treatment approach for panic disorder. We also discuss the potential impact, and such brief treatment can have relative to dissemination issues and the desire for the timely end to psychological suffering., (© 2012 Wiley Periodicals, Inc.)

Background: Maintenance of gains with cognitive-behavioral treatment for trichotillomania (TTM) has historically been problematic., Methods: We conducted follow-up assessments 3 and 6 months after completion of a 3-month maintenance phase on 10 individuals with DSM-IV-TR TTM who participated in an open trial of a dialectical behavior therapy (DBT)-enhanced habit reversal treatment (HRT)., Results: Significant improvement from baseline was reported at 3-and 6-month follow-up on all measures of hair pulling severity and emotion regulation, although some worsening was reported on some measures from earlier study time points. At 6-month follow-up, five and four participants were full and partial responders, respectively. Significant correlations were reported at both follow-up time points between changes in hair pulling severity and emotion regulation capacity., Conclusions: DBT-enhanced HRT offers promise for improved long-term treatment results in TTM. Changes in TTM severity from baseline to 3-and 6-month follow-up is correlated with changes in emotion regulation capacity., (© 2010 Wiley-Liss, Inc.)

Background: Not all hair pullers improve acutely with cognitive-behavioral treatment (CBT) and few maintain their gains over time., Methods: We conducted an open clinical trial of a new treatment that addresses affectively triggered pulling and emphasizes relapse prevention in addition to standard CBT approaches. Ten female participants satisfying DSM-IV criteria for trichotillomania (TTM) at two study sites received Dialectical Behavior Therapy (DBT)-enhanced CBT consisting of 11 weekly sessions and 4 maintenance sessions over the following 3 months. Independent assessors rated hair pulling impairment and global improvement at several study time points. Participants completed self-report measures of hair pulling severity and emotion regulation., Results: Significant improvement in hair pulling severity and emotion regulation, as well as hair pulling impairment and anxiety and depressive symptoms, occurred during acute treatment and were maintained during the subsequent 3 months. Significant correlations were reported between changes in emotion regulation and hair pulling severity during both the acute treatment and maintenance phases., Conclusions: This study offers preliminary evidence for the efficacy of DBT-enhanced CBT for TTM and suggests the importance of addressing emotion regulation during TTM treatment., (Depression and Anxiety, 2010. © 2010 Wiley-Liss, Inc.)

Background: There is growing evidence suggesting that early adversity may be a marker for a distinct pathway to major depressive disorder (MDD). We examined associations between childhood adversity and a broad variety of clinical characteristics and response to pharmacotherapy in a large sample of patients with chronic forms of MDD., Methods: Subjects included 808 patients with chronic forms of MDD (chronic MDD, double depression, or recurrent MDD with incomplete recovery between episodes and a total continuous duration of >2 years) who were enrolled in a 12-week open-label trial of algorithm-guided pharmacotherapy. Baseline assessments included a semi-structured diagnostic interview, and clinician- and self-rated measures of depressive symptoms, social functioning, depressotypic cognitions, and personality traits, and childhood adversity. Patients were re-evaluated every 2 weeks., Results: A longer duration of illness; earlier onset; greater number of episodes, symptom severity, self-rated functional impairment, suicidality, and comorbid anxiety disorder; and higher levels of dysfunctional attitudes and self-criticism were each associated with multiple forms of childhood adversity. A history of maternal overcontrol, paternal abuse, paternal indifference, sexual abuse, and an index of clinically significant abuse each predicted a lower probability of remission. Among patients completing the 12-week trial, 32% with a history of clinically significant abuse, compared to 44% without such a history, achieved remission., Conclusions: These findings indicate that a history of childhood adversity is associated with an especially chronic form of MDD that is less responsive to antidepressant pharmacotherapy., ((c) 2009 Wiley-Liss, Inc.)

The Anxiety Disorders Association of America convened a conference of experts to address treatment-resistant anxiety disorders and review promising novel approaches to the treatment of refractory anxiety disorders. Workgroup leaders and other participants reviewed the literature and considered the presentations and discussions from the conference. Authors placed the emerging literature on new therapeutic approaches into clinical perspective and identified unmet needs and priority areas for future research. There is a relative paucity of efforts addressing inadequate response to anxiety disorder treatment. Systematic efforts to exhaust all therapeutic options and overcome barriers to effective treatment delivery are needed before patients can be considered treatment refractory. Cognitive behavioral therapy, especially in combination with pharmacotherapy, must be tailored to accommodate the effects of clinical context on treatment response. The literature on pharmacologic treatment of refractory anxiety disorders is small but growing and includes studies of augmentation strategies and non-traditional anxiolytics. Research efforts to discover new pharmacologic targets are focusing on neuronal systems that mediate responses to stress and fear. A number of clinical and basic science studies were proposed that would advance the research agenda and improve treatment of patients with anxiety disorders. Significant advances have been made in the development of psychotherapeutic and pharmacologic treatments for anxiety disorders. Unfortunately, many patients remain symptomatic and functionally impaired. Progress in the development of new treatments has great promise, but will only succeed through a concerted research effort that systematically evaluates potential areas of importance and properly uses scarce resources.

This study used an open clinical trial to test a cognitive-behavioral treatment for public-speaking anxiety that utilized virtual reality as a tool for exposure therapy. Treatment was completed by participants (n = 10) meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria for social phobia, or panic disorder with agoraphobia in which public speaking was the predominantly feared stimulus. Treatment was conducted by a licensed psychologist in an outpatient clinic. Treatment consisted of eight individual therapy sessions, including four sessions of anxiety management training and four sessions of exposure therapy using a virtual audience, according to a standardized treatment manual. Participants completed standardized self-report questionnaires assessing public-speaking anxiety at pre-treatment, post-treatment, and 3-month follow-up. Participants were asked to give a speech to an actual audience at pre- and post-treatment. Results showed decreases on all self-report measures of public-speaking anxiety from pre- to post-treatment, which were maintained at follow-up (n = 8; all P = 05). Participants were no more likely to complete a speech post-treatment than at pre-treatment. This study provides preliminary evidence that a cognitive-behavioral treatment using virtual reality for exposure to public speaking may reduce public-speaking anxiety and suggests that further research with a controlled design is needed., (Copyright 2005 Wiley-Liss, Inc.)