Efficacy of Virtual Reality Exposure Therapy in the Treatment of PTSD: A Systematic Review

Institute of Pschology, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
PLoS ONE (Impact Factor: 3.23). 12/2012; 7(12):e48469. DOI: 10.1371/journal.pone.0048469
Source: PubMed


The use of Information and Communication Technologies, such as virtual reality, has been employed in the treatment of anxiety disorders with the goal of augmenting exposure treatment, which is already considered to be the first-line treatment for Post-traumatic Stress Disorder (PTSD). To evaluate the efficacy of virtual reality exposure therapy (VRET) in the treatment of PTSD, we performed a systematic review of published articles using the following electronic databases: Web of Science, PubMed, PsycINFO, and PILOTS. Eligibility criteria included the use of patients diagnosed with PTSD according to DSM-IV, the use of cognitive behavioral therapy (CBT) and the use of virtual reality for performing exposure. 10 articles were selected, seven of which showed that VRET produced statistically significant results in comparison to the waiting list. However, no difference was found between VRET and exposure treatment. Of these 10, four were randomized, two were controlled but not randomized and four were non-controlled. The majority of the articles used head-mounted display virtual reality (VR) equipment and VR systems specific for the population that was being treated. Dropout rates do not seem to be lower than in traditional exposure treatment. However, there are a few limitations. Because this is a new field of research, there are few studies in the literature. There is also a need to standardize the number of sessions used. The randomized studies were analyzed to assess the quality of the methodology, and important deficiencies were noted, such as the non-use of intent-to- treat-analysis and the absence of description of possible concomitant treatments and comorbidities. Preliminary data suggest that VRET is as efficacious as traditional exposure treatment and can be especially useful in the treatment of patients who are resistant to traditional exposure.

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    • "We are, for example, interested in supporting work using virtual reality to treat PTSD due to combat, in which treatment exposes the subject to virtual stimuli that are highly suggestive of the physical situations that induced the trauma. Through carefully controlled use of VR, the patient is gradually desensitized over a period of weeks so that the likelihood of triggering of the trauma declines (Gerardi et al., 2008), as confirmed through fMRI measurements (Gonçalves et al., 2012). Our stimulus and experiments were developed with this in mind. "
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    ABSTRACT: Three-dimensional interactive virtual environments are a powerful tool for brain-imaging based cognitive neuroscience that are presently under-utilized. This paper presents machine-learning based methods for identifying brain states induced by realistic virtual environments with improved accuracy as well as the capability for mapping their spatial topography on the neocortex. Virtual environments provide the ability to study the brain under conditions closer to the environment in which humans evolved, and thus to probe deeper into the complexities of human cognition. As a test case, we designed a stimulus to reflect a military combat situation in the Middle East, motivated by the potential of using real-time functional magnetic resonance imaging (fMRI) in the treatment of post-traumatic stress disorder. Each subject experienced moving through the virtual town where they encountered 1—6 animated combatants at different locations, while fMRI data was collected. To analyze the data from what is, compared to most studies, more complex and less controlled stimuli, we employed statistical machine learning in the form of Multi-Voxel Pattern Analysis (MVPA) with special attention given to artificial Neural Networks (NN). Extensions to NN that exploit the block structure of the stimulus were developed to improve the accuracy of the classification, achieving performances from 58%—93% (chance was 16.7%) with 6 subjects. This demonstrates that MVPA can decode a complex cognitive state, viewing a number of characters, in a dynamic virtual environment. To better understand the source of this information in the brain, a novel form of sensitivity analysis was developed to use NN to quantify the degree to which each voxel contributed to classification. Compared with maps produced by general linear models and the searchlight approach, these sensitivity maps revealed a more diverse pattern of information relevant to the classification of cognitive state.
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    • "2011 ) or emergency medicine personnel ( Andreatta et al . , 2010 ) . There - fore , VRET seems to be as effective as in vivo exposure in reducing PTSD symptoms . This is highly relevant as it is not always pos - sible to exposure patients to trauma - related material and some patients find it difficult to immerse themselves in a traumatic scene ( Gonçalves et al . , 2012 ) . Recently , immersive VR has been applied in an experimental setting to study bystander interven - tions in interpersonal violent incidents ( Slater et al . , 2013 ) . This study indicated that individuals can react realistically in VR and emotions were reported that were in line with the violent scene displayed ( i . e . , feelings "
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    ABSTRACT: Most people are exposed to a violent or life-threatening situation during their lives, but only a minority develops post-traumatic stress disorder (PTSD). Experimental studies are necessary to assess risk factors, such as imagery ability, for the development of PTSD. Up to now the trauma film paradigm (TFP) has functioned as an analogue for PTSD. This paradigm is known to induce involuntary intrusions, a core symptom of PTSD. Though useful, the film paradigm has a drawback, the participant remains an “outsider” and does not immerse in the film scenes. The aim of the present study was to develop a fitting virtual reality (VR) analogue for PTSD and to assess risk factors for the development of PTSD-symptoms, such as intrusions. To this end a novel VR paradigm was compared to the traditional TFP. Both the VR and TFP elicited a negative mood and induction-related intrusions. More immersion was observed in the VR paradigm compared to the TFP. The results of the risk factors were mixed; more imagery ability coincided with a higher intrusion frequency, but also with less distressing intrusions. The results, implications and suggestions for future research are discussed.
    Full-text · Article · May 2015 · Frontiers in Psychology
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    • "Although we were not able to perform a meta-analysis of the present data, the present findings point in the same direction. As previously stated, Gonçalves et al. (2012) performed a similar review, although they differ in the following aspects: (1) There are a few month between the two searches, ours were made in September, 2011, while theirs in May, 2011; (2) The databases were the same, although we also searched EBSCO end SciELO/Pepsic; and (3) Our review had a broader scope (all empirical data), while Gonçalves et al. narrowed theirs to 10 studies, excluding case studies and subclinical PTSD. Given the interventions novelty, we consider the broaden search and more liberal criteria as an advantage. "
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    ABSTRACT: The objective of the present study is a systematic review on the use of VRE (Virtual Reality Exposure) for PTSD (Post-Traumatic Stress Disorder). The following keywords were used: PTSD, Post-Traumatic Stress Disorder, Posttraumatic Stress Disorder, Virtual Reality in these databases: PsycINFO/PsycLIT, PubMed/Medline, EBSCO, ProQuest, ISI Web of Science, and SciELO/Pepsic. The studies included should have their own empirical data and the intervention should consist of exposure to virtual reality. A total of 241 publications were found, of which 28 were selected for this review: 11 case studies, eight uncontrolled case series, and nine randomized controlled trials. The treatment ranged between 3 and 22 VRE sessions (M (Mean) = 9.09, SD (standard deviation) = 1.57). Among the case studies, the results were promising; all studies were able to reduce the PTSD symptomatology. As to the uncontrolled case series, overall they showed promising results. Regarding the randomized clinical trials, there was found a wide variation concerning the VRE intervention as well as the combined and control intervention. The majority of the studies presented significant results, except two which returned modest or non-significant results. The findings of this study suggest that the use of virtual reality as a tool for exposure therapy for PTSD can be an asset. Introduction PTSD (Post-Traumatic Stress Disorder) is defined as a symptomatic answer to a traumatic event involving recollections, avoidance, numbing, and increased arousal. It is a disturbance that causes clinically significant distress or functional impairment, with presence of symptoms for more than one month (American Psychiatric Association, 2000). The lifetime prevalence of PTSD has been estimated at 6.8% among the general population (Kessler, Chiu, Demler, & Walters, 2005). Although women are less likely to be exposed to traumatic stressors events, they show greater prevalence of the disorder, as well as more conditional risk to develop PTSD after exposure to a particular traumatic event (Breslau, 2002). PTSD has been considered the fifth most common
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