(Two of the three computer systems, with HMD and headphones, utilized by VRMC with various VR research and clinical projects.)
Click here to see how Dr. Wood answered these questions:
- 1) Dr. Wood, what key advances in your research will you be presenting at this year’s meeting?
- 2) Your therapy appears to focus on immersing patients in a simulated war environment. How does this immersive experience reduce depression and PTSD? Is there a possibility the patient’s condition could be worsened by immersion?
- 3) Please tell us some details about the VRGET therapy.
- 4) Do you use any kind of web 2.0 tools in your research (e.g. blogs, wikis, social bookmarking, etc.)?
- 5) At MMVR17, will you demonstrate how your virtual reality system actually works?
- 6) What developments do you predict will be most noteworthy in the future of the gaming/simulation industry/technology?
1. Concerning the key advances I will be presenting during MMVR17:
More recently, the percentage of Army and Marine Corps personnel, who participated in combat during Operation Iraqi Freedom or Operation Enduring Freedom between March and October 2003, who met screening criteria for major depression, generalized anxiety disorder or PTSD, ranged from 11.2% to 17.1%. Grieger et al reported that 12% of U.S. soldiers, hospitalized followings serious combat injury in Iraq, were diagnosed with PTSD at 7 months following hospitalization. DOD officials have also expected that the PTSD rates will be higher among troops who have been to Iraq more than once.
Research has suggested that virtual reality exposure (VRE) therapy as a new and effective medium of exposure therapy for treating veterans with PTSD. Walshe et al have reported on the successful use of Virtual Reality to treat Driving Phobia and PTSD in individuals who had experienced a motor vehicle accident. The Virtual Reality Medical Center (VRMC) has developed a Virtual Reality Graded Exposure Therapy (VRGET) protocol for treating warriors diagnosed with combat-related PTSD. During MMVR15, I presented the description of the successful use of Virtual Reality Graded Exposure Therapy with a combat-wounded Navy Hospital Corpsman who developed PTSD while attached to a U.S. Marine Corps Battalion deployed to Iraq. During MMVR16, I described the successful VRGET intervention with the first six warriors, diagnosed with combat-related PTSD, enrolled in the VRMC/ONR funded project at Naval Medical Center San Diego (NMCSD). During MMVR17, I will report on the treatment outcome of the first eight volunteers, randomized to VRGET, who were participants in the VRMC/ONR funded study.
Eight male volunteers, with the DSM-IV criteria for Chronic PTSD, met the study requirements for participation, and following randomization to VRGET, initiated VR Therapy. These participants were all members of the United States Navy or the United States Marine Corps. These eight participants were originally diagnosed with PTSD between January 2004 and July 2008; all of our participants initiated VRGET since August 2007. As part of the treatment VRGET protocol, treatment was delivered in 10, 100 minute sessions conducted weekly by one of the authors (DPW). The VRGET system relied on a combined visual and auditory presentation. The participants “walked” in the virtual environment or “drove” a Humvee in the environment by pushing buttons on the hand-held joy-stick. The participants “fired” an M-16 rifle or 50 caliber machine gun by depressing another button on the joy-stick. The clinician-rated and self-report measures were taken and full assessments were conducted at pre-treatment, post-treatment (following 10 sessions of treatment) and three months following the conclusion of treatment. During the treatment sessions, the patient utilized a Head-Display-Monitor (HMD) and headphones. Additionally, the participants’ psychophysioloigcal measurements (i.e., heart rate, breaths per minute, skin conductance and peripheral temperature) were taken during each treatment session and also pre-treatment, post-treatment and during the three month post treatment assessment. During each assessment period, the participants’ psychophysioloigcal measures were assessed at baseline, during a recall stressor, and during recovery from the recall stressor.
My presentation will review not only the protocol utilized to treat combat-related PTSD with Virtual Reality Graded Exposure Therapy (VRGET), but also my presentation will review the treatment outcome results for the first eight participants in our randomized treatment group. I will also discuss recommendations for the future VRGET treatment of combat-personnel diagnosed with PTSD. Additionally, my presentation will demonstrate VRMC’s Virtual Reality treatment system involving three computers, one that displays the visual and auditory displays to the patient trough Virtual Reality Goggles with built-in headphones, a second system which has the control panel and menu which therapist can use to add arousing elements into the Virtual Reality environment (e.g., various combat events and background sounds, weather, and time of day), and the third computer which is utilized to track and record the biofeedback data (i.e., heart rate, breaths per minute, skin conductance and peripheral temperature) of our participants.
2. Your therapy appears to focus on immersing patients in a simulated war environment. How does this immersive experience reduce depression and PTSD? Is there a possibility the patient’s condition could be worsened by immersion?
The VR treatment used by VRMC at NMCSD and NHCP is multi-faceted, drawing upon the principles of cognitive behavioral and experiential therapies. In contrast to flooding type exposure therapy which attempts to extinguish conditioned reactions, VRGET trains patients to control their physical arousal and attentional focus in order to tolerate exposure to a wide range of cues (i.e., combat, gun fire, being wounded, sounds of helicopters, vehicle sounds, explosions, etc). This approach is based upon the interactive nature of VR. Research, conducted at VRMC, has documented that the more interactive the VR environment, the better the immersion and therapeutic results (i.e., reduction in PTSD symptoms and symptoms of depression). Optimally, the patient will be given a joystick to navigate through the VR environment. This gives the patient a measure of control, but also increases the immersive quality of the VR environment. Immersion represents one more level of arousal that can be utilized by the therapist, when needed, to assist the patient in directly confronting and gradually making sense out of, in the VR world, those stimuli/memories/recollections/intrusive thoughts/nightmares that have continued to energize their feeling of being out of control, avoidant, excessively startled, excessively anxious, irritable and hopeless.
Using virtual reality assisted exposure therapy has been demonstrated to be an effective means of delivering exposure therapy in treating phobias and PTSD. The use of in virtuo-physiologically-facilitated graded exposure therapy in combat PTSD has only recently begun to be studied in a randomized controlled design at NMCSD and Navy Hospital Camp Pendleton (NHCP).
Due to the emphasis on personal control and skill development, with the warriors in VRGET, we, at VRMC, believe that VRGET will be optimal for those suffering from acute or chronic combat-related PTSD. For instance, the warriors in treatment can end a VR session by simply removing their HMD and/or informing the therapist that, “the hop is over” and the session immediately terminates. Alternatively, by the therapist “keeping a eye” on the warrior’s breaths per minute (BPM) and heart rate (HR), the therapist can assess the level of arousal being experienced by the warrior and guide the VR session appropriately, or terminate the session, to gain the most therapeutic value. We, at VRMC, also believe, that the VRGET approach will greatly assist our warriors in treatment to better generalize their VR learning to a wider range of symptoms and situations and experience the best likelihood of a long-term benefit for VRGET.
Of note, with any therapeutic technique or intervention, there is always the possibility that the patient’s condition can be worsened. However, through the development of the therapeutic relationship between the patient and the therapist and relying on the therapist’s skill level with VRGET in particular and traditional psychotherapy in general, this risk can be appropriately modulated.
(A Screenshot of what the VRGET treated warrior would be viewing through their HMD during treatment.)
3. Please tell us some details about the VRGET therapy.
For details describing VRGET, the reader is referred to our article, published in the MMVR16 Proceedings, titled “Combat Related Post Traumatic Stress Disorder: A Multiple Case Report Using virtual Reality Graded Exposure Therapy with Physiological Monitoring”, pp. 556 – 561. Also, the reader is referred to the Virtual Reality Medical Center web page for these details (www.vrphobia.com).
4. Do you use any kind of web 2.0 tools in your research (e.g., blogs, wikis, social bookmarking, etc.)?
No, not at this time.
5. At MMVR17, will you demonstrate how your virtual reality system actually works?
I have been asked by Jim Westwood to demo our VRGET system and I and VRMC have agreed. The date, time and place of this VRGET demo have not yet been determined.
6. What developments do you predict will be most noteworthy in the future of the gaming/simulation industry/technology?
In terms of the research being conducted at VRMC with VR for treating PTSD and other anxiety disorders, chronic pain and ADHD and also utilizing VRGET with various types of rehabilitation, including rehabilitation secondary to stroke and TBI, I would look to the day when VRGET has demonstrated its clinical effectiveness and the VRGET technology and treatment paradigms are “in residence” at an increasing number of military and civilian medical centers and also co-located in the private offices of a wide range of practitioners. Additionally, I look forward to the day when VRGET can be a web based treatment paradigm similar to the pain management program currently being researched and utilized by Dr. Hunter Hoffman at the University of Washington. Of interest, VRMC has been working with a number of university based research programs to develop web based protocols for VRGET. Hopefully, by the time MMVR17 convenes, VRMC hopes to have information available documenting the currently status of these research and clinical endeavors.