Development and testing of virtual reality exposure therapy for post-traumatic stress disorder in active duty service members who served in Iraq and Afghanistan.

Abstract

This study was an open-label, single-group, treatment-development project aimed at developing and testing a method for applying virtual reality exposure therapy (VRET) to active duty service members diagnosed with combat post-traumatic stress disorder (PTSD). Forty-two service members with PTSD were enrolled, and 20 participants completed treatment. The PTSD Checklist-Military version, Patient Health Questionnaire-9 for depression, and the Beck Anxiety Inventory were used as outcome measures. Of those who completed post-treatment assessment, 75% had experienced at least a 50% reduction in PTSD symptoms and no longer met DSM-IV criteria for PTSD at post treatment. Average PSTD scores decreased by 50.4%, depression scores by 46.6%, and anxiety scores by 36%. Intention-to-treat analyses showed that statistically significant improvements in PTSD, depression, and anxiety occurred over the course of treatment and were maintained at follow up. There were no adverse events associated with VRET treatment. This study provides preliminary support for the use of VRET in combat-related PTSD. Further study will be needed to determine the wider utility of the method and to determine if it offers advantages over other established PTSD treatment modalities.

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VR PTSD Exposure Therapy
Results with Active Duty OIF/OEF
Combatants
Albert A. RIZZO1, JoAnn DIFEDE2, Barbara O. ROTHBAUM3, Scott
JOHNSTON4, Robert N. McLAY4, Greg REGER5, Greg GAHM5,
Thomas PARSONS1, Ken GRAAP , and Jarrell PAIR1
1University of Southern California - Institute for Creative Technologies; 2Weill
Cornell Medical College; 3Emory University; 4Naval Medical Center - San Diego;
5Madigan Army Medical Center Army; 6Virtually Better Inc.
Contact Author (Rizzo): arizzo@usc.edu
Abstract. Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic
events that are outside the range of usual human experience including military combat,
violent personal assault, being kidnapped or taken hostage and terrorist attacks. Reports
indicate that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression,
anxiety and PTSD. Virtual Reality exposure therapy has been previously used for PTSD
with reports of positive outcomes. This paper will present a brief description of the
USC/ICT Virtual Iraq/Afghanistan PTSD therapy application and present clinical
outcome data from active duty patients treated at the Naval Medical Center-San Diego
(NMCSD) as of October 2009. Initial outcomes from the first twenty patients to complete
treatment indicate that 16 no longer meet diagnostic criteria for PTSD at post treatment.
Research and clinical tests using the Virtual Iraq/Afghanistan software are also currently
underway at Weill Cornell Medical College, Emory University, Fort Lewis and WRAMC
along with 20 other test sites.
Keywords. PTSD, Virtual Reality, Exposure Therapy
Introduction
War is perhaps one of the most challenging situations that a human being can
experience. The physical, emotional, cognitive and psychological demands of a combat
environment place enormous stress on even the best-prepared military personnel. Such
stressful experiences that commonly occur in combat environments have a considerable
likelihood for producing significant numbers of returning soldiers at risk for developing
PTSD. The data coming from both survey studies and anecdotal observations indicate
that a large number of returning military personnel from the Iraq/Afghanistan conflicts
are reporting symptoms that are congruent with the diagnosis of PTSD [1-3].
Among the many approaches that have been used to treat PTSD, cognitive-
behavioral treatment (CBT) with Prolonged Exposure (PE) appears to have the best-
documented therapeutic efficacy [4-5]. PE is a form of individual psychotherapy based
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IOS Press, 2009
© 2009 The authors. All rights reserved.
doi:10.3233/978-1-58603-964-6-277
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on Foa and Kozak’s [6] emotional processing theory, which posits that PTSD involves
pathological fear structures that are activated when information represented in the
structures is encountered. These fear structures are composed of harmless stimuli that
have been associated with danger and are reflected in the belief that the world is a
dangerous place. Successful treatment requires emotional processing of the fear
structures in order to modify their pathological elements so that the stimuli no longer
invoke fear. Imaginal exposure entails engaging mentally with the fear structure
through repeatedly revisiting the traumatic event in a safe environment. In practice, a
person with PTSD typically is guided and encouraged by the clinician gradually to
imagine, narrate and emotionally process the traumatic event within the safe and
supportive environment of the clinician’s office. This approach is believed to provide a
low-threat context where the patient can begin to therapeutically process the emotions
that are relevant to the traumatic event as well as de-condition the learning cycle of the
disorder via a habituation/extinction process. Expert treatment guidelines for PTSD
published for the first time in 1999 recommended that CBT with PE should be the first-
line therapy for PTSD [4]. The comparative empirical support for exposure therapy was
also recently documented in a review by the Institute of Medicine at the National
Academies of Science of 53 studies of pharmaceuticals and 37 studies of
psychotherapies used in PTSD treatment [5]. The report concluded that while there is
not enough reliable evidence to draw conclusions about the effectiveness of most
PTSD treatments, there is sufficient evidence to conclude that exposure therapies are
effective in treating people with PTSD.
While the efficacy of imaginal PE has been established in multiple studies with
diverse trauma populations, many patients are unwilling or unable to effectively
visualize the traumatic event. This is a crucial concern since avoidance of cues and
reminders of the trauma is one of the cardinal symptoms of the DSM diagnosis of
PTSD. In fact, research on this aspect of PTSD treatment suggests that the inability to
emotionally engage (in imagination) is a predictor for negative treatment outcomes [7].
To address this problem, researchers have recently turned to the use of Virtual Reality
(VR) to deliver exposure therapy (VRET) by immersing clients in simulations of
trauma-relevant environments in which the emotional intensity of the scenes can be
precisely controlled by the clinician. In this fashion, VRET offers a way to circumvent
the natural avoidance tendency by directly delivering multi-sensory and context-
relevant cues that evoke the trauma without demanding that the patient actively try to
access his/her experience through effortful memory retrieval. Within a VR environment,
the hidden world of the patient’s imagination is not exclusively relied upon and VRET
may also offer an appealing, non-traditional treatment approach that is perceived with
less stigma by “digital generation” service members and veterans who may be reluctant
to seek out what they perceive as traditional talk therapies. Previous successful research
applying VRET for the treatment of PTSD has been detailed elsewhere [10-11].
1. Brief Virtual Iraq System Description
With this history in mind, the USC Institute for Creative Technologies (ICT) has
created an immersive virtual reality system for exposure therapy with combat-related
PTSD. The treatment environment is based on a creative approach to recycling virtual
assets that were initially built for the commercially successful X-Box game and tactical
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training simulation scenario, Full Spectrum Warrior. As well, other existing and newly
created assets available to ICT have been integrated into this rapidly evolving
application. The Virtual Iraq application (and the new Virtual Afghanistan scenario)
consists of a series of virtual scenarios designed to represent relevant contexts for VR
exposure therapy, including middle-eastern themed city and desert road environments
(See Figures 1-2). In addition to the visual stimuli presented in the VR HMD,
directional 3D audio, vibrotactile and olfactory stimuli of relevance can be delivered.
The presentation of additive, combat-relevant stimuli in the VR scenarios can be
controlled by a therapist via a separate “wizard of oz” Clinical Interface (Figure 3),
while in full audio contact with the patient. The clinical interface is a key feature in that
it provides a clinician with the capacity to customize the therapy experience to the
individual needs of the patient. The clinician can place the patient in VR scenario
locations that resemble the setting in which the traumatic events initially occurred and
can gradually introduce and control real time “trigger” stimuli (visual, auditory,
olfactory and tactile) as is required to foster the anxiety modulation needed for
therapeutic habituation. More system details can be found in Rizzo et al. [12].
Figure 1. Virtual Iraq City
Figure 2. Virtual Afghan Roadway Figure 3. Clinician Interface
2. Results
2.1. Initial Assessment of Service Member (SMs) Acceptance of VR in Treatment
User-centered design feedback needed to iteratively evolve the system was gathered
from a system deployed in Iraq with an Army Combat Stress Control Team and from
returning Iraq War veterans in the USA. The user-centered results indicated that Virtual
Iraq was capable of producing the level of “presence” in Iraq-experienced SMs that
was believed to be required for exposure therapy. However, successful clinical
implementation also requires patients to accept the approach as a useful and credible
behavioral health treatment. To address this issue, a survey study with 325 Army
Service Members (SMs) from the Madigan Army Medical Center/Fort Lewis
deployment screening clinic was conducted to assess knowledge of current
technologies and attitudes towards the use of technology in behavioral healthcare [13].
One section of the survey asked these active duty SMs to rate on a 5-point scale how
willing they would be to receive mental health treatment (“Not Willing at All” to “Very
Willing”) via traditional approaches (e.g. face-to-face counseling) and a variety of
technology-oriented delivery methods (e.g. website, video teleconferencing, use of VR).
Eighty-three percent of participants reported that they were neutral-to-very willing to
use some form of technology as part of their behavioral healthcare, with 58% reporting
some willingness to use a VR treatment program. Seventy-one percent of SMs were
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equally or more willing to use some form of technological treatment than solely talking
to a therapist in a traditional setting. Most interesting is that 20% of SMs who stated
they were not willing to seek traditional psychotherapy, rated their willingness to use a
VR-based treatment as neutral to very willing. One possible interpretation of this
finding is that a subgroup of this sample of SMs with a significant disinterest in
traditional mental health treatment would be willing to pursue treatment with a VR-
based approach. It is also possible that these findings generalize to SMs who have
disengaged from or terminated traditional treatment.
2.2. Results from a Clinical Trial using Virtual Iraq at the NMCSD/Camp Pendleton
The Virtual Iraq/Afghanistan system built from this user-centered design process has
been tested in an open clinical trial with PTSD-diagnosed active duty SMs at NMCSD
and Camp Pendleton. The Office of Naval Research funded the initial system
development of Virtual Iraq along with this initial trial to evaluate the feasibility of
using VRET with active duty participants. The participants were SMs who recently
redeployed from Iraq and who had engaged in previous PTSD treatments (e.g., group
counseling, SSRIs, etc.) without benefit. The standard treatment protocol consisted of
2X weekly, 90-120 minute sessions over five weeks that also included physiological
monitoring (HR, GSR and respiration) as part of the data collection. However, in this
open clinical trial, elements of the protocol were occasionally modified (i.e., adjusting
the number and timing of sessions) to meet patients’ needs and thus these data
represent an uncontrolled feasibility trial. The VRET exposure exercises followed the
principles of graded prolonged behavioral exposure and the pace was individualized
and patient-driven. The first VRET session consisted of a clinical interview that
identified the index trauma, provided psychoeducation on trauma and PTSD, and
instruction on a deep breathing technique for general stress management purposes. The
second session provided instruction on the use of Subjective Units of Distress (SUDS),
the rationale for prolonged exposure (PE), including imaginal exposure and in-vivo
exposure. The participants also engaged in their first experience of imaginal exposure
of the index trauma and an in-vivo hierarchical exposure list was constructed, with the
first item assigned as homework. Session three introduced the rationale for VRET and
the participant experienced the VR environment without recounting the index trauma
narrative for approximately 25 minutes with no provocative trigger stimuli introduced.
Sessions four through ten focused on the participant engaging in the VR while
recounting the trauma narrative. Generally, participants were instructed that they would
be asked to recount their trauma in the first person, as if it were happening again with
as much attention to sensory detail as they could provide. Using clinical judgment, the
therapist might prompt the patient with questions about their experience or provide
encouraging remarks as deemed necessary to facilitate the recounting of the trauma
narrative. The treatment included homework, such as requesting the participant to listen
to the audiotape of their exposure narrative from the most recent session as a form of
continual exposure for processing the index trauma to further enhance the probability
for habituation to occur. Self-report measures were obtained at baseline and prior to
sessions 3,5,7,9,10 and one week and three months post treatment to assess in-
treatment and follow-up symptom status. The measures used were the PTSD Checklist-
Military Version (PCL-M) [14], Beck Anxiety Inventory (BAI) [15] and Patient Health
Questionnaire-Depression (PHQ-9) [16].
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Initial analyses of results from the first 20 Virtual Iraq treatment completers (19
male, 1 female, Mean Age=28, Age Range: 21-51) have indicated positive clinical
outcomes. For this sample, mean pre/post PCL-M scores decreased in a statistical and
clinically meaningful fashion; Mean (standard deviation) values went from 54.4 (9.7)
to 35.6 (17.4). Paired pre/post t-test analysis showed these differences to be significant
(t=5.99, df=19, p < .001). Correcting for the PCL-M no-symptom baseline of 17
indicated a greater than 50% decrease in symptoms and 16 of the 20 completers no
longer met DSM criteria for PTSD at post treatment. Five participants in this group
with PTSD diagnoses had pre-treatment baseline scores below the conservative cutoff
value of 50 (prescores= 49, 46, 42, 36, 38) and reported decreased values at post
treatment (postscores= 23, 19, 22, 22, 24, respectively). Individual participant PCL-M
scores at baseline, post treatment and 3-month follow-up are in Figure 4. For this same
group, mean Beck Anxiety Inventory scores significantly decreased 33% from 18.6
(9.5) to 11.9 (13.6), (t=3.37, df=19, p < .003) and mean PHQ-9 (depression) scores
decreased 49% from 13.3 (5.4) to 7.1 (6.7), (t=3.68, df=19, p < 0.002) (see Figure 5).
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Figure 4. PTSD Checklist scores across treatment Figure 5. BAI and PHQ-Depression scores
The average number of sessions for this sample was just under 11. Also, two of the
successful treatment completers had documented mild and moderate traumatic brain
injuries, which suggest that this form of exposure can be usefully applied with this
population. In spite of these initial positive results for treatment completers, challenges
existed with dropouts from this active duty sample. Seven participants who were
assessed and approved for the study failed to appear at the first session, six attended the
first session and dropped out prior to formal commencement of VRET at session four,
and seven dropped out at various points following session four. While some of these
active duty participants left due to transfers and other reasons beyond their control,
these dropout numbers are concerning and we intend to examine all data gathered from
this subset of the total sample to search for discriminating factors.
3. Conclusions
The positive clinical outcomes observed from our initial 20 treatment completers are
encouraging, although we are cautious not to make excessive claims based on these
early results. At the current time we are continuing to gather data and feedback from
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patients regarding the therapy and the Virtual Iraq/Afghanistan environment in order to
continue our iterative system development process. And in fact, we recently released an
updated version of the system in October 2008 with added functionality that has its
design “roots” from feedback acquired from these initial patients and the therapists
who have used the system thus far. It should also be noted that this project is currently
in an open clinical trial phase. As such, we intend to use such initial results to develop,
explore and test hypotheses as to how we can improve assessment, treatment, and most
importantly, determine what patient characteristics may predict who will benefit from
VR exposure therapy and who may be best served by other approaches. Other clinical
trials are currently underway at Ft. Lewis, Emory University, Weill Cornell Medical
College, Walter Reed Army Medical Center and 20 other sites to assess this approach.
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