VA partnering with DoD, NIH on trials of virtual reality therapy for PTSD From: VA Research Currents - March 2007 - page 1 First there was "Virtual Vietnam," and now there is "Middle East World." Researchers and clinicians have been using virtual reality to treat posttraumatic stress since the late 1990s, when David Ready, PhD, at the Atlanta VA and Emory University teamed with Barbara Rothbaum, PhD, and others on studies involving Vietnam veterans and software simulating the sights and sounds of Huey helicopters, mortar blasts and troops calling for help. Now, a renewed push for virtual- reality therapy, fueled by advances in 3D multisensory technology and funded by VA, the Department of Defense and the National Institutes of Health, is targeting a new population: active-duty troops or veterans who recently returned from Iraq or Afghanistan and who show symptoms of PTSD. Treating these men and women within months of their trauma - rather than some 30 years later, as in the case of the Vietnam veterans - may make a crucial difference, say psychologists. Untreated PTSD, over the years, can become "like a snowball rolling down a hill, getting bigger and bigger," notes Ready, of the Atlanta VA Trauma Recovery Team. He says early treatment may help today's new veterans "not develop some of the problems we see in Vietnam veterans who suffer from PTSD." "Early intervention is key," adds Russell Shilling, PhD, a psychologist and program officer at the Office of Naval Research who is overseeing three projects on virtual reality and PTSD. "We hope this type of therapy, with its videogame-like qualities, will resonate well with the current generation of warfighters." Jeffrey Pyne, MD, of the Little Rock VA and University of Arkansas, is participating in two of the Naval grants - one aimed at developing new virtual environments to help active-duty military members, and the other focused on using VR therapy to help non-combat personnel, such as medics and truck drivers. He is also leading a new VA-funded study that will integrate VR therapy in a larger effort to better understand the pathology and physiology of PTSD. Hawaii VA teams with DoD on trial of active-duty troops Sarah Miyahira, PhD, director of intramural research at the Pacific Telehealth and Technology Hui, part of the Honolulu-based VA Pacific Islands Health Care System, is co-principal investigator on the third Naval grant. She and partner Hunter Hoffman, PhD, of the University of Washington have launched a study that will involve 60 Army soldiers who have come back from operations OIF and OEF and are seeking treatment for PTSD. Participants will receive therapy twice a week for five weeks, and be followed up at six months and a year. According to Miyahira, the goal of the therapy is to expose patients to gradually increasing levels of stimuli that trigger memories of their traumas, while using cognitive behavioral techniques to help them modify the thoughts, feelings and behaviors linked to those events. "We use graded exposure to the scenarios to prevent the soldier from becoming emotionally overwhelmed during treatment," she says. "We begin at the lowest level of intensity - driving through a Mideast town with no incidents. We want to get a baseline of how sensitive they are to being in an environment that reminds them of Iraq. "Over the course of treatment, we gradually increase the intensity as the soldier's response to each level of anxiety-producing events decreases. You gauge how much the person can tolerate, and then you work through that till they're comfortable with the memory. Our goal is to help them overcome their trauma memories, not revitalize them." Miyahira emphasizes that administering the therapy properly requires extensive training. "It's not like you have a 'cookbook' and can just follow the directions. Even mental health providers who have solid training in treating PTSD still require extensive preparation for doing this therapy. We train our therapists in our protocol for several weeks and then have them practice for months before we actually let them go ahead and perform it on their own." Part of the required skill involves controlling the virtual environment that patients see, hear and feel. (The chair in Miyahira's clinic, like some consumer "gaming chairs," has a subwoofer that produces a rumbling sensation. Users can feel like they're riding in a Humvee, or experience a jolt when an "explosion" goes off. Newer VR software even incorporates smells associated with combat or other trauma environments.) Therapists press pre-set buttons on their keyboard to control whether or not an event occurs - such as gunfire or a blast. They can also modulate the intensity, such as by varying the sound level. Superior graphics now possible According to Ready, today's virtual reality treatments benefit from numerous advances in technology over the past decade, such as better head-mounted displays; superior graphics with more realistic "people"; and much faster refreshing rates. In the late 1990s, he said, some users would experience "simulator sickness" because of the delay between when they moved their head and when they saw something new in the environment. Miyahira points out that while VR therapy and research borrows technologically from the consumer gaming world, that's where the similarity ends. "The VR we're using is not equivalent to playing a game. We try to emphasize that to providers and to our potential participants. They're not to expect the kind of graphics or interactivity that you get when you're playing Full Spectrum Warrior or any of the other commercial games on the market. In our case, we want the therapist to have maximum control of the environment - and not have the patient wander anywhere and trigger off anything they desire, because that's not therapeutic." Treatment based on conventional exposure therapy While today's virtual reality treatments may hinge on sophisticated computer graphics and super-fast hardware, they are rooted in traditional exposure therapy, which by itself been shown as an effective cognitive behavioral therapy for PTSD. In this "lower-tech" form of exposure therapy, patients rely on their own ability to recall memories of their trauma. One limitation, however, is that patients typically want to avoid their traumatic memories. "Part of PTSD is that you want to avoid recalling things that are so distressing to you," explains Miyahira. "That's why you find high comorbidity with substance abuse - people self-medicate. In imaginal therapy, you're relying on them to be able to trigger their own memories. Sometimes those memories are distorted, or hard to get to. With virtual reality, because they're being presented with visual, audio and sometimes kinesthetic cues, the memory is easier for them to access." She adds that once patients connect with the virtual environment, they will "populate" it with people and objects relating to their own individual experiences. "Virtual reality gives us the opportunity to provide a compelling type of exposure therapy," adds Ready, whose VA site will soon be involved in a National Institute of Mental Health-funded study on using the therapy to treat Iraq veterans with PTSD, under the leadership of Emory's Rothbaum. Miyahira and her Hawaii team, besides studying the efficacy of virtual reality treatment, played an extensive role in developing the scenarios that were built into the VR software by their contractor on the project, Seattle-based Imprint Interactive Technology. "The content evolved from our consultations with returning soldiers from Iraq and Afghanistan about their experiences with high-stress, high-risk events in the combat theaters, and reviews of their personal videos and photos," says Miyahira. The researchers also obtained feedback from soldiers on a rough-cut of the simulation, and are now working on developing new scenarios to better fit troops returning from other types of missions. 'Virtual reality gives us the opportunity to provide a compelling type of exposure therapy.' Having learned lessons from the experiences of Vietnam veterans, researchers such as Miyahira and Ready and others are eager to make quick progress in establishing evidence-based treatments for this new generation of American heroes with PTSD. VA figures show that some 34,000 OIF/OEF veterans have received a possible diagnosis of PTSD. "We may find that younger veterans who have grown up with computer technology may be more willing to participate in VR treatment," notes Ready. "We may also find that due to the compelling sense of presence that VR provides, we will need fewer sessions to reduce PTSD symptoms and can efficiently treat more veterans." He acknowledges more research will be needed to answer these questions, but nevertheless asserts, "I believe the importance of VR in our arsenal of PTSD treatments will grow over time." From: http://www.research.va.gov/resources/pubs/docs/va_research_currents_mar_07.pdf Links: Treating Anxiety with Virtual Reality Exposure http://www.webmd.com/content/article/1/1700_50444.htm Barbara Rothbaum http://prod-med.emory.edu/faculty/profile_cv.cfm?id=916 A virtual cure http://www.apa.org/monitor/julaug05/cure.html Virtual war, real healing http://www.latimes.com/news/local/la-me-virtual9feb09,0,6132803.story?coll=la-home-headlines Combat trauma theater http://govhealthit.com/article97677-02-19-07-Print Hunter Hoffman http://www.hitl.washington.edu/people/hunter/